Predictors of hypoxaemia in hospital admissions with acute lower respiratory tract infection in a developing country

Work of Breathing: Physiology, Measurement, and Diagnostic Value in Childhood Pneumonia

In clinical practice, increased "work of breathing" (WOB) is used to rapidly identify the acutely ill child in need of immediate clinical care, and is commonly used to support a clinical diagnosis of pneumonia. However, this key clinical sign is poorly understood and inconsistently defined. This review discusses the physiology, measurement, and clinical assessment of WOB, highlighting its utility in the recognition of pneumonia in under-resourced settings, where access to diagnostic imaging may be limited.

Clinical predictors of hypoxic pneumonia in children from the Eastern Highlands Province, Papua New Guinea: secondary analysis of two prospective observational studies

Background

Pneumonia is the leading cause of death in young children globally and is prevalent in the Papua New Guinea highlands. We investigated clinical predictors of hypoxic pneumonia to inform local treatment guidelines in this resource-limited setting.

Methods

Between 2013 and 2020, two consecutive prospective observational studies were undertaken enrolling children 0-4 years presenting with pneumonia to health-care facilities in Goroka Town, Eastern Highlands Province. Logistic regression models were developed to identify clinical predictors of hypoxic pneumonia (oxygen saturation <90% on presentation). Model performance was compared against established criteria to identify severe pneumonia.

Findings

There were 2067 cases of pneumonia; hypoxaemia was detected in 36.1%. The strongest independent predictors of hypoxic pneumonia were central cyanosis on examination (adjusted odds ratio [aOR] 5.14; 95% CI 3.47-7.60), reduced breath sounds (aOR 2.92; 95% CI 2.30-3.71), and nasal flaring or grunting (aOR 2.34; 95% CI 1.62-3.38). While the model developed to predict hypoxic pneumonia outperformed established pneumonia severity criteria, it was not sensitive enough to be clinically useful at this time.

Interpretation

Given signs and symptoms are unable to accurately detect hypoxia, all health care facilities should be equipped with pulse oximeters. However, for the health care worker without access to pulse oximetry, consideration of central cyanosis, reduced breath sounds, nasal flaring or grunting, age-specific tachycardia, wheezing, parent-reported drowsiness, or bronchial breathing as suggestive of hypoxaemic pneumonia, and thus severe disease, may prove useful in guiding management, hospital referral and use of oxygen therapy.

Funding

Funded by Pfizer Global and the Bill & Melinda Gates Foundation.

Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial

BACKGROUND

Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh.

METHODS AND ANALYSIS

A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03588377.

Performance of five pulse oximeters to detect hypoxaemia as an indicator of severe illness in children under five by frontline health workers in low resource settings - A prospective, multicentre, single-blinded, trial in Cambodia, Ethiopia, South Sudan, and Uganda

BACKGROUND

Low blood oxygen saturation (SpO₂), or hypoxaemia, is an indicator of severe illness in children. Pulse oximetry is a globally accepted, non-invasive method to identify hypoxaemia, but rarely available outside higher-level facilities in resource-constrained countries. This study aims to evaluate the performance of different types of pulse oximeters amongst frontline health workers in Cambodia, Ethiopia, South Sudan, and Uganda.

METHODS

Five pulse oximeters (POx) which passed laboratory testing, out of an initial 32 potential pulse oximeters, were evaluated by frontline health workers for performance, defined as agreement between the SpO₂ measurements of the test device and the reference standard. The study protocol is registered with the Australia New Zealand Clinical Trials Registry (Ref: ACTRrn12615000348550).

FINDINGS

Two finger-tip pulse oximeters (Contec and Devon), two handheld pulse oximeters (Lifebox and Utech), and one phone pulse oximeter (Masimo) passed the laboratory testing. They were evaluated for performance on 1,313 children under five years old by 207 frontline health workers between February and May 2015. Phone and handheld pulse oximeters had greater overall agreement with the reference standard (56%; 95% CI 0.52 - 0.60 to 68%; 95% CI 0.65 - 0.71) than the finger-tip POx (31%; 95% CI 0.26 to 0.36 and 47%; 95% CI 0.42 to 0.52). Fingertip POx performance was substantially lower in the 0-2 month olds; having just 17% and 25% agreement. The finger-tip devices more often underreported SpO₂ readings (mean difference -7.9%; 95%CI -8.6,-7.2 and -3.9%; 95%CI -4.4,-3.4), and therefore over diagnosed hypoxaemia in the children assessed.

INTERPRETATION

While the Masimo phone pulse oximeter performed best, all handheld POx with age-specific probes performed well in the hands of frontline health workers, further highlighting their suitability as a screening tool of severe illness. The poor performance of the fingertip POx suggests they should not be used in children under five by frontline health workers. It is essential that POx are performance tested on children in routine settings (in vivo), not only in laboratories or controlled settings (in vitro), before being introduced at scale.

FUNDING

Bill & Melinda Gates Foundation [OPP1054367].

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Community case management of chest indrawing pneumonia in children aged 2 to 59 months by community health workers: study protocol for a multi-country cluster randomized open label non-inferiority trial

BACKGROUND

The World Health Organization (WHO) integrated management of childhood illness (IMCI) protocol recommends treatment of chest indrawing in 2-59 months old children with oral amoxicillin by trained health facility workers. Whereas, the WHO/UNICEF integrated community case management (iCCM) protocol recommends referral by community level health workers (CLHWs) to a health facility. This study aims to evaluate whether CLHWs can treat chest indrawing pneumonia effectively and safely.

METHODS

This multi-centre cluster randomized controlled open label, non-inferiority trial will be conducted in Bangladesh, Ethiopia, India and Malawi. All sites will use a common protocol with the same study design, participants, intervention, control and outcomes. CLHWs will identify 2-59 months old children with chest indrawing. Study supervisors, trained in the iCCM protocol, will confirm CLHWs' findings. Pulse oximetry will be used to identify hypoxaemic children. In the intervention group, enrolled children will be treated with oral amoxicillin for 5 days, and in the control group they will be referred to a health facility, after providing first dose of oral amoxicillin. An independent outcome assessor will visit each enrolled child on days 6 and 14 of enrolment, to assess study outcomes.

CONCLUSIONS

If CLHWs can effectively and safely treat chest indrawing pneumonia in 2-59 months old children, it will increase access to pneumonia treatment substantially, as in many settings, health facilities and trained health workers are not easily accessible. Moreover, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with the IMCI protocol.

TRIAL REGISTRATION

The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals

BACKGROUND

Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria.

METHODS

We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not).

FINDINGS

Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission.

INTERPRETATION

Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.

Use of pulse oximetry during initial assessments of children under five with pneumonia: a retrospective cross-sectional study from 14 hospitals in Ethiopia

Background

Hypoxemia, a fatal condition characterized by low concentration of oxygen in the blood, is strongly associated with death among children with pneumonia. Ethiopia’s Federal Ministry of Health launched its first National Oxygen and Pulse Oximetry Scale-up road map to improve access and utilization of pulse oximetry and oxygen. This study aimed to describe the use of pulse oximetry during the initial patient assessment among children under five diagnosed with pneumonia and serves as a benchmark to measure progress of the road map.

Methods

The study design was an observational study using retrospective review of patient medical records at 14 hospitals. Medical records of 443 children age 0-59 months with a primary diagnosis of pneumonia were randomly selected for review. The primary outcome was whether an arterial blood oxygen saturation (SpO₂) measurement was recorded in the patient’s medical record at the initial assessment.

