Radiographic Assessment Of Lung Edema Score Research Articles

Remdesivir versus Favipiravir in Hospitalized Patients with Moderate to Severe COVID-19 Pneumonia: A Propensity Score-Matched Retrospective Cohort Study.

Remdesivir treatment was associated with a reduced 28-day mortality and recovery time among patients hospitalized with severe COVID-19. Favipiravir is broadly used to treat COVID-19. However, various studies have had conflicting results on the efficacy of favipiravir for COVID-19. We hypothesized that remdesivir is more effective in clinical outcomes regarding the 29-day mortality rates, length of stay, and recovery rate than favipiravir in patients with moderate to severe COVID-19 pneumonia. We performed a retrospective cohort study that included adult hospitalized COVID-19 pneumonia patients with hypoxemia. Patients were classified into two groups according to the antiviral drugs. Age, oxygen saturation, fraction of inspired oxygen, and Charlson comorbidity index were used for propensity score matching. The primary objective was to determine whether the type of antiviral agent is associated with 29-day mortality. Other outcomes were the 15-day recovery rate and the length of intensive care unit or hospital stay. A total of 249 patients with moderate to severe COVID-19 pneumonia were included. With an adjustment for propensity score-matched, there were 204 patients for further analysis (102 patients in each antiviral drug group). Remdesivir patients had higher Radiographic Assessment of Lung Edema (RALE) scores on Chest X-ray (14.32±9.08 vs 11.34±8.46; standardized mean difference =33.9%). The Charlson Comorbidity Index Scores were comparable. The prevalences of diabetes, obesity, hypertension, and non-HIV immunocompromised state were higher in the remdesivir group. Regarding the primary outcomes, after adjusting by diabetes, obesity, and RALE score, there was no difference in the 29-day mortality rate between both groups [26 patients (25.5%) in the remdesivir group vs 28 patients (27.5%) in the favipiravir group]. The Kaplan-Meier curve analysis at 29 days indicated no significant difference in cumulative survival rate. The two groups' adjusted hazard ratio was 0.72; 95% CI, 0.41 to 1.25, p=0.24. A Kaplan-Meier analysis on the 15-day cumulative survival rate observed a trend towards a higher survival rate in the remdesivir group (adjusted hazard ratio 0.41; 95% CI, 0.20 to 0.84; p= 0.02) The proportion of patients who recovered on day 15, the length of intensive care unit(ICU) stays, and the hospital stay were not different between remdesivir and favipiravir groups (62 patients (60.8%) vs 56 patients (54.9%), p=0.39; 11.48 ± 11.88 days vs 10.87 ± 9.31 days, p=0.69; and 16.64±14.28 days vs 16.59 ±11.31 days, p=0.98, respectively). In patients with moderate to severe COVID-19 pneumonia, Remdesivir did not demonstrate superior benefits over Favipiravir regarding 29-day mortality, 15-day recovery rates, or hospital and ICU stay lengths. However, further investigation into the 15-day cumulative survival rate revealed a trend towards improved survival in the Remdesivir group.

The chest X-ray score baseline in predicting continuous oxygen therapy failure in low-risk aged patients after thoracic surgery.

