The effect of chest radiographs on the management and clinical course of patients with acute cough

Chest Radiograph Utilization Among Children Treated for Pneumonia in a Primary Care Network

This retrospective cohort study across 77 pediatric practices in Massachusetts assessed the frequency of CXR utilization among children with pneumonia diagnosed in the primary care setting and determined whether CXR utilization was associated with differences in antibiotic treatment and outcomes. Multivariable logistic regression was used to evaluate the association between CXR performance and future clinic revisit, CXR performance, antibiotic change, and a composite treatment failure outcome, adjusting for markers of illness severity. Among 29 528 children treated for pneumonia, 2462 (10.1%) had a CXR performed. CXR utilization varied by practice (range 0%-75% [IQR 2.7%-16.5%]). The odds of a composite outcome of treatment failure did not differ between children who had a CXR performed and those who did not (aOR 1.06; 95% CI [0.68, 1.65]). CXR was performed in the minority of patients diagnosed with pneumonia. Children who had a CXR performed had similar outcomes to those treated for pneumonia without CXR.

Diagnosis of common pulmonary diseases in children by X-ray images and deep learning

Acute lower respiratory infection is the leading cause of child death in developing countries. Current strategies to reduce this problem include early detection and appropriate treatment. Better diagnostic and therapeutic strategies are still needed in poor countries. Artificial-intelligence chest X-ray scheme has the potential to become a screening tool for lower respiratory infection in child. Artificial-intelligence chest X-ray schemes for children are rare and limited to a single lung disease. We need a powerful system as a diagnostic tool for most common lung diseases in children. To address this, we present a computer-aided diagnostic scheme for the chest X-ray images of several common pulmonary diseases of children, including bronchiolitis/bronchitis, bronchopneumonia/interstitial pneumonitis, lobar pneumonia, and pneumothorax. The study consists of two main approaches: first, we trained a model based on YOLOv3 architecture for cropping the appropriate location of the lung field automatically. Second, we compared three different methods for multi-classification, included the one-versus-one scheme, the one-versus-all scheme and training a classifier model based on convolutional neural network. Our model demonstrated a good distinguishing ability for these common lung problems in children. Among the three methods, the one-versus-one scheme has the best performance. We could detect whether a chest X-ray image is abnormal with 92.47% accuracy and bronchiolitis/bronchitis, bronchopneumonia, lobar pneumonia, pneumothorax, or normal with 71.94%, 72.19%, 85.42%, 85.71%, and 80.00% accuracy, respectively. In conclusion, we provide a computer-aided diagnostic scheme by deep learning for common pulmonary diseases in children. This scheme is mostly useful as a screening for normal versus most of lower respiratory problems in children. It can also help review the chest X-ray images interpreted by clinicians and may remind possible negligence. This system can be a good diagnostic assistance under limited medical resources.

Prediction model for pneumonia in primary care patients with an acute respiratory tract infection: role of symptoms, signs, and biomarkers

BACKGROUND

Diagnosing pneumonia can be challenging in general practice but is essential to distinguish from other respiratory tract infections because of treatment choice and outcome prediction. We determined predictive signs, symptoms and biomarkers for the presence of pneumonia in patients with acute respiratory tract infection in primary care.

METHODS

From March 2012 until May 2016 we did a prospective observational cohort study in three radiology departments in the Leiden-The Hague area, The Netherlands. From adult patients we collected clinical characteristics and biomarkers, chest X ray results and outcome. To assess the predictive value of C-reactive protein (CRP), procalcitonin and midregional pro-adrenomedullin for pneumonia, univariate and multivariate binary logistic regression were used to determine risk factors and to develop a prediction model.

RESULTS

Two hundred forty-nine patients were included of whom 30 (12%) displayed a consolidation on chest X ray. Absence of runny nose and whether or not a patient felt ill were independent predictors for pneumonia. CRP predicts pneumonia better than the other biomarkers but adding CRP to the clinical model did not improve classification (- 4%); however, CRP helped guidance of the decision which patients should be given antibiotics.

