Prognostic Value of the Radiographic Assessment of Lung Edema Score in Mechanically Ventilated ICU Patients.

INTRODUCTION: The Radiographic Assessment of Lung Edema (RALE) score provides a semi-quantitative measure of pulmonary edema. In patients with acute respiratory distress syndrome (ARDS), the RALE score is associated with mortality. In mechanically ventilated patients in the intensive care unit (ICU) with respiratory failure not due to ARDS, a variable degree of lung edema is observed as well. We aimed to evaluate the prognostic value of RALE in mechanically ventilated ICU patients. METHODS: Secondary analysis of patients enrolled in the 'Diagnosis of Acute Respiratory Distress Syndrome' (DARTS) project with an available chest X-ray (CXR) at baseline. Where present, additional CXRs at day 1 were analysed. The primary endpoint was 30-day mortality. Outcomes were also stratified for ARDS subgroups (no ARDS, non-COVID-ARDS and COVID-ARDS). RESULTS: 422 patients were included, of which 84 had an additional CXR the following day. Baseline RALE scores were not associated with 30-day mortality in the entire cohort (OR: 1.01, 95% CI: 0.98-1.03, p = 0.66), nor in subgroups of ARDS patients. Early changes in RALE score (baseline to day 1) were only associated with mortality in a subgroup of ARDS patients (OR: 1.21, 95% CI: 1.02-1.51, p = 0.04), after correcting for other known prognostic factors. CONCLUSIONS: The prognostic value of the RALE score cannot be extended to mechanically ventilated ICU patients in general. Only in ARDS patients, early changes in RALE score were associated with mortality.

The radiographic assessment of lung edema score of lung edema severity correlates with inflammatory parameters in patients with coronavirus disease 2019-Potential new admission biomarkers to predict coronavirus disease 2019 worsening.

Background: Coronavirus disease 2019 (COVID-19) has placed enormous pressure on intensive care units (ICUs) and on healthcare systems in general. A deeper understanding of the pathophysiology of the most severe forms of COVID-19 would help guide the development of more effective interventions. Herein, we characterized the inflammatory state of patients with COVID-19 of varying degrees of severity to identify admission biomarkers for predicting COVID-19 worsening. Design: Admission blood samples were obtained from 78 patients with COVID-19. Radiographic assessment of lung edema (RALE) scoring was calculated by imaging. Platelet and leukocyte counts were measured by flow cytometry, and plasma levels of C-reactive protein were assessed by immunoturbidimetry, and interleukin (IL)-8/CXCL8, IL-10, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, and monocyte chemoattractant protein-1 (MCP-1/CCL2) levels by enzyme-linked immunosorbent assay (ELISA). Results: The RALE score correlated with several admission hemogram (platelets, neutrophils, and lymphocytes) and inflammatory (IL-8/CXCL8, MCP-1/CCL2, IL-10, and C-reactive protein) parameters. COVID-19 worsening, based on the need for oxygen (Δoxygen supply) during hospitalization, correlated negatively with admission lymphocyte counts but positively with neutrophil-to-lymphocyte ratio and with plasma levels of the inflammatory parameters correlating with RALE score. Conclusion: Our data indicate a correlation between the RALE score and Δoxygen supply and admission inflammatory status. The identification of a panel of biomarkers that reflect COVID severity might be useful to predict disease worsening during hospitalization and to guide clinical management of COVID-19-related complications. Finally, therapies targeting IL-8/CXCL8- or IL-10 activity may offer therapeutic approaches in COVID-19 treatment.

The RALE Score Versus the CT Severity Score in Invasively Ventilated COVID-19 Patients-A Retrospective Study Comparing Their Prognostic Capacities.