Radiographic severity assessment can be instrumental in diagnosing postoperative pulmonary complications (PPCs) and guiding oxygen therapy. The radiographic assessment of lung edema (RALE) and Brixia scores correlate with disease severity, but research on low-risk elderly patients is lacking. This study aimed to assess the efficacy of two chest X-ray scores in predicting continuous oxygen therapy (COT) treatment failure in patients over 70 years of age after thoracic surgery. From January 2019 to December 2021, we searched for patients aged 70 years and above who underwent thoracic surgery and received COT treatment, with a focus on those at low risk of respiratory complications. Bedside chest X-rays, RALE, Brixia scores, and patient data were collected. Univariate, multivariate analyses, and 1:2 matching identified risk factors. Receiver operating characteristic (ROC) curves determined score sensitivity, specificity, and predictive values. Among the 242 patients surviving to discharge, 19 (7.9%) patients experienced COT failure. COT failure correlated with esophageal cancer surgeries, thoracotomies (36.8% vs. 9%, P=0.003; 26.3% vs. 9.4%, P=0.004), and longer operation time (3.4 vs. 2.8 h, P=0.003). Surgical approach and RALE score were independent risk factors. The prediction model had an area under the curve (AUC) of 0.839 [95% confidence interval (CI), 0.740-0.938]. Brixia and RALE scores predicted COT failure with AUCs of 0.764 (95% CI, 0.650-0.878) with a cut-off value of 6.027 and 0.710 (95% CI, 0.588-0.832) with a cut-off value of 17.134, respectively, after 1:2 matching. The RALE score predict the risk of COT failure in elderly, low-risk thoracic patients better than the Brixia score. This simple, cheap, and noninvasive method helps evaluate postoperative lung damage, monitor treatment response, and provide early warning for oxygen therapy escalation. Further studies are required to confirm the validity and applicability of this model in different settings and populations.

Radiographic scores as a predictor of oxygenation index in very low-birthweight infants.

Very low birthweight infants (VLBWIs) often undergo chest radiographic examinations without standardization or objectivity. This study aimed to assess the association of two radiographic scores, the Brixia and radiographic assessment of lung edema (RALE), with oxygenation index (OI) in ventilated VLBWIs and to determine the optimal cutoff values to predict hypoxic respiratory severity. VLBWIs who received invasive respiratory support with arterial lines between January 2010 and October 2023 were enrolled in this study (n = 144). The correlation between the Brixia or RALE scores and OI was investigated. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff points of the two radiographic scores for predicting OI values (OI ≥5, ≥10, and ≥15). The enrolled infants had a median gestational age of 27 weeks (interquartile range [IQR], 25-28 weeks) and a median birthweight of 855 g (IQR, 684-1003 g). Radiographic scoring methods correlated with the OI (Brixia score: r = 0.79, p < 0.001; RALE score: r = 0.72, p < 0.001). The optimal cutoff points for predicting OI values were as follows: Brixia score: OI ≥5, 10; OI ≥10, 13; OI ≥15, 15; RALE score: OI ≥5, 22; OI ≥10, 31; and OI ≥15, 40. Brixia and RALE scores are useful predictive markers of the oxygenation status in intubated VLBWIs with stable hemodynamics. These scores are easy to use and promising tools for clinicians to identify patients with a higher risk of hypoxic respiratory failure.

Association of Late Radiographic Assessment of Lung Edema Score with Clinical Outcome in Patients with Influenza-Associated Acute Respiratory Distress Syndrome

Background: Influenza virus infection leads to acute pulmonary injury and acute respiratory distress syndrome (ARDS). The Radiographic Assessment of Lung Edema (RALE) score has been proposed as a reliable tool for the evaluation of the opacity of chest X-rays (CXRs). This study aimed to examine the RALE scores and outcomes in patients with influenza-associated ARDS. Methods: Patients who were newly diagnosed with influenza-associated ARDS from December 2015 to March 2016 were enrolled. Two independent reviewers scored the CXRs obtained on the day of ICU admission and on days 2 and 7 after intensive care unit (ICU) admission. Results: During the study, 47 patients had influenza-associated ARDS. Five died within 7 days of ICU admission. Of the remaining 42, non-survivors (N = 12) had higher Sequential Organ Failure Assessment scores (SOFA) at ICU admission and higher day 7 RALE scores than survivors (N = 30). The day 7 RALE score independently related to late in-hospital mortality (aOR = 1.121, 95% CI: 1.014–1.240, p = 0.025). Conclusions: The RALE score for the evaluation of opacity on CXRs is a highly reproducible tool. Moreover, RALE score on day 7 was an independent predictor of late in-hospital mortality in patients with influenza-associated ARDS.

Redefining Unilateral Pulmonary Edema after Mitral Valve Surgery on Chest X-ray Imaging Using the RALE Scoring System.

