“Keep it simple – a lesson from COVID-19”: highlighting the utility of chest X-rays in ARDS-associated illnesses through the Zonal Scoring System
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St. John’s Medical College, Bengaluru, Karantaka, India
Submission date: 2022-09-14
Acceptance date: 2022-11-21
Publication date: 2023-03-03
Pol J Radiol, 2023; 88: 124-134
The post-pandemic era calls for appropriate literature on chest X-ray score cut-offs, enabling swift categorization and faster radiological reporting of patients with acute respiratory distress syndrome (ARDS)-like illnesses, hence prompting healthcare equity in low-resource centres where extortionate modalities of imaging such as computed tomography (CT) are unavailable. In this study, we aim to bridge the literature gap using the versatile zonal scoring system.

Material and methods:
This retrospective cohort study uses data from 751 COVID-19 RT-PCR+ patients. Concordant chest radiograph (CXR) scores were reported, and inter-rater reliability was measured using kappa indices. receiver operating characteristic curves were used to establish cut-off scores for the outcomes of interest: mild or severe disease, admission to an intensive care unit (ICU), and intubation. Categorical data were expressed using means and percentages, and  or t-tests were used for comparison at an χ2 level of 0.05. Unadjusted odds ratios for each outcome of interest vs. CXR score and comorbidity were then calculated using binary logistic regression.

CXR findings included infiltrates (46.07%), pleural effusions (7.05%), consolidation and fibrosis (4.43%), pneumothoraces (2.71%), and cardiomegaly (2.26%). Most patients had an index CXR score of 0 (54.19%). The index cut-off score of ≤ 1 (82.95, 81.68) was established for mild disease, ≥ 4 for severe disease (85.71, 83.99), ≥ 3 for ICU admission (86.90, 71.91), and ≥ 4 for intubation (87.61, 72.90). Hypertension, type 2 diabetes mellitus, hypothyroidism, history of ischaemic heart disease, and history of tuberculosis were independent risk factors for a high CXR index score, intubation, and ICU admission.

CXR scores can be effectively used in low-resource settings for triaging patients, maintaining records, and disease prognostication.

Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun 2020; 109: 102433. doi: 10.1016/j.jaut.2020.102433.
Callaway E. Beyond Omicron: what’s next for COVID’s viral evolution. Nature 2021; 600: 204-207.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; 323: 1239-1242.
Katzourakis A. COVID-19: endemic doesn’t mean harmless. Nature 2022; 601: 485. doi: 10.1038/d41586-022-00155-x.
Zhang Y, Xue H, Wang M, et al. Lung ultrasound findings in patients with coronavirus disease (COVID-19). Am J Roentgenol 2021; 216: 80-84.
Schiaffino S, Tritella S, Cozzi A, et al. Diagnostic performance of chest X-Ray for COVID-19 pneumonia during the SARS-CoV-2 pandemic in Lombardy, Italy. J Thorac Imaging 2020; 35: W105-W106.
Hani C, Trieu NH, Saab I, et al. COVID-19 pneumonia: a review of typical CT findings and differential diagnosis. Diagn Interv Imaging 2020; 101: 263-268.
Yasin R, Gouda W. Chest X-ray findings monitoring COVID-19 disease course and severity. Egypt J Radiol Nucl Med 2020; 51: 193. doi: 10.1186/s43055-020-00296-x.
Bernheim A, Mei X, Huang M, et al. Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection. Radiology 2020; 295: 200463. doi: 10.1148/radiol.2020200463.
Benmalek E, Elmhamdi J, Jilbab A. Comparing CT scan and chest X-ray imaging for COVID-19 diagnosis. Biomed Eng Adv 2021; 1: 100003. doi: 10.1016/j.bea.2021.100003.
Sverzellati N, Ryerson CJ, Milanese G, et al. Chest x-ray or CT for COVID-19 pneumonia? Comparative study in a simulated triage setting. Eur Respir J 2021. doi: 10.1183/13993003.04188-2020.
ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection [Internet]. [cited 2022 May 18]. Available from:
Kaleemi R, Hilal K, Arshad A, et al. The association of chest radiographic findings and severity scoring with clinical outcomes in patients with COVID-19 presenting to the emergency department of a tertiary care hospital in Pakistan. PLoS One 2021; 16: e0244886. doi: 10.1371/journal.pone.0244886.
Toussie D, Voutsinas N, Finkelstein M, et al. Clinical and chest radio­graphy features determine patient outcomes in young and middle-aged adults with COVID-19. Radiology 2020; 297: E197-206.
Warren MA, Zhao Z, Koyama T, et al. Severity scoring of lung oedema on the chest radiograph is associated with clinical outcomes in ARDS. Thorax 2018; 73: 840-846.
Borghesi A, Maroldi R. COVID-19 outbreak in Italy: experimental chest X-ray scoring system for quantifying and monitoring disease progression. Radiol Med 2020; 125: 509-513.
Alqahtani JS, Oyelade T, Aldhahir AM, et al. Prevalence, severity and mortality associated with COPD and smoking in patients with COVID-19: a rapid systematic review and meta-analysis. PLoS One 2020; 15: e0233147. doi: 10.1371/journal.pone.0233147.
Westreich D. Berkson’s bias, selection bias, and missing data. Epidemiology 2012; 23: 159-164.
Jazieh AR, Kozlakidis Z. Healthcare transformation in the post-coronavirus pandemic era. Front Med (Lausanne) 2020; 7: 429. doi: 10.3389/fmed.2020.00429.
Sailer AM, van Zwam WH, Wildberger JE, Grutters JPC. Cost-effectiveness modelling in diagnostic imaging: a stepwise approach. Eur Radiol 2015; 25: 3629-3637.
Vaughan L, McAlister G, Bell D. ‘August is always a nightmare’: results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey. Clin Med 2011; 11: 322-326.
Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 2020; 20: 425-434.
Colman J, Zamfir G, Sheehan F, et al. Chest radiograph characteristics in COVID-19 infection and their association with survival. Eur J Radiol Open 2021; 8: 100360. doi: 10.1016/j.ejro.2021.100360.
Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: state-of-the-art review. Heart Lung 2021; 50: 481-490.
Rathore SS, Hussain N, Manju AH, et al. Prevalence and clinical outcomes of pleural effusion in COVID-19 patients: a systematic review and meta-analysis. J Med Virol 2022; 94: 229-239.
Hooper C, Lee YCG, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010; 65 (Suppl 2): ii4-17.
Cunningham JW, Vaduganathan M, Claggett BL, et al. Clinical outcomes in young US adults hospitalized with COVID-19. JAMA Intern Med 2020; 181: 379-381.
Luhar S, Timæus IM, Jones R, et al. Forecasting the prevalence of overweight and obesity in India to 2040. PLoS One 2020; 15: e0229438. doi: 10.1371/journal.pone.0229438.
Gupta R, Gaur K, S. Ram CV. Emerging trends in hypertension epidemiology in India. J Hum Hypertens 2019; 33: 575-587.
Pradeepa R, Mohan V. Epidemiology of type 2 diabetes in India. Indian J Ophthalmol 2021; 69: 2932-2938.
Gao Y, Liu M, Chen Y, et al. Association between tuberculosis and COVID‐19 severity and mortality: a rapid systematic review and meta‐analysis. J Med Virol 2021; 93: 194-196.
Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for COVID-19 hospital admission. Clin Infect Dis 2020; 71: 896-897.
Kim HW, Capaccione KM, Li G, et al. The role of initial chest X-ray in triaging patients with suspected COVID-19 during the pandemic. Emerg Radiol 2020; 27: 617-621.
Jain VK, Iyengar Karthikeyan P, Vaishya R. Differences between first wave and second wave of COVID-19 in India. Diabetes Metab Syndr 2021; 15: 1047-1048.
Brakohiapa EKK, Sarkodie BD, Botwe BO, et al. Comparing radiological presentations of first and second strains of COVID-19 infections in a low-resource country. Heliyon 2021; 7: e07818. doi: 10.1016/j.heliyon.2021.e07818.
Brady Z, Scoullar H, Grinsted B, et al. Technique, radiation safety and image quality for chest X-ray imaging through glass and in mobile settings during the COVID-19 pandemic. Phys Eng Sci Med 2020; 43: 765-779.
Boini S, Guillemin F. Radiographic scoring methods as outcome measures in rheumatoid arthritis: properties and advantages. Ann Rheum Dis 2001; 60: 817-827.
Podder P, Mondal MRH. Machine learning to predict COVID-19 and ICU requirement. In: 2020 11th International Conference on Electrical and Computer Engineering (ICECE); 2020, p. 483-486.
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