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Variation in Pediatric Asthmonia Diagnosis and Outcomes among Hospitalized Children. Ann Am Thorac Soc 2021; 18:1514-1522. [PMID: 33566750 DOI: 10.1513/annalsats.202009-1146oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Although <5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals asthma-pneumonia co-diagnosis is so common that the term "asthmonia" is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted healthcare costs and contribute to unnecessary antibiotic prescribing. OBJECTIVE To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals' asthmonia diagnosis rates and clinical outcomes. METHODS We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015-6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio (MOR) was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes. RESULTS Of 24606 asthma exacerbations, 19402 (78.9%) were diagnosed with asthma alone and 5204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (IQR:16.2-27.2%, range:8.4-55.9%). The MOR was 1.75 (95% CI:1.63-1.86). Compared to hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, non-teaching, rural hospitals with minimal subspecialty support (all p<0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic utilization, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission. CONCLUSIONS Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, non-teaching hospitals with minimal pediatric specialty support.
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Abeles M, Akerman M, Halaby C, Pirzada M. Do subtle findings on chest X-ray predict worse outcomes for paediatric asthma? Postgrad Med J 2020; 98:183-186. [PMID: 33273110 DOI: 10.1136/postgradmedj-2020-139165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/09/2020] [Accepted: 11/14/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Asthma, a common childhood condition, often presents with chronic cough. While evaluating for chronic cough, many specialists obtain a baseline chest radiograph (CR) to assess for other causes. Usually read as 'normal', sometimes CRs will reveal evidence of airway inflammation in the form of subtle findings, such as 'increased interstitial markings' or 'peribronchial thickening'. There is sparse literature in the outpatient setting correlating findings on baseline CRs with adverse outcomes such as systemic steroid use, emergency department (ED) visit or hospitalisation. METHODS This was a retrospective study of patients seen at our institution's Pediatric Pulmonology outpatient clinic. We reviewed the charts of all new patients aged 0-18 years who presented between January 2015 and December 2017. Patients were included if they were diagnosed with asthma, had a CR after the initial visit and were followed up at least twice. Adverse outcomes include systemic steroid use, ED visit or hospitalisation. RESULTS 130 subjects were included. 89 subjects had clear CRs and 41 subjects had CRs with airway inflammation. Overall events were higher in the airway inflammation group (22.5% vs 46.3%, respectively, p<0.0058). There were no significant differences between in terms of oral corticosteroid use or hospitalisations. There was a significant difference between the two groups in terms of ED visits (2.2% vs 14.6%, respectively, p=0.0121). CONCLUSION This study shows a positive correlation between airway inflammation findings on baseline CR and subsequent ED visits in patients with asthma.
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Affiliation(s)
- Michael Abeles
- Pediatric Pulmonology, NYU Winthrop Hospital, Mineola, New York, USA
| | | | - Claudia Halaby
- Pediatric Pulmonology, NYU Winthrop Hospital, Mineola, New York, USA
| | - Melodi Pirzada
- Pediatric Pulmonology, NYU Winthrop Hospital, Mineola, New York, USA
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The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians. Pediatr Emerg Care 2020; 36:16-20. [PMID: 31851079 DOI: 10.1097/pec.0000000000002015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.
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Abstract
Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.
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Affiliation(s)
- Amy L Puchalski
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Christyn Magill
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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Tetsuhara K, Tsuji S, Nakano K, Kubota M. Heart failure in dilated cardiomyopathy mimicking asthma triggered by pneumonia. BMJ Case Rep 2017; 2017:bcr-2017-222082. [PMID: 29127129 DOI: 10.1136/bcr-2017-222082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Heart failure is a rare cause of wheezing and may develop into a critical condition in children. Few cases report patients with heart failure, secondary to dilated cardiomyopathy, with high fever. A 23-month-old girl visited the emergency department with high fever, cough, first wheezing episode, chest retraction and tachycardia. The chest X-ray revealed consolidation on the left lower lung field; the cardiothoracic ratio was 60%. She was diagnosed with bronchial asthma triggered by pneumonia, which remained unchanged during four visits. Subsequently, she was diagnosed with heart failure in idiopathic dilated cardiomyopathy and discharged without sequelae. During the first wheezing episode in children with abnormal vital signs, heart failure should be considered in the differential diagnosis, and a chest X-ray should be performed. Additionally, when the cardiothoracic ratio is greater than 50%, 12-lead ECG and echocardiography should be performed. Moreover, cognitive bias should be considered in all emergency care unit situations.
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Affiliation(s)
- Kenichi Tetsuhara
- Division of Emergency Service and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Tsuji
- Division of Emergency Service and Transport Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsutoshi Nakano
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
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Allie EH, Dingle HE, Johnson WN, Birnbaum JR, Hilmes MA, Singh SP, Arnold DH. ED chest radiography for children with asthma exacerbation is infrequently associated with change of management. Am J Emerg Med 2017; 36:769-773. [PMID: 29137905 DOI: 10.1016/j.ajem.2017.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information. OBJECTIVE To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic. DESIGN/METHODS Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes. RESULTS Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p>0.11). Crackles were associated with antibiotic administration (p=0.03), but not PNA on CXR (p=0.07). Only previous antibiotic use within 7days had both significant univariate associations (p=0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3). CONCLUSION CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles.
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Affiliation(s)
- Evan H Allie
- Pediatric Emergency Medicine, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States.
| | - Henry E Dingle
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Jeffrey R Birnbaum
- Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Melissa A Hilmes
- Pediatric Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Sudha P Singh
- Pediatric Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Donald H Arnold
- Pediatric Emergency Medicine, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States; Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, TN, United States
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Pardue Jones B, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma 2016; 53:607-17. [PMID: 27116362 DOI: 10.3109/02770903.2015.1067323] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU. DATA SOURCES We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines. RESULTS AND CONCLUSIONS Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.