Introduction: Unilateral pulmonary edema (UPE) is a potential complication after mitral valve surgery (MVS), and its cause is not yet fully understood. Definitions are inconsistent, and previous studies have reported wide variance in the incidence of UPE. This research aims at the evaluation of the Radiographic Assessment of Lung Edema (RALE) score concerning assessment of UPE after MVS in order to provide an accurate and consistent definition of this pathology. Methods and Results: Postoperative chest X-ray images of 676 patients after MVS (minimally invasive MVS, n = 434; conventional MVS, n = 242) were retrospectively analyzed concerning presence of UPE. UPE was diagnosed only after exclusion of other pathologies up until the eighth postoperative day. RALE values were calculated for each patient. ROC analysis was performed to assess diagnostic performance. UPE was diagnosed in 18 patients (2.8%). UPE occurred significantly more often in the MI-MVS group (p = 0.045; MI-MVS n = 15; C-MVS n = 3). Postoperative RALE values for the right hemithorax (Q1 + Q2) > 12 and the right-to-left RALE difference ((Q1 + Q2) - (Q3 + Q4)) > 13 provide a sensitivity of up to 100% and 94.4% and a specificity of up to 88.4% and 94.2% for UPE detection. Conclusion: The RALE score is a practical tool for assessment of chest X-ray images after MVS with regard to UPE and provides a clear definition of UPE. In addition, it enables objective comparability when assessing of the postoperative course. The given score thresholds provide a sensitivity and specificity of up to 94%. Further, UPE after MVS seems to be a rather rare pathology with an incidence of 2.6%.

A Retrospective Cohort Study Characteristics of Chest X-Ray Findings in COVID-19 Patients that Presented to a Tertiary Care Facility in Dubai: Can a Severe Radiological Appearance Predict Clinical Outcome?

Aim: We aimed to describe the most prominent features of COVID-19 on the chest X-ray (CXR) and to classify them using the radiographic assessment of lung edema (RALE) score. Furthermore, we aimed to correlate the RALE scores with clinically significant outcomes namely intensive care unit (ICU) admission and intubation from the emergency versus during hospital stay. In-hospital, death was studied as a secondary endpoint for severe RALE score. Materials and Methods: A retrospective cohort study was conducted on patients presenting to the emergency department (ED) of a tertiary hospital between the periods of March 2020 to August 2020. Included patients were symptomatic, COVID-19 positive by nasopharyngeal real-time polymerase chain reaction (RT-PCR), who also performed an initial CXR in the ED. Two experienced radiologists interpreted the CXRs and categorized them using RALE score into normal mild, moderate, and severe for further correlation with clinical endpoints. Results: From the 404 CXRs, most were categorized as mild and characteristically CXRs had bilateral lower and mid-zone ground-glass opacities. The frequency of intubation and ICU admission increased as the RALE score worsened with a statistically significant p value of <0.001. Severe CXR required earlier intervention and was found to have the highest proportion of mortality. Discussion: The RALE score has shown to be a highly reliable indicator for worse outcome in patients with acute respiratory distress syndrome. While RT-PCR has variable sensitivities, CXR has demonstrated to have characteristic findings and higher RALE scores having a significant correlation for intubation and ICU admission in this research. Conclusion: The prognostic utility of CXR in COVID-19 has been found to be of statistical significance for intubation and ICU admission. CXR is a simple, portable, and easy-to-disinfect method of evaluation that can be invaluable in determining timely intervention and disposition of patients expecting deterioration.

Correlation between CRP levels and RALE Score in COVID-19 patients with hypertension

Coronavirus Disease 2019 (COVID-19) is a disease caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. Hypertension is one of the comorbidities of COVID-19 which has a 1.442 times greater risk of worsening the body's condition than patients without hypertension. Radiographic Assessment of Lung Edema (RALE) score is a radiologic numerical scoring system in determining the severity of lung lesions based on the degree of consolidation and density of opacification on chest X-rays. Examination of CRP levels in COVID-19 patients is the initial examination of hospital admission to assess the inflammation that occurs. Therefore, the researcher aims to analyze the correlation of the CRP level examination in representing the severity of COVID-19 disease experienced by patients using the RALE score. The research method used was cross sectional analytic observational method. The subjects in the study were patients diagnosed with COVID-19 with comorbid hypertension at Dr. Moewardi Hospital, Surakarta in March 2021 - March 2022. The data obtained were then analyzed using Mann-Whitney U test and Spearman's rho bivariate correlation analysis. The results analyzed from 115 patient samples obtained the mean RALE score was 13.75. As for CRP levels, this study obtained an average of 8.0473 mg/dl. In this study, there was a significant correlation with a weak correlation level and one way correlation direction between RALE score and CRP levels (p = 0,02; r = 0.287). In conclusion, There is a significant relationship between the RALE score of thoracic photographs and CRP levels of COVID-19 patients with hypertension

