This document from the European Society of Radiology (ESR) and the European Society of Thoracic Imaging (ESTI) aims to present the main imaging features, and the role of CT scan in the early ...diagnosis of COVID-19, describing, in particular, the typical findings which make it possible to identify the disease and distinguish it from bacterial causes of infection, and to define which category of patients may benefit from CT imaging. The precautions that must be taken when performing scans to protect radiologists and technologists from infection will be described. The organisational measures that can be taken within radiology departments in order to cope with the influx of patients, while continuing to manage other emergency and time-sensitive activity (e.g. oncology, other infectious diseases etc.), will be discussed.
Key points
• Bilateral ground glass opacities are typical CT manifestations of COVID-19.
• Crazy paving and organising pneumonia pattern are seen at a later stage.
• Extensive consolidation is associated with a poor prognosis.
Objectives
To evaluate the inter-rater agreement of chest X-ray (CXR) findings in coronavirus disease 2019 (COVID-19) and to determine the value of initial CXR along with demographic, clinical, and ...laboratory data at emergency department (ED) presentation for predicting mortality and the need for ventilatory support.
Methods
A total of 340 COVID-19 patients who underwent CXR in the ED setting (March 1–13, 2020) were retrospectively included. Two reviewers independently assessed CXR abnormalities, including ground-glass opacities (GGOs) and consolidation. Two scoring systems (
Brixia
score and percentage of lung involvement) were applied. Inter-rater agreement was assessed by weighted Cohen’s kappa (
κ
) or intraclass correlation coefficient (ICC). Predictors of death and respiratory support were identified by logistic or Poisson regression.
Results
GGO admixed with consolidation (
n
= 235, 69%) was the most common CXR finding. The inter-rater agreement was almost perfect for type of parenchymal opacity (
κ
= 0.90),
Brixia
score (ICC = 0.91), and percentage of lung involvement (ICC = 0.95). The
Brixia
score (OR: 1.19; 95% CI: 1.06, 1.34;
p
= 0.003), age (OR: 1.16; 95% CI: 1.11, 1.22;
p
< 0.001), PaO
2
/FiO
2
ratio (OR: 0.99; 95% CI: 0.98, 1;
p
= 0.002), and cardiovascular diseases (OR: 3.21; 95% CI: 1.28, 8.39;
p
= 0.014) predicted death. Percentage of lung involvement (OR: 1.02; 95% CI: 1.01, 1.03;
p
= 0.001) and PaO
2
/FiO
2
ratio (OR: 0.99; 95% CI: 0.99, 1.00;
p
< 0.001) were significant predictors of the need for ventilatory support.
Conclusions
CXR is a reproducible tool for assessing COVID-19 and integrates with patient history, PaO
2
/FiO
2
ratio, and SpO
2
values to early predict mortality and the need for ventilatory support.
Key Points
• Chest X-ray is a reproducible tool for assessing COVID-19 pneumonia.
•
The Brixia score and percentage of lung involvement on chest X-ray integrate with patient history, PaO
2
/FIO
2
ratio, and SpO
2
values to early predict mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department.
With more than 900,000 confirmed cases worldwide and nearly 50,000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health ...care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.
Purpose
This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia.
Methods
Twenty-five ...patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmH
2
O and during recruiting maneuver (supine, 35 cmH
2
O). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmH
2
O of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO
2
/FiO
2
. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction.
Results
The average values of venous admixture and PaO
2
/FiO
2
ratio were similar in supine-5 and prone-5. However, the PaO
2
/FiO
2
changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (
p
= 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (
p
= 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (
p
= 0.004) while PaO
2
/FiO
2
ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (
p
= 0.04). Consolidated tissue, PaCO
2
and respiratory system elastance were higher in patients assessed late (all
p
< 0.05), suggesting, all together, “fibrotic-like” changes of the lung over time.
Conclusion
The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers.
European position statement on lung cancer screening Oudkerk, Matthijs; Devaraj, Anand; Vliegenthart, Rozemarijn ...
The lancet oncology,
December 2017, 2017-12-00, 20171201, Letnik:
18, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Lung cancer screening with low-dose CT can save lives. This European Union (EU) position statement presents the available evidence and the major issues that need to be addressed to ensure the ...successful implementation of low-dose CT lung cancer screening in Europe. This statement identified specific actions required by the European lung cancer screening community to adopt before the implementation of low-dose CT lung cancer screening. This position statement recommends the following actions: a risk stratification approach should be used for future lung cancer low-dose CT programmes; that individuals who enter screening programmes should be provided with information on the benefits and harms of screening, and smoking cessation should be offered to all current smokers; that management of detected solid nodules should use semi-automatically measured volume and volume-doubling time; that national quality assurance boards should be set up to oversee technical standards; that a lung nodule management pathway should be established and incorporated into clinical practice with a tailored screening approach; that non-calcified baseline lung nodules greater than 300 mm3, and new lung nodules greater than 200 mm3, should be managed in multidisciplinary teams according to this EU position statement recommendations to ensure that patients receive the most appropriate treatment; and planning for implementation of low-dose CT screening should start throughout Europe as soon as possible. European countries need to set a timeline for implementing lung cancer screening.