CONCLUSIONS

Adding CRP measurements to a clinical model in selected patients with an acute respiratory infection does not improve prediction of pneumonia, but does help in giving guidance on which patients to treat with antibiotics. Our findings put the use of biomarkers and chest X ray in diagnosing pneumonia and for treatment decisions into some perspective for general practitioners.

Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report

BACKGROUND

Patients commonly present to primary care services with upper and lower respiratory tract infections, and guidelines to help physicians investigate and treat acute cough due to suspected pneumonia and influenza are needed.

METHODS

A systematic search was carried out with eight patient, intervention, comparison, outcome questions related to acute cough due to suspected pneumonia or influenza.

RESULTS

There was a lack of randomized controlled trials in the setting of outpatients presenting with acute cough due to suspected pneumonia or influenza who were not hospitalized. Both clinical suggestions and research recommendations were made on the evidence available and CHEST Expert Cough Panel advice.

CONCLUSIONS

For outpatient adults with acute cough due to suspected pneumonia, we suggest the following clinical symptoms and signs are suggestive of pneumonia: cough; dyspnea; pleural pain; sweating, fevers, or shivers; aches and pains; temperature ≥ 38°C; tachypnea; and new and localizing chest examination signs. Those suspected of having pneumonia should undergo chest radiography to improve diagnostic accuracy. Although the measurement of C-reactive protein levels strengthens both the diagnosis and exclusion of pneumonia, there was no added benefit of measuring procalcitonin levels in this setting. We suggest that there is no need for routine microbiological testing. We suggest the use of empiric antibiotics according to local and national guidelines when pneumonia is suspected in settings in which imaging cannot be performed. Where there is no clinical or radiographic evidence of pneumonia, we do not suggest the routine use of antibiotics. There is insufficient evidence to make recommendations for or against specific nonantibiotic, symptomatic therapies. Finally, for outpatient adults with acute cough and suspected influenza, we suggest that initiating antiviral treatment (according to Centers for Disease Control and Prevention advice) within 48 hours of symptoms could be associated with decreased antibiotic use and hospitalization and improved outcomes.

In with acute bronchitis; out with duodenal perforation: the potentially harmful cascade of over-testing. A case report

Overutilization of diagnostic imaging can lead to unnecessary interventions and subsequently can jeopardize patient safety. When ordered, the results of these images should always be interpreted in the appropriate clinical context taking into consideration the patient clinical presentation and the natural history of the diseases which are being investigated. We presented a case that demonstrates for the practicing physicians how violating these two notions can lead ultimately to patient harm.

Community-acquired pneumonia in the post 13-valent pneumococcal conjugate vaccine era

PURPOSE OF REVIEW

This review covers the outpatient management of pediatric community-acquired pneumonia (CAP), discussing the changing microbiology of CAP since the introduction of the 13-valent pneumococcal conjugate vaccine in 2010, and providing an overview of national guideline recommendations for diagnostic evaluation and treatment.

RECENT FINDINGS

Rates of invasive pneumococcal disease and pneumococcal antibiotic resistance have plummeted since widespread 13-valent pneumococcal conjugate vaccine immunization. Viruses remain the most common cause of CAP in young children; children over age 5 years have increased rates of Mycoplasma pneumoniae. A recent national guideline offers recommendations for office-based diagnostic evaluation and treatment of pediatric CAP.

SUMMARY

This review offers a discussion of the above findings with practical recommendations for the office-based practitioner in the evaluation and treatment of an infant (>3 months) or child with suspected CAP.

Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia

OBJECTIVE

National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia.

METHODS

Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results.

RESULTS

Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%).

CONCLUSIONS

Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Chest radiographs for acute lower respiratory tract infections

BACKGROUND

Acute lower respiratory tract infections (LRTIs) (e.g. pneumonia) are a major cause of morbidity and mortality and management focuses on early treatment. Chest radiographs (X-rays) are one of the commonly used strategies. Although radiological facilities are easily accessible in high-income countries, access can be limited in low-income countries. The efficacy of chest radiographs as a tool in the management of acute LRTIs has not been determined. Although chest radiographs are used for both diagnosis and management, our review focuses only on management.