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

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. 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). 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. 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.

Inter-rater reliability and prognostic value of baseline Radiographic Assessment of Lung Edema (RALE) scores in observational cohort studies of inpatients with COVID-19

ObjectivesTo reliably quantify the radiographic severity of COVID-19 pneumonia with the Radiographic Assessment of Lung Edema (RALE) score on clinical chest X-rays among inpatients and examine the prognostic value of...

Radiologic Assessment of Lung Edema Score as a Predictor of Clinical Outcome in Children with Acute Respiratory Distress Syndrome.

The radiographic assessment of lung edema (RALE) score enables objective quantification of lung edema and is a valuable prognostic marker of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the validity of RALE score in children with ARDS. The RALE score was measured for its reliability and correlation to other ARDS severity indices. ARDS-specific mortality was defined as death from severe pulmonary dysfunction or the need for extracorporeal membrane oxygenation therapy. The C-index of the RALE score and other ARDS severity indices were compared via survival analyses. Among 296 children with ARDS, 88 did not survive, and there were 70 ARDS-specific non-survivors. The RALE score showed good reliability with an intraclass correlation coefficient of 0.809 [95% confidence interval (CI), 0.760-0.848]. In univariable analysis, the RALE score had a hazard ratio (HR) of 1.19 (95% CI, 1.18-3.11), and the significance was maintained in multivariable analysis adjusting with age, ARDS etiology, and comorbidity, with an HR of 1.77 (95% CI, 1.05-2.91). The RALE score was a good predictor of ARDS-specific mortality, with a C-index of 0.607 (95% CI, 0.519-0.695). The RALE score is a reliable measure for ARDS severity and a useful prognostic marker of mortality in children, especially for ARDS-specific mortality. This score provides information that clinicians can use to decide the proper time of aggressive therapy targeting severe lung injury and to appropriately manage the fluid balance of children with ARDS.

The impact of reduction in intensity of mechanical ventilation upon venovenous ECMO initiation on radiographically assessed lung edema scores: A retrospective observational study.

BackgroundPatients with severe acute respiratory distress syndrome (ARDS) typically receive ultra-protective ventilation after extracorporeal membrane oxygenation (ECMO) is initiated. While the benefit of ECMO appears to derive from supporting “lung rest”, reductions in the intensity of mechanical ventilation, principally tidal volume limitation, may manifest radiologically. This study evaluated the relative changes in radiographic assessment of lung edema (RALE) score upon venovenous ECMO initiation in patients with severe ARDS.MethodsDigital chest x-rays (CXR) performed at baseline immediately before initiation of ECMO, and at intervals post (median 1.1, 2.1, and 9.6 days) were reviewed in 39 Adult ARDS patients. One hundred fifty-six digital images were scored by two independent, blinded radiologists according to the RALE (Radiographic Assessment of Lung Edema) scoring criteria. Ventilatory data, ECMO parameters and fluid balance were recorded at corresponding time points. Multivariable analysis was performed analyzing the change in RALE score over time relative to baseline.ResultsThe RALE score demonstrated excellent inter-rater agreement in this novel application in an ECMO cohort. Mean RALE scores increased from 28 (22–37) at baseline to 35 (26–42) (p < 0.001) on D1 of ECMO; increasing RALE was associated with higher baseline APACHE III scores [ß value +0.19 (0.08, 0.30) p = 0.001], and greater reductions in tidal volume [ß value −2.08 (−3.07, −1.10) p < 0.001] after ECMO initiation. Duration of mechanical ventilation, and ECMO support did not differ between survivors and non-survivors.ConclusionsThe magnitude of reductions in delivered tidal volumes correlated with increasing RALE scores (radiographic worsening) in ARDS patients receiving ECMO. Implications for patient centered outcomes remain unclear. There is a need to define appropriate ventilator settings on venovenous ECMO, counterbalancing the risks vs. benefits of optimal “lung rest” against potential atelectrauma.

