What is the best course of action for an 80-year-old female, 10 days post Covid-19 (Coronavirus disease 2019) infection, presenting with shortness of breath and dizziness, oxygen saturation at 97%, and no fever, regarding the need for a chest X-ray?

Chest X-ray for 80-Year-Old Female with Post-COVID Shortness of Breath

A chest X-ray is recommended for this 80-year-old female patient presenting with shortness of breath and dizziness 10 days after COVID-19 infection, despite normal oxygen saturation and absence of fever. 1

Rationale for Imaging

• Chest radiography is considered a useful initial imaging examination for patients with persistent symptoms after COVID-19 infection, as 13.8% to 38% of patients may have fibrosis or other persistent opacities 2-6 months after COVID-19 diagnosis 1
• Advanced age (80 years) places this patient at higher risk for disease progression and complications from COVID-19 1
• The combination of shortness of breath and dizziness 10 days post-infection suggests potential pulmonary or cardiovascular complications that warrant imaging evaluation 1
• WHO guidelines suggest using chest imaging in addition to clinical assessment for patients who are at high risk of disease progression (e.g., elderly patients over 60 years) 1

Benefits of Chest X-ray in This Case

• Chest radiography is less resource-intensive, has lower radiation dose, and can be performed with portable equipment at the point of care, minimizing cross-infection risk 1
• PA and lateral chest radiography is typically of higher quality and is preferred over AP portable radiography when feasible 1
• Can help detect common post-COVID pulmonary complications such as:
  • Persistent ground-glass opacities (most common finding - 75% of abnormal X-rays) 2
  • Peripheral lung opacities 2
  • Consolidation patterns 2
  • Fibrotic changes 1

Clinical Decision Algorithm

1. Initial Assessment:

   • Patient characteristics: 80-year-old female (high-risk age group) 1
   • Current symptoms: Shortness of breath and dizziness (concerning symptoms) 1
   • Clinical parameters: No fever, oxygen saturation 97% (relatively reassuring) 3
   • Timing: 10 days post-COVID (period when lung involvement may peak) 4

2. Recommendation:

   • Perform chest X-ray as initial imaging 1
   • Consider portable chest X-ray if patient mobility is limited 1, 5

3. Follow-up Based on X-ray Findings:

   • If normal: Monitor clinically, consider alternative causes for symptoms 1
   • If abnormal but mild findings: Outpatient management with appropriate follow-up 1
   • If moderate to severe findings: Consider admission for further evaluation and management 1
   • If inconclusive but high clinical suspicion: Consider CT chest for more detailed evaluation 6

Important Considerations

• Despite normal oxygen saturation (97%), persistent shortness of breath in elderly post-COVID patients warrants evaluation as it may indicate ongoing pulmonary inflammation or fibrosis 1
• Dizziness should be evaluated as a potential sign of cardiopulmonary compromise or neurological involvement 7
• The WHO recommends chest imaging for patients who are at higher risk of disease progression due to age and comorbidities 1
• Maximum lung involvement in COVID-19 typically peaks at approximately 10 days from symptom onset, making this a critical time for assessment 4

Potential Pitfalls and Caveats

• Normal chest X-ray does not exclude significant lung disease, as radiography has lower sensitivity compared to CT 1
• Portable chest X-rays have lower sensitivity than standard PA/lateral views 5
• Consider the possibility of other causes for symptoms beyond COVID-19 sequelae, including cardiac complications, pulmonary embolism, or secondary bacterial infection 7
• If symptoms persist or worsen despite normal chest X-ray, consider additional imaging with CT 6