OBJECTIVES

To assess the effectiveness of chest radiographs in addition to clinical judgement, compared to clinical judgement alone, in the management of acute LRTIs in children and adults.

SEARCH METHODS

We searched CENTRAL 2013, Issue 1; MEDLINE (1948 to January week 4, 2013); EMBASE (1974 to February 2013); CINAHL (1985 to February 2013) and LILACS (1985 to February 2013). We also searched NHS EED, DARE, ClinicalTrials.gov and WHO ICTRP (up to February 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of chest radiographs versus no chest radiographs in acute LRTIs in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, extracted data and assessed risk of bias. A third review author compiled the findings and any discrepancies were discussed among all review authors. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Two RCTs involving 2024 patients (1502 adults and 522 children) were included in this review. Both RCTs excluded patients with suspected severe disease. It was not possible to pool the results due to incomplete data. Both included trials concluded that the use of chest radiographs did not result in a better clinical outcome (duration of illness and of symptoms) for patients with acute LRTIs. In the study involving children in South Africa, the median time to recovery was seven days (95% confidence interval (CI) six to eight days (radiograph group) and six to nine days (control group)), P value = 0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34). In the study with adult participants in the USA, the average duration of illness was 16.9 days versus 17.0 days (P value > 0.05) in the radiograph and no radiograph groups respectively. This result was not statistically significant and there were no significant differences in patient outcomes between the groups with or without chest radiograph.The study in adults also reports that chest radiographs did not affect the frequencies with which clinicians ordered return visits or antibiotics. However, there was a benefit of chest radiographs in a subgroup of the adult participants with an infiltrate on their radiograph, with a reduction in length of illness (16.2 days in the group allocated to chest radiographs and 22.6 in the non-chest radiograph group, P < 0.05), duration of cough (14.2 versus 21.3 days, P < 0.05) and duration of sputum production (8.5 versus 17.8 days, P < 0.05). The authors mention that this difference in outcome between the intervention and control group in this particular subgroup only was probably a result of "the higher proportion of patients treated with antibiotics when the radiograph was used in patient care".Hospitalisation rates were only reported in the study involving children and it was found that a higher proportion of patients in the radiograph group (4.7%) required hospitalisation compared to the control group (2.3%) with the result not being statistically significant (P = 0.14). None of the trials report the effect on mortality, complications of infection or adverse events from chest radiographs. Overall, the included studies had a low or unclear risk for blinding, attrition bias and reporting bias, but a high risk of selection bias. Both trials had strict exclusion criteria which is important but may limit the clinical practicability of the results as participants may not reflect those presenting in clinical practice.

AUTHORS' CONCLUSIONS

Data from two trials suggest that routine chest radiography does not affect the clinical outcomes in adults and children presenting to a hospital with signs and symptoms suggestive of a LRTI. This conclusion may be weakened by the risk of bias of the studies and the lack of complete data available.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

WITHDRAWN: Chest radiograph in acute respiratory infections

BACKGROUND

Chest radiography is widely used during the management of acute lower respiratory infections, but the benefits are unknown.

OBJECTIVES

To assess the effects of chest radiography on clinical outcome in acute lower respiratory infections.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1950 to January 2007) and EMBASE (January 1976 to February 2007).

SELECTION CRITERIA

Randomised or quasi-randomised trials of chest radiography in acute respiratory infections.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the inclusion criteria, extracted data and assessed trial quality.

MAIN RESULTS

We identified two trials. One, of 522 outpatient children (and performed by the review authors), found that 46% of both radiography and control participants had recovered by seven days (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.31). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (RR 1.02, 95% CI 0.79 to 1.30) and 3% of both radiography and control participants were subsequently admitted to hospital within four weeks (RR 1.02, 95% CI 0.41 to 2.52). The other trial involving 1502 adults attending an emergency department found no significant difference in length of illness, the single outcome prespecified for this review (mean of 16.9 days in radiograph group versus 17.0 days in control group, P > 0.05).