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Affiliation(s)
| | | | | | | | - Donald H Arnold
- a Department of Pediatrics , Division of Emergency Medicine.,d Center for Asthma Research, Vanderbilt University School of Medicine , Nashville , TN , USA
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Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice Pattern Variation in the Care of Children With Acute Asthma. Acad Emerg Med 2016; 23:166-70. [PMID: 26766222 DOI: 10.1111/acem.12857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/30/2015] [Accepted: 08/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pediatric asthma is a highly prevalent disease, affecting over 7 million U.S. children and accounting for 750,000 annual emergency department (ED) visits. Guidelines from the National Asthma Education and Prevention Program recommend limited use of chest radiography (CXR), complete blood counts (CBCs), and antibiotics when managing acute exacerbations of asthma. However, studies suggest frequent overutilization of these resources. The objective was to evaluate differences between pediatric and general EDs in rates of CXRs, CBCs, and use of antibiotics for pediatric asthma exacerbations. METHODS This was a repeated cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2000 through 2010 of CXR, CBCs, and antibiotics during ED visits for pediatric acute asthma exacerbations. Multivariable logistic regression was performed to identify differences in asthma management by ED type (pediatric vs. general) after adjusting for demographic covariates. RESULTS There were 3,313 observations, representing an estimated 10.9 million (95% confidence interval [CI] = 9.7 to 12.1 million) ED visits for acute asthma without bacterial coinfection. Of these, 17.4% occurred in pediatric EDs. Multivariable logistic regression revealed that visits to pediatric EDs were less likely to include CXRs (adjusted odds ratio [AOR] = 0.39; 95% CI = 0.25 to 0.60), CBCs (AOR = 0.42; 95% CI = 0.22 to 0.80), and antibiotics (AOR = 0.50; 95% CI = 0.31 to 0.82) after adjustment for race/ethnicity, triage level, academic ED, metropolitan statistical area, and geographic region. CONCLUSIONS There are substantial differences in diagnostic testing and antibiotic usage for management of acute exacerbations of asthma by ED type, suggesting potential resource overuse in general EDs. Future studies should focus on evaluating the effect of quality improvement efforts for ED asthma management.
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Affiliation(s)
- James M. Chamberlain
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Stephen J. Teach
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Katie L. Hayes
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Gia Badolato
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Monika K. Goyal
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
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Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, Prasad KT, Yenge LB, Singh N, Behera D, Jindal SK, Gupta D, Balamugesh T, Bhalla A, Chaudhry D, Chhabra SK, Chokhani R, Chopra V, Dadhwal DS, D’Souza G, Garg M, Gaur SN, Gopal B, Ghoshal AG, Guleria R, Gupta KB, Haldar I, Jain S, Jain NK, Jain VK, Janmeja AK, Kant S, Kashyap S, Khilnani GC, Kishan J, Kumar R, Koul PA, Mahashur A, Mandal AK, Malhotra S, Mohammed S, Mohapatra PR, Patel D, Prasad R, Ray P, Samaria JK, Singh PS, Sawhney H, Shafiq N, Sharma N, Sidhu UPS, Singla R, Suri JC, Talwar D, Varma S. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015; 32:S3-S42. [PMID: 25948889 PMCID: PMC4405919 DOI: 10.4103/0970-2113.154517] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Venkata N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Lakshmikant B Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Thanagakunam Balamugesh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashish Bhalla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dhruva Chaudhry
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sunil K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ramesh Chokhani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Devendra S Dadhwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - George D’Souza
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Shailendra N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Bharat Gopal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Krishna B Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Indranil Haldar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sanjay Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vikram K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surender Kashyap
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai Kishan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok Mahashur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Amit K Mandal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Samir Malhotra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sabir Mohammed
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Pallab Ray
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Potsangbam Sarat Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Honey Sawhney
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nusrat Shafiq
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Updesh Pal S Sidhu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jagdish C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Subhash Varma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
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Ecochard-Dugelay E, Beliah M, Perreaux F, de Laveaucoupet J, Bouyer J, Epaud R, Labrune P, Ducou-Lepointe H, Gajdos V. Clinical predictors of radiographic abnormalities among infants with bronchiolitis in a paediatric emergency department. BMC Pediatr 2014; 14:143. [PMID: 24906343 PMCID: PMC4053285 DOI: 10.1186/1471-2431-14-143] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute viral respiratory exacerbation is one of the most common conditions encountered in a paediatric emergency department (PED) during winter months. We aimed at defining clinical predictors of chest radiography prescription and radiographic abnormalities, among infants with bronchiolitis in a paediatric emergency department. METHODS We conducted a prospective cohort study of children less than 2 years of age with clinical bronchiolitis, who presented for evaluation at the paediatric emergency department of an urban general hospital in France. Detailed information regarding historical features, examination findings, and management were collected. Clinical predictors of interest were explored in multivariate logistic regression models. RESULTS Among 410 chest radiographs blindly interpreted by two experts, 40 (9.7%) were considered as abnormal. Clinical predictors of chest radiography achievement were age (under three months), feeding difficulties, fever over 38°C, hypoxia under than 95% of oxygen saturation, respiratory distress, crackles, and bronchitis rales. Clinical predictors of radiographic abnormalities were fever and close to significance hypoxia and conjunctivitis. CONCLUSION Our study provides arguments for reducing chest radiographs in infants with bronchiolitis. For infants with clinical factors such as age less than three months, feeding difficulties, respiratory distress without hypoxia, isolated crackles or bronchitis rales, careful clinical follow-up should be provided instead of chest radiography.
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Halaby C, Feuerman M, Barlev D, Pirzada M. Chest radiography in supporting the diagnosis of asthma in children with persistent cough. Postgrad Med 2014; 126:117-22. [PMID: 24685975 DOI: 10.3810/pgm.2014.03.2747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To establish whether chest radiographic findings suggestive of lower airway obstruction (LAO) disease support the diagnosis of asthma in pediatric patients with persistent cough in an outpatient setting. METHODS 180 patient charts were reviewed. The patients were children aged 1 to 18 years referred over a 3-year period to a pediatric pulmonary subspecialty clinic for evaluation of cough lasting ≥ 4 weeks. Chest radiographic images obtained after the initial evaluation of 90 patients diagnosed with cough-variant asthma and 90 patients diagnosed with persistent cough from nonasthma origins were compared with radiologic findings of a control group consisting of patients with a positive tuberculin skin test and no respiratory symptoms. Increased peribronchial markings/peribronchial cuffing and hyperinflation were considered radiographically suggestive findings of LAO disease. RESULTS Children diagnosed with cough-variant asthma at the initial evaluation had higher rates of chest radiographic findings suggestive of LAO disease (30.00%) than children with persistent cough from other causes (17.80%) or those with a positive tuberculin skin test and no respiratory symptoms (8.16%) (overall P value = 0.0063). They also had higher rates of spirometry abnormalities suggestive of an LAO defect. Children with chest radiographic findings suggestive of LAO disease were found to be younger than those with normal chest radiographic findings (5.0 ± 2.7 years vs 8.6 ± 4.7 years; P < 0.0001). CONCLUSION This study suggests that chest radiographic findings indicative of an LAO in correlation with the clinical presentation can support the diagnostic suspicion of asthma, especially in younger children unable to perform spirometry.
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Affiliation(s)
- Claudia Halaby
- Winthrop University Hospital, Pediatric Pulmonary Division, Mineola, NY.
