As COVID-19 spreads in the U.S., there is growing interest in the role and appropriateness of chest radiographs (CXR) and computed tomography (CT) for the screening, diagnosis and management of patients with suspected or known COVID-19 infection. Contributing to this interest are limited availability of viral testing kits to date, concern for test sensitivity from earlier reports in China, and the growing number of publications describing the CXR and CT appearance in the setting of known or suspected COVID-infection.
To date, most of the radiologic data comes from China. Some studies suggest that chest CT in particular may be positive in the setting of a negative test. We want to emphasize that knowledge of this new condition is rapidly evolving, and not all of the published and publicly available information is complete or up-to-date.
Key goals for the U.S. health care system in response to the COVID-19 outbreak are to reduce morbidity and mortality, minimize disease transmission, protect health care personnel, and preserve health care system functioning.
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The ACR believes that the following factors should be considered regarding the use of imaging for suspected or known COVID-19 infection:
The Centers for Disease Control (CDC) does not currently recommend CXR or CT to diagnose COVID-19. Viral testing remains the only specific method of diagnosis. Confirmation with the viral test is required, even if radiologic findings are suggestive of COVID-19 on CXR or CT.
For the initial diagnostic testing for suspected COVID-19 infection, the CDC recommends collecting and testing specimens from the upper respiratory tract (nasopharyngeal AND oropharyngeal swabs) or from the lower respiratory tract when available for viral testing.
Generally, the findings on chest imaging in COVID-19 are not specific, and overlap with other infections, including influenza, H1N1, SARS and MERS. Being in the midst of the current flu season with a much higher prevalence of influenza in the U.S. than COVID-19, further limits the specificity of CT.
The current ACR Appropriateness Criteria® statement on Acute Respiratory Illness , last updated in 2018 states that chest CT is “Usually Not Appropriate.”
A review from the Cochrane Database of Systematic Reviews on chest radiographs for acute lower respiratory tract infections concluded that CXR did not improve clinical outcomes (duration of illness) for patients with lower respiratory tract infection; the review included two randomized trials comparing use of CXRs to no CXRs in acute lower respiratory tract infections for children and adults.
