This pandemic began last December 2019 in China, in January and February it was characterized as an emergency in Europe, especially Italy, Spain, Germany and Iran in south-west Asia, in March it has reached the countries of Latin America, highlighting Brazil and Chile countries most affected in our region.  The CIR - Inter-American College of Radiology takes on the challenge that is presented for radiologists in our region, in front of COVID-19 and, in that sense, we have turned to our affiliates, seeking excellence in supports, access to technological resources and scientific reflections on experiences, so that we can better help each other. right now.

We try to answer some key questions they say regarding developing our work in computed tomography, the differential diagnosis of COVID-19, regarding the preparation of the Department of Radiology for COVID-19, other resources important for radiologists and personal care that the radiologist should take.

According to RSNA (Radiological Society of North America), radiologists should know more about the outbreak of this new respiratory disease, which clinically resembles viral pneumonia and manifests as fever, cough and shortness of breath, similar to flu, but more severe and Fatal.  The new coronavirus belongs to a family of viruses including Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). The outbreak is increasing rapidly, with hundreds of thousands of globally confirmed cases, and early recognition of the disease is critical to treatment success, patient isolation, containment and effective public health response.  RSNA is publishing original research, slides, panels and talks.  For more information:

The ACR (American College of Radiology) recommends that the following factors of using imaging methods be considered:
a. Currently, the Centers for Disease Control (CDC) does not recommend CXR or CT to diagnose COVID-19. Viral examination (CSC) remains the only specific method of diagnosis. 
b. Collection and examination of samples of upper respiratory treatment (nasopharyngeal and oropharyngeal swabs) and lower respiratory treatment are recommended when available for viral examinations.
c. Ventilation is an important issue for airborne transmission control in health units. Also the complete cleaning of all used surfaces and environmental decontamination, to each patient.

ESR (European Society of Radiology), has created a Resource Center for Radiologists on Covid-9, with the aim of collecting important resources for radiologists, including information on guidelines, publications, research and support measures, inviting professionals to continually add to the page, participate in discussions, connect other image professionals, by

ESR provides an overview of European and global research, monitoring and support from the European Union, highlights the actions of the World Health Organization (WHO), to help countries respond to the COVID-19 pandemic, through a fund created by the United Nations Foundation and the Swiss Philanthropy Foundation together with WHO, which allows individuals, corporations and private institutions from anywhere in the world to come together to contribute directly to pandemic response efforts.

SERAM (Spanish Society of Medical Radiology), publishes documents with recommendations on what imaging techniques to do in infection or suspect COVID-19 infection. It is accompanied by an appendix with information on what to evaluate on the chest x-ray and CT and how to make the report. 
To download the document, click here

CBR (BRAZILIAN COLLEGE OF RADIOLOGY AND DIAGNOSTIC IMAGING), offers the text that we translate in full:

Coronaviruses can cause different pathological processes, from a flu case similar to a common cold to severe acute respiratory failure.  The new virus is a branch of the coronavirus family that until then had not been identified in humans (SARS-Cov-2).
The virus is transmitted from person to person, when small drops of viral particles of a sick or asymptomatic carrier come into contact with mucous membranes of the mouth, nose or eyes of healthy people. 

Among the main measures to prevent pollution are social isolation, avoiding close or direct contact with other people, maintaining social distance between 1.5m and 2.0m; avoid touching your face; wash your hands frequently with soap and water or apply alcohol gel to your hands.

However, during ultrasound examinations proximity to patients becomes unavoidable, as the doctor must touch the patient with the transducer for the acquisition of diagnostic images.  The safety of doctors, as well as that of all health professionals, which cannot be omitted in times of health crisis like this, have absolute priority.  In this way, the Brazilian College of Radiology, with other scientific societies, has taken the initiative to disseminate this document, emphasizing the importance of conducting the exams with maximum security. 

1. Safety begins with the proper indication of the test.  Patients should not be exposed to unnecessary risks and health equipment should not be used with tests that will not add relevant information to the patient's management. Routine and checkups may be postponed for more timely times.  This also reduces the risk of contamination for people who won't have to transfer from one service to another and allows medical teams better manage their time and effort to care for those who really need it.
2. We encourage the study specifically directed towards the patient's complaint or the suspected diagnosis of the prescriber, in order to reduce the examination time.  And finally, individual protection measures must be implemented that differ from specific contexts or scenarios. 

Scenario 1: Ultrasound examination performed on an outpatient WITHOUT respiratory symptoms.
The patient does not need to wear a mask. The doctor should use a mask with minimum filtration equivalent to PFF1-surgical mask. Non-sterile disposable gloves, long-sleeved waterproof apron, preferably disposable.

Scenario 2: Ultrasound examination performed on an external patient with respiratory symptoms.
The patient should wear a mask with a minimum filtration equivalent to PFF1, as surgical masks since entering the clinic.  The doctor should use a mask with minimum filtration equivalent to PFF2 – N95, disposable gloves, non-sterile, long-sleeved waterproof apron, preferably disposable glasses or full mask. 