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Narayanan S, Magruder T, Walley SC, Powers T, Wall TC. Relevance of chest radiography in pediatric inpatients with asthma. J Asthma 2014; 51:751-5. [PMID: 24673123 DOI: 10.3109/02770903.2014.909459] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The goals of this study are to identify factors associated with ordering of chest radiographs (CXR's) in children hospitalized with acute asthma exacerbations and determine the overall clinical impact of these CXR's. METHODS A retrospective study was performed with children ≥ 2 years of age admitted from our emergency department (ED) between 6/1/2011 and 5/31/2012 with a primary diagnosis of acute asthma exacerbation or status asthmaticus. Patients were excluded if they had been on antibiotics prior to the emergency visit, received continuous albuterol or intravenous magnesium during the hospitalization, or had another chronic disease affecting lung function. RESULTS 180 of the 405 children in the study (44%) had CXR's ordered, of which 18 (10%) had imaging that altered the patient's treatment plan. There were six cases of radiologist-diagnosed pneumonia, nine cases of atelectasis treated with antibiotics and three cases of pneumothorax. Factors associated with CXR ordering were: fever at home or in the ED (OR 4.5, 95% CI 2.8-7.4), triage oxygen saturation less than or equal to 92% (OR 1.8, 95% CI 1.2-2.7) and age 4 years or less (OR 2.3, 95% CI 1.4-3.7). Patients with treatment-altering CXR's were more likely to have oxygen saturations less than or equal to 92% (OR 4.2, 95% CI 1.4-13.0; p = 0.006) or fever in the ED (OR 3.8, 95% CI 1.0-13.6; p < 0.05). No patients with triage oxygen saturation above 96% had a treatment-altering CXR. CONCLUSIONS The majority of CXR's ordered in pediatric inpatients with asthma exacerbation do not provide clinically relevant information.
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Ellis KC. The differential diagnosis and management of asthma in the preschool-aged child. ACTA ACUST UNITED AC 2011; 21:463-73. [PMID: 19845803 DOI: 10.1111/j.1745-7599.2009.00423.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To discuss the diagnosis and management of asthma in preschool-aged children by nurse practitioners in primary care. DATA SOURCES Selected research and clinical articles; 2007 National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma. CONCLUSIONS Proper diagnosis leads to appropriate treatment of asthma in preschool-aged children, which facilitates asthma control. Well-controlled asthma results in fewer asthma exacerbations, fewer nighttime awakenings, and an increased ability to engage in normal childhood activities. IMPLICATIONS FOR PRACTICE Advanced practice nurses are in the position to aid in the initial diagnosis of asthma in preschool-aged children through taking detailed medical histories, providing thorough physical examinations, and, if needed, initiating a therapeutic trial with an inhaled corticosteroid. Proper diagnosis and management of asthma is essential to reduce asthma complications, such as exacerbations leading to emergency department visits and hospitalizations.
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Affiliation(s)
- Kathleen C Ellis
- Department of Nursing, University of Tampa, Tampa, Florida 33606, USA.
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Imaging the Chest. DIAGNOSTIC IMAGING FOR THE EMERGENCY PHYSICIAN 2011. [PMCID: PMC8139021 DOI: 10.1016/b978-1-4160-6113-7.10005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Practice variation in the management for nontraumatic pediatric patients in the ED. Am J Emerg Med 2010; 28:275-83. [DOI: 10.1016/j.ajem.2008.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 11/25/2008] [Accepted: 11/28/2008] [Indexed: 11/21/2022] Open
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Groeben H, Brown RH, Kaba S, Mitzner W. DIFFERENT MECHANISMS OF ATELECTASIS FORMATION REQUIRE DIFFERENT TREATMENT STRATEGIES. Exp Lung Res 2009; 34:115-24. [DOI: 10.1080/01902140701884356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mathews B, Shah S, Cleveland RH, Lee EY, Bachur RG, Neuman MI. Clinical predictors of pneumonia among children with wheezing. Pediatrics 2009; 124:e29-36. [PMID: 19564266 DOI: 10.1542/peds.2008-2062] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting. METHODS A prospective cohort study was performed with children <or=21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists. RESULTS A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7-4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3-7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13-1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08-7.54]), triage temperature of >or=38 degrees C (positive LR: 2.03 [95% CI: 1.34-3.07]), maximal temperature in the ED of >or=38 degrees C (positive LR: 1.92 [95% CI: 1.48-2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15-8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38 degrees C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0-4.7]). CONCLUSIONS Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.
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Affiliation(s)
- Bonnie Mathews
- Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts 02115, USA
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Yong JHE, Schuh S, Rashidi R, Vanderby S, Lau R, Laporte A, Nauenberg E, Ungar WJ. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol 2009; 44:122-7. [PMID: 19142890 DOI: 10.1002/ppul.20948] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To carry out a cost-effectiveness analysis of omitting chest radiography in the diagnosis of infant bronchiolitis. HYPOTHESIS Omitting chest radiographs in the diagnosis of typical bronchiolitis was expected to reduce costs without adversely affecting the detection rate of alternate diseases. STUDY DESIGN An economic evaluation was conducted using clinical and health resources. Emergency department (ED) physicians provided diagnoses pre- and post-radiography as well as a management plan. The primary outcome was the diagnostic accuracy (false-negative rate) of alternate diagnoses with and without X-ray. The incremental costs of omitting radiography in comparison to routine radiography per patient were assessed from a health system perspective. PATIENT SELECTION We studied 265 infants, 2-23 months old, presenting at the ED with typical bronchiolitis. Patients with pre-existing conditions or radiographs were omitted from the study. METHODOLOGY Expected costs to the health care system of including and excluding chest radiographs were compared, including costs associated with misdiagnosis. RESULTS All alternate diagnoses (two cases) were missed by ED physicians pre- and post-radiography, resulting in a 100% false negative rate. The specificity in detecting alternate diseases was 96.6% pre-radiography and 88.6% post-radiography. Of the 17 cases of coexistent pneumonia, 88% were missed pre-radiography and 59% post-radiography, with respective false positive rates of 10.5% and 16.1%. Omission of routine chest radiograph saved CDN $59 per patient, primarily due to savings in radiography and hospitalization costs. The economic benefit persisted after the inpatient length of stay, ED overhead and radiograph costs were varied. CONCLUSION For infants with typical bronchiolitis, omitting radiography is cost saving without compromising diagnostic accuracy of alternate diagnoses and of associated pneumonia.
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Affiliation(s)
- Jean Hai Ein Yong
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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Abstract
We report a case of a late-presenting congenital diaphragmatic hernia (CDH) in an otherwise healthy infant initially presenting to the emergency department with wheezing and respiratory distress. Late-presenting CDH can manifest a vast array of clinical symptoms and therefore may frequently masquerade as other more common pediatric entities. Prompt and accurate diagnosis is essential in the management of late-presenting CDH; patients may be critically ill at presentation, and selection of appropriate therapeutic interventions may avoid potentially life-threatening complications. In this case report, we seek to inform emergency physicians about this rare, but serious, disorder.
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Affiliation(s)
- Mercedes M Blackstone
- University of Pennsylvania School of Medicine, Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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21
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Hung GR. Principles of managing children with asthma in the emergency department. Paediatr Child Health 2007; 12:479-481. [PMID: 19030412 DOI: 10.1093/pch/12.6.479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2007] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION: Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families. OBJECTIVE: To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up. CONCLUSIONS: Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.
