Use of radiograph scoring systems to assess pulmonary disease severity in patients with COVID-19 pneumonia

doi:10.5492/wjccm.v15.i1.113684

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World Journal of Critical Care Medicine

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World J Crit Care Med. Mar 9, 2026; 15(1): 113684
Published online Mar 9, 2026. doi: 10.5492/wjccm.v15.i1.113684

Table 1 Summary of demographic characteristics, BRIXIA and Radiographic Assessment of Lung Edema scores, and oxygen use via oxygen delivery device, n (%)

Category	Variable	Summary
Total sample size	n	950 (100.0)
Demographics	Age (mean ± SD)	48.4 (13.6)
Demographics	Male	861 (90.6)
Chest X-ray scores, median (IQR)	BRIXIA	8.0 (6.0)
Chest X-ray scores, median (IQR)	RALE	12.0 (16.0)
Comorbidities	No comorbidities	475 (50.0)
	Diabetes mellitus	306 (32.2)
	Hypertension	293 (30.8)
	Coronary artery disease/CHF	59 (6.2)
	Asthma/COPD	35 (3.7)
	Chronic kidney disease	36 (3.7)
	Others	68 (7.1)
Clinical variables median (IQR)	Temperature	38.0 (1.3)
	Respiratory rate	22.0 (6.0)
	Heart rate	102.0 (24.3)
	Systolic blood pressure	129.0 (23.0)
	White blood cells	6.8 (4.0)
	C-reactive protein	71.5 (97.9)
Oxygen delivery device use in ED	Room air	481 (50.6)
	Nasal cannula	338 (35.6)
	Hudson mask	22 (2.3)
	NRBM	89 (9.4)
	HFNC/CPAP/BiPAP	20 (2.1)
Oxygen device used during hospitalization	Nasal cannula	890 (93.7)
	Hudson mask	14 (1.5)
	NRBM	383 (40.3)
	HFNC/CPAP/BiPAP	182 (19.2)
	Oral intubation/tracheostomy	133 (14.0)

n: Number of participants; IQR: Interquartile range; RALE: Radiographic Assessment of Lung Edema; CHF: Congestive heart failure; COPD: Chronic obstructive pulmonary disease; ED: Emergency department; NRBM: Non-rebreather mask; HFNC: High flow nasal cannula; CPAP: Continuous positive airway pressure; BiPAP: Bi-level positive airway pressure.

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Table 2 Performance of BRIXIA and Radiographic Assessment of Lung Edema scores for predicting oxygen delivery device and discharge outcomes in the emergency department and during hospitalization

BRIXIA score	Cut-off point (95%CI)	Sensitivity	Specificity	AUC at cut-point (95%CI)
Oxygen delivery device in ED
Room air	7 (6-8)	0.43	0.39	0.41 (0.38-0.44)
Nasal cannula	8 (7-9)	0.51	0.60	0.56 (0.52-0.59)
Hudson mask	9 (6-12)	0.36	0.61	0.49 (0.38-0.59)
NRBM	9 (8-10)	0.66	0.64	0.65 (0.60-0.70)
HFNC/CPAP/BiPAP	12 (9-15)	0.65	0.84	0.74 (0.64-0.85)
Oxygen delivery device during hospitalization
Nasal cannula	6 (4-8)	0.60	0.48	0.54 (0.47-0.61)
Hudson mask	13 (6-20)	0.29	0.86	0.57 (0.42-0.72)
NRBM	8 (7-9)	0.58	0.66	0.62 (0.59-0.65)
HFNC/CPAP/BiPAP	8 (7-9)	0.63	0.61	0.62 (0.58-0.66)
Oral intubation/tracheostomy	8 (6-10)	0.65	0.60	0.63 (0.58-0.67)
RALE score
Oxygen delivery device in ED
Room air	12 (8-16)	0.49	0.57	0.42 (0.39-0.45)
Nasal cannula	10 (7-13)	0.58	0.57	0.54 (0.51-0.57)
Hudson mask	14 (8-20)	0.41	0.61	0.54 (0.43-0.64)
NRBM	16 (10-22)	0.54	0.72	0.62 (0.57-0.68)
HFNC/CPAP/BiPAP	17 (12-22)	0.65	0.77	0.74 (0.65-0.83)
Oxygen delivery device during hospitalization
Nasal cannula	12 (6-18)	0.29	0.85	0.52 (0.46-0.59)
Hudson mask	13 (0-29)	0.58	0.65	0.55 (0.42-0.69)
NRBM	13 (10-16)	0.64	0.61	0.6 (0.57-0.63)
HFNC/CPAP/BiPAP	16 (11-21)	0.66	0.59	0.59 (0.55-0.64)
Oral intubation/tracheostomy	16 (12-20)	0.52	0.36	0.62 (0.57-0.66)