Results

Overall, 10% (95% confidence interval CI = 4%-22%) of patient medical records had a SpO₂ measurement. Admitted patients were more likely to have a SpO₂ measurement recorded in their medical records than patients treated in the outpatient department (P<0.01). Among admitted patients, 19% (95% CI = 8%-38%) had a SpO₂ measurement compared to 3% (95% CI = 1%-11%) of patients treated in the outpatient department.

Conclusion

In Ethiopia, patients under five with a primary diagnosis of pneumonia are rarely screened for hypoxemia with a pulse oximeter, and hypoxemia may be severely underdiagnosed. Much needs to be done to improve the routine use of pulse oximetry.

Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation

Introduction

Pulse oximetry is a life-saving tool for identifying children with hypoxaemia and guiding oxygen therapy. This study aimed to evaluate the adoption of oximetry practices in 12 Nigerian hospitals and identify strategies to improve adoption.

Methods

We conducted a mixed-methods realist evaluation to understand how oximetry was adopted in 12 Nigerian hospitals and why it varied in different contexts. We collected quantitative data on oximetry use (from case notes) and user knowledge (pretraining/post-training tests). We collected qualitative data via focus groups with project nurses (n=12) and interviews with hospital staff (n=11). We used the quantitative data to describe the uptake of oximetry practices. We used mixed methods to explain how hospitals adopted oximetry and why it varied between contexts.

Results

Between January 2014 and April 2017, 38 525 children (38% aged ≤28 days) were admitted to participating hospitals (23 401 pretraining; 15 124 post-training). Prior to our intervention, 3.3% of children and 2.5% of neonates had oximetry documented on admission. In the 18 months of intervention period, all hospitals improved oximetry practices, typically achieving oximetry coverage on >50% of admitted children after 2-3 months and >90% after 6-12 months. However, oximetry adoption varied in different contexts. We identified key mechanisms that influenced oximetry adoption in particular contexts.

Conclusion

Pulse oximetry is a simple, life-saving clinical practice, but introducing it into routine clinical practice is challenging. By exploring how oximetry was adopted in different contexts, we identified strategies to enhance institutional adoption of oximetry, which will be relevant for scale-up of oximetry in hospitals globally.

Trial registration number

ACTRN12617000341325.

Improved oxygen systems in district hospitals in Lao PDR: a prospective field trial of the impact on outcomes for childhood pneumonia and equipment sustainability

BACKGROUND

Hypoxaemia is a common and potentially fatal complication of many childhood, newborn and maternal conditions but often not well recognised or managed in settings where resources are limited. Oxygen itself is often inaccessible due to cost or logistics. This paper describes implementation of oxygen systems in Lao district hospitals, clinical outcomes after 24 months and equipment outcomes after 40 months postimplementation.

METHODS

A prospective field trial was conducted in 20 district hospitals, including 10 intervention hospitals that received oxygen concentrators and 10 control hospitals. Equipment outcomes were evaluated at baseline, 12, 24 and 40 months. Clinical outcomes of children under 5 years of age with pneumonia were evaluated using a before-and-after controlled study design with information retrospectively collected from medical records.

RESULTS

Fourteen (37%), 7 (18%) and 12 (34%) of 38 concentrators required repair at 12, 24 and 40 months, respectively. The proportion of children discharged well increased in intervention (90% (641/712) to 95.2% (658/691)) and control hospitals (87.1% (621/713) to 92.1% (588/606)). In intervention hospitals, case fatality rates for childhood pneumonia fell from 2.7% (19/712) preintervention to 0.80% (6/691) postintervention with no change in control hospitals (1.7% (12/713) preintervention and 2.3% (14/606) postintervention).

CONCLUSION

Medium-term sustainability of oxygen concentrators in hospitals accompanied by reduced case fatality for childhood pneumonia has been demonstrated in Lao PDR. Significant local engineering capacity to address multiple causes of equipment malfunction was critical. The ongoing requirements and fragile structures within the health system remain major risks to long-term sustainability.

Is Pulse Oximetry Useful for Screening Neonates for Critical Congenital Heart Disease at High Altitudes?

Now that pulse oximetry is used widely to screen for critical congenital heart disease, it is time to consider whether this screening method is applicable to those who live at high altitudes. Consideration of basic physical principles and reports from the literature indicate that not only is the 95 % cutoff point for arterial oxygen saturation incorrect at high altitudes, but the lower saturations are accompanied by greater variability and therefore there is the possibility of a greater percentage of false-positive screening tests at high altitudes. Because of ethnic differences in response to high altitudes, normative data will have to be collected separately in different countries and perhaps for different ethnic groups.

Low- versus high-flow oxygen delivery systems in children with lower respiratory infection

BACKGROUND

Delivery of supplemental oxygen is the initial vital management of hypoxemic acute lower respiratory infection (HALRI). Oxygen delivery systems include low-flow and high-flow devices. In high-flow devices such as the Venturi mask, a constant mixture of oxygen is delivered. As a result, increased rate of breathing does not affect the concentration of oxygen delivered. In this study, we compared the efficacy of oxygen masks and Venturi masks in the management of hypoxemia in pediatric patients.

METHODS

A total of 65 children, aged 3-36 months, diagnosed with HALRI, were enrolled. Patients were allocated into groups, via simple alternate randomization, to receive oxygen through an oxygen mask or through a Venturi mask. Respiratory rate, heart rate, retraction, blood gas parameters, oxygen saturation, length of hospitalization, and oxygenation were recorded before and after oxygen treatment.

RESULTS

After 24 h of treatment, respiratory rate was significantly lower among patients in the Venturi mask group compared with the oxygen mask group. Duration of supplemental oxygen and length of hospitalization were significantly lower in the Venturi mask group compared with the oxygen mask group.

CONCLUSION

In both groups, there was marked improvement in all measured parameters following introduction of supplemental oxygen. Oxygen was delivered more efficiently, however, by high-flow systems. The Venturi mask may decrease the total duration of oxygen usage time as well as the length of hospitalization among young children with HALRI through rapid symptom resolution.

Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age

BACKGROUND

Treatment for lower respiratory tract infections (LRTIs) includes administering complementary oxygen. The effectiveness of oxygen therapy and of different delivery methods remains uncertain.

OBJECTIVES

To determine the effectiveness and safety of oxygen therapy and oxygen delivery methods in the treatment of LRTIs and to define the indications for oxygen therapy in children with LRTIs.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, EMBASE and LILACS from March 2008 to October 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or non-RCTs comparing oxygen versus no oxygen therapy or different methods of oxygen delivery in children with LRTI aged from three months to 15 years. To determine the indications for oxygen therapy, we included observational studies or diagnostic test accuracy studies.

DATA COLLECTION AND ANALYSIS

Three review authors independently scanned the search results to identify studies for inclusion. Two authors independently performed the methodological assessment and the third author resolved any disagreements. We calculated risk ratios (RRs) and their 95% confidence intervals (CIs) for dichotomous outcomes and adverse events (AEs). We performed fixed-effect meta-analyses for the estimation of pooled effects whenever there was no heterogeneity between included RCTs. We summarised the results reported in the included observational studies for the clinical indicators of hypoxaemia.