Recent screening trial results indicate that low-dose computed tomography (LDCT) reduces lung cancer mortality in high-risk patients. However, high false-positive rates, costs, and potential harms ...highlight the need for complementary biomarkers. The diagnostic performance of a noninvasive plasma microRNA signature classifier (MSC) was retrospectively evaluated in samples prospectively collected from smokers within the randomized Multicenter Italian Lung Detection (MILD) trial.
Plasma samples from 939 participants, including 69 patients with lung cancer and 870 disease-free individuals (n = 652, LDCT arm; n = 287, observation arm) were analyzed by using a quantitative reverse transcriptase polymerase chain reaction-based assay for MSC. Diagnostic performance of MSC was evaluated in a blinded validation study that used prespecified risk groups.
The diagnostic performance of MSC for lung cancer detection was 87% for sensitivity and 81% for specificity across both arms, and 88% and 80%, respectively, in the LDCT arm. For all patients, MSC had a negative predictive value of 99% and 99.86% for detection and death as a result of disease, respectively. LDCT had sensitivity of 79% and specificity of 81% with a false-positive rate of 19.4%. Diagnostic performance of MSC was confirmed by time dependency analysis. Combination of both MSC and LDCT resulted in a five-fold reduction of LDCT false-positive rate to 3.7%. MSC risk groups were significantly associated with survival (χ1(2) = 49.53; P < .001).
This large validation study indicates that MSC has predictive, diagnostic, and prognostic value and could reduce the false-positive rate of LDCT, thus improving the efficacy of lung cancer screening.
Although increasing used in the preclinical testing of new anti-fibrotic drugs, a thorough validation of micro-computed tomography (CT) in pulmonary fibrosis models has not been performed. Moreover, ...no attempts have been made so far to define density thresholds to discriminate between aeration levels in lung parenchyma. In the present study, a histogram-based analysis was performed in a mouse model of bleomycin (BLM)-induced pulmonary fibrosis by micro-CT, evaluating longitudinal density changes from 7 to 21 days after BLM challenge, a period representing the progression of fibrosis. Two discriminative densitometric indices (i.e. 40th and 70th percentiles) were extracted from Hounsfield Unit density distributions and selected for lung fibrosis staging. The strong correlation with histological findings (r
= 0.76, p < 0.01) confirmed that variations in 70th percentile could reflect a pathological lung condition and estimate the effect of antifibrotic treatments. This index was therefore used to define lung aeration levels in mice distinguishing in hyper-inflated, normo-, hypo- and non-aerated pulmonary compartments. A retrospective analysis performed on a large cohort of mice confirmed the correlation between the proposed preclinical density thresholds and the histological outcomes (r
= 0.6, p < 0.01), strengthening their suitability for tracking disease progression and evaluating antifibrotic drug candidates.
Surgical lung biopsy is often required for a confident multidisciplinary diagnosis of idiopathic pulmonary fibrosis (IPF). Alternative, less-invasive biopsy methods, such as bronchoscopic lung ...cryobiopsy (BLC), are highly desirable.
To address the impact of BLC on diagnostic confidence in the multidisciplinary diagnosis of IPF.
In this cross-sectional study we selected 117 patients with fibrotic interstitial lung disease without a typical usual interstitial pneumonia pattern on high-resolution computed tomography. All cases underwent lung biopsies: 58 were BLC, and 59 were surgical lung biopsy (SLB). Two clinicians, two radiologists, and two pathologists sequentially reviewed clinical-radiologic findings and biopsy results, recording at each step in the process their diagnostic impressions and confidence levels.
We observed a major increase in diagnostic confidence after the addition of BLC, similar to SLB (from 29 to 63%, P = 0.0003 and from 30 to 65%, P = 0.0016 of high confidence IPF diagnosis, in the BLC group and SLB group, respectively). The overall interobserver agreement in IPF diagnosis was similar for both approaches (BLC overall kappa, 0.96; SLB overall kappa, 0.93). IPF was the most frequent diagnosis (50 and 39% in the BLC and SLB group, respectively; P = 0.23). After the addition of histopathologic information, 17% of cases in the BLC group and 19% of cases in the SLB group, mostly idiopathic nonspecific interstitial pneumonia and hypersensitivity pneumonitis, were reclassified as IPF.
BLC is a new biopsy method that has a meaningful impact on diagnostic confidence in the multidisciplinary diagnosis of interstitial lung disease and may prove useful in the diagnosis of IPF. This study provides a robust rationale for future studies investigating the diagnostic accuracy of BLC compared with SLB.
This Review provides an updated approach to the diagnosis of idiopathic pulmonary fibrosis (IPF), based on a systematic search of the medical literature and the expert opinion of members of the ...Fleischner Society. A checklist is provided for the clinical evaluation of patients with suspected usual interstitial pneumonia (UIP). The role of CT is expanded to permit diagnosis of IPF without surgical lung biopsy in select cases when CT shows a probable UIP pattern. Additional investigations, including surgical lung biopsy, should be considered in patients with either clinical or CT findings that are indeterminate for IPF. A multidisciplinary approach is particularly important when deciding to perform additional diagnostic assessments, integrating biopsy results with clinical and CT features, and establishing a working diagnosis of IPF if lung tissue is not available. A working diagnosis of IPF should be reviewed at regular intervals since the diagnosis might change. Criteria are presented to establish confident and working diagnoses of IPF.
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