AJTCCM VOL. 28 NO. 4 2022 143
EDITORIAL
On 8 November 1895, Wilhelm Conrad Röentgen imaged his wife’s
hand and changed the history of medicine. Because he was uncertain
of the nature of the rays that produced the image, he gave them the name
‘X-rays’. is discovery represents one of the most signicant advances
in science, aording man the ability to look through skin and muscles
in a non-invasive fashion. Within a year of his original description,
around one thousand publications had appeared on the subject. He
received the rst Nobel Prize for Physics in 1901 for his revolutionary
discovery, which heralded the age of modern physics and revolutionised
diagnostic medicine. X-rays are currently an indispensable part of any
hospital establishment, and the chest X-ray or chest radiograph remains
the most commonly performed type of imaging.
In this issue of AJTCCM, Patnayak et al.[1] describe the utility of the
chest radiograph in a retrospective hospital-based study to predict
the severity of COVID-19 disease. ey demonstrated a signicant
correlation between the chest radiograph on admission and oxygenation
based on a predesigned proforma severity scoring system, as well as
predicting the need for ventilatory support. e authors conclude that
the chest radiograph scoring system is a useful screening tool in this
setting that has important clinical implications, and as a consequence
may limit morbidity and mortality.
Several others have demonstrated and reported similar utility and
benet of the chest radiograph in this context, including the association
with severity and need for intubation and mechanical ventilation.[2-10]
Despite major technological advances in chest imaging, including
elements such as pragmatic point-of-care ultrasound, the chest
radiograph remains an essential tool in our daily clinical armamentarium.
Mastering interpretation of the chest radiograph enhances one’s clinical
acumen, and its utility in the clinical context for the astute clinician
is protean. Clinicians who are comfortable with interpretation of the
chest radiograph are at an innite advantage. Additionally, when used
in combination with some of the more recent advances in imaging,
clinical insights may be further complemented, potentially aiding and
improving patient management and outcomes. Various authorities
and supervisory boards and institutions have recently emphasised the
need for chest radiograph interpretation to be considered as a core
competency.[11] However, data have indicated lack of competency at all
levels and that it is an under-recognised element in the eld.[11] is
important component of our daily clinical armamentarium is extremely
useful and should be seen as an essential competency for the practising
clinician, and a valuable adjunct in our quest to oer and deliver sound
and excellent clinical care.
e chest radiograph may be used to assist in the diagnosis of many
conditions and a variety of disease entities that involve the bones and
structures contained within the thoracic cavity, and on occasion those
contained within the abdomen. Although the interpretation of chest
radiographs goes beyond the scope of this commentary, a very useful
initial approach as an aide-mémoire to identify any potential problems
in an appropriate clinical setting may be considered as ABCDEF:
A: airways, including hilar adenopathy or enlargement
B: breast shadows, bones (e.g. rib fractures, lytic bone lesions, rib
crowding suggestive of volume loss, bony anomalies)
C: cardiomediastinal contour (includes cardiac silhouette, assessment
of cardiac and chamber size, central structures), costophrenic
angles (e.g. presence of pleural eusion/s)
D: diaphragm (position of hemidiaphragms, evidence of free air under
the diaphragm suggestive of perforation of an abdominal viscus)
E: edges (e.g. pneumothorax, pleural thickening, plaques, apices for
brosis), extrathoracic tissues
F: fields (lung parenchyma: divide into upper, mid and lower zones
and compare each side), evidence of failure (alveolar air space
disease, prominent vascularity, pleural eusions).
Chest radiographs have impacted on countless lives and will continue
to do so well into the future. ey remain an integral and key part of
modern medicine more than 100 years aer their introduction. ere is
indeed still a very important role for this humble but extremely helpful
clinical adjunct!
Mervyn Mer, MB BCh, Dip PEC (SA), FCP (SA) Pulmonology sub-
specialty, Cert Critical Care (SA), MMed (Int Med), FRCP (Lond),
FCCP (USA), PhD
Divisions of Pulmonology and Critical Care, Department of Medicine,
Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South Africa
mervyn.mer@wits.ac.za
1. Patnayak G, Rajul R, Lakshay K, et al. Role of the chest radiograph in predicting the need
for ventilatory support in COVID-19 patients. Afr J orac Crit Care Med 2022;28(4):157-
162. https://doi.org/10.7196/AJTCCM.2022.v28i4.248
2. Kim HW, Capaccione KM, Li G, et al. e role of initial chest X-ray in triaging patients
with suspected COVID-19 during the pandemic. Emerg Radiol 2020;27(6):617-621.
https://doi.org/10.1007/s10140-020-01808-y
3. Sadiq Z, Rana S, Mahfoud Z, Raoof A. Systematic review and meta-analysis of chest
radiograph (CXR) ndings in COVID-19. Clin Imaging 2021;80:229-238. https://doi.
org/10.1016/j.clinimag.2021.06.039
4. Sathi S, Tiwari R, Verma S, et al. Role of chest x-ray in coronavirus disease and correlation
of radiological features with clinical outcomes in Indian patients. Can J Infect Dis Med
Microbiol 2021;2021:6326947. https://doi.org/10.1155/2021/6326947
5. Hui TCH, Khoo HW, Young BE, et al. Clinical utility of chest radiography for severe
COVID-19. Quant Imaging Med Surg 2020;10(7):1540-1550. https://doi.org/10.21037/
qims-20-642
6. Xiao N, Cooper JG, Godbe JM, et al. Chest radiograph at admission predicts early
intubation among COVID-19 patients. Eur Radiol 2021;31(5):2825-2823. https://doi.
org/10.1007/s00330-020-07354-y
7. Gourdeau D, Potvin O, Biem JH, et al. Deep learning of chest X-rays can predict mechanical
ventilation outcome in ICU-admitted COVID-19 patients. Sci Rep 2022;12(1):6193.
https://doi.org/10.1038/s41598-022-10136-9
8. Gourdeau D, Potvin O, Archambault P, et al. Tracking and predicting COVID-19
radiological trajectory on chest X-rays using deep learning. Sci Rep 2022;12(1):5616.
https://doi.org/10.1038/s41598-022-09356-w
9. Rubin GD, Ryerson CJ, Haramati LB, et al. The role of chest imaging in patient
management during the COVID-19 pandemic: A mutinational consensus statement
from the Fleischner Society. Radiology 2020;296(1):172-180. https://doi.org/10.1016/j.
chest.2020.04.003
10. Islam N, Ebrahimzadeh S, Salameh J-P; Cochrane COVID-19 Diagnostic Test Accuracy
Group. oracic imaging tests for the diagnosis of COVID-19. Cochrane Database Syst
Rev 2021, Issue 3. Art. No.: CD013639. https://doi.org/10.1002/14651858.CD013639.pub4
11. Satia I, Bashagha S, Bibi A, Ahmed R, Mellor S, Zaman F. Assessing the accuracy
and certainty in interpreting chest X-rays in the medical division. Clin Med (Lond)
2013;13(4):349-352. https://doi.org/10.7861/clinmedicine.13-4-349
Afr J Thoracic Crit Care Med 2022;28(4):143
https://doi.org/10.7196/AJTCCM.2022.v28i4.300
Still a role for the chest radiograph – humble but helpful!