MAIN RESULTS

In this review update, we included four studies (479 participants) assessing the efficacy of non-invasive delivery methods for the treatment of LRTI in children and 14 observational studies assessing the clinical sign indicators of hypoxaemia in children with LRTIs.Three RCTs (399 participants) compared the effectiveness of nasal prongs or nasal cannula with nasopharyngeal catheter; one non-RCT (80 participants) compared head box, face mask, nasopharyngeal catheter and nasal cannula. The nasopharyngeal catheter was the control group. Treatment failure was defined as number of children failing to achieve adequate arterial oxygen saturation. All included studies had a high risk of bias because of allocation methods and lack of blinded outcome assessment.For nasal prongs versus nasopharyngeal catheter, the pooled effect estimate for RCTs showed a worrying trend towards no difference between the groups (two RCTs; 239 participants; RR 0.93, 95% CI 0.36 to 2.38). Similar results were shown in the one non-RCT (RR 1.0, 95% CI 0.44 to 2.27). The overall quality of this evidence is very low. Nasal obstruction due to severe mucus production was different between treatment groups (three RCTs, 338 participants; RR 0.20, 95% CI 0.09 to 0.44; I(2) statistic = 0%). The quality of this evidence is low.The use of a face mask showed a statistically significant lower risk of failure to achieve arterial oxygen > 60 mmHg than the nasopharyngeal catheter (one non-RCT; 80 participants; odds ratio (OR) 0.20, 95% CI 0.05 to 0.88).The use of a head box showed a non-statistically significant trend towards a reduced risk of treatment failure compared to the nasopharyngeal catheter (one non-RCT; OR 0.40, 95% CI 0.13 to 1.12). The quality of this evidence is very low.To determine the presence of hypoxaemia in children presenting with LRTI, we assessed the sensitivity and specificity of nine clinical signs reported by the included observational studies and used this information to calculate likelihood ratios. The results showed that there is no single clinical sign or symptom that accurately identifies hypoxaemia.

AUTHORS' CONCLUSIONS

It appears that oxygen therapy given early in the course of pneumonia via nasal prongs at a flow rate of 1 to 2 L/min does not prevent children with severe pneumonia from developing hypoxaemia. However, the applicability of this evidence is limited as it comes from a small pilot trial.Nasal prongs and nasopharyngeal catheter are similar in effectiveness when used for children with LRTI. Nasal prongs are associated with fewer nasal obstruction problems. The use of a face mask and head box has been poorly studied and it is not superior to a nasopharyngeal catheter in terms of effectiveness or safety in children with LRTI.Studies assessing the effectiveness of oxygen therapy and oxygen delivery methods in children with different baseline risks are needed.There is no single clinical sign or symptom that accurately identifies hypoxaemia in children with LRTI. The summary of results presented here can help clinicians to identify children with more severe conditions.This review is limited by the small number of trials assessing oxygen therapy and oxygen delivery methods as part of LRTI treatment. There is insufficient evidence to determine which non-invasive delivery methods should be used in children with LRTI and low levels of oxygen in their blood.

Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children

BACKGROUND

Although hypoxemic children have high mortality, little is known about hypoxemia prevalence and oxygen administration in African hospitals. We aimed to determine the hypoxemia prevalence and quality of oxygen treatment by local clinicians for hospitalized Malawian children.

METHODS

The study was conducted in five Malawian hospitals during January-April 2011. We prospectively measured the peripheral oxygen saturation (SpO(2)) using pulse oximetry for all children <15 years old and also determined clinical eligibility for oxygen treatment using WHO criteria for children <5 years old. We determined oxygen treatment quality by Malawian clinicians by comparing their use of WHO criteria for patients <5 years old using two standards: hypoxemia (SpO(2) <90%) and the use of WHO criteria by study staff.

RESULTS

Forty of 761 (5.3%) hospitalized children <15 years old had SpO(2) <90%. No hospital used pulse oximetry routinely, and only 9 of 40 (22.5%) patients <15 years old with SpO(2) <90% were treated with oxygen by hospital staff. Study personnel using WHO criteria for children <5 years old achieved a higher sensitivity (40.0%) and lower specificity (82.7%) than Malawian clinicians (sensitivity 25.7%, specificity 94.1%).

CONCLUSION

Although hypoxemia is common, the absence of routine pulse oximetry results in most hospitalized, hypoxemic Malawian children not receiving available oxygen treatment.

Prevalence and predictors of hypoxaemia in respiratory and non-respiratory primary diagnoses among emergently ill children at a tertiary hospital in south western Nigeria

BACKGROUND

Hypoxaemia is a potentially harmful complication of both acute lower respiratory tract infections (ALRI) and non-ALRI in children but its contribution to burden and outcomes of hospital admissions in Africa is unclear. We investigated prevalence and predictors of hypoxaemia in ALRI and non-ALRI according to age and primary diagnoses in emergently ill children in south western Nigeria.

METHODS

In 1726 emergently ill children admitted to a tertiary hospital in Ibadan, south western Nigeria, oxygen saturation was measured shortly after admission. Hypoxaemia was defined as oxygen saturation <90%. Clinical features and the primary admission diagnoses were recorded. Prevalence of hypoxaemia according to age and diagnoses was calculated. Symptoms and signs associated with hypoxaemia were compared between children with ALRI and those with non-ALRI.

RESULTS

Hypoxaemia was detected in 28.6% (494/1726) of admissions. Prevalence of hypoxaemia varied in different conditions: it was 49.2% (154/313) in ALRI, 41.1% (188/454) in neonates, 27.2% (6/22) in post-neonatal tetanus, 23.3% (14/60) in sickle cell anaemia, 22.6% (38/168) in septicaemia and 14.4% (76/527) of malaria cases. Nasal flaring (OR 3.86; 95% CI 1.70 to 8.74) and chest retraction (OR 4.77; 95% CI 1.91 to 11.92) predicted hypoxaemia in ALRI but not in non-ALRI.

CONCLUSIONS

Hypoxaemia is common among Nigerian children admitted to an emergency unit and is associated with a poor outcome irrespective of primary admission diagnosis. Provision of equipment to measure oxygen saturation and facilities for effective oxygen delivery might substantially reduce mortality.

Oxygen saturation can predict pediatric pneumonia in a resource-limited setting

BACKGROUND

The World Health Organization (WHO) recommends using age-specific respiratory rates for diagnosing pneumonia in children. Past studies have evaluated the WHO criteria with mixed results.

OBJECTIVE

We examined the accuracy of clinical and laboratory factors for diagnosing pediatric pneumonia in resource-limited settings.

METHODS

We conducted a retrospective chart review of children under 5 years of age presenting with respiratory complaints to three rural hospitals in Rwanda who had received a chest radiograph. Data were collected on the presence or absence of 31 historical, clinical, and laboratory signs. Chest radiographs were interpreted by pediatric radiologists as the gold standard for diagnosing pneumonia. Overall correlation and test characteristics were calculated for each categorical variable as compared to the gold standard. For continuous variables, we created receiver operating characteristic (ROC) curves to determine their accuracy for predicting pneumonia.

RESULTS

Between May 2011 and April 2012, data were collected from 147 charts of children with respiratory complaints. Approximately 58% of our sample had radiologist-diagnosed pneumonia. Of the categorical variables, a negative blood smear for malaria (χ(2) = 6.21, p = 0.013) and the absence of history of asthma (χ(2) = 4.48, p = 0.034) were statistically associated with pneumonia. Of the continuous variables, only oxygen saturation had a statistically significant area under the ROC curve (AUC) of 0.675 (95% confidence interval [CI] 0.581-0.769 and p = 0.001). Respiratory rate had an AUC of 0.528 (95% CI 0.428-0.627 and p = 0.588).

CONCLUSION

Oxygen saturation was the best clinical predictor for pediatric pneumonia and should be further studied in a prospective sample of children with respiratory symptoms in a resource-limited setting.

Reference values for oxygen saturation by pulse oximetry in healthy children at sea level in Chennai

There is little information on oxygen saturation (SaO2) values in children in developing countries.

AIM

To determine the reference values for oxygen saturation by pulse oximetry in healthy children living at sea level in Chennai and aged between 1 mth and 5 yrs.

DESIGN AND SETTING

A prospective study was conducted in Kanchi Kamakoti CHILDS Trust Hospital from February to May 2005.