BACKGROUND: Quantitative radiological scores for the extent and severity of pulmonary infiltrates based on chest radiography (CXR) and computed tomography (CT) scan are increasingly used in critically ill invasively ventilated patients. This study aimed to determine and compare the prognostic capacity of the Radiographic Assessment of Lung Edema (RALE) score and the chest CT Severity Score (CTSS) in a cohort of invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to COVID-19. METHODS: Two-center retrospective observational study, including consecutive invasively ventilated COVID-19 patients. Trained scorers calculated the RALE score of first available CXR and the CTSS of the first available CT scan. The primary outcome was ICU mortality; secondary outcomes were duration of ventilation in survivors, length of stay in ICU, and hospital-, 28-, and 90-day mortality. Prognostic accuracy for ICU death was expressed using odds ratios and Area Under the Receiver Operating Characteristic curves (AUROC). RESULTS: A total of 82 patients were enrolled. The median RALE score (22 [15-37] vs. 26 [20-39]; p = 0.34) and the median CTSS (18 [16-21] vs. 21 [18-23]; p = 0.022) were both lower in ICU survivors compared to ICU non-survivors, although only the difference in CTSS reached statistical significance. While no association was observed between ICU mortality and RALE score (OR 1.35 [95%CI 0.64-2.84]; p = 0.417; AUC 0.50 [0.44-0.56], this was noticed with the CTSS (OR, 2.31 [1.22-4.38]; p = 0.010) although with poor prognostic capacity (AUC 0.64 [0.57-0.69]). The correlation between the RALE score and CTSS was weak (r2 = 0.075; p = 0.012). CONCLUSIONS: Despite poor prognostic capacity, only CTSS was associated with ICU mortality in our cohort of COVID-19 patients.

Chest Radiograph Severity Scores, Comorbidity Prevalence, and Outcomes of Patients with Coronavirus Disease Treated at the King Abdullah University Hospital in Jordan: A Retrospective Study.

Introduction: Hospitalized patients with coronavirus disease (COVID-19) often undergo chest x-ray (CXR). Utilizing CXR findings could reduce the cost of COVID-19 treatment and the resultant pressure on the Jordanian healthcare system. Methods: We evaluated the association between the CXR severity score, based on the Radiographic Assessment of Lung Edema (RALE) scoring system, and outcomes of patients with COVID-19. The main objective of this work is to assess the role of the RALE scoring system in predicting in-hospital mortality and clinical outcomes of patients with COVID-19. Adults with a positive severe acute respiratory syndrome COVID-19 two reverse-transcription polymerase chain reaction test results and a baseline CXR image, obtained in November 2020, were included. The RALE severity scores were calculated by expert radiologists and categorized as normal, mild, moderate, and severe. Chi-square tests and multivariable logistic regression were used to assess the association between the severity category and admission location and clinical characteristics. Results: Based on the multivariable regression analysis, it has been found that male sex, hypertension, and the RALE severity score were significantly associated with in-hospital mortality. The baseline RALE severity score was associated with the need for critical care (P<0.001), in-hospital mortality (P<0.001), and the admission location (P=0.002). Discussion: The utilization of RALE severity scores helps to predict clinical outcomes and promote prudent use of resources during the COVID-19 pandemic.

Correlation of Chest X-Ray Scores in SARS-CoV-2 Patients With the Clinical Severity Classification and the Quick COVID-19 Severity Index.

Objectives This study aimed to assess the role of chest X-ray (CXR) scoring methods and their correlations with the clinical severity categories and the Quick COVID-19 Severity Index (qCSI). Methods We conducted a retrospective study of 159 COVID-19 patients who were diagnosed and treated at the University Medical Center between July and September 2021. Chest X-ray findings were evaluated, and severity scores were calculated using the modified CXR (mCXR), Radiographic Assessment of Lung Edema (RALE), and Brixia scoring systems. The three scores were then compared to the clinical severity categories and the qCSI using Spearman's correlation coefficient. Results Overall, 159 patients (63 males and 96 females) (mean age: 58.3 ± 15.7 years) were included. The correlation coefficients between the mCXR score and the Brixia and RALE scores were 0.9438 and 0.9450, respectively. The correlation coefficient between the RALE and Brixia scores was marginally higher, at 0.9625. The correlation coefficients between the qCSI and the Brixia, RALE, and mCXR scores were 0.7298, 0.7408, and 0.7156, respectively. The significant difference in the mean values of the three CXR scores between asymptomatic, mild, moderate, severe, and critical groups was also noted. Conclusions There were strong correlations between the three CXR scores and the clinical severity classification and the qCSI.

