WORSENING RADIOGRAPHIC EDEMA IS ASSOCIATED WITH ICU ADMISSION AND 30-DAY MORTALITY IN ADULT PATIENTS HOSPITALIZED WITH COVID-19

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Severity of radiographic abnormalities on chest X-rays (CXR) in patients with COVID-19 has been shown to be associated with outcomes, but whether the evolution of radiographic edema in hospitalized patients with COVID-19 predicts need for ICU admission and mortality has not been rigorously studied. We sought to evaluate this question using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system including all adult (age >= 18) patients. METHODS: We collected CXRs over a 5-day period from patients hospitalized with diagnosis of COVID-19 between March and September 2020. CXR periods were defined as baseline (day of admission), early (1-2 days after admission) and late (3-5 days after admission). Need for ICU admission, mechanical ventilation and mortality at 30 days from admission were obtained from the charts. Two independent reviewers quantified radiographic edema using the RALE scoring system. RESULTS: 392 patients were identified (median age 62, 50% female). Inter-rate agreement for RALE score was excellent (interclass correlation coefficient = 0.87, 95% CI 0.83 - 0.90, p < 0.0001). 82 (21%) patients had a normal (RALE = 0) CXR on admission. Patients with a higher RALE score were more likely to require ICU admission and had higher 30-mortality at all time periods. An increase of 6 or more in RALE score from baseline to early period was associated with need for ICU admission (OR 5.1, 95% CI [1.71 – 17.3], p = 0.002) and 30-day mortality (OR 4.4, 95% CI [1.55 – 13.3], p = 0.003 even after adjustment for baseline hypoxemia, age and history of diabetes. CONCLUSIONS: The RALE score is highly reproducible and easily implementable in adult patients presenting hospitalized with COVID-19. Early increase in RALE score is associated with 30-day mortality and need for ICU admission, suggesting that worsening pulmonary edema may be an independent negative prognostic marker in adult patients with COVID-19. CLINICAL IMPLICATIONS: Worsening pulmonary edema in adult patients with COVID-19 may help identify those at higher risk for deterioration. This may facilitate early triage and provide early prognostic information for caregivers and families by using readily available clinical tools such as the CXR. DISCLOSURES: No relevant relationships by Samantha Gillenwater, source=Web Response No relevant relationships by Christine Girard, source=Web Response No relevant relationships by Anas Hadeh, source=Web Response No relevant relationships by Andrew Kim, source=Web Response No relevant relationships by Daniel Kotok, source=Web Response No relevant relationships by Allen Lavina, source=Web Response No relevant relationships by Jose Rivera, source=Web Response No relevant relationships by Shruti Shettigar, source=Web Response