Are routine chest X-rays (CXR) recommended after Coronavirus disease 2019 (Covid-19)?

Routine Chest X-rays After COVID-19

Routine chest X-rays are not recommended after COVID-19 infection unless patients have persistent respiratory symptoms, functional impairment, or were hospitalized with moderate-to-severe disease. 1

Evidence-Based Approach to Post-COVID Imaging

When Chest Imaging IS Indicated:

1. Patients with persistent symptoms after COVID-19:

   • Persistent dyspnea/shortness of breath
   • Functional impairment
   • Hypoxemia after recovery 1
   • Moderate-to-severe respiratory symptoms 1

2. Patients with history of severe COVID-19 infection:

   • 13.8% to 38% of patients with severe disease had persistent fibrosis or opacities on chest radiographs 2-6 months after diagnosis 1
   • CT abnormalities are more common in patients who required hospitalization 1

3. Evidence of worsening respiratory status in recovered patients 1

When Chest Imaging IS NOT Indicated:

1. Asymptomatic individuals (regardless of COVID-19 history) 1

2. Patients with mild COVID-19 features (no hypoxemia, no or mild dyspnea) unless they have risk factors for disease progression 1

3. Routine follow-up in patients who have recovered without persistent symptoms 1

4. Stable intubated patients with COVID-19 (daily chest radiographs are NOT indicated) 1

Imaging Selection When Indicated

• Initial imaging: PA and lateral chest radiography (preferred over portable AP radiography when feasible) 1

• For persistent/concerning symptoms: Consider CT chest without contrast for patients with:

  • Functional impairment
  • Hypoxemia after recovery
  • History of moderate-to-severe COVID-19 infection 1

Common Pitfalls to Avoid

1. Unnecessary radiation exposure: Routine use of chest X-rays for asymptomatic recovered patients leads to unnecessary radiation exposure with low diagnostic yield 2

2. Resource constraints: In resource-limited settings, CXR may be preferred over CT unless features of respiratory worsening warrant CT use 1

3. Misinterpretation: Recognize that some radiographic abnormalities may persist after clinical recovery, particularly in patients who had severe disease, without necessarily requiring intervention 1

4. Lack of standardized reporting: When imaging is performed, standardized reporting language should be used to ensure consistency and facilitate comparison between examinations 3

By following these evidence-based guidelines, clinicians can appropriately select patients who would benefit from post-COVID chest imaging while avoiding unnecessary testing in those who are unlikely to have clinically significant findings.