Are respiratory rate counters really so bad? Throwing the baby out with the bath water

Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study

BACKGROUND

In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA).

METHODS

Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis.

RESULTS

All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended.

CONCLUSION

Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.

An openly available wearable, a diaper cover, monitors infant's respiration and position during rest and sleep

AIM

To describe and test the accuracy of respiratory rate assessment in long-term surveillance using an open-source infant wearable, NAPping PAnts (NAPPA).

METHODS

We recorded 24 infants aged 1-9 months using our newly developed infant wearable that is a diaper cover with an integrated programmable electronics with accelerometer and gyroscope sensors. The sensor collects child's respiration rate (RR), activity and body posture in 30-s epochs, to be downloaded afterwards into a mobile phone application. An automated RR quality measure was also implemented using autocorrelation function, and the accuracy of RR estimate was compared with a reference obtained from the simultaneously recorded capnography signal that was part of polysomnography recordings.

RESULTS

Altogether 88 h 27 min of data were recorded, and 4147 epochs (39% of all data) were accepted after quality detection. The median of patient wise mean absolute errors in RR estimates was 1.5 breaths per minute (interquartile range 1.1-2.6 bpm), and the Blandt-Altman analysis indicated an RR bias of 0.0 bpm with the 95% limits of agreement of -5.7-5.7 bpm.

CONCLUSION

Long-term monitoring of RR and posture can be done with reasonable accuracy in out-of-hospital settings using NAPPA, an openly available infant wearable.

Evaluating the Interrater Agreement and Acceptability of a New Reference Tool for Assessing Respiratory Rate in Children under Five with Cough and/or Difficulty Breathing

BACKGROUND

Manual assessment of respiratory rate (RR) in children is unreliable, but remains the main method to diagnose pneumonia in low-resource settings. While automated RR counters offer a potential solution, there is currently no gold standard to validate these diagnostic aids. A video-based reference tool is proposed that allows users to annotate breaths and distortions including movement periods, allowing the exclusion of distortions from the computation of RR measures similar to how new diagnostic aids account for distortions automatically. This study evaluated the interrater agreement and acceptability of the new reference tool.

METHODS

Annotations were based on previously recorded reference videos of children under five years old with cough and/or difficulty breathing (n = 50). Five randomly selected medical experts from a panel of ten annotated each video. RR measures (breaths per minute, bpm) were computed as the number of annotated certain breaths divided by the length of calm periods after removing annotated distorted periods.

RESULTS

Reviewers showed good interrater agreement on continuous RR {standard error of measurement (SEM) [4.8 (95%CI 4.4-5.3)]} and substantial agreement on classification of fast breathing (Fleiss kappa, κ 0.71). Agreement was lowest in the youngest age group [< 2 months: SEM 6.2 (5.4-7.4) bpm, κ 0.48; 2-11 months: 4.7 (4.0-5.8) bpm, κ 0.84; 12-59 months: 2.6 (2.2-3.1) bpm, κ 0.8]. Reviewers found the functionalities of the tool helpful in annotating breaths, but remained uncertain about the validity of their annotations.

CONCLUSIONS

Before the new tool can be considered a reference standard for RR assessments, interrater agreement in children younger than 2 months must be improved.