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Affiliation(s)
- Geoffrey R Hung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia
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Stanley RM, Teach SJ, Mann NC, Alpern ER, Gerardi MJ, Mahajan PV, Chamberlain JM. Variation in ancillary testing among pediatric asthma patients seen in emergency departments. Acad Emerg Med 2007; 14:532-8. [PMID: 17446195 DOI: 10.1197/j.aem.2007.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Variation in the management of acute pediatric asthma within emergency departments is largely unexplored. OBJECTIVES To investigate whether ancillary testing for patients with asthma would be associated with patient, physician, and hospital characteristics. METHODS The authors performed an analysis of a subset of patients from an extensive retrospective chart review of randomly selected charts at all 25 member emergency departments of the Pediatric Emergency Care Applied Research Network. Patients with a diagnosis of asthma were selected for supplemental review and included in this study. Ancillary tests analyzed were chest radiographs and selected blood tests. Hierarchical analyses were performed to describe the associations between ancillary testing and the variables of interest. RESULTS A total of 12,744 chart abstractions were completed, of which 734 (6%) were patients with acute exacerbations of asthma. Overall, 302 patients with asthma (41%) had ancillary testing. Of the 734 patients with asthma, 198 (27%) had chest radiographs and 104 (14%) had blood tests. Chest radiographs were more likely to be ordered in patients with fever. Less blood testing was associated with physician subspecialty training in pediatric emergency medicine, patients treated at children's hospitals, higher patient oxygen saturation, and patient disposition to home. CONCLUSIONS Ancillary testing occurred in more than one third of children with asthma, with chest radiographs ordered most frequently. Efforts to reduce the use of chest radiographs should target the management of febrile patients with asthma, whereas efforts to reduce blood testing should target providers without subspecialty training in pediatric emergency medicine and patients treated in nonchildren's hospitals who are more ill.
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Affiliation(s)
- Rachel M Stanley
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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Abstract
Spontaneous pneumomediastinum (SPM) is a rare, generally benign condition in young children caused by alveolar rupture and dissection of air into the mediastinum and hilum. In children, SPM is seen most commonly in asthmatics but may also occur in any patient who induces a Valsalva maneuver, including coughing, forceful vomiting, or first-time wheezing. There are limited reports on SPM in first-time wheezing episodes. We report a case of a 4-year-old girl with no history of wheezing who presents with wheezing, mild respiratory distress, and salient radiographic findings of pneumomediastinum, including spinnaker sail sign and continuous diaphragm sign. The SPM is generally a benign entity that requires supportive care, and resolution occurs spontaneously. This article will allow the clinician to become familiar with the specific clinical and radiological signs associated with SPM.
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Affiliation(s)
- Francesca M Bullaro
- Departments of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Health Center, Pittsburgh, PA 15213, USA.
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Priftis KN, Mermiri D, Papadopoulou A, Anthracopoulos MB, Vaos G, Nicolaidou P. The Role of Timely Intervention in Middle Lobe Syndrome in Children. Chest 2005; 128:2504-10. [PMID: 16236916 DOI: 10.1378/chest.128.4.2504] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Middle lobe syndrome (MLS) in children is characterized by a spectrum of clinical and radiographic presentations, from persistent or recurrent atelectasis to pneumonitis and bronchiectasis of the right middle lobe (RML) and/or lingula. This study was undertaken to evaluate the effect of early intervention, including fiberoptic bronchoscopy (FOB), in the development of bronchiectasis in MLS. DESIGN Children with atelectasis of the RML and/or lingula persisting for > 1 month or recurring two or more times despite conventional treatment underwent high-resolution CT (HRCT) scanning and FOB. Appropriate treatment and follow-up were provided, and the effect of the duration of symptoms on clinical outcome and the development of bronchiectasis was investigated. The patient cohort was retrospectively reviewed. PATIENTS We evaluated 55 children with MLS. The median age at diagnosis, duration of symptoms, and duration of clinical deterioration before diagnosis were 5.5 years (range, 3 months to 12 years), 14.5 months (range, 3 to 48 months), and 8 months (range, 3 to 36 months), respectively. MEASUREMENTS AND RESULTS FOB revealed marked obstruction in two children (ie, a foreign body and an endobronchial tumor) and positive findings for a culture of BAL fluid in 49.1% of patients. The remaining 53 patients were followed up for a median duration of 24 months (range, 5 to 96 months). The clinical outcome was "cure" in 60.4% of patients, "improvement" in 32.1% of patients, and "no change" in the remaining patients. Bronchiectasis was documented prior to FOB by HRCT scan in 15 patients (27.3%). The duration of the deterioration of symptoms prior to presentation positively correlated with the development of bronchiectasis (p = 0.03) and an unfavorable clinical outcome (ie, improvement or no change) [p = 0.02]; a positive correlation was also found between the duration of symptoms and the development of bronchiectasis (p = 0.04). CONCLUSIONS Timely medical intervention in patients with MLS that includes FOB with BAL prevents bronchiectasis that may be responsible for an ultimately unfavorable outcome.
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Affiliation(s)
- Kostas N Priftis
- Department of Allergology-Pulmonology, Penteli Children's Hospital, 152 36 P. Penteli, Greece.
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Pifferi M, Caramella D, Pietrobelli A, Ragazzo V, Boner AL. Blood gas analysis and chest x-ray findings in infants and preschool children with acute airway obstruction. Respiration 2005; 72:176-81. [PMID: 15824528 DOI: 10.1159/000084049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Accepted: 08/25/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The importance of SaO2 in the assessment of respiratory distress in bronchial asthma has been reported. OBJECTIVES To evaluate the correlation between blood gas analysis and chest X-ray lung opacities in young children presenting with acute respiratory symptoms. METHODS Eighty patients (43 males and 37 females aged 0.5-24 months; mean+/-SD 9.1+/-7.2 months), either with acute wheezing respiratory symptoms and/or with crackles were enrolled in our study. In all children, blood gas analysis and chest X-rays were performed within 12 h following admission to the emergency department. RESULTS In 55 children (68.75%) chest X-rays demonstrated lung opacities. Subjects with normal X-rays had paO2 and SaO2 higher than subjects with lung opacities (p<0.0001 and p=0.0001, respectively). Children with lung opacities almost always presented paO2<80 mm Hg. Sensitivity and specificity for the presence of lung opacities of paO2<80 mm Hg were 81 and 90%, respectively, while sensitivity and specificity of SaO2<95% were 92 and 40%, respectively. paO2<80 mm Hg in association with SaO2<95% had a positive predictive value for the diagnosis of pneumonia of 90.9%. CONCLUSIONS Our study suggests that blood gas analysis, particularly paO2, may help in predicting the presence of lung opacities in patients aged less than 2 years. However, chest X-rays may still be needed to define the actual extension of opacities as well as the possible concomitant presence of complications.
