• Andrew Pagano, Mark Finkelstein, Jessica Overbey, Sharon Steinberger, Trevor Ellison, Sayan Manna, Danielle Toussie, Mario A Cedillo, Adam Jacobi, Yogesh S Gupta, Adam Bernheim, Michael Chung, Corey Eber, Zahi A Fayad, and Jose Concepcion.
• Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address: paganoa@mskcc.org.
• Chest. 2021 Jul 1; 160 (1): 238-248.

BackgroundChest radiography (CXR) often is performed in the acute setting to help understand the extent of respiratory disease in patients with COVID-19, but a clearly defined role for negative chest radiograph results in assessing patients has not been described.Research QuestionIs portable CXR an effective exclusionary test for future adverse clinical outcomes in patients suspected of having COVID-19?Study Design And MethodsCharts of consecutive patients suspected of having COVID-19 at five EDs in New York City between March 19, 2020, and April 23, 2020, were reviewed. Patients were categorized based on absence of findings on initial CXR. The primary outcomes were hospital admission, mechanical ventilation, ARDS, and mortality.ResultsThree thousand two hundred forty-five adult patients, 474 (14.6%) with negative initial CXR results, were reviewed. Among all patients, negative initial CXR results were associated with a low probability of future adverse clinical outcomes, with negative likelihood ratios of 0.27 (95% CI, 0.23-0.31) for hospital admission, 0.24 (95% CI, 0.16-0.37) for mechanical ventilation, 0.19 (95% CI, 0.09-0.40) for ARDS, and 0.38 (95% CI, 0.29-0.51) for mortality. Among the subset of 955 patients younger than 65 years and with a duration of symptoms of at least 5 days, no patients with negative CXR results died, and the negative likelihood ratios were 0.17 (95% CI, 0.12-0.25) for hospital admission, 0.09 (95% CI, 0.02-0.36) for mechanical ventilation, and 0.09 (95% CI, 0.01-0.64) for ARDS.InterpretationInitial CXR in adult patients suspected of having COVID-19 is a strong exclusionary test for hospital admission, mechanical ventilation, ARDS, and mortality. The value of CXR as an exclusionary test for adverse clinical outcomes is highest among young adults, patients with few comorbidities, and those with a prolonged duration of symptoms.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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