Current status quo on COVID-19 including chest imaging

Table 1 A summary on the consensus statements/recommendations from various international organizations on the use of chest radiographs and computed tomography in coronavirus disease 2019 suspected patients

Fleischner Society Consensus Statement
Mild respiratory diseases are those with no evidence of pulmonary dysfunction or damage (e.g., no or minimal dyspnea, no hypoxemia, etc.)
Moderate-severe respiratory disease: Evidence of significant pulmonary dysfunction or damage (e.g., moderate-severe dyspnea, hypoxemia, etc.)
Main Recommendations:
Asymptomatic COVID-19 patients: Imaging is not routinely indicated for screening
Mild respiratory features of COVID-19: Imaging is not indicated unless they at risk for disease progression, i.e., the patient has underlying risk factors (refer text)
Moderate-severe respiratory features of COVID-19 regardless of COVID-19 test result: Imaging is indicated
Patients with COVID-19 and with evidence of worsening respiratory symptoms/signs: Imaging is indicated
Healthcare facility with limited resources including limited access to CT: CXR may be done in this category of patients. However, CT may be warranted in those cases where there is evidence of respiratory worsening
Additional recommendations:No role for daily CXRs in stable intubated patients with COVID-19
CT is indicated in those patients that have recovered from COVID-19 but show functional impairment and/or hypoxemia
Patients found to have incidental finding on CT suggestive of COVID-19 should undergo a COVID-19 testing
American College of Radiology (ACR) Recommendations
Viral testing (RT-PCR) remains the only accepted method for diagnosing COVID-19 disease. Confirmation with viral testing is required even if the CXR or CT findings are suggestive of the disease
CXR or CT is not currently recommended to diagnose COVID-19
The findings on chest imaging in COVID-19 patients are not specific and can overlap with other diseases such as influence, H1N1, SARS and MERS; thereby limiting the specificity of chest CT
British Society of Thoracic Imaging (BSTI) Guidelines
No role for chest CT in the diagnosis of COVID-19 unless, the patient is seriously ill or if PCR testing is unavailable
The current position is that there is no recommended use of CT, beyond “routine clinical care”
Imaging (CXR or CT) may be useful in guiding patient management decisions, complications or when looking for alternate diagnosis
Canadian Association of Thoracic Radiology/Canadian Association of Radiologists Consensus Statement
RT-PCR assay remains the gold standard for diagnosis
Chest radiograph: Should not be used to exclude COVID-19 infection. CXR is often normal early in the disease, and even when present the imaging features are non-specific for COVID-19. CXRs are most useful when an alternate diagnosis is suspected e.g., pneumothorax, pulmonary edema, large pleural effusions, lung mass or lung collapse. The study needs to be limited to those in whom the findings are expected to change the management in order to reduce the risk of transmission of the virus to healthcare workers
Chest CT: Similar to CXR, CT should only be performed if the results are expected to influence patient management. CT should not be used to routinely screen patients for possible COVID-19. Although not limited to, potential indications for CT chest in COVID-19 include detection of intrathoracic complications (e.g., pulmonary embolism), immunosuppressed or high-risk patients with suspected respiratory infection and a negative chest radiograph, initial negative RT-PCR result and normal CXR but high clinical suspicion for COVID-19 infection or clinical deterioration. In patients requiring urgent intervention or procedure, it is impractical to wait 24 h for a swab result to decide on the level of PPE required. In such situations CT chest may be used as additional tool to guide the use of PPE. Although a negative CT does not completely rule out COVID-19 infection, it can help stratify the patients into low or high-risk category

COVID-19: Coronavirus disease 2019; CT: Computed tomography; CXR: Chest radiograph; RT-PCR: Reverse transcription polymerase chain reaction; H1N1: Influenza A; SARS: Severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; PPE: Personal protective equipment.