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Piastra M, Polidori G, De Carolis MP, Tempera A, Caresta E, Pulitanò S, Chiaretti A, Valentini P, De Rosa G. Fatal coronary artery anomaly presenting as bronchiolitis. Eur J Pediatr 2005; 164:515-9. [PMID: 15889276 DOI: 10.1007/s00431-005-1684-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Accepted: 03/30/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED During winter outbreaks of respiratory syncytial virus bronchiolitis from 2002 to 2004, three infants presented with a presumptive diagnosis of lower respiratory tract infection and wheezing. The clinical condition in two cases was rapidly progressive and precipitated into intractable shock; clinical and instrumental examinations revealed a cardiac origin of their illness. A subacute presentation permitted a cardiological assessment and a proper treatment in the third infant. An abnormal origin of the left coronary artery from the pulmonary trunk was demonstrated in all cases. The concurrent acute airway infection had a catastrophic effect on the underlying cardiovascular anomaly leading to refractory cardiogenic shock and death. CONCLUSION Admission chest X-ray film and arterial gas analysis can raise the suspicion of cardiac involvement when treating a severe wheezing episode in young infants. Paediatric cardiological evaluation with two-dimensional echocardiography may eventually reveal this rare condition, whereas cardiac catheterisation with aortography remains the standard means of diagnosis.
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Affiliation(s)
- Marco Piastra
- Paediatric Intensive Care Unit, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168 Rome, Italy.
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Naito A, Satoh H, Ohtsuka M, Sekizawa K. Atelectasis of the right medial basal segment mimicking primary lung cancer in an asthmatic patient. Int J Clin Pract 2005:109-10. [PMID: 15875643 DOI: 10.1111/j.1368-504x.2005.00393.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A segmental collapse due to mucous plug in the bronchus tree may mimic malignant pathological conditions. We present a case of 58-year-old asthmatic patient with an obstruction of right medial basal bronchus due to mucous plug, which was simulating mediastinal mass. To the best knowledge, a similar case is not reported in the English medical literature.
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Affiliation(s)
- A Naito
- Division of Respiratory Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba-city, Ibaraki, Japan
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Lantner R, Brennan RA, Gray L, McElroy D. Inpatient management of asthma in the Chicago suburbs: the Suburban Asthma Management Initiative (SAMI). J Asthma 2005; 42:55-63. [PMID: 15801330 DOI: 10.1081/jas-200046951] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Assessment of inpatient asthma management has generally been limited to urban settings, including Chicago, which is known for its high asthma morbidity and mortality. Previously published data have been based on survey methodology. The Suburban Asthma Consortium (SAC) sought to obtain patient-based data unique to the Chicago suburbs to improve asthma care in those areas. OBJECTIVE To evaluate current inpatient asthma management based on the 1997 National Asthma Education and Prevention Program (NAEPP). DESIGN Retrospective chart review of all hospitalized patients 3-65 years bearing asthma-related ICD-9 codes for fiscal year 2002 in community, nonteaching hospitals in Chicago suburbs. RESULTS Nine hundred two cases were submitted from seven hospitals. The majority ( > or = 75%) received inhaled bronchodilators, systemic steroids, oxygen and pulse oximetry. Antibiotic use (67%), chest radiography (85%), complete blood count (77%), and electrolytes (59%) appeared excessive in view of NAEPP recommendations. Peak flow monitoring (PFM) was recorded on admission in 45% of patients 5 years old and older; 52% had PFM during hospitalization. Thirty-eight percent of patients were taking ICS prior to admission; of those not on ICS, only 12% were newly diagnosed asthmatics. Overall, 51% of patients were discharged with ICS. Patients were more likely to receive ICS at discharge if they had required intensive care (ICU), had been on ICS prior to admission, were referred to an asthma specialist while hospitalized, or were insured. Patients with Medicare/Medicaid (MC/MA) had more repeat emergency visits and hospitalizations, longer lengths of stay, and received less ICS at discharge. Depending on the parameter, 41% or less patients received discharge planning education and were not more likely to have received education if in the ICU. Results ranged significantly between hospitals for most parameters (p < 0.05 or less). CONCLUSION Study subjects received appropriate acute therapy and oxygen monitoring, but there was a divergence from NAEPP recommendations regarding PFM, ICS use, antibiotics, and laboratory evaluation. Patients receiving MC/MA experienced higher morbidity and received less ICS. Discharge asthma education was suboptimal for most hospitals. Most parameters demonstrated significantly wide practice variations between hospitals. Peak flow monitoring and patient education findings differed significantly from those in survey-conducted studies.
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Reduce the rads: a quality assurance project on reducing unnecessary chest X-rays in children with asthma. J Paediatr Child Health 2005; 41:107-11. [PMID: 15790320 DOI: 10.1111/j.1440-1754.2005.00559.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To quantify and then reduce the number of unnecessary chest X-rays (CXR) being performed on children presenting with asthma. METHODS A retrospective review of case notes of all children, aged 1-15 years, who presented with asthma and had a CXR performed. The setting was two General Hospitals that see all children presenting to an emergency department in the region. The period of review was before and after the development and implementation of a simple guide for staff, with an education programme, outlining when CXR were deemed unnecessary (known asthmatic, primary diagnosis asthma, improving with treatment, pneumothorax not suspected, and not in Intensive Care Unit). RESULTS In the 12 months prior to the education programme, 466 children presented with asthma: 260 had a CXR, of which 211 (81.1%) were unnecessary. During the 6 month period following implementation of the programme 197 presented with asthma: 72 had a CXR, of which 56 (78%) were deemed unnecessary. However the percentage of all children presenting with asthma who had an unnecessary CXR fell from 45.3% (211/466) to 28.4% (56/197): P = 0.00005. There was also a decrease in the admission rate from 46% before to 31% after the period of education. CONCLUSION This study determined that an unacceptably high rate of unnecessary CXR was being ordered in children presenting to hospital with asthma. It also showed how a clinically and statistically significant reduction in the overall number of CXR could be achieved, through a simple and easy to implement educational programme. Further measures are needed in addition to ongoing education in order to improve on this achievement.