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.

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.

BackgroundCoronavirus 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.DesignAdmission 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).ResultsThe 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.ConclusionOur 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.

Clinical Outcome Discrimination in Pediatric ARDS by Chest Radiograph Severity Scoring.

Background There is no accurate radiological measurement to estimate the severity of pediatrics acute respiratory distress syndrome (PARDS). We validated the effectiveness of an adult radiographic assessment of lung edema (RALE) score in PARDS. Aim To assess the severity and prognosis of PARDS based on a chest radiograph (CXR) RALE scoring method. Methods Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria were used to diagnose PARDS. General demographics, pulmonary complications, and 28‐day mortality of the patients were recorded. Subgroups were compared by prognosis (survive and death) and etiology (infection and noninfection). Two observers calculated RALE independently. Each quadrant of CXR was scored by consolidation scores 0 (none alveolar opacity), 1 (extent <25%), 2 (extent 25%–50%), 3 (50%–75%), and 4 (>75%) and density scores 1 (hazy), 2 (moderate), and 3 (dense). Quadrant score equals consolidation score times density score. Total score equals to the sum of four quadrants scores. The ROC curve and survival curve were established, and the optimal cutoff score for discrimination prognosis was set. Results 116 PARDS (72 boys and 44 girls) and 463 CXRs were enrolled. The median age was 25 months (5 months, 60.8 months) and with a mortality of 37.9% (44/116). The agreement between two independent observers was excellent (ICC = 0.98, 95% CI: 0.97–0.99). Day 3 score was independently associated with better survival (p < 0.001). The area under the curve of ROC was 0.773 (95% CI: 0.709–0.838). The cutoff score was 21 (sensitivity 71.7%, specificity 76.5%), and the hazard ratio (HR) was 9.268 (95% CI: 1.257–68.320). The pulmonary complication showed an HR of 3.678 (95% CI: 1.174–11.521) for the discrimination. Conclusion CXR RALE score can be used in PARDS for discriminating the prognosis and has a better agreement among radiologist and pediatrician. PARDS with pulmonary complications, day 3 score whether greater than 21 points, have a better predictive effectiveness.

Role of chest radiography in COVID-19

OBJECTIVES: The objective of this study is to evaluate the clinical profile of coronavirus disease-2019 (COVID-19) patients admitted to our hospital and to correlate their chest radiographic patterns with disease severity. MATERIALS AND METHODS: We retrospectively reviewed 500 patients with COVID-19 confirmed by reverse transcription-polymerase chain reaction who had abnormal baseline chest X-rays (CXRs) at the time of hospital admission. CXRs were characterized based on the site and nature of the lesions. Disease severity was determined using the Radiographic Assessment of Lung Edema (RALE) score. RESULTS: Significant associations were found between (1) the lesion site and patient outcome (P &lt; 0.00001): patients with diffuse and basal infiltrates had high intensive care unit (ICU) admission rates (55.5% and 40%) and mortality rates (30.5% and 20%); (2) the nature of the lesion and patient outcome: patients with ground-glass opacities and consolidation had high mortality (20% and 18%, respectively); and (3) the RALE score and patient outcome: patients with a RALE score &gt;15 had higher ICU admission and mortality rates. CONCLUSIONS: The CXR distribution patterns helped to triage patients and predict outcomes.

