Defined | Why have medical doctors cautioned towards misuse of CT scans and steroids to diagnose and deal with COVID-19?

Explained | Why have doctors cautioned against misuse of CT scans and steroids to diagnose and treat COVID-19?

2021-05-09 03:07:11

Are a number of CT scans dangerous? Why are steroids being prescribed for COVID-19 sufferers?

The story to date: As medical doctors check out completely different protocols to handle sufferers with COVID-19, Dr. Randeep Guleria, director of the All India Institute of Medical Sciences (AIIMS) and member of the Nationwide Taskforce on COVID-19, has cautioned towards using CT scans indiscriminately to diagnose the illness, particularly within the early levels. This exposes people to pointless radiation, which might be dangerous in the long term, he mentioned. A single CT scan is the same as 300 X-rays, Dr. Guleria warned, which can enhance the chance of most cancers later in life for younger individuals. Docs and the World Well being Group (WHO) are additionally cautioning towards using corticosteroids like dexamethasone, a potent anti-inflammatory drug, for sufferers who’ve non-severe COVID-19. Corticosteroids have been confirmed to profit sufferers with reasonable and extreme an infection.

When is a CT scan suggested for a COVID-19 affected person?

An RT-PCR check is the usual for prognosis or affirmation of COVID-19. Use of CT for the prognosis of COVID-19 must be restricted to that subgroup of sufferers who could have classical signs of the sickness however have a unfavorable RT-PCR check consequence. Nonetheless, a chest CT will be helpful in evaluating sufferers with reasonable or extreme illness, to establish problems like thromboembolism or pneumomediastinum.


There are particular conditions involving COVID-19 sufferers through which a clinician may rely upon a CT scan to reach at remedy selections. These embody situations the place a affected person could have classical signs of COVID-19 however his RT-PCR check is unfavorable, or conditions when a CT pulmonary angiogram could be as a way to rule out pulmonary embolism in a affected person who’s on anti-coagulants and steroids and isn’t displaying any indicators of restoration. Additionally, in instances the place a affected person within the ICU with extreme COVID-19 will not be displaying any enchancment and a chest X-ray exhibits new lesions, a CT look may give a clue in direction of a prognosis of harmful COVID-19-associated fungal super-infections like aspergillosis or mucormycosis. In a fourth state of affairs, a clinician may order a CT chest to rule out spontaneous pneumomediastinum, a life-threatening complication.

“Nonetheless, these 4 situations collectively represent lower than 2% of conditions the place a CT chest is ordered in COVID-19 instances. Slightly than CT findings, it’s oxygen saturation that’s the key to remedy selections. But, in 95% of the instances, CT scan is a misused device, typically prescribed to rule out pneumonia even in delicate instances of COVID-19. There isn’t any level in ordering CT early in the middle of COVID-19 as a result of even sufferers with delicate severity could have some ground-glass opacities within the lungs, which don’t advantage remedy and can resolve on their very own,” says R. Aravind, Head of Infectious Ailments, Authorities Medical Faculty, Thiruvananthapuram.

The consensus assertion from Fleischner Society, a global, multidisciplinary affiliation for thoracic radiology, states that “imaging will not be indicated” in suspected COVID-19 an infection with delicate scientific options. The assertion helps using imaging in sufferers with worsening respiratory standing in addition to in these with reasonable to extreme scientific options which can be indicative of COVID-19 pneumonia.

Additionally learn | CT scan machines will be spreaders if protocols not adopted

To sum up, though CT has been utilized in assessing the severity of COVID-19 pneumonia, its routine use will not be beneficial.

Are a number of CT scans dangerous?

When indicated, a chest CT must be carried out with a low-dose, single-phase protocol utilizing quick scanning strategies to minimise movement artifacts (affected person motion resulting in refined errors).