METHODS

A total of 626 healthy children aged between 1 mth and 5 yrs were examined for heart rate, respiratory rate and SaO2.

RESULTS

The mean SaO2 levels for children in the age groups 1-3 mths, 3 mths to 1 yr, 1-3 years and 3-5 years were 98.5%, 98.8%, 98.9% and 99.1%, respectively. The overall mean and median SaO(2) values for the children in the different age groups were 99%. The mean -2 SD values of oxygen saturation in the age groups were 96.5%, 96.4%, 96.3% and 97.1%, respectively, with an overall mean of 96.6%.

CONCLUSION

The reference value for mean SaO2 in healthy children aged between 1 mth and 5 yrs and living at sea level in Chennai city was 98.5% or more, but the -2SD values had a mean of 96.6%.

Predictors and outcome of hypoxemia in severely malnourished children under five with pneumonia: a case control design

BACKGROUND

There is lack of information in the medical literature on predictors of hypoxemia in severely malnourished children with pneumonia, although hypoxemia is common and is often associated with fatal outcome in this population. We explored the predictors of hypoxemia in under-five children who were hospitalized for the management of pneumonia and severe acute malnutrition (SAM).

METHODS

In this unmatched case-control design, SAM children of both sexes, aged 0-59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) with radiological pneumonia and hypoxemia during April 2011 to April 2012 were studied. SAM children with pneumonia and hypoxemia (SpO(2)<90%) constituted the cases (n = 37), and randomly selected SAM children with pneumonia but without hypoxemia constituted controls (n = 111).

RESULTS

The case-fatality was significantly higher among the cases than the controls (30% vs. 4%; p<0.001). In logistic regression analysis, after adjusting for potential confounders such as nasal flaring, head nodding, inability to drink, and crackles in lungs, fast breathing (95% CI = 1.09-13.55), lower chest wall in-drawing (95% CI = 2.48-43.41), and convulsion at admission (95% CI = 3.14-234.01) were identified as independent predictors of hypoxemia in this population. The sensitivity of fast breathing, lower chest wall in-drawing and convulsion at admission and their 95% confidence intervals (CI) to predict hypoxemia were 84 (67-93)%, 89 (74-96)%, and 19 (9-36)% respectively, and their specificity were 53 (43-63)%, 60 (51-69)% and 98 (93-100)% respectively.

CONCLUSION AND SIGNIFICANCE

Fast breathing and lower chest wall in-drawing were the best predictors of hypoxemia in SAM children with pneumonia. There thus, in resources poor settings where pulse oximetry is not available, identification of these simple clinical predictors of hypoxemia in such children could be reliably used for early O(2) supplementation in addition to other appropriate management to reduce morbidity and deaths.

Long term sequelae from childhood pneumonia; systematic review and meta-analysis

Background

The risks of long term sequelae from childhood pneumonia have not been systematically assessed. The aims of this study were to: (i) estimate the risks of respiratory sequelae after pneumonia in children under five years; (ii) estimate the distribution of the different types of respiratory sequelae; and (iii) compare sequelae risk by hospitalisation status and pathogen.

Methods

We systematically reviewed published papers from 1970 to 2011. Standard global burden of disease categories (restrictive lung disease, obstructive lung disease, bronchiectasis) were labelled as major sequelae. ‘Minor’ sequelae (chronic bronchitis, asthma, other abnormal pulmonary function, other respiratory disease), and multiple impairments were also included. Thirteen papers were selected for inclusion. Synthesis was by random effects meta-analysis and meta-regression.

Results

Risk of at least one major sequelae was 5.5% (95% confidence interval [95% CI] 2.8–8.3%) in non hospitalised children and 13.6% [6.2–21.1%]) in hospitalised children. Adenovirus pneumonia was associated with the highest sequelae risk (54.8% [39.2–70.5%]) but children hospitalised with no pathogen isolated also had high risk (17.6% [10.9–24.3%]). The most common type of major sequela was restrictive lung disease (5.4% [2.5–10.2%]) . Potential confounders such as loss to follow up and median age at infection were not associated with sequelae risk in the final models.

Conclusions

All children with pneumonia diagnosed by a health professional should be considered at risk of long term sequelae. Evaluation of childhood pneumonia interventions should include potential impact on long term respiratory sequelae.

Co-morbidity: exploring the clinical overlap between pneumonia and diarrhoea in a hospital in Dhaka, Bangladesh

BACKGROUND

There is limited information on risk factors for pneumonia and pneumonia-related deaths in children who also have diarrhoea.

AIM

To identify risk factors for the above in order to improve strategies for case management and to develop appropriate public health messages.

METHODS

All children under 5 years of age admitted to the Special Care Ward, Dhaka Hospital of the International Centre for Diarrhoeal Disease Research (ICDDR,B) from 1 September to 31 December 2007 were considered for enrollment if they also had diarrhoea. Of the 258 children with diarrhoea enrolled, those with (n=198) or without (n=60) WHO-defined pneumonia constituted the pneumonia and comparison groups, respectively. Among the 198 children with pneumonia, children who survived (n=174) were compared with those who died in hospital (n=24).

RESULTS

After adjusting for socio-demographic factors, including low levels of literacy of either parent, low household income, not having a window or exhaust fan in the kitchen, household smoking and over-crowding, children with pneumonia were more likely to sleep on a bare wooden-slatted or bamboo bed (OR 2·7, 95% CI 1·40-5·21, p = 0·003) than on other bedding, and were also more likely to have a parent/care-giver with poor knowledge of pneumonia (OR 1·94, 95% CI 1·02-3·70, p=0·043). Independent risk factors for death include severe underweight (OR 5·2, 95% CI 1·2-22·0, p=0·03), hypoxaemia (OR 17·5, 95% CI I 1·9-160·0, p=0·01), severe sepsis (OR 8·7, 95% CI I 1·8-41·5, p=0·007) and lobar consolidation (OR 11·9, 95% CI 2·3-61·6, p=0·003).

CONCLUSIONS

Increased public awareness of signs of pneumonia and severe sepsis in children under 5 is important to mitigate the risks of pneumonia and pneumonia-related deaths, and the importance of appropriate bedding for young children in reducing the risk of pneumonia needs to be addressed.

Predictors of death in under-five children with diarrhoea admitted to a critical care ward in an urban hospital in Bangladesh

AIM

To evaluate the clinical and laboratory predictors of death in hospitalized under-five children with diarrhoea.

METHODS

This is a prospective cohort study carried out in the Special Care Ward (SCW) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh. All admitted diarrhoeal children of both sexes, aged 0-59 months, from September 2007 through December 2007 were enrolled. We compared and analysed factors among diarrhoeal children who died (n = 29) with those who survived (n = 229).

RESULTS

In logistic regression analysis, after adjusting for potential confounders (infusion of intravenous fluid and immature PMN), absent peripheral pulse even after complete rehydration (OR 10.9, 95% CI 2.1-56.8; p < 0.01), severe malnutrition (OR 7.9, 95% CI 1.8-34.8; p < 0.01), hypoxaemia (OR 8.5, 95% CI 1.0-75.0; p = 0.05), radiological lobar pneumonia (OR 17.8, 95% CI 3.7-84.5; p < 0.01) and hypernatraemia (OR 15.8, 95% CI 3.0-81.8; p < 0.01) were independently associated with deaths among diarrhoeal children admitted to SCW.

CONCLUSIONS

Thus, the absence of peripheral pulses even after full rehydration, severe malnutrition, hypoxaemia, lobar pneumonia and hypernatraemia are independent predictors of death among the under-five children with diarrhoea admitted to critical care ward of a resource-limited setting in Bangladesh.

