What is the role of chest X‐ray imaging in the acute management of children with sickle cell disease?

Abstract

Children with sickle cell disease (SCD) frequently present to hospital acutely unwell and are often exposed to diagnostic chest X-rays (CXRs). Little evidence exists to determine when CXRs are clinically useful. Using electronic hospital records, we audited CXR use in children aged 0-18 who presented to hospital over the past 10 years in both an inpatient and emergency department setting. From a total of 915 first CXRs, only 28Á2% of CXRs (n = 258) had clinically significant findings that altered management or final diagnosis. Of these abnormalities, consolidation represented 52Á3%, effusion 8Á9%, cardiomegaly 8Á4% and sickle cell-related bone changes 6Á3%. Indications for CXR of respiratory distress (OR = 3Á74, 95% CI 2Á28-6Á13), hypoxia (OR = 1Á86, 95% CI 1Á50-2Á31) and cough (OR = 1Á64, 95% CI 1Á33-2Á02), were more likely to have significant CXR findings. Patients who had higher peak fever (38Á4°C vs. 37Á4°C, P = 0Á001), higher peak CRP (156Á4 vs. 46Á1, P < 0Á001) and higher WCC (20Á2 vs. 13Á6, P < 0Á001) were more likely to have clinically significant abnormalities on CXR. We found a decision tool using either hypoxia, cough, respiratory distress, T > 38°C, CRP > 50 or WCC > 15 × 10 9 /l as indications for CXR, to have a sensitivity of 88% (with 95% CI 0Á78-0Á95) and specificity of 46% (95% CI 0Á43-0Á50) for clinically significant findings.

Precision Medicine and Sickle Cell Disease

“…Although widely used, it is not clear exactly when even simple tests such as chest and limb x-rays should be requested in SCD, although there is some evidence that they are probably used inappropriately. 45 …”

“…Although widely used, it is not clear exactly when even simple tests such as chest and limb x-rays should be requested in SCD, although there is some evidence that they are probably used inappropriately. 45 Perhaps the best example of precision medicine in SCD is the use of transcranial Doppler (TCD) ultrasound assessment of the circle of Willis, to identify children at increased risk of stroke, as developed by Dr Robert Adams. 46 The use of blood transfusions, 47 hydroxyurea, 48 and HSCT 49 in children with abnormal TCDs has seen a fall in the incidence of stroke in SCD in high-income countries of more than 90%, which will hopefully be translated into similar benefits in sub-Saharan Africa.…”

“…Modern imaging techniques offer the possibility of precise diagnoses, although their use has mostly not been evaluated in SCD. Although widely used, it is not clear exactly when even simple tests such as chest and limb x‐rays should be requested in SCD, although there is some evidence that they are probably used inappropriately 45 …”