Radiological phenotyping in COVID-19 Acute Respiratory Distress Syndrome: a secondary analysis of a retrospective cohort study

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Abstract Objective To assess whether focal and non-focal COVID-19 ARDS exhibit different respiratory mechanics and arterial blood gas (ABG) trajectories during the first extended prone positioning (PP) session. Design Post-hoc analysis of a previously published retrospective monocentric cohort study. Setting A university-affiliated intensive care unit in Paris (France) between March 2020 and April 2021. Patients Seventy-four adult patients with moderate-to-severe COVID-19 ARDS who underwent extended prone positioning (PP) and had chest imaging (CT or X-ray) performed within five days before the first PP session. Interventions None Measurements Changes in compliance, driving pressure, PaO 2 /FiO 2 ratio, and ventilatory ratio between pre-PP and end-of-PP; chest X-rays and CT scans diagnostic agreement between reviewers assessed by crude agreement and Cohen’s kappa coefficient. Main results Diffuse ARDS predominated, identified in 91% by the intensivist and 86% by the radiologist. Crude diagnostic agreement was 89% (95% CI 79.8–95.2), while interrater reliability was only fair (κ = 0.44, 95% CI 0.08–0.81). Discrepancies mainly involved focal classifications on chest X-rays, whereas agreement was perfect when CT scans were available. The small number of focal cases precluded comparative analysis of PP trajectories. Conclusions PP indication or duration should probably not be based on ARDS phenotypes and when differentiating focal from diffuse COVID ARDS is necessary, chest CT scans should be preferred to ensure accurate and reproducible phenotyping.

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