AUTHORS' CONCLUSIONS

There is no evidence that chest radiography improves outcome in outpatients with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to outpatients only.

Chest radiograph in acute respiratory infections

BACKGROUND

Chest radiography is widely used during the management of acute lower respiratory infections, but the benefits are unknown.

OBJECTIVES

To assess the effects of chest radiography on clinical outcome in acute lower respiratory infections.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1950 to January 2007) and EMBASE (January 1976 to February 2007).

SELECTION CRITERIA

Randomised or quasi-randomised trials of chest radiography in acute respiratory infections.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the inclusion criteria, extracted data and assessed trial quality.

MAIN RESULTS

We identified two trials. One, of 522 outpatient children (and performed by the review authors), found that 46% of both radiography and control participants had recovered by seven days (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.31). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (RR 1.02, 95% CI 0.79 to 1.30) and 3% of both radiography and control participants were subsequently admitted to hospital within four weeks (RR 1.02, 95% CI 0.41 to 2.52). The other trial involving 1502 adults attending an emergency department found no significant difference in length of illness, the single outcome prespecified for this review (mean of 16.9 days in radiograph group versus 17.0 days in control group, P > 0.05).

AUTHORS' CONCLUSIONS

There is no evidence that chest radiography improves outcome in outpatients with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to outpatients only.

Assessing, treating and preventing community acquired pneumonia in older adults: findings from a community-wide survey of emergency room and family physicians

BACKGROUND

Respiratory infections, like pneumonia, represent an important threat to the health of older Canadians. Our objective was to determine, at a community level, family and emergency room physicians' knowledge and beliefs about community acquired pneumonia (CAP) in older adults and to describe their self-reported assessment, management and prevention strategies.

METHODS

All active ER and family physicians in Brant County received a mailed questionnaire. An advance notification letter and three follow-up mailings were used to maximize physician participation rate. The questionnaire collected information about physicians' assessment, management, and prevention strategies for CAP in older adults (>or=60 years of age) plus demographic, training, and practice characteristics. The analysis highlights differences in approaches between office-based and emergency department physicians.

RESULTS

Seventy-seven percent of physicians completed and returned the survey. Although only 16% of physicians were very confident in assessing CAP in older adults, more than half reported CAP to be a very important health concern in their practices. In-service training for family physicians was associated with increased confidence in CAP assessment and more frequent use of diagnostic tests. Family physicians who reported always requesting chest x-rays were also more likely to request pulse oximetry (OR 5.6, 95% CI 1.40 to 22.5) and recommend both follow-up x-rays (OR 5.4, 95% CI 1.7 to 16.6) and pneumococcal vaccination (OR 3.4, 95% CI 1.1 to 10.0).

CONCLUSION

The findings of this study provide a snapshot of how non-specialists from a non-urban Ontario community assess, manage and prevent CAP in older adults and highlight differences between office-based and emergency department physicians. This information can guide researchers and clinicians in their efforts to improve the management and prevention of CAP in older adults.

Local guidelines for community-acquired pneumonia: development, implementation, and outcome studies

Published outcome studies mostly report a positive effect of successfully implemented pneumonia guidelines. Confirmatory studies are needed that use randomized, parallel groups with precisely defined treatments, however. Further research also is needed to develop methodology for more easily providing guideline logic to clinicians at the point of care.