Scenario 3: ultrasound examination performed on an inpatient WITHOUT respiratory symptoms. 
The patient does not need to wear a mask.  For the doctor should use a mask with minimum filtration equivalent to PFF2-N95, disposable gloves, non-sterile, long-sleeved waterproof apron, preferably disposable. 

Scenario 4: Ultrasound examination performed on an inpatient with respiratory symptoms.
The patient should wear a mask with minimum filtration equivalent to PFF1. The doctor should use a mask with minimum filtration equivalent to PFF2-N95, disposable gloves, non-sterile, long-sleeved waterproof apron, preferably disposable glasses or full mask.

Another important point is the cleaning and antisepsis of ultrasound equipment and transducers.  Coronavirus is involved by a lipid capsid that makes it particularly sensitive to routine-use disinfectants.  There is evidence that the virus is effectively inactivated with appropriate procedures including the use of common disinfectants in diagnostic clinics and hospital settings. WHO suggests that "the complete cleaning of environmental surfaces with water and detergent, followed by the application of disinfectants commonly used at the hospital level", should be done, these are effective and sufficient procedures for inactivating the new coronavirus. The device can be cleaned with a 70% alcohol-moist tissue.

To clean the transducers, disinfection must be effective for any transmissible pathogen and that can be done with several products:
. Based on sodium hypochlorite as Dakin liquid (0.5 active sodium hypochlorite solution)
. Based on quaternary ammonia (QUAT), taking care that the total concentration for use should be less than 0.8%
. Based on hydrogen peroxide accelerated to a maximum of 0.5%
. Based on alcohol or alcohol and quaternary ammonia (QUAT). Alcohol content may not exceed 70%.

It should be noted that not all cleaning solutions are compatible with transducers.  Therefore, it is recommended to consult the maintenance and cleaning manuals of each device, which contain information on which products can be used to ensure patient safety without damaging the equipment. 

Conductive gel: to avoid contamination of the ultrasound gel, it is recommended to cover the bottle or tube, after each use. When applying the gel, do not allow the gel container to touch the patient's skin or the transducer surface.

CLASSIC REPORTING ROOMS: Proper cleaning of computer tables, keyboards and mouses in report rooms, can be done with common products, including alcohol at 70%.  For cases without suspicion of COVID-19, without epidemiology and without respiratory symptoms, usual disinfection is performed and the room and equipment are released for examinations, shortly after. 
After testing in patients with high suspicion and/or with confirmed COVID-19, it is necessary to proceed with the disinfection recommended above and the room (and equipment) can only be used again after 2 hours, preferably after 3 hours.

According to the available medical literature, CBR, through its Department of Thoracic Radiology, recommends:
1. CT scan should NOT be used as a screening test or for initial diagnosis of COVID-19 images;
2. Its use should be reserved for inpatients, symptomatic, in specific clinical situations.  CT findings do not influence results;
3. When indicated, the protocol is a high resolution CT (TCAR), if possible with a low-dose protocol.  The use of intravenous contrast media, in general, is not indicated, being reserved for specific situations to be determined by the radiologist.
4. After use by patients with a suspected or confirmed diagnosis of COVID-19 infection, the room and equipment used should undergo a disinfection process, as described in another CBR document, available at:
5. When a chest x-ray is indicated in suspected/confirmed cases of hospitalized patients, we should prioritize the use of portable x-ray, as the surfaces of these machines can be cleaned more easily and still avoid the need to take patients to the imaging sector of the hospital. 

With the spread of COVID-19 infection around the world and in our country, imaging methods have received special attention and it is important to highlight the role of simple x-ray and chest CT in the context of a patient with suspicion or even with confirmed diagnosis of COVID-19 infection.

Several publications have described the most common findings in X-ray and tomographic images.  Interest is even greater due to a shortage of confirmatory serological tests in some specific countries and regions, as well as due to some reports caused by infection in China, where CT already showed findings even in patients with serologies still negative. We emphasize that the recommendations and findings written here can be changed and/or supplemented due to the rapid evolution of the pandemic and because we deal with acute cases of an infection in which not all its nuances are known.

Some key considerations should be made in relation to the use of imaging methods in COVID-19 infection.  The Centers for Disease Control (CDC), a U.S. government agency, does not currently recommend XR or CT for the diagnosis of COVID-19 infection.  Serological testing remains the only specific method for this purpose.  All international organizations, so far, reaffirm the need for laboratory confirmation, even in patients with highly suggestive imaging.  Imaging findings of COVID-19 infection are not specific and overlap with several other acute infections such as influenza, SARS, MERS and H1N1.  Many of them are known to be much more frequent than COVID-19.

It is also necessary to bear in mind that infection control in radiological services, which involves reducing the misuse of imaging methods, is extremely important.  We remind you that the proper disinfection of the CT/XR environment may take a long time, sometimes more than 30 minutes, which restricts the ability to test.  For this reason, well-defined indication is required for image examinations. 