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García García ML, Calvo Rey C, Quevedo Teruel S, Martínez Pérez M, Sánchez Ortega F, Martín del Valle F, Verjano Sánchez F, Pérez-Breña P. [Chest radiograph in bronchiolitis: is it always necessary?]. An Pediatr (Barc) 2005; 61:219-25. [PMID: 15469805 DOI: 10.1016/s1695-4033(04)78800-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The routine use of chest radiograph in infants with bronchiolitis increases health costs and can often unnecessarily expose the patient to radiation. OBJECTIVES To evaluate the prevalence of infiltrate/atelectasis in infants younger than 2 years who presented to the emergency department with bronchiolitis, to assess whether patient management is changed after viewing the chest radiograph and to determine which clinical variables can accurately identify children with normal radiographs, with a view to reducing unnecessary radiological investigations. PATIENTS AND METHODS From October 2003 to December 2004, infants aged < 24 months evaluated in the emergency department of the Severo Ochoa Hospital (Madrid) with a diagnosis of bronchiolitis were included in this study. The variables registered were age, sex, time since onset, respiratory rate, temperature, asymmetry on auscultation, oxygen saturation and the virus identified. A chest radiograph was obtained and the need for admission was evaluated before and after obtaining the results. RESULTS Two hundred fifty-two infants were included, of which 50 % were aged less than 5 months. Infiltrate/atelectasis was identified in 14.3 % (95 % CI: 10.1-18.5; kappa coefficient: 0.64). Patients with infiltrate/atelectasis were 2.5 times more likely to have a temperature of > or = 38 degrees C (p: 0.004), O2 saturation of < 94 % (p: 0,006) and to be admitted before the results of chest radiograph were known. No differences were found between children with and without infiltrate in age at presentation, sex, disease duration, respiratory rate or identified virus. Patient management was modified in 30 % of patients with infiltrate/ atelectasis. Patients with a temperature of < 38 degrees and O2 saturation of > 94 % had a 92 % probability of normal chest radiograph. CONCLUSIONS Most infants presenting with bronchiolitis had a normal chest radiograph. Temperature >or = 38 degrees and O2 saturation < 94 % were significantly associated with infiltrate/atelectasis. In most infants with bronchiolitis, the absence of fever and hypoxia are good predictors of normal chest radiographs.
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Abstract
Chest X-ray in 60 children (0-6 yr old) with newly diagnosed asthma at the primary care level showed normal findings in 85% at paediatric follow-up. The pathological findings were transient. The only X-ray tht led to change in treatment was performed on clinical grounds due to concurrent disease. In conclusion, routine X-ray need not be part of the initial routine work up of asthma in preschool children.
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Affiliation(s)
- Carl-Axel Hederos
- Primary Care Research Centre, Karolinska Institutet, Stockholm, Sweden.
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Gentile NT, Ufberg J, Barnum M, McHugh M, Karras D. Guidelines reduce x-ray and blood gas utilization in acute asthma. Am J Emerg Med 2003; 21:451-3. [PMID: 14574649 DOI: 10.1016/s0735-6757(03)00165-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Using a retrospective chart review, we compared the use of chest radiography (CXR) and arterial blood gas testing (ABG) before (pre-P) and after (post-P) initiation of specific ordering guidelines for the use of these studies for patients presenting to the ED with acute asthma exacerbation. We noted the number of tests performed, the indication for the test, and the results when performed. There was a 55% reduction in the number of chest radiographs (85 of 213 patients pre-P had CXR as compared with 40 of 222 patients post-P, P <.001). Of the patients who did not have a chest x-ray in the ED, none had an abnormal chest x-ray obtained after admission or if they returned to the ED within 72 hours. There was a 57% reduction in the number of arterial blood gases post-P (9 of 222 patients) as compared with pre-P (20 of 213 patients, P <.001). Although patients with abnormal ABGs had a discernible indication for testing, all of the ABGs for which no indication could be found were normal. A protocol containing criteria for obtaining chest x-rays and arterial blood gas testing can reduce the use of diagnostic testing, thereby improving ED efficiency without adversely impacting patient care.
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Affiliation(s)
- Nina T Gentile
- Emergency Medicine, Temple University Hospital and School of Medicine, 1107 Jones Hall, 3401 N. Broad Street, Philadelphia, PA 10140 , USA.
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Abstract
The increasing incidence and prevalence of asthma in many parts of the world continue to make it a global health concern. The heterogeneous nature of the clinical manifestations and therapeutic responses of asthma in both adult and pediatric patients indicate that it may be more of a syndrome rather than a specific disease entity. Numerous triggering factors including viral infections, allergen and irritant exposure, and exercise, among others, complicate both the acute and chronic treatment of asthma. Therapeutic intervention has focused on the appreciation that airway obstruction in asthma is composed of both bronchial smooth muscle spasm and variable degrees of airway inflammation characterized by edema, mucus secretion, and the influx of a variety of inflammatory cells. The presence of only partial reversibility of airflow obstruction in some patients indicates that structural remodeling of the airways may also occur over time. Choosing appropriate medications depends on the disease severity (intermittent, mild persistent, moderate persistent, severe persistent), extent of reversibility, both acutely and chronically, patterns of disease activity (exacerbations related to viruses, allergens, exercise, etc), and the age of onset (infancy, childhood, adulthood).
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Affiliation(s)
- Robert F Lemanske
- Departments of Medicine and Pediatrics, University of Wisconsin Medical School, Madison, WI 53792, USA
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Farah MM, Padgett LB, McLario DJ, Sullivan KM, Simon HK. First-time wheezing in infants during respiratory syncytial virus season: chest radiograph findings. Pediatr Emerg Care 2002; 18:333-6. [PMID: 12395001 DOI: 10.1097/00006565-200210000-00001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the prevalence of pathologic chest radiographs in infants presenting with a first episode of wheezing during respiratory syncytial virus (RSV) seasons and to compare demographics and clinical variables between patients with benign and pathologic chest radiographs. METHODS We conducted a descriptive study of infants presenting to the emergency departments and urgent care centers of two tertiary care children's hospitals. All previously healthy infants aged 0 to 12 months presenting with a first episode of wheezing were eligible. Signs and symptoms were recorded, and then a chest radiograph was obtained. After the completion of the study, all chest radiographs were reviewed by two pediatric radiologists blinded to the child's clinical presentation and diagnosis. Associations between signs and symptoms and chest radiograph findings were evaluated. RESULTS A total of 140 patients were enrolled. One (0.7%) patient had a cardiac anomaly, and 23 patients (16%) had an infiltrate versus atelectasis. The cardiac anomaly was suspected based on the clinical signs and symptoms present prior to obtaining the chest radiograph. Of the 23 patients with infiltrate/atelectasis, only eight (35%) were febrile, 12 (52%) were tachypneic, and nine (39%) were hypoxemic. CONCLUSION Seventeen percent of 140 previously healthy infants presenting with a first episode of wheezing during RSV seasons had a pathologic chest radiograph. However, only one patient (0.7%) had a cardiac anomaly, and all others had chest radiograph findings consistent with a respiratory tract infection.