Clinical predictors and outcome of hypoxaemia among under-five diarrhoeal children with or without pneumonia in an urban hospital, Dhaka, Bangladesh

OBJECTIVE

To explore the predictors and outcome of hypoxaemia in children under 5 years of age who were hospitalized for the management of diarrhoea in Dhaka, where comorbidities are common.

METHODS

In a prospective cohort study, we enrolled all children <5 years of age admitted to the special care ward (SCW) of the Dhaka Hospital of ICDDR,B from September to December 2007. Those who presented with hypoxaemia (SpO(2) < 90%) constituted the study group, and those without hypoxaemia formed the comparison group.

RESULTS

A total of 258 children were enrolled, all had diarrhoea. Of the total, 198 (77%) had pneumonia and 106 (41%) had severe malnutrition (<-3 Z-score of weight for age of the median of the National Centre for Health Statistics), 119 (46%) had hypoxaemia and 138 children did not have hypoxaemia at the time of admission. Children with hypoxaemia had a higher probability of a fatal outcome (21%vs. 4%; P < 0.001). Using logistic regression analysis, the independent predictors of hypoxaemia at the time of presentation were lower chest wall indrawing [OR 6.91, 95% confidence intervals (CI) 3.66-13.08, P < 0.001], nasal flaring (OR 3.22, 95% CI 1.45-7.17, P = 0.004) and severe sepsis (OR 4.48, 95% CI 1.62-12.42, P = 0.004).

CONCLUSION

In this seriously ill population of children with diarrhoea and comorbidities, hypoxaemia was associated with high case-fatality rates. Independent clinical predictors of hypoxaemia in this population, identifiable at the time of admission, were lower chest wall indrawing, nasal flaring and the clinical syndrome of severe sepsis.

An evaluation of oxygen systems for treatment of childhood pneumonia

BACKGROUND

Oxygen therapy is recommended for all of the 1.5 - 2.7 million young children who consult health services with hypoxemic pneumonia each year, and the many more with other serious conditions. However, oxygen supplies are intermittent throughout the developing world. Although oxygen is well established as a treatment for hypoxemic pneumonia, quantitative evidence for its effect is lacking. This review aims to assess the utility of oxygen systems as a method for reducing childhood mortality from pneumonia.

METHODS

Aiming to improve priority setting methods, The Child Health and Nutrition Research Initiative (CHNRI) has developed a common framework to score competing interventions into child health. That framework involves the assessment of 12 different criteria upon which interventions can be compared. This report follows the proposed framework, using a semi-systematic literature review and the results of a structured exercise gathering opinion from experts (leading basic scientists, international public health researchers, international policy makers and representatives of pharmaceutical companies), to assess and score each criterion as their "collective optimism" towards each, on a scale from 0 to 100%.

RESULTS

A rough estimate from an analysis of the literature suggests that global strengthening of oxygen systems could save lives of up to 122,000 children from pneumonia annually. Following 12 CHNRI criteria, the experts expressed very high levels of optimism (over 80%) for answerability, low development cost and low product cost; high levels of optimism (60-80%) for low implementation cost, likelihood of efficacy, deliverability, acceptance to end users and health workers; and moderate levels of optimism (40-60%) for impact on equity, affordability and sustainability. The median estimate of potential effectiveness of oxygen systems to reduce the overall childhood pneumonia mortality was ~20% (interquartile range: 10-35%, min. 0%, max. 50%). However, problems with oxygen systems in terms of affordability, sustainability and impact on equity are noted in both expert opinion scores and on review.

CONCLUSION

Oxygen systems are likely to be an effective intervention in combating childhood mortality from pneumonia. However, a number of gaps in the evidence base exist that should be addressed to complete the investment case and research addressing these issues merit greater funding attention.

Oxygen is an essential medicine: a call for international action

Hypoxaemia is commonly associated with mortality in developing countries, yet feasible and cost-effective ways to address hypoxaemia receive little or no attention in current global health strategies. Oxygen treatment has been used in medicine for almost 100 years, but in developing countries most seriously ill newborns, children and adults do not have access to oxygen or the simple test that can detect hypoxaemia. Improving access to oxygen and pulse oximetry has demonstrated a reduction in mortality from childhood pneumonia by up to 35% in high-burden child pneumonia settings. The cost-effectiveness of an oxygen systems strategy compares favourably with other higher profile child survival interventions, such as new vaccines. In addition to its use in treating acute respiratory illness, oxygen treatment is required for the optimal management of many other conditions in adults and children, and is essential for safe surgery, anaesthesia and obstetric care. Oxygen concentrators provide the most consistent and least expensive source of oxygen in health facilities where power supplies are reliable. Oxygen concentrators are sustainable in developing country settings if a systematic approach involving nurses, doctors, technicians and administrators is adopted. Improving oxygen systems is an entry point for improving the quality of care. For these broad reasons, and for its vital importance in reducing deaths due to lung disease in 2010: Year of the Lung, oxygen deserves a higher priority on the global health agenda.

Narrative review: should teaching of the respiratory physical examination be restricted only to signs with proven reliability and validity?

OBJECTIVE

To review the reported reliability (reproducibility, inter-examiner agreement) and validity (sensitivity, specificity and likelihood ratios) of respiratory physical examination (PE) signs, and suggest an approach to teaching these signs to medical students.

METHODS

Review of the literature. We searched Paper Chase between 1966 and June 2009 to identify and evaluate published studies on the diagnostic accuracy of respiratory PE signs.

RESULTS

Most studies have reported low to fair reliability and sensitivity values. However, some studies have found high specificites for selected PE signs. None of the studies that we reviewed adhered to all of the STARD criteria for reporting diagnostic accuracy.

CONCLUSIONS

Possible flaws in study designs may have led to underestimates of the observed diagnostic accuracy of respiratory PE signs. The reported poor reliabilities may have been due to differences in the PE skills of the participating examiners, while the sensitivities may have been confounded by variations in the severity of the diseases of the participating patients. IMPLICATION FOR PRACTICE AND MEDICAL EDUCATION: Pending the results of properly controlled studies, the reported poor reliability and sensitivity of most respiratory PE signs do not necessarily detract from their clinical utility. Therefore, we believe that a meticulously performed respiratory PE, which aims to explore a diagnostic hypothesis, as opposed to a PE that aims to detect a disease in an asymptomatic person, remains a cornerstone of clinical practice. We propose teaching the respiratory PE signs according to their importance, beginning with signs of life-threatening conditions and those that have been reported to have a high specificity, and ending with signs that are "nice to know," but are no longer employed because of the availability of more easily performed tests.

Harnessing color vision for visual oximetry in central cyanosis

Central cyanosis refers to a bluish discoloration of the skin, lips, tongue, nails, and mucous membranes, and is due to poor arterial oxygenation. Although skin color is one of its characteristic properties, it has long been realized that by the time skin color signs become visible, oxygen saturation is dangerously low. Here we investigate the visibility of cyanosis in light of recent discoveries on what color vision evolved for in primates. We elucidate why low arterial oxygenation is visible at all, why it is perceived as blue, and why it can be so difficult to perceive. With a better understanding of the relationship between color vision and blood physiology, we suggest two simple techniques for greatly enhancing the clinician's ability to detect cyanosis and other clinical color changes. The first is called "skin-tone adaptation", wherein sheets, gowns, walls and other materials near a patient have a color close to that of the patient's skin, thereby optimizing a color-normal viewer's ability to sense skin color modulations. The second technique is called "biosensor color tabs", wherein adhesive tabs with a color matching the patient's skin tone are placed in several spots on the skin, and subsequent skin color changes have the effect of making the initially-invisible tabs change color, their hue and saturation indicating the direction and magnitude of the skin color shift.