Utility of a Pulmonary Oedema Score for Predicting the Need for Mechanical Ventilation in COVID-19 Patients in a General Hospital

BackgroundThe Radiographic Assessment of Lung Edema (RALE) score has been used to estimate the extent of pulmonary damage in patients with acute respiratory distress syndrome and might be useful in patients with COVID-19.Aim of the studyTo examine factors associated with the need for mechanical ventilation in hospitalized patients with a clinical diagnosis of COVID-19, and to estimate the predictive value of the RALE score.MethodsIn a series of patients admitted between April 14 and August 28, 2020, with a clinical diagnosis of COVID-19, we assessed lung involvement on the chest radiograph using the RALE score. We examined factors associated with the need for mechanical ventilation in bivariate and multivariate analysis. The area under the receiver operating curve (AUC) indicated the predictive value of the RALE score for need for mechanical ventilation.ResultsAmong 189 patients, 90 (48%) were judged to need mechanical ventilation, although only 60 were placed on a ventilator. The factors associated with the need for mechanical ventilation were a RALE score >6 points, age >50 years, and presence of chronic kidney disease. The AUC for the RALE score was 60.9% (95% CI 52.9–68.9), indicating it was an acceptable predictor of needing mechanical ventilation.ConclusionsA score for extent of pulmonary oedema on the plain chest radiograph was a useful predictor of the need for mechanical ventilation of hospitalized patients with COVID-19.

Radiographic assessment of lung edema (RALE) score is associated with clinical outcomes in patients with refractory cardiogenic shock and refractory cardiac arrest after percutaneous implantation of extracorporeal life support.

VA-ECMO is a promising therapeutic option in refractory cardiogenic shock (RCS) and refractory cardiac arrest (RCA). However, increase in left ventricular afterload enhances further reduction of LV contractility and pulmonary edema. The aim of this study was to evaluate pulmonary edema based on the RALE score and the prognostic value of the score on ECLS weaning and mortality. In this retrospective study, data from 40 patients (16 RCAs and 24 RCSs) were analyzed. Demographic, clinical data and the RALE score for evaluating pulmonary edema were assessed. Descriptive statistics, intraclass correlation, and receiver operating characteristic (ROC) curves were computed. Weaning from ECLS was successful in 30 (75%) patients, 16 patients (40%) were discharged alive. Overall, the survivors were younger, presenting with a higher left ventricular ejection fraction (30 ± 2% vs.23 ± 9%;p < 0.01) and a lower initial serum lactate concentration 7.7 ± 4.5mmol/l vs. 11.5 ± 4.9mmol/l; p = 0.017). Survivors had lower RALE scores than non-survivors (16.3 ± 9.4 vs. 26.4 ± 10.4; p = 0.0034). The interobserver variability of the RALE score was good (0.832). The AUC predicting mortality and weaning from ECLS presented comparable results to the established parameters (SAVE, serum lactate). Implementation of the RALE score could support prediction of outcome parameters during VA-ECMO therapy.