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Affiliation(s)
- Mirna M Farah
- Department of Emergency Medicine, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
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35
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Abstract
OBJECTIVE To determine if clinical variables assessed in relation to Albuterol aerosol treatments accurately identify children with pathologic radiographs during their initial episode of bronchospasm. METHODS A prospective convenience sample of children with a first episode of wheezing. Data collected included demographics, baseline and post-treatment clinical score and physical examination, number of aerosols, requirement for supplemental oxygen, and disposition. Chest radiographs were obtained and interpreted, and patients were divided into 2 groups based on a pathologic versus nonpathologic radiograph interpretation. Chi2 testing was performed for categoric variables, and the student t test was performed for continuous variables. A discriminant analysis was used to develop a model. RESULTS Pathologic radiographs were identified in 61 patients (9%). Between groups, a significant difference was noted for pretreatment oxygen saturation only. Clinical score, respiratory rate, and presence of rales both pretreatment and posttreatment were not significantly different between groups. The discriminant analysis correctly predicted 90% of nonpathologic radiographs but only 15% of pathologic radiographs. CONCLUSIONS Clinical variables, either isolated or as components of a model, could not identify all children with pathologic radiographs.
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Skogvoll E, Grammeltvedt AT, Aadahl P, Mostad U, Slørdahl S. Life-threatening upper airway obstruction in a child caused by retropharyngeal emphysema. Acta Anaesthesiol Scand 2001; 45:393-5. [PMID: 11207480 DOI: 10.1034/j.1399-6576.2001.045003393.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 2 1/2-year-old boy with acute obstructive lung disease from adenovirus infection developed cough-induced paroxysms of intense dyspnoea leading to respiratory failure. Chest x-ray and fluoroscopy demonstrated retropharyngeal air occluding the airway. The clinical management of this and similar air-leak problems is discussed.
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Affiliation(s)
- E Skogvoll
- Department of Paediatrics, Trondheim University Hospital, Norway.
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Mahabee-Gittens EM, Dowd MD, Beck JA, Smith SZ. Clinical factors associated with focal infiltrates in wheezing infants and toddlers. Clin Pediatr (Phila) 2000; 39:387-93. [PMID: 10914302 DOI: 10.1177/000992280003900702] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It can be challenging to determine which findings are associated with focal infiltrates in young wheezing children. A prospective study of wheezing children < or = 18 months of age revealed focal infiltrates on chest radiograph in 23%. By use of multivariate analysis, findings significantly associated with focal infiltrates included grunting (OR 4.1, 95% CI, 2.0, 8.6) and oxygen saturation < or = 93% (OR 2.2, 95% CI, 1.1, 4.8); with a sensitivity and specificity of 12.5% and 97%, respectively. Variables not associated with focal infiltrates included first-time wheezing, fever, and tachypnea. The combination of grunting and oxygen saturation < or = 93% is highly specific and can be used to help diagnose pneumonia in wheezing infants and toddlers.
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Affiliation(s)
- E M Mahabee-Gittens
- Children's Hospital Medical Center, Division of Emergency Medicine, Cincinnati, Ohio 45229-2899, USA
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Affiliation(s)
- R J Scarfone
- Division of Emergency Medicine, Children's Hospital of Philadelphia, PA 19104-4399, USA
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Mahabee-Gittens EM, Bachman DT, Shapiro ED, Dowd MD. Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila) 1999; 38:395-9. [PMID: 10416095 DOI: 10.1177/000992289903800703] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are no widely accepted predictors of pneumonia in wheezing infants and toddlers who present to the emergency department (ED). A 10-month retrospective review of ED visits of wheezing children < or = 18 months of age revealed the following chest radiograph (CXR) results: normal (21%), findings consistent with uncomplicated bronchiolitis or asthma (61%), focal infiltrates (18%), and other abnormalities (< 1%). Patients with focal infiltrates on CXR were more likely to have the following: a history of fever (p = 0.03, OR 2.1, 95% CI 1.0, 4.4), temperature > or = 38.4 degrees (p = 0.01, OR 2.5, 95% CI 1.1, 5.8) or crackles on examination (p < 0.0005, OR 3.9, 95% CI 1.7, 9.0). Selective use of CXRs has the potential to save health care dollars and limit unnecessary radiation.
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Affiliation(s)
- E M Mahabee-Gittens
- Division of Emergency Medicine, Children's Hospital Medical Center, Cincinnati, Ohio 45229-2899, USA
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van der Jagt ÉW. CONTEMPORARY ISSUES IN THE EMERGENCY CARE OF CHILDREN WITH ASTHMA. Immunol Allergy Clin North Am 1998. [DOI: 10.1016/s0889-8561(05)70357-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
We present a review of specific health status measures, including symptoms, physical examination, and laboratory tests (exclusive of lung function tests), in terms of their suitability for assessing the presence and severity of asthma in epidemiologic and clinical research. We focus on the validity, reliability, and responsiveness to clinical intervention of these measures. Several adult questionnaires designed for epidemiologic research include questions on asthma and wheezing that have demonstrated repeatability and validity against concurrent measurements of nonspecific airway responsiveness. The International Union Against Tuberculosis Bronchial Symptoms Questionnaire was designed specifically to detect asthma and airway hyperresponsiveness in adult populations, and its reliability and validity have been well documented. A childhood questionnaire developed by Australian investigators has been demonstrated to provide information on asthma and wheezing that is reliable and valid against the criterion of concurrently measured nonspecific airway responsiveness. Although suitable for epidemiologic research, these questionnaires do not provide sufficient data on the severity of current asthma symptoms (aspects of which include intensity, duration, and frequency of symptoms) to be useful for clinical research involving subjects with established asthma. Many different methods of obtaining and analyzing symptom data have been used in clinical trials, but these have not received the methodologic scrutiny that allow the recommendation of a "best" approach for evaluating symptoms in clinical trials of interventions for asthma. The use of daily symptom diaries in short-term drug trials is common, but the optimal symptom-reporting interval for such studies has not been established. Similarly, a particular approach to integrating different symptoms (wheeze, dyspnea, cough, sputum) and the different aspects of these symptoms (intensity, duration, frequency) cannot be recommended on the basis of available data. Physical examination findings have little utility as asthma outcome measures because they may be normal between symptom episodes, they have relatively poor interobserver reliability, and they are relatively poor predictors of the outcome of emergency room visits for asthma. The finding of an elevated arterial PCO2 has utility as an indicator of a severe asthma attack, but arterial blood gas measurements have little other utility as asthma outcome measures. The chest radiograph is generally normal in patients with asthma and therefore not useful as an asthma outcome measure.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- G T O'Connor
- Pulmonary Center, Boston University School of Medicine, MA 02118
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Emerman CL, Cydulka RK. Evaluation of high-yield criteria for chest radiography in acute exacerbation of chronic obstructive pulmonary disease. Ann Emerg Med 1993; 22:680-4. [PMID: 8457095 DOI: 10.1016/s0196-0644(05)81847-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
STUDY OBJECTIVES The objectives of this study were to assess the incidence of abnormal chest radiographs and to test the validity of previously developed high-yield criteria. There is disagreement about the need for chest radiography in acute exacerbation of chronic obstructive pulmonary disease, although high-yield criteria have been developed. DESIGN Retrospective chart review study. SETTING County-owned, university-affiliated, urban emergency department. PARTICIPANTS ED patients seen between January 1988 and July 1991 with chronic obstructive pulmonary disease. RESULTS Eight hundred forty-seven ED visits were identified; medical records were available for 742. Radiographs were not taken in 8%, leaving 685 ED visits in the study. One hundred nine patients (16%) had significant abnormalities, including 88 new infiltrates, two new lung masses, one pneumothorax, and 20 episodes of pulmonary edema. A history of congestive heart failure and fever was associated with abnormalities, as were findings of rales, pedal edema, and jugular venous distension. There was no association with WBC count, temperature, coronary artery disease, chest pain, or sputum production. Previously published high-yield criteria had a sensitivity of .76; specificity, .41; positive predictive value, 20; negative predictive value, .90; and accuracy, .47. CONCLUSION Radiographic abnormalities are common findings in acute exacerbation of chronic obstructive pulmonary disease. We found that almost one fourth of radiographic abnormalities are not predictable on the basis of previously developed high-yield criteria. Routine chest radiography should be considered in patients with acute exacerbation of chronic obstructive pulmonary disease to diagnose treatable, radiographically apparent abnormalities.