The prevalence of hypoxaemia among ill children in developing countries: a systematic review

Hypoxaemia is a common complication of childhood infections, particularly acute lower respiratory tract infections. In pneumonia-a disease that disproportionately impacts developing countries, and accounts for more than two million deaths of children worldwide-hypoxaemia is a recognised risk factor for death, and correlates with disease severity. Hypoxaemia also occurs in severe sepsis, meningitis, common neonatal problems, and other conditions that impair ventilation and gas exchange or increase oxygen demands. Despite this, hypoxaemia has been overlooked in worldwide strategies for pneumonia control and reducing child mortality. Hypoxaemia is also often overlooked in developing countries, mainly due to the low accuracy of clinical predictors and the limited availability of pulse oximetry for more accurate detection and oxygen for treatment. In this Review of published and unpublished studies of acute lower respiratory tract infection, the median prevalence of hypoxaemia in WHO-defined pneumonia requiring hospitalisation (severe and very severe classifications) was 13%, but prevalence varied widely. This corresponds to at least 1.5 to 2.7 million annual cases of hypoxaemic pneumonia presenting to health-care facilities. Many more people do not access health care. With mounting evidence of the impact that improved oxygen systems have on mortality due to acute respiratory infection in limited-resource health-care facilities, there is a need for increased awareness of the burden of hypoxaemia in childhood illness.

Emergency triage assessment for hypoxaemia in neonates and young children in a Kenyan hospital: an observational study

OBJECTIVE

To describe the prevalence of hypoxaemia in children admitted to a hospital in Kenya for the purpose of identifying clinical signs of hypoxaemia for emergency triage assessment, and to test the hypothesis that such signs lead to correct identification of hypoxaemia in children, irrespective of their diagnosis.

METHODS

From 2002 to 2005 we prospectively collected clinical data and pulse oximetry measurements for all paediatric admissions to Kilifi District Hospital, Kenya, irrespective of diagnosis, and assessed the prevalence of hypoxaemia in relation to the WHO clinical syndromes of 'pneumonia' on admission and the final diagnoses made at discharge. We used the data collected over the first three years to derive signs predictive of hypoxaemia, and data from the fourth year to validate those signs.

FINDINGS

Hypoxemia was found in 977 of 15 289 (6.4%) of all admissions (5% to 19% depending on age group) and was strongly associated with inpatient mortality (age-adjusted risk ratio: 4.5; 95% confidence interval, CI: 3.8-5.3). Although most hypoxaemic children aged > 60 days met the WHO criteria for a syndrome of 'pneumonia' on admission, only 215 of the 693 (31%) such children had a final diagnosis of lower respiratory tract infection (LRTI). The most predictive signs for hypoxaemia included shock, a heart rate < 80 beats per minute, irregular breathing, a respiratory rate > 60 breaths per minute and impaired consciousness. However, 5-15% of the children who had hypoxaemia on admission were missed, and 18% of the children were incorrectly identified as hypoxaemic.

CONCLUSION

The syndromes of pneumonia make it possible to identify most hypoxaemic children, including those without LRTI. Shock, bradycardia and irregular breathing are important predictive signs, and severe malaria with respiratory distress is a common cause of hypoxaemia. Overall, however, clinical signs are poor predictors of hypoxaemia, and using pulse oximetry in resource-poor health facilities to target oxygen therapy is likely to save costs.

Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age

BACKGROUND

Usual practice in lower respiratory tract infections (LRTIs) includes administering complementary oxygen. The effectiveness of oxygen therapy and different methods of delivery is unknown. This review contributes to the rational use of oxygen in the treatment of LRTIs.

OBJECTIVES

To determine in the treatment of LRTIs: the effectiveness of oxygen therapy and oxygen delivery methods; the safety of these methods; and indications for oxygen therapy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2008, issue 2); MEDLINE (January 1966 to March 2008); EMBASE (1990 to December 2007); and LILACS (January 1982 to March 2008).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing oxygen versus no oxygen therapy or methods of oxygen delivery for hypoxaemic LRTIs in children (3 months to 15 years of age). To determine indications for oxygen therapy, observational studies were included.

DATA COLLECTION AND ANALYSIS

We assessed 551 titles. No studies comparing oxygen versus no oxygen were found. Four RCTs comparing delivery methods and 12 observational studies assessing the accuracy of clinical signs indicating hypoxaemia were eligible. A meta-analysis of the RCTs comparing oxygen delivery methods was performed.

MAIN RESULTS

Three studies assessed the effectiveness of nasal prongs (NP) versus nasopharyngeal catheters (NPC). The pooled estimate effect showed no differences (OR 0.96; 95% CI 0.48 to 1.93) in treatment failure (number of children failing to achieve adequate SaO2). One study compared the effectiveness of NP versus nasal catheter (NC). No differences were found in treatment failure (the mean number of episodes of desaturation/child: NC group 2.75, SD +/- 2.18 episodes/child; NP group 3, SD +/- 2.5 episodes/child, p = 0.64). Another study compared face mask (FM) and head box (HB) versus NPC. Use of FM showed lower risk of treatment failure (failure to achieve PaO2 > 60 mmHg) than the NPC (OR 0.20; 95% CI 0.55 to 0.88). As did the use of HB compared with NPC (OR 0.40; 95% CI 0.13 to 1.12).Studies assessing the accuracy of signs and/or symptoms indicating hypoxaemia showed that cyanosis, grunting, difficulty in feeding and mental alertness have better specificity in predicting hypoxaemia and its results were consistent among studies.

AUTHORS' CONCLUSIONS

NP and NPC seem to be similar in effectiveness and safety when used in patients with LRTI. There is no single clinical sign or symptom that accurately identifies hypoxaemia. Studies identifying the most effective and safe oxygen delivery method are needed.

Case management of childhood pneumonia in developing countries

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality in children worldwide. Appropriate management depends on accurate assessment of disease severity, and for the majority of children in developing countries the assessment is based on clinical signs alone. This article reviews recent evidence on clinical assessment and severity classification of pneumonia and reported results on the effectiveness of currently recommended treatments.

METHODS

Potential studies for inclusion were identified by Medline (1990-2006) search. The Oxford Center for Evidence Based Medicine criteria were used to describe the methodologic quality of selected studies.

RESULTS

In the included studies the sensitivity of current definitions of tachypnea for diagnosing radiologic pneumonia ranged from 72% to 94% with specificities between 38% and 99%; chest indrawing had reported sensitivities of between 46% and 78%. Data provide some support for the value of current clinical criteria for classifying pneumonia severity, with those meeting severe or very severe criteria being at considerably increased risk of death, hypoxemia or bacteremia. Results of randomized controlled trials report clinically defined improvement at 48 hours in at least 80% of children treated using recommended antibiotics. However, a limitation of these data may include inappropriate definitions of treatment failure.

CONCLUSION

Particularly with regard to severe pneumonia, issues that specifically need to be addressed are the adequacy of penicillin monotherapy, or oral amoxicillin or alternative antibiotics; the timing of introduction of high-dose trimethoprim-sulfamethoxazole in children at risk for or known to be infected by HIV and the value of pulse oximetry.

Hypoxaemia among children in rural hospitals in Papua New Guinea: epidemiology and resource availability--a study to support a national oxygen programme

AIMS

To support a national approach to oxygen systems in Papua New Guinea, we conducted a study to document the incidence of hypoxaemia, its geographical distribution, epidemiological determinants and resource availability in several regions of the country. We also established baseline mortality rate data for all children admitted to five hospitals, for children with a diagnosis of pneumonia and for neonates to evaluate a future intervention.