RALE SCORE AS A PROGNOSTICATION TOOL FOR PATIENTS WITH COVID-19 ON ECMO

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Non-cardiogenic pulmonary edema is a key radiographical finding in patients with acute respiratory distress syndrome (ARDS). The Radiographic Assessment of Lung Edema (RALE) score has been proposed as a tool to measure ARDS severity, with studies demonstrating an independent association with ICU admission rates and survival. During the COVID-19 pandemic, patients have developed severe ARDS requiring extracorporeal membrane oxygenation (ECMO) therapy. We aim to examine this population to evaluate the association between RALE score and ECMO outcomes. METHODS: From March 1 to August 31, 2020, COVID-19 ARDS patients requiring ECMO therapy were retrospectively identified. Demographics and pre-cannulation characteristics were then obtained. A chest radiograph immediately prior to ECMO cannulation was scored using the RALE system by two independent, blinded researchers. A third blinded researcher reviewed the score if there was a discrepancy. Patients were followed for a 90-day period after hospital discharge and divided based on survival (deceased versus alive). Survivors were further subdivided between those discharged to rehabilitation versus home. Continuous variables were presented as medians and the Kruskal-Wallis test was used for statistical analysis (Statasoftware version 16). A univariate logistics model was created to evaluate the association of RALE score with mortality. RESULTS: 40 patients were identified of which 23 were males (57.5%). At the end of the study, 23 patients remained alive (17 rehabilitation and 6 home) with 17 deaths (42.5%). Patients who died were older (55 years vs. 47 years, p = 0.016) and had more males (13 [76.5%], p = 0.05). There was no significant difference in terms of ethnicity, SOFA or Murray Scores, lung compliance, PaO2/FiO2 ratios, and driving pressures prior to ECMO cannulation. For the RALE score, the intraclass correlation between the two raters showed good reliability at 0.88 (0.78-0.94, CI 95%). The median RALE score was 32 in the alive group and 38 in the deceased group (p = 0.126). In the alive group, the median RALE score was 36.5 in the home group and 41 in the rehabilitation group (p = 0.345). Furthermore, the univariate logistical model revealed no statistical association between RALE score and mortality [OR 0.94 (0.88 - 1.01, p = 0.085)]. CONCLUSIONS: The RALE scoring system is not a good prognostication tool for COVID-19 ARDS patients requiring ECMO support. Severity of the score also did not correlate with discharge disposition. CLINICAL IMPLICATIONS: While there have been studies describing the RALE score as a measurement tool for predicting ARDS severity, it did not predict outcomes in those with severe COVID-19 ARDS requiring ECMO. Therefore, clinicians should practice caution if using the RALE score in this patient population. DISCLOSURES: Advisory Committee Member relationship with GSK Please note: 03/21 to 03/22 Added 04/30/2021 by Deepa Gotur, source=Web Response, value=Honoraria No relevant relationships by Steven Hsu, source=Web Response No relevant relationships by Adriana Ordonez, source=Web Response No relevant relationships by Akhilesh Padhye, source=Web Response

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

IntroductionThe 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.MethodsData 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.ResultsA 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).ConclusionThe 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.

Correlation of Oxygenation and Radiographic Assessment of Lung Edema (RALE) Score to Lung Ultrasound Score (LUS) in Acute Respiratory Distress Syndrome (ARDS) Patients in the Intensive Care Unit.

BackgroundLung ultrasound score (LUS) as well as radiographic assessment of lung edema (RALE) score as calculated from chest radiography (CXR) have been applied to assess Acute Respiratory Distress Syndrome (ARDS) severity. CXRs, which are frequently performed in ARDS patients, pose a greater risk of radiation exposure to patients and health care staff.Aims and objectivesThe aim of the study was to evaluate if LUS had a better correlation to oxygenation (PaO2/FiO2) compared with the RALE score in ARDS patients. We also aimed to analyse if there was a correlation between RALE score and LUS. We wanted to determine the LUS and RALE score cut-off, which could predict a prolonged length of intensive care unit (ICU) stay (≥10 days) and survival.MethodsThirty-seven patients aged above 18 years with ARDS as per Berlin definition and admitted to the ICU were included in the study. It was a retrospective study done over a period of 11 months. On the day of admission to ICU, the global and basal LUS, global and basal RALE score, and PaO2 /FiO2 were recorded. Outcome and days of ICU stay were noted.ResultsGlobal LUS score and PaO2/FiO2 showed the best negative correlation (r = –0.491), which was significant (p = 0.002), followed by global RALE score and PaO2/FiO2 (r = –0.422, p = 0.009). Basal LUS and PaO2/FiO2 also had moderate negative correlation (r = –0.334, p = 0.043) followed by basal RALE score and PaO2/FiO2 (r = –0.34, p = 0.039). Global RALE score and global LUS did not show a significant correlation. Similarly, there was no significant correlation between basal RALE score and basal LUS. Global and basal LUS as well as global and basal RALE score were not beneficial in predicting either a prolonged length of ICU stay or survival as the area under curve was low.ConclusionIn ARDS patients, global LUS had the best correlation to oxygenation (PaO2/FiO2), followed by global RALE score. Basal LUS and basal RALE score also had moderate correlation to oxygenation. However, there was no significant correlation between global LUS and global RALE score as well as between basal LUS and basal RALE score. Global and basal LUS as well as global and basal RALE scores were not able to predict a prolonged ICU stay or survival in ARDS patients.