Can We Predict Which Children With Clinically Suspected Pneumonia Will Have the Presence of Focal Infiltrates on Chest Radiographs?

Abstract

ABSTRACT. Objective. To determine predictive factors for the presence of focal infiltrates in children with clinically suspected pneumonia in a pediatric emergency department.Methods. Children (1-16 years) with clinically suspected pneumonia were studied prospectively. The presenting features were compared between the children with and without focal infiltrates using 2 analysis, t test, and odds ratio with 95% confidence intervals. A multivariate prediction rule was developed using logistic regression.Results. A total of 570 were studied. Risk factors (odds ratio; 95% confidence interval) for the presence of focal infiltrates included history of fever (3.1; 1.7-5.3), decreased breath sounds (1.4; 1.0 -2.0), crackles (2.0; 1.4 -2.9), retractions (2.8; 1.0 -7.6), grunting (7.3; 1.1-48.1), fever (1.5; 1.2-1.9), tachypnea (1.8; 1.3-2.5), and tachycardia (1.3; 1.0 -1.6). We then used logistic regression to develop a candidate prediction rule for the variables of fever, decreased breath sounds, crackles, and tachypnea, which had an area under the receiver operating curve of 0.668. This rule had excellent sensitivity (93.1%-98%) yet poor specificity (5.7%-19.4%).Conclusions. Multiple predictive factors for children with suspected pneumonia have been identified. Patients with focal infiltrates were more likely in our study to have a history of fever, tachypnea, increased heart rate, retractions, grunting, crackles, or decreased breath sounds. A multivariate prediction rule shows promise for the accurate prediction of pneumonia in children. However, the prospective evaluation of this multivariate prediction rule in a clinical setting is still required. Pediatrics 2004;113:e186 -e189. URL: http://www.pediatrics.org/ cgi/content/full/113/3/e186; pneumonia, chest radiographs, children, predictive factors.ABBREVIATIONS. ED, emergency department; OR, odds ratio; CI, confidence interval.T he accurate diagnosis of pneumonia in children remains an important yet difficult clinical problem. The chest radiograph remains the diagnostic test of choice in tertiary care centers. Given that the decision to pursue a diagnostic chest radiograph in the context of suspected pneumonia is largely influenced by clinical predictors of pediatric pneumonia, it is important to have these determined accurately.The clinical findings of patients with radiographic pneumonia have been described previously in both adult and pediatric populations in developed countries. 1-6 Some studies limit themselves to very young children. [7][8][9] However, the number of pediatric patients studied with radiographic pneumonia has been small. [1][2][3][4][5] In 1997, an evidence-based review of the literature dealing with pediatric pneumonia was published by a group of pediatric infectious disease specialists and a microbiologist. 10 The authors concluded that the absence of the pulmonary cluster as defined by Leventhal 1 of respiratory distress, tachypnea, rales, and decreased breath sounds accurately excluded pneumonia. This specific recommendation was based on a st...

Characteristics of Community-Acquired Pneumonia in Hospitalized Lebanese Children and their Correlation

“…This result was seen in a study done by Bilkis et al (p=0.009) [10], where cough and chest pain were also correlated with pneumonia, however, patients younger than 1 year of age or who were treated with "more than one bronchodilator treatment in the emergency unit" were excluded from the study. This can explain the variation in the results, as children younger than 12 months of age are more prone to having a viral respiratory infection specifically bronchiolitis than a pneumonia [11]. Virkki et al showed that nasal congestion was significantly more prevalent among RSV positive patients; our study didn't find such results, the difference in the study designs might be the cause [12].…”

“…Till now, there is no criterion standard for the diagnosis of pneumonia in children. [19,20] The chest radiograph remains the diagnostic test of choice in tertiary care centers [11,21]. Several studies tried to generate a clinical prediction algorithm for bacterial pneumonia [11,19] but no one succeeded [5].…”

“…Most of the literature has shown that both were significantly associated with pneumonia. A prospective cohort study demonstrated that patients with radiographic pneumonia were more likely than patients with normal chest radiographs to have among other clinical features crackles (p=0.001) and decreased breath sounds (p=0.034) [11]. Recall bias may be responsible for that divergence since crackles were considered absent if not mentioned to be present.…”

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How good are the examination findings in predicting the chest radiographic abnormalities amongst children with LRTI?

“…9 Lynch T et al showed that tachycardia was present in 51% cases with CXR positive and 40% cases with CXR negative with a p-value of 0.02 which was significant. 10 Tachycardia might be associated with multiple reasons like anaemia, fever etc. which are not associated with LRI.…”