International Collaboration Key to Consensus on Thoracic Imaging in COVID-19

On March 20, with the fast-moving COVID-19 cases increasing rapidly around the world, Geoffrey D. Rubin, MD, from Duke University School of Medicine in Durham, NC, got a call from his long-time colleague and friend David A. Bluemke, MD, editor of Radiology.

Dr. Bluemke said he believed more clarity was needed on when and how thoracic imaging should be used in the management of COVID-19 patients. He wanted a consensus statement and he wanted it as quickly as possible to provide guidance for radiologists during the current pandemic.

“When Dave Bluemke made that request, the first thing that occurred to me was that we needed to produce a statement that was authoritative and, as much as possible, unassailable,” Dr. Rubin said. “Immediately, my thoughts turned to the Fleischner Society.”

As his first course of action, Dr. Rubin reached out to the Fleischner Society Executive Committee who unanimously approved a fast-tracked process to produce the Fleischner publication.  He then contacted his Fleischner Society colleagues Ann Leung, MD, of Stanford University, and Chris Ryerson, MD, of the University of British Columbia. Dr. Rubin is a former president of the Society which is dedicated to the diagnosis and treatment of diseases of the chest.

The trio quickly assembled a team of 29 experts in radiology, pulmonology and other medical disciplines in 10 countries that were hard-hit by the virus. Nine days after Dr. Bluemke’s request and following many conversations, the full team was convened and participated in discussions leading to independent and anonymous voting on 14 key questions associated with several clinical scenarios.

A day later, Dr. Rubin had a manuscript out to the other 28 authors. Within 24 hours, every reviewer had returned the draft with comments. The manuscript was approved for publication only 12 days after Dr. Bluemke’s call.

“I’ve never in my career experienced anything akin to the level of cooperation and prioritization that occurred from the time Dave Bluemke initially called to the time this manuscript was published simultaneously in Radiology and Chest,” Dr. Rubin said.

Evaluating Different COVID-19 Scenarios

In crafting the statement, Dr. Rubin and colleagues evaluated the utility of imaging within different scenarios while accounting for the availability of resources like personal protection equipment (PPE) and COVID-19 testing. The team also had to consider the potential exposure of clinicians, technologists and nurses to the virus.

In the end, the results were aggregated into several recommendations:

•            Chest imaging is not routinely indicated in asymptomatic individuals or patients with suspected COVID-19 and mild clinical symptoms.

•            Chest imaging is indicated in COVID-19 patients with worsening respiratory status.

•            Chest imaging is indicated for patients with moderate to severe features of COVID-19 regardless of test results.

•            In a resource-constrained environment, chest imaging is indicated for medical triage of patients with suspected COVID-19 who present with moderate to severe clinical features and a high pre-test probability of disease.

•            CT is appropriate in patients with functional impairment and/or hypoxemia (low level of oxygen in the blood) after recovery from COVID-19.

•            When evidence of COVID-19 is found incidentally on CT scans, patients should be tested for the virus.

In general, the authors recommended that chest imaging be used cautiously.

“We don’t want to image patients for which there is no value added,” said Dr. Leung during an April 17 RSNA webinar on the Fleischner statement. “I think that’s very critical, particularly when we’re talking about a contagious disease and we need and must protect health care workers.”

The authors of the statement avoided choosing between chest X-ray or CT in the COVID-19 setting in recognition of the myriad scenarios that might arise with different patients in different countries.

For instance, a patient with mild features and risk factors for disease progression would likely be sent home from the hospital after getting a chest X-ray to look for any major abnormalities that might change management of care. If the same patient returned to the hospital with signs of disease progression, the next step would depend on multiple factors.

“There will be a whole bunch of different things that will dictate whether we would prefer to do a chest X-ray or a CT scan,” said Dr. Ryerson during the webinar. “That’s why we made these decisions agnostic to the type of imaging.”

The statement also addressed the risk to radiologists, nurses and technologists performing or assisting in imaging exams. Based on current Centers of Disease Control recommendations, when providing care for patients with known or suspected COVID-19, medical personnel should wear N95 or surgical masks along with face shields or goggles, gloves and gowns. Medical staff should be trained in putting on and taking off protective clothing. Patients should be masked and imaged using dedicated equipment that is cleaned and disinfected after each use.

The recommendations are likely to be refined as the pandemic evolves and treatments start to become available, the researchers said. Thoracic imaging could eventually play an important role in the evaluation of response to treatment and in characterizing patients as likely responders to novel therapies. The Fleischner Society and RSNA will continue to issue updates as these developments occur.

The audience of nearly 2,000 responded to a series of questions related to the recommendations during the webinar, and their answers indicated strong agreement with the authors’ recommendations.

“Look up the Fleischner statement online,” said Dr. Bluemke in his April 7 podcast. “Print it out. Put it in the reading room. Have a staff meeting to discuss it. You might agree, you might disagree, but you have a place to start.”

For More Information

Access, “The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society,” in Radiology and Chest. 

Access the on-demand RSNA webinar on the RSNA YouTube channel.

Access Dr. Bluemke’s podcast on the Fleischner Statement.

Access RSNA’s COVID-19 resources.