Integrated Clinical and CT Based Artificial Intelligence Nomogram for Predicting Severity and Need for Ventilator Support in COVID-19 Patients: A Multi-Site Study

Almost 25% of COVID-19 patients end up in ICU needing critical mechanical ventilation support. There is currently no validated objective way to predict which patients will end up needing ventilator support, when the disease is mild and not progressed. N = 869 patients from two sites (D(1): N = 822, D(2): N = 47) with baseline clinical characteristics and chest CT scans were considered for this study. The entire dataset was randomly divided into 70% training, D(1)(train) (N = 606) and 30% test-set (D(test): D(1)(test) (N = 216) + D(2) (N = 47)). An expert radiologist delineated ground-glass-opacities (GGOs) and consolidation regions on a subset of D(1)(train), (D(1)(train_sub), N = 88). These regions were automatically segmented and used along with their corresponding CT volumes to train an imaging AI predictor (AIP) on D(1)(train) to predict the need of mechanical ventilators for COVID-19 patients. Finally, top five prognostic clinical factors selected using univariate analysis were integrated with AIP to construct an integrated clinical and AI imaging nomogram (ClAIN). Univariate analysis identified lactate dehydrogenase, prothrombin time, aspartate aminotransferase, %lymphocytes, albumin as top five prognostic clinical features. AIP yielded an AUC of 0.81 on D(test) and was independently prognostic irrespective of other clinical parameters on multivariable analysis (p<0.001). ClAIN improved the performance over AIP yielding an AUC of 0.84 (p = 0.04) on D(test). ClAIN outperformed AIP in predicting which COVID-19 patients ended up needing a ventilator. Our results across multiple sites suggest that ClAIN could help identify COVID-19 with severe disease more precisely and likely to end up on a life-saving mechanical ventilation.