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Affiliation(s)
- C L Emerman
- Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, Ohio
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43
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Affiliation(s)
- C A Hirshman
- Department of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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44
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Dalton AM. A review of radiological abnormalities in 135 patients presenting with acute asthma. Arch Emerg Med 1991; 8:36-40. [PMID: 1854391 PMCID: PMC1285731 DOI: 10.1136/emj.8.1.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Six hundred and ninety-five attendances were made to the Accident and Emergency Department of a district general hospital over a 6-month period by patients with acute asthma. On hundred and thirty-five chest radiographs were performed, and the radiologists' reports analysed. Nineteen abnormalities were reported (14%) which may have altered the management of the patient. It is recommended that chest radiographs be considered in patients who do not rapidly respond to initial therapy.
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Affiliation(s)
- A M Dalton
- Department of Accident and Emergency Medicine, Ealing Hospital, Southall, Middlesex, U.K
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45
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Anderson HR. Trends and district variations in the hospital care of childhood asthma: results of a regional study 1970-85. Thorax 1990; 45:431-7. [PMID: 1975463 PMCID: PMC462524 DOI: 10.1136/thx.45.6.431] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Trends and district variations in the pre-hospital and hospital care of children aged 0-14 years admitted with acute asthma were surveyed in all 13 districts of a health region by examining case notes for 1970, 1978, and 1985. From 1970 to 1985 there was a substantial increase in admissions and some reduction of hospital stay. Over this time adrenergic drugs remained the most frequently used treatment with a large shift towards selective beta2 agonists administered by nebulisation. Use of corticosteroids fell in the under 5s with a decrease in the parenteral route of administration but rose in the 5-14 age group with an increase in the oral route of administration. There was an increase the use of oral xanthines but this was outweighed by falls in the use of suppositories and in parenteral administration. The use of antibiotics became less frequent and that of sedatives and antihistamines fell to almost nil. There were also important changes in other aspects of management, notably an increase in the use of lung function tests (from 3% to 70%) and falls in the use of chest radiographs, blood tests, bacteriology, and physiotherapy. In nearly all aspects of management there were significant and often very extreme variations in practice between districts, which were unlikely to be explained by differences in morbidity. These variations would be a suitable focus for medical audit, with the aim of establishing which treatment regimens have the best outcome and avoiding unnecessary cost and discomfort. Because early hospital drug treatment is closely related to the type of treatment given before admission such audit activities would need to include general practitioners.
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Affiliation(s)
- H R Anderson
- Department of Public Health Sciences, St George's Hospital Medical School, London
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46
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Affiliation(s)
- B K Rubin
- Pulmonary Defense Group, University of Alberta, Edmonton, Canada
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Alario AJ, McCarthy PL, Markowitz R, Kornguth P, Rosenfield N, Leventhal JM. Usefulness of chest radiographs in children with acute lower respiratory tract disease. J Pediatr 1987; 111:187-93. [PMID: 3612388 DOI: 10.1016/s0022-3476(87)80065-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To determine how frequently and under what circumstances the chest radiograph changes pre-x-ray diagnoses and plans for management of suspected acute lower respiratory tract disease, experienced pediatricians performed a three-phased sequential evaluation (observation, history, physical examination), determined an initial diagnosis and the need for a chest radiograph after each phase, and recorded pre- and post-x-ray diagnoses and plans of management. Of the 102 children evaluated, the chest radiograph resulted in a change of the pre-x-ray diagnosis in 21% and pre-x-ray management plans in 16%. In the majority of these cases, a diagnosis previously considered less likely was "ruled in" or therapy was instituted rather than withheld. More important, when the pattern of decision making was consistent, with the initial diagnosis and the need for a chest radiograph remaining the same throughout all phases, the chest radiograph resulted in a change of pre-x-ray diagnosis in five (10%) of 48 patients, compared with a change in 16 (30%) of 54 when the pattern was inconsistent (P less than 0.02). Similarly, when the pattern was consistent, the pre-x-ray management was modified in only three (6%) of 48 patients versus 13 (24%) of 54 inconsistent cases (P less than 0.015). Chest radiographs are least useful when information from sequential observation, history, and physical examination is consistent in suggesting the same diagnosis and need for a chest radiograph. Radiographs appear to have greater impact on diagnosis and management when any inconsistencies arise.
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49
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Simel DL, Feussner JR, DeLong ER, Matchar DB. Intermediate, indeterminate, and uninterpretable diagnostic test results. Med Decis Making 1987; 7:107-14. [PMID: 3574020 DOI: 10.1177/0272989x8700700208] [Citation(s) in RCA: 104] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diagnostic tests do not always yield positive or negative results; sometimes the results are intermediate, indeterminate, or uninterpretable. No consensus exists for the incorporation of such results into data assessment. Conventional Bayesian analysis leads investigators to either exclude patients with non-positive, non-negative results from their studies or categorize such results into inappropriate cells of the standard four-cell decision matrix. The authors propose a standardized method for reporting results in studies dealing with diagnostic test use and discuss how researchers should expand the four-cell matrix to six cells when non-positive, non-negative results occur. They suggest that the six-cell matrix with new operational definitions of sensitivity, specificity, likelihood ratios, and test yield should be adopted routinely. In addition, they define the different types of non-positive, non-negative results and demonstrate how clinicians can use tree-structured decision analysis from the six-cell matrix. While their method does not solve all problems posed by non-positive, non-negative results, it does suggest a standard method for reporting these results and utilizing all the data in decision making.
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Jaffe DM, Binns H, Radkowski MA, Barthel MJ, Engelhard HH. Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med 1987; 16:270-6. [PMID: 3813160 DOI: 10.1016/s0196-0644(87)80171-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To define a subset of injured children for whom emergency cervical spine radiography may be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each child's chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice.
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