The Prognostic Capacity of the Radiographic Assessment for Lung Edema Score in Patients With COVID-19 Acute Respiratory Distress Syndrome-An International Multicenter Observational Study.

Background: The radiographic assessment for lung edema (RALE) score has an association with mortality in patients with acute respiratory distress syndrome (ARDS). It is uncertain whether the RALE scores at the start of invasive ventilation or changes thereof in the next days have prognostic capacities in patients with COVID-19 ARDS. Aims and Objectives: To determine the prognostic capacity of the RALE score for mortality and duration of invasive ventilation in patients with COVID-19 ARDS. Methods: An international multicenter observational study included consecutive patients from 6 ICUs. Trained observers scored the first available chest X-ray (CXR) obtained within 48 h after the start of invasive ventilation ("baseline CXR") and each CXRs thereafter up to day 14 ("follow-up CXR"). The primary endpoint was mortality at day 90. The secondary endpoint was the number of days free from the ventilator and alive at day 28 (VFD-28). Results: A total of 350 CXRs were scored in 139 patients with COVID-19 ARDS. The RALE score of the baseline CXR was high and was not different between survivors and non-survivors (33 [24-38] vs. 30 [25-38], P = 0.602). The RALE score of the baseline CXR had no association with mortality (hazard ratio [HR], 1.24 [95% CI 0.88-1.76]; P = 0.222; area under the receiver operating characteristic curve (AUROC) 0.50 [0.40-0.60]). A change in the RALE score over the first 14 days of invasive ventilation, however, had an independent association with mortality (HR, 1.03 [95% CI 1.01-1.05]; P < 0.001). When the event of death was considered, there was no significant association between the RALE score of the baseline CXR and the probability of being liberated from the ventilator (HR 1.02 [95% CI 0.99-1.04]; P = 0.08). Conclusion: In this cohort of patients with COVID-19 ARDS, with high RALE scores of the baseline CXR, the RALE score of the baseline CXR had no prognostic capacity, but an increase in the RALE score in the next days had an association with higher mortality.

Modified Chest X-Ray Scoring System in Evaluating Severity of COVID-19 Patient in Dr. Soetomo General Hospital Surabaya, Indonesia.

INTRODUCTION: The management of COVID-19 patients requires efficiency and accuracy in methods of detection, identification, monitoring, and treatment feasible in every hospital. Aside from clinical presentations and laboratory markers, chest x-ray imaging could also detect pneumonia caused by COVID-19. It is also a fast, simple, cheap, and safe modality used for the management of COVID-19 patients. Established scoring systems of COVID-19 chest x-ray imaging include Radiographic Assessment of Lung Edema (RALE) and Brixia classification. A modified scoring system has been adopted from BRIXIA and RALE scoring systems and has been made to adjust the scoring system needs at Dr. Soetomo General Hospital, Indonesia. This study aims to determine the value of scoring systems through chest x-ray imaging in evaluating the severity of COVID-19. METHODS: Data were collected from May to June of 2020 who underwent chest x-ray evaluation. Each image is then scored using three types of classifications: modified score, RALE score, and Brixia score. The scores are then analyzed and compared with the clinical conditions and laboratory markers to determine their value in evaluating the severity of COVID-19 infection in patients. RESULTS: A total of 115 patients were males (51.1%) and 110 were females (48.9%). All three scoring systems are significantly correlated with the clinical severity of the disease, with the strengths of correlation in order from the strongest to weakest as Brixia score (p<0.01, correlation coefficient 0.232), RALE score (p<0.01, correlation coefficient 0.209), and Dr. Soetomo General Hospital score (p<0.01, correlation coefficient 0.194). All three scoring systems correlate significantly with each other. Dr. Soetomo General Hospital score correlates more towards Brixia score (p<0.01, correlation coefficient 0.865) than RALE score (p<0.01, correlation coefficient 0.855). Brixia to RALE score correlates with a coefficient of 0.857 (p<0.01). CONCLUSION: The modified scoring system can help determine the severity of the disease progression in COVID-19 patients especially in areas with shortages of facilities and specialists.

