A Self-criticism of Diagnostic and Therapeutic Decision Making in Children Admitted With Acute Lower Respiratory Infection at a Single Pediatric Emergency Department

Abstract

Objectives: Acute bronchiolitis and community-acquired pneumonia are the most common acute lower respiratory infections (LRIs) leading to emergency admission and hospitalization in children. The aim of this study is to investigate clinical, laboratory, and radiology findings; diagnostic and therapeutic decisions; and the relationships between them in patients younger than 2 years of age, hospitalized for LRI.Methods: Patients hospitalized for acute LRI (aged 28 days to 24 months) between November 1, 2017, and March 31, 2018, at a referral hospital were included. Patients' characteristics, clinical, laboratory, and radiologic findings and diagnostic and therapeutic decisions, along with reason for hospitalization, were recorded retrospectively. Chest x-rays were reinterpreted by the pediatric radiologist. Associations of these data with the radiologic signs and treatment modalities including antibiotics, bronchodilators, and high-flow oxygen therapy (HFOT) were assessed.Results: One hundred eighty-two patients were included. One hundred sixty (87.9%) had at least one of the following criteria for hospitalization: dehydration, feeding difficulties, young age (<12 weeks), and hypoxia. One hundred forty-five (79.6%) and 71 (39.0%) patients were administered antibiotic and antiviral therapy, respectively. Twenty-three patients (13.7%) were given HFOT, and 179 (99.4%) were given bronchodilators. None of the complaints, physical signs, or laboratory parameters had statistically significant associations with radiologic findings (P > 0.05). History of wheezing and presence of rales and dehydration in physical examination were associated with antibiotic use (P < 0.001). Conclusions:The decision of hospitalization was generally appropriate.However, laboratory and radiologic tests and treatments including HFOT, bronchodilator, antibiotic, and antiviral therapies were used excessively and inefficiently. Physicians' decisions were not based on evidence or on the clinical findings of the patient. The results of this study should prompt investigations into the reasons underlying these clinical decisions and development of practice models that can provide solutions specifically targeting the decision-making processes of physicians caring for young children with LRI at the emergency department.

The Spectrum of Pediatric Respiratory Emergencies in King Fahad Hospital Albaha Saudi Arabia

“…Small airways and inadequate compensatory mechanisms in infants may explain the higher number of cases. Average duration of admission was 4 days (3-5 days), while the average duration was 5 days in other studies [12]. Hyperactive airway was the most common cause of respiratory distress in diagnosed in 48 patients (22.85%) aged less than 2 years.…”

“…Information regarding demographic and clinical details, including age, sex, history of contact, comorbidities, clinical features, and lab investigations, were recorded. As shown in (Table 1), this study used Clinical Respiratory Score (CRS) to divide children with respiratory distress into three categories: Mild (< 3), Moderate (4-7), and Severe (8)(9)(10)(11)(12), [14,15]. CRS is used to quickly assess the patients in the emergency department, where a quick diagnosis is essential.…”

“…Acute respiratory distress in infants aged 0 to 90 days associated with positive COVID is mild and self-limiting in majority of the cases [11]. Ideal clinical evaluation, identification of etiology and risk factors and proper management can significantly improve the outcome of this illness [12]. The common symptoms and signs of respiratory distress presenting to the emergency department are cough, fever, breathing difficulty, tachypnea, and wheezing.…”

“…The Clinical Respiratory Score (CRS) in children with respiratory distress presenting to the emergency department; CRS score: Mild (< 3), Moderate (4-7), Severe(8)(9)(10)(11)(12).…”