METHODS

Data were collected prospectively from over 1300 hospital admissions in five hospitals in 2004. To establish the baseline case fatality rates, data on outcome were collected retrospectively over 3 years (2001-2003) for over 20,000 children admitted to five hospitals.

RESULTS

A total of 1313 admissions were studied prospectively in the five hospitals. Altogether, 384 (29.25%, 95% CI 26.8-31.8) had hypoxaemia, defined as SpO(2) <90%. The incidence of hypoxaemia was much greater in highland hospitals (40% of all admissions) than on the coast (10% of all admissions). This large difference in incidence persisted when the uniform definition of hypoxaemia was adjusted for altitude, and was largely because of differences in the incidence of acute respiratory tract infection. Oxygen was not available on the day of admission for 22% of children (range between hospitals, 3-38), including 13% of all children with hypoxaemia. Oxygen was less available in remote rural district hospitals than in provincial hospitals in regional towns. Clinical signs proposed by WHO as indicators for oxygen would have missed 29% of children with hypoxaemia and, if these clinical signs were used, 30% of children without hypoxaemia would have been considered in need of supplemental oxygen.

CONCLUSIONS

Based on this study, an approach to improving the detection of hypoxaemia and the availability of oxygen has been trialled in these five hospitals where a programme of clinical and technical training in the use and maintenance of pulse oximetry and oxygen concentrators has been introduced.

Role of Acute Illness Observation Scale (AIOS) in managing severe childhood pneumonia

OBJECTIVE

In the perspective of integrated management of childhood illness (IMCI) strategy and recent evidence favoring use of oral antibiotics in severe pneumonia, a generic illness severity index--Acute Illness Observation Scale (AIOS)--was prospectively validated in children with severe pneumonia in a civil hospital in remote hilly region.

METHODS

AIOS was used in quantifying overall severity of illness for eighty-nine consecutive children (age, 2-59 months) hospitalized with community-acquired severe pneumonia. A detailed clinimetric evaluation of scale was carried out and logistic regression analyses predicted the following outcomes: 1) mode of initial antimicrobial therapy (oral vs. parenteral); and 2) need for intravenous fluids at admission.

RESULTS

Majority of children (80.9%) with severe pneumonia scored abnormally (AIOS score> 10) at initial evaluation. Children with abnormal AIOS scores (>10) had significantly greater severity of respiratory distress and higher incidence of radiological pneumonia. Outcome measures i.e. time to defervescence and length of hospital stay were also positively and significantly correlated with the scores. The six-item scale had good internal consistency (Cronbach's alpha 0.81); and its factor analysis yielded a single latent factor explaining 54% of variance in illness severity at admission. Furthermore, logistic regression analyses revealed an independent predictive ability of AIOS in aiding clinician to decide the mode of initial antimicrobial therapy (oral or parenteral), as well as need for intravenous fluids.

CONCLUSION

Authors study indicates the clinimetric validity of AIOS in managing, Severe childhood pneumonia and suggests its role in further enriching IMCI strategy.

Hypoxemia in children with pneumonia and its clinical predictors

OBJECTIVES

To assess the prevalence of hypoxemia in children, 2 months to 5 years of age, with pneumonia and to identify its clinical predictors.

METHODS

Children between 2-60 months of age presenting with a complaint of cough or difficulty breathing were assessed. Hypoxemia was defined as an arterial oxygen saturation of < 90% recorded by a portable pulse oximeter. Patients were categorized into groups: cough and cold, pneumonia, severe pneumonia and very severe pneumonia.

RESULTS

The prevalence of hypoxemia (SpO2 of < 90%) in 150 children with pneumonia was 38.7%. Of them 100% of very severe pneumonia, 80% of severe and 17% of pneumonia patients were hypoxic. Number of infants with respiratory illness (p value = 0.03) and hypoxemia (Odds ratio = 2.21, 95% CI 1.03, 4.76) was significantly higher. Clinical predictors significantly associated with hypoxemia on univariate analysis were lethargy, grunting, nasal flaring, cyanosis, and complaint of inability to breastfeed/drink. Chest indrawing with 68.9% sensitivity and 82.6% specificity was the best predictor of hypoxemia.

CONCLUSION

The prevalence and clinical predictors of hypoxemia identified validate the WHO classification of pneumonia based on severity. Age < 1 year in children with ARI is an important risk factor for hypoxemia.

Decrease in emergency department length of stay as a result of triage pulse oximetry

OBJECTIVES

Many emergency departments do not perform pulse oximetry in triage, in spite of its potential for altering management decisions. We attempted to quantify the decrease in patient throughput time in a pediatric emergency department following the introduction of triage pulse oximetry.

METHODS

One hundred fifty-nine bronchiolitis patients from 2004 served as the preintervention group, and were evaluated against 89 severity-matched postintervention bronchiolitis patients from 2005. Their mean lengths of ED stay were compared by a t test.

RESULTS

The preintervention group had a mean length of stay of 4 hours and 59 minutes, and the postintervention group had a mean length of stay of 4 hours and 9 minutes, which was significantly different (P = 0.03). The sensitivity of respiratory distress on the triage exam for predicting hypoxia was fair (74%).

CONCLUSIONS

Institution of triage pulse oximetry significantly decreases ED throughput times. Clinical exam alone is not a replacement for measurement of oxygen saturation.

The spectrum of hypoxaemia in children admitted to hospital in The Gambia, West Africa

OBJECTIVE

Hypoxia predicts mortality in children with acute lower respiratory infections (ALRIs). We investigated the prevalence and predictive value of hypoxia in ALRI and other acute infectious diseases.

METHODS

We studied the spectrum of hypoxaemia in 4,047 children admitted to a tertiary hospital in The Gambia. Oxygen saturation was measured shortly after admission. Severe hypoxaemia was defined as an oxygen saturation below 90%.

RESULTS

5.8% of all admissions had severe hypoxaemia. Prevalence of hypoxaemia varied between disease groups: it was 11.7% in ALRI cases, 16.5% in neonates; 2.9% in malaria cases overall but 6.5% in cerebral malaria patients; and 2.7% in children with meningitis. Hypoxaemia predicted a poor outcome; the odds ratio for death among paediatric admissions overall was 7.45 [95% confidence intervals (CI) 5.40-10.29]. Surprisingly, it was lowest for children with ALRI [OR 3.53 (95% CI 1.13-10.59)], and higher for those with malaria 9.90 [95% CI 4.39-22.35].

CONCLUSION

Hypoxaemia is common among Gambian children admitted to hospital and it is often associated with a poor outcome. A similar situation is likely in many other developing countries. Thus, equipment for measuring oxygen saturation, and facilities and equipment for effective oxygen delivery need to be made available in developing countries.

Can clinical signs predict hypoxaemia in Papua New Guinean children with moderate and severe pneumonia?

Pulse oximetry was performed on 77 children admitted with acute lower respiratory tract infections (ALRI) to the children's ward in Port Moresby General Hospital, Papua New Guinea over a 4-month period in 2002. Clinical findings were correlated with different levels of hypoxaemia, <93%, <90% and <85%. Cyanosis, head nodding and drowsiness were good predictors of hypoxia but lacked sensitivity. Decisions to use oxygen based on these signs would therefore result in a significant number of children with hypoxia not receiving oxygen. Pulse oximetry is the best indicator of hypoxaemia in children with ALRI and, although relatively expensive, its use might be cost-effective in controlling oxygen requirements.