AUC: Area under the curve; CI: Confidence interval; ED: Emergency department; NRBM: Non-rebreather mask; HFNC: High flow nasal cannula; CPAP: Continuous positive airway pressure; BiPAP: Bi-level positive airway pressure; RALE: Radiographic Assessment of Lung Edema.

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Table 3 Logistic regression analysis of oxygen delivery requirements by BRIXIA and Radiographic Assessment of Lung Edema scores

	Crude OR (95%CI)	P value	a-OR¹ (95%CI)	P value	a-OR² (95%CI)	P value
BRIXIA score
Oxygen delivery device in ED
Model 1: Room air	0.9 (0.87-0.92)	< 0.001	0.9 (0.87-0.93)	< 0.001
Model 2: Nasal cannula	1.05 (1.02-1.08)	0.001	1.05 (1.02-1.08)	0.002
Model 3: Hudson mask	0.92 (0.84-1.02)	0.108	0.93 (0.84-1.02)	0.134
Model 4: NRBM	1.15 (1.1-1.21)	< 0.001	1.15 (1.09-1.21)	< 0.001
Model 5: HFNC/CPAP/BiPAP	1.27 (1.14-1.42)	< 0.001	1.27 (1.14-1.41)	< 0.001
Oxygen delivery device during hospitalization
Model 6: Nasal cannula	1.01 (0.95-1.07)	0.784	1 (0.95-1.06)	0.868	1.04 (0.97-1.1)	0.249
Model 7: Hudson mask	1.02 (0.91-1.14)	0.761	1.01 (0.9-1.14)	0.830	0.99 (0.88-1.12)	0.898
Model 8: NRBM	1.13 (1.1-1.16)	< 0.001	1.12 (1.09-1.16)	< 0.001	1.09 (1.06-1.13)	< 0.001
Model 9: HFNC/CPAP/BiPAP	1.12 (1.08-1.16)	< 0.001	1.11 (1.07-1.15)	< 0.001	1.05 (1.01-1.09)	0.018
Model 10: Oral intubation/tracheostomy	1.11 (1.07-1.16)	< 0.001	1.1 (1.06-1.15)	< 0.001	1.04 (1-1.09)	0.049
RALE score
Oxygen delivery device in ED
Model 14: Room air	0.96 (0.95-0.97)	< 0.001	0.96 (0.95-0.97)	< 0.001
Model 15: Nasal cannula	1.01 (1-1.02)	0.040	1.01 (1-1.02)	0.065
Model 16: Hudson mask	0.98 (0.94-1.02)	0.417	0.99 (0.95-1.03)	0.485
Model 17: NRBM	1.05 (1.04-1.07)	< 0.001	1.05 (1.03-1.07)	< 0.001
Model 18: HFNC/CPAP/BiPAP	1.07 (1.04-1.11)	< 0.001	1.07 (1.04-1.11)	< 0.001
Oxygen delivery device during hospitalization
Model 19: Nasal cannula	1 (0.97-1.02)	0.842	1 (0.97-1.02)	0.760	1.01 (0.99-1.04)	0.358
Model 20: Hudson mask	1.02 (0.98-1.07)	0.316	1.02 (0.98-1.07)	0.356	1.01 (0.96-1.06)	0.733
Model 21: NRBM	1.05 (1.04-1.06)	< 0.001	1.05 (1.03-1.06)	< 0.001	1.04 (1.02-1.05)	< 0.001
Model 22: HFNC/CPAP/BiPAP	1.04 (1.03-1.06)	< 0.001	1.04 (1.02-1.05)	< 0.001	1.02 (1-1.03)	0.037
Model 23: Oral intubation/tracheostomy	1.04 (1.03-1.06)	< 0.001	1.04 (1.02-1.05)	< 0.001	1.02 (1-1.04)	0.042

¹Adjusted for age.