Pneumonia--a clinical or radiographic diagnosis? Etiology and clinical features of lower respiratory tract infection in adults in general practice

Etiology and clinical manifestations have been studied in 153 adult patients with lower respiratory tract infection, and the results are presented according to clinical and radiographic diagnosis. Laboratory investigations revealed that bacterial infection, mycoplasma and chlamydia included, occurred as often in 22 patients whose clinical diagnoses of pneumonia were not evident radiographically, as in 20 patients with radiographic pneumonia. In the latter group significantly higher values of erythrocyte sedimentation rate and C-reactive protein were demonstrated. The most common pathogen was influenzavirus A, followed by respiratory syncytial virus, Streptococcus pneumoniae, and Mycoplasma pneumoniae. Chlamydia pneumoniae infection was found in 3 patients with radiographic pneumonia. The study supports the traditional view that patients with a positive chest radiograph as a rule present more serious manifestations of lower respiratory tract pathology than patients with a normal radiograph. However, as only 1/9 patients with pneumococcal infection and 2/7 with mycoplasmal infection had radiographic evidence of pneumonia, radiography alone did not seem to offer sufficient information for selecting patients for antibacterial therapy.

Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients

STUDY OBJECTIVES

To compare physician judgment in the use of chest radiographs for diagnosing pneumonia with decision rules developed by Diehr, Singal, Heckerling, and Gennis.

DESIGN

Propsective observational investigation with preradiograph survey of physicians' intent to order chest radiographs for patients presenting with respiratory complaints. All patients had uniform clinical data collected, including chest radiographs and sufficient information to retrospectively apply the four clinical prediction rules.

SETTING

The emergency department and medical outpatient clinic of a major urban teaching hospital.

PARTICIPANTS

Adult patients presenting with recent history of acute cough or exacerbation of chronic cough plus either fever, sputum production, or hemoptysis.

RESULTS

Of 290 patients, 21 (7%) had pneumonia. The sensitivity of physician judgment (0.86) exceeded that of all four decision rules. The specificity of the Diehr (0.67), Heckerling (0.67), and Gennis (0.76) rules exceeded that of physician judgment (0.58). The accuracy of the Gennis (0.76) and Heckerling (0.68) rules also exceeded that of the physicians (0.60).

DISCUSSION

Physicians' diagnostic and therapeutic decisions were characterized by high sensitivity but lower specificity for ordering chest radiographs to diagnose pneumonia. The higher specificity and accuracy of two of the decision rules suggest that they may have a role in patient evaluation.

Prediction of pneumonia in outpatients with acute cough--a statistical approach

Cough is the fifth most common reason for physician visits, but data on acute cough have rarely been collected in a standardized manner and have not been analyzed in a multivariate fashion. We report data on 1819 patients presenting with cough, all of whom received a standardized history and physical, and a chest X-ray. Only 48 (2.6%) were found to have an acute radiographic infiltrate (pneumonia). The prevalence of common signs and symptoms is shown for the patients with and without pneumonia. Thirty-two of these findings were significant predictors of pneumonia (p less than 0.05, one-tailed). These 32 did not include some of the expected predictors of pneumonia and did include some predictors not previously described in the literature. A diagnostic rule is developed which identifies pneumonia patients with 91% sensitivity and 40% specificity, or 74% sensitivity and 70% specificity. The study results suggest that many pneumonias could be predicted based only on the patients histories. Physician visits to determine physical findings and chest X-rays might be avoided by telephone triage, with substantial cost savings.

Physicians' misunderstanding of normal findings

Gorry, Pauker, and Schwartz [1] demonstrated that a normal test result, when assessed quantitatively, can sometimes be extremely valuable in differential diagnosis. In the present study we extend the principle of the normal finding to include signs and symptoms. This extension proved to be clinically valuable for the present population of patients with acute cough, because the identified normal findings provided significant (p less than 0.001) information predictive of radiographic pneumonia and unrelated to that provided by the abnormal findings. This suggests that both types of findings should be used to diagnose pneumonia efficiently. Another result of the extension of this principle to signs and symptoms was the identification of the clinicians' use (p less than 0.001) of abnormal findings but not (p greater than 0.75) normal findings when managing patients with acute cough. Several possible causes for this misuse of normal findings are discussed, including limitations in the clinicians' cognitive processing of "absent problems," emphasis on abnormal findings by patients, and confusing epidemiological terminology that discourages the recognition of pertinent normal findings.