Radiologists should be familiar with the findings of images of COVID-19 infection, which is briefly summarized here:
a. Simple chest scan:
Chest x-rays usually show multifocal opacity in airspace similar to other coronavirus infections.  Chest x-ray findings are late, when compared to high-resolution computer tomography, which appears earlier. 

b. High-resolution chest CT:
Pulmonary abnormalities in COVID-19 infection are usually opacities with peripheral, focal or multifocal frosted glass attenuation, and bilateral in 50-75% of cases.  With disease progression, between 9 and 13 days, lesions appear with paving mosaic pattern and consolidations.  Injuries slowly go away for 1 month or more.  In the pediatric group, the finding of consolidation surrounded by attenuation in frosted glass (halo indication), appears to be more common than in adults.
To facilitate the understanding of these findings, we recommend the website provided by the Italian Society of Medical Radiology, with images of COVID-19 infection, available at:
It should be noted that the course of this pandemic is acute and recommendations can be changed/adjusted at any time. 


1. Decrease the chance of exposure.
When scheduling routine (preventive, elective) medical care exams and appointments, instruct patients to discuss rescheduling, especially if they experience symptoms of a respiratory infection (e.g., cough, sore throat, fever).
If the patient needs to undergo tests, set up a screening test and request that possible symptoms of respiratory infection be reported so that appropriate preventive measures can be taken (mask at the entrance and during the visit).

2. Consider limiting entry and transit points for patients with symptoms of respiratory infection.
Identify a separate, well-ventilated space that allows waiting patients to be isolated and easy access to respiratory hygiene supplies.

3. Take steps to ensure that patients and professionals have access to hand hygiene supplies, health service entrances, waiting rooms, and service areas.

4. Use visual alerts (signs, warnings, etc.), at the entrance and in strategic locations (e.g. waiting areas, elevators, cafes, etc.), to provide patients with instructions (in appropriate languages), on hand hygiene, breathing hygiene and courtesy when coughing.  Instructions should include how to use handkerchiefs to cover your nose and mouth when coughing or sneezing, discarding contaminated fabrics and items in trash cans, and how and when to perform hand hygiene.

5. Provide specific information on transmission prevention and training to all health facility personnel (doctors, nurses, technicians, cleaning, laundry, maintenance, students, administrative staff, and others). 

6 .Hand hygiene: Healthcare professionals must perform hand hygiene before and after all contact with the patient, contact with potentially infectious material and before putting on and removing personal protective equipment, including gloves.  Wash your hands with soap and water for at least 20 seconds or use specific alcohol-based products with a concentration of 60-90%

7. Personal Protective Equipment (PPE): Professionals involved in care and in contact with patients must have access to PPE, receive training and show that they understand; when to use PPE, what PPE is needed, how to use it, remove PPE appropriately to avoid contamination, how to dispose or disinfect and maintain PPE properly, and PPE limitations. 
The training of professionals involved in the placement and removal of PPE is recommended.  There is evidence that the increased possibility of infection occurs in the process of improper removal of these materials. 

Recommended EPIs when treating a patient with COVID-19, known or suspected symptomatic, include:
a. Breather or mask.
The patient must have a simple surgical mask when entering the examination area.  The goal is to reduce droplet transmission. Wear the face mask before contacting patients with respiratory symptoms.  It is recommended that these guidelines be updated frequently according to the instructions of health authorities. Face masks should be removed and discarded after leaving the patient's room or care area and closing the door.  Perform hand hygiene after disposing of the mask.

b. Eye protection
Glasses or a disposable face protector that covers the front and sides of the face when entering the patient's room or care area.  Personal glasses and contact lenses are not considered adequate eye protection. Remove eye protection before leaving the service area.
These PPE items are only recommended for procedures such as puncture or interventions. 

c. Gloves
Wear clean, non-sterile gloves when entering the service area. Remove and dispose of gloves when you leave the care area and perform hand hygiene immediately. 

d. Aprons
Wear clean insulating clothing when entering the patient's area. Remove and dispose of the apron in an appropriate container before leaving the service area. Non-disposable aprons should be washed after each use.  Give preference to disposable aprons.

e. Implement environmental infection control. 
All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected in accordance with manufacturer's instructions and installation policies.
Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.  The handling of clothing, food service utensils and medical waste should also be carried out in accordance with protective care.  The disposal of the material must follow the health surveillance rules. 

f. Collaborators and employees.  PPE - Personal Protective Equipment
In hospitals that care for patients with COVID-19 confirmed infection, consider placing part of the health team working remotely to avoid simultaneous contamination of a significant portion of professionals, which makes it difficult to maintain the service operation.

Health care services should implement flexible and consistent sick leave policies, according to public health guidelines, for professionals showing symptoms of respiratory infection.

Source for this image: Journal of the American College of Radiology JACR