There isn’t any proof to assist using routine multi-phase chest CT in sufferers with COVID-19 pneumonia. Dr. Guleria mentioned based on knowledge from the Worldwide Atomic Vitality Company, one CT scan was equal to nearly 300 to 400 chest X-rays, which put children at substantial threat of most cancers in the long run. A research printed within the New England Journal of Medication in 2007 mentioned based mostly on knowledge from 1991 to 1996, 0.4% of all cancers within the U.S. could also be attributable to radiation from CT research and that the present estimate might be within the vary of 1.5% to 2%.

Aside from all this, the dangers of transmission and contamination confronted by radiology technicians and workers each time a COVID-19 affected person undergoes diagnostic imaging, particularly in an air-conditioned, closed house, can’t be dismissed.

Why are steroids being prescribed for COVID-19 sufferers?

Although many medical doctors in India had began treating critically ailing COVID-19 sufferers with corticosteroids like dexamethasone a lot earlier through the pandemic, suggestion on their use from worldwide businesses just like the WHO got here solely in September 2020, following the U.Okay.’s RECOVERY Trial, which discovered mortality profit for sufferers who obtained steroids.

In lots of sufferers, dying happens following a hyper-immune response (cytokine storm) to the SARS-CoV-2 virus, which damages the lungs and different organs, resulting in multi-organ dysfunction syndrome. Corticosteroids like dexamethasone, as anti-inflammatory brokers, work by calming down the immune system and stopping the development of organ harm.

“Steroids are essentially the most potent weapon we’ve to fight COVID-19. However the therapeutic window for beginning steroids must be spot-on. Figuring out the timing, dosage and length is an artwork which must be mastered,” says Dr. Aravind.

One of many most important considerations is that we don’t wish to begin steroids too early within the sickness when viral replication is going on as it would intrude with the immune system’s pure potential to battle again. We additionally don’t wish to miss that important level when steroids can stop the immune system from unleashing the cytokine storm, he says.

The WHO tips say that steroids could also be administered to sufferers whose resting saturation ranges are under 94% and whose respiration charge at relaxation is over 24 per minute. Nonetheless, steroids can profit some sufferers who will not be on supplementary oxygen but however are displaying early indications that they could worsen.

Kerala’s tips thus speak about recognising exertional desaturation — the autumn or depletion in oxygen saturation studying by over 3% from the baseline oxygen ranges, post-exercise or after the six-minute stroll check — and addressing it on the proper time in order that interstitial irritation will be arrested. The stroll check requires people to stroll for six straight minutes, with no pause, on an excellent floor with an oximeter on the finger. After six minutes, if the oxygen degree doesn’t go down, the person will likely be thought of wholesome. But when the oxygen degree drops under 93%, or by 3%, or if the person suffers from breathlessness, then they’re suggested to hunt medical consideration.

“We wish to choose up sufferers who’re liable to progressing to hypoxemia at relaxation. The earliest characteristic of COVID-19 pneumonia will likely be interstitial involvement, which results in a demand-supply mismatch of oxygen. So, sufferers with regular oxygen saturation (> 94%) at relaxation in room air and who’re clinically steady are put by way of the six-minutes/40-step stroll check. If the oxygen ranges drop after the stroll check, these sufferers could also be began on low-dose steroids after consulting the pulmonary specialist or a doctor to forestall the cytokine storm syndrome,” says Dr. Aravind.

When do steroids turn out to be a double-edged sword?

That mentioned, steroids can transform a double-edged sword if the dosage, timing or length of the drug goes mistaken. Steroids will not be mandated for all sufferers and definitely not for delicate sufferers within the early levels of the sickness. The set off for beginning steroids must be exertional desaturation and never the day of sickness.

Dr. Guleria had identified lately that he was seeing many delicate COVID-19 instances the place steroids had stimulated viral replication, inflicting oxygen ranges to drop. There’s potential hurt related to the long-term use of steroids in a critical COVID-19 affected person. This features a rise in blood glucose ranges, which can have to be fastidiously managed with insulin to forestall secondary bacterial or fungal infections.

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