Age, neutrophil lymphocyte ratio, and radiographic assessment of the quantity of lung edema (RALE) score to predict in-hospital mortality in COVID-19 patients: a retrospective study.

Background: Available data suggest that case fatality rate of COVID-19 patients in Surabaya is higher than global cases. Thus, it is important to identify risk factors to prevent the mortality. This study aimed to assess the factors associated with hospital mortality of COVID-19 patients, and develop a prediction score based on these findings. Methods: We analyzed 111 patients, who were diagnosed with COVID-19 based on reverse-transcriptase polymerase chain reaction. The following patient characteristics were obtained from records: age, gender, type of symptoms, onset of symptoms, neutrophil lymphocyte ratio (NLR), absolute lymphocyte count, chest x-ray abnormalities, lung involvement, type of lesion, radiographic assessment of the quantity of lung edema (RALE) score, and mortality. Data were analyzed using SPSS 25.0. Results Multivariate analysis showed that age >50 years ( p=0.043), NLR score >5.8 ( p=0.016) and RALE score >2 ( p=0.002) can predict the mortality of COVID-19 patients in the hospital. ROC curve analysis of the score ability to predict mortality showed an area under the curve of 0.794. The cut-off point is 4.5, with a sensitivity of 96.7% and specificity of 49.4% to predict the mortality of COVID-19 patient in the hospital. Conclusions Age, NLR score and RALE score were associated with mortality of COVID-19 patients in the hospital and might be used as a predictor for mortality of COVID-19 patients in health care centre where radiologists are available. The prediction score may be useful for frontline physicians to effectively manage patients with a higher score to prevent mortality.

Early predictors of clinical outcomes of COVID-19 outbreak in Milan, Italy.

BACKGROUND: National health-system hospitals of Lombardy faced a heavy burden of admissions for acute respiratory distress syndromes associated with coronavirus disease (COVID-19). Data on patients of European origin affected by COVID-19 are limited. METHODS: All consecutive patients aged ≥18 years, coming from North-East of Milan's province and admitted at San Raffaele Hospital with COVID-19, between February 25th and March 24th, were reported, all patients were followed for at least one month. Clinical and radiological features at admission and predictors of clinical outcomes were evaluated. RESULTS: Of the 500 patients admitted to the Emergency Unit, 410 patients were hospitalized and analyzed: median age was 65 (IQR 56-75) years, and the majority of patients were males (72.9%). Median (IQR) days from COVID-19 symptoms onset was 8 (5-11) days. At hospital admission, fever (≥ 37.5 °C) was present in 67.5% of patients. Median oxygen saturation (SpO2) was 93% (range 60-99), with median PaO2/FiO2 ratio, 267 (IQR 184-314). Median Radiographic Assessment of Lung Edema (RALE) score was 9 (IQR 4-16). More than half of the patients (56.3%) had comorbidities, with hypertension, coronary heart disease, diabetes and chronic kidney failure being the most common. The probability of overall survival at day 28 was 66%. Multivariable analysis showed older age, coronary artery disease, cancer, low lymphocyte count and high RALE score as factors independently associated with an increased risk of mortality. CONCLUSION: In a large cohort of COVID-19 patients of European origin, main risk factors for mortality were older age, comorbidities, low lymphocyte count and high RALE.