The use of pulse oximetry to exclude pneumonia in children

The objective of this study was to determine whether pulse oximetry alone or in conjunction with the clinical examination is predictive of pneumonia in children who present to the emergency department with respiratory complaints. A retrospective comparison of children with radiographic pneumonia with children with respiratory complaints and negative chest radiography was used. The study took place in an emergency department of a large academic, tertiary care hospital. All children less than 24 months of age who presented with a respiratory complaint and underwent chest radiography during a 1-year period were included. Charts of children with radiographic pneumonia were compared with charts of children without pneumonia, retrospectively. Data abstracted onto data collection forms included: pulse oximetry measurement, vital signs, general appearance, lung examination, and final radiology interpretation of chest radiographs. Pneumonia was defined as a chest radiograph showing any opacity consistent with pneumonia as read by a board-prepared or -certified radiologist. A total of 803 children qualified for the study. Radiograph interpretations were available for 762, and 10.5% were found to have radiographic pneumonia. The median pulse oximetry reading of children with radiographic pneumonia was 97% (interquartile range 95th-98th percentile) compared with 98% (interquartile range 96th-99th percentile) in the control group. Forty-five percent (35 of 78) of the children with radiographic pneumonia showed oxygen saturations of 98% or higher with greater than 10% (8 of 78) displaying oxygen saturations of 100%. By using logistic regression, pulse oximetry was not found to be a statistically significant predictive variable for radiographic pneumonia. Pulse oximetry could not be used to rule out the presence of radiographic pneumonia in children less than 2 years of age who presented with respiratory complaints.

Hypoxaemia in acute respiratory and non-respiratory illnesses in neonates and children in a developing country

AIMS

To determine, in sick neonates and children requiring admission to a hospital in the highlands of Papua New Guinea: (1) the incidence and severity of hypoxaemia; (2) the proportion with hypoxaemia who do not fulfil criteria for acute lower respiratory infection (ALRI); and (3) the power of clinical signs to predict hypoxaemia, according to age and disease category.

METHODS

Age dependent normal values for transcutaneous oxygen saturation (SpO(2)) were established in 218 well neonates and children in Goroka. A total of 491 sick neonates and children were then studied on presentation to the paediatric department at Goroka Hospital.

RESULTS

A total of 257 sick neonates and children (52%) were hypoxaemic. Hypoxaemia was present in 179/245 (73%) with clinical criteria for ALRI; 79/246 (32%) with non-ALRI illnesses (including meningitis, septicaemia, severe malnutrition, low birth weight, birth asphyxia, and congenital syphilis) were also hypoxaemic. For children aged 1 month to 5 years with ALRI, the clinical signs best predicting hypoxaemia were cyanosis, respiratory rate >60, poor feeding, or reduced spontaneous activity; in those without ALRI the best predictors were cyanosis, respiratory rate >60 per minute, and inability to feed, but the positive predictive value was much lower than for children with ALRI. For neonates cyanosis was predictive of hypoxaemia, but tachypnoea or inability to feed were not.

CONCLUSIONS

Hypoxaemia is an under recognised complication of non-ALRI illnesses in children and in sick neonates in developing countries. Use of algorithms with high sensitivity for the recognition of hypoxaemia, and protocols for administration of oxygen to neonates, and to children with non-ALRI illnesses, might substantially reduce case fatality.

Tachypnoea is a good predictor of hypoxia in acutely ill infants under 2 months

OBJECTIVE

To evaluate the respiratory rate as an indicator of hypoxia in infants < 2 months of age.

SETTING

Pediatric emergency unit of an urban teaching hospital.

SUBJECTS

200 infants < 2 months, with symptom(s) of any acute illness.

METHODS

Respiratory rate (by observation method), and oxygen saturation (SaO(2)) by means of a pulse oximeter were recorded at admission. Infants were categorised by presence or absence of hypoxia (SaO(2) </= 90%).

RESULTS

The respiratory rate was >/= 50/min in 120 (60%), >/= 60/min in 101 (50. 5%), and >/= 70/min in 58 (29%) infants. Hypoxia (SaO(2) </= 90%) was seen in 77 (38.5%) infants. Respiratory rate and SaO(2) showed a significant negative correlation (r = -0.39). Respiratory rate >/= 60/min predicted hypoxia with 80% sensitivity and 68% specificity.

CONCLUSION

These results indicates that a respiratory rate > 60/min is a good predictor of hypoxia in infants under 2 months of age brought to the emergency service of an urban hospital for any symptom(s) of acute illness.

Clinical predictors of hypoxaemia in Gambian children with acute lower respiratory tract infection: prospective cohort study

OBJECTIVES

To determine clinical correlates and outcome of hypoxaemia in children admitted to hospital with an acute lower respiratory tract infection.

DESIGN

Prospective cohort study.

SETTING

Paediatric wards of the Royal Victoria Hospital and the hospital of the Medical Research Council's hospital in Banjul, the Gambia.

SUBJECTS

1072 of 42 848 children, aged 2 to 33 months, who were enrolled in a randomised trial of a Haemophilus influenzae type b vaccine in the western region of the Gambia, and who were admitted with an acute lower respiratory tract infection to two of three hospitals.

MAIN OUTCOME MEASURES

Prevalence of hypoxaemia, defined as an arterial oxygen saturation <90% recorded by pulse oximetry, and the relation between hypoxaemia and aetiological agents.

RESULTS

1072 children aged 2-33 months were enrolled. Sixty three (5.9%) had an arterial oxygen saturation <90%. A logistic regression model showed that cyanosis, a rapid respiratory rate, grunting, head nodding, an absence of a history of fever, and no spontaneous movement during examination were the best independent predictors of hypoxaemia. The presence of an inability to cry, head nodding, or a respiratory rate >/= 90 breaths/min formed the best predictors of hypoxaemia (sensitivity 70%, specificity 79%). Hypoxaemic children were five times more likely to die than non-hypoxaemic children. The presence of malaria parasitaemia had no effect on the prevalence of hypoxaemia or on its association with respiratory rate.

CONCLUSION

In children with an acute lower respiratory tract infection, simple physical signs that require minimal expertise to recognise can be used to determine oxygen therapy and to aid in screening for referral. The association between hypoxaemia and death highlights the need for early recognition of the condition and the potential benefit of treatment.

The clinical spectrum of respiratory syncytial virus disease in The Gambia

BACKGROUND

Respiratory syncytial virus (RSV) is a well-recognized cause of lower respiratory tract infections in early childhood in industrialized countries, but less is known about RSV infection in developing countries.

METHODS

Four outbreaks of RSV infection that occurred between 1993 and 1996 in The Gambia, West Africa, were studied. RSV was sought by immunofluorescent staining of nasopharyngeal aspirate samples among young children who presented with respiratory infections at three hospitals in the Western Region of the country.

RESULTS

Five hundred seventy-four children with RSV infection were identified. The median ages of children seen in 1993 through 1996 were 3, 7, 8 and 5 months, respectively. Sixty-two percent of children <6 months old were boys. Thirteen children (2.4%) had conditions considered to increase the risk of severe RSV infection. On physical examination crepitations were heard in 80% of the children admitted to hospital, whereas wheezes were heard in only 39%. Eighty (16%) children received oxygen because of hypoxemia. Nine of 255 blood cultures (3.5%) were positive: 4 Streptococcus pneumoniae; 2 Haemophilus influenzae type b; 2 Staphylococcus aureus; and 1 Enterobacter agglomerans. Thirteen children died (2.4%). During the 4 study years 90, 25, 75 and 95% of isolates typed were RSV Subgroup A, respectively.

CONCLUSIONS

RSV is a significant cause of lower respiratory tract infection in young children in The Gambia, causing epidemics of bronchiolitis. It poses a significant burden on the health system, especially through the demand for supplementary oxygen. The clinical spectrum of RSV disease in The Gambia is similar to that seen in developed countries; concomitant bacterial infections are uncommon.