²Adjusted for age and initial oxygen delivery device in the emergency department.

OR: Odds ratio; CI: Confidence interval; ED: Emergency department; NRBM: Non-rebreather mask; HFNC: High flow nasal cannula; CPAP: Continuous positive airway pressure; BiPAP: Bi-level positive airway pressure; RALE: Radiographic Assessment of Lung Edema.

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Table 4 Inter-rater agreement coefficients for BRIXIA and Radiographic Assessment of Lung Edema scores (n = 44)

Weight type	Measure	BRIXIA (95%CI)	RALE (95%CI)	Benchmarking interval	Extent of agreement
Ordinal weights	Percent agreement	0.95 (0.94-0.96)	0.95 (0.94-0.96)	(0.80-1.00)	Almost perfect
	Scott/Fleiss’ Kappa	0.57 (0.46-0.67)	0.58 (0.46-0.70)	(0.40-0.60)	Moderate
	Gwet’s AC	0.74 (0.69-0.80)	0.75 (0.70-0.80)	(0.60-0.80)	Substantial
Linear weights	Percent agreement	0.83 (0.81-0.85)	0.85 (0.84-0.87)	(0.80-1.00)	Almost perfect
	Scott/Fleiss’ Kappa	0.38 (0.03-0.47)	0.37 (0.27-0.46)	(0.20-0.40)	Fair
	Gwet’s AC	0.54 (0.48-0.59)	0.54 (0.50-0.59)	(0.40-0.60)	Moderate
Quadratic weights	Percent agreement	0.95 (0.94-0.96)	0.96 (0.96-0.97)	(0.80-1.00)	Almost perfect
	Scott/Fleiss’ Kappa	0.59 (0.48-0.70)	0.59 (0.46-0.71)	(0.40-0.60)	Moderate
	Gwet’s AC	0.76 (0.71-0.82)	0.77 (0.72-0.83)	(0.60-0.80)	Substantial

CI: Confidence interval; RALE: Radiographic Assessment of Lung Edema; AC: Agreement coefficient.

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Table 5 Intra-rater agreement coefficients for BRIXIA and Radiographic Assessment of Lung Edema scores (n = 220)

Score	Measure	Agreement coefficient (95%CI)	Benchmarking interval	Extent of agreement
BRIXIA	Percent agreement	0.97 (0.96-0.98)	(0.80-1.00)	Almost perfect
	Scott/Fleiss’ Kappa	0.77 (0.71-0.83)	(0.60-0.80)	Substantial
	Gwet’s AC	0.85 (0.81-0.89)	(0.80-1.00)	Almost perfect
RALE	Percent agreement	0.98 (0.97-0.98)	(0.80-1.00)	Almost perfect
	Scott/Fleiss’ Kappa	0.85 (0.81-0.90)	(0.80-1.00)	Almost perfect
	Gwet’s AC	0.88 (0.85-0.91)	(0.80-1.00)	Almost perfect

CI: Confidence interval; RALE: Radiographic Assessment of Lung Edema; AC: Agreement coefficient.

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Citation: Mohammed H, Y Fadul K, Naqvi SGA, Kharma N, Alfian Yusof A, Ahmad S, Farooq M, Javid S, Mohamed A, Abdel-Rahman ME, Harris T. Use of radiograph scoring systems to assess pulmonary disease severity in patients with COVID-19 pneumonia. World J Crit Care Med 2026; 15(1): 113684
URL: https://www.wjgnet.com/2220-3141/full/v15/i1/113684.htm
DOI: https://dx.doi.org/10.5492/wjccm.v15.i1.113684