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Shah SN, Monuteaux MC, Neuman MI. Prevalence and predictors of radiographic pneumonia in children with wheeze: A systematic review and meta-analysis. Acad Emerg Med 2024. [PMID: 39189186 DOI: 10.1111/acem.15006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Diagnostic uncertainty exists surrounding the identification of radiographic pneumonia in children with wheeze. It is important to determine the prevalence and clinical predictors of pneumonia in this population to limit chest radiography (CXR) and promote judicious antibiotic use. OBJECTIVES The objectives were to (1) estimate the prevalence of radiographic pneumonia in children with wheeze and (2) systematically review the diagnostic accuracy of clinical findings for the identification of radiographic pneumonia. METHODS Data sources were MEDLINE, PubMed Central, Cochrane Library, CINAHL, and Web of Science (January 1995 to September 2023). For study selection, two reviewers identified high-quality studies reporting on clinical characteristics associated with radiographic pneumonia in wheezing children (age 0-21 years). Using Covidence software, data regarding study characteristics, methodologic quality, and results were extracted. Data were pooled using random-effects meta-analysis. RESULTS A total of 8333 unique titles and abstracts were reviewed. Twelve studies, representing 7398 patients, were included. Fifteen percent of children with wheeze undergoing CXR had pneumonia. Findings associated with radiographic pneumonia included temperature ≥ 38.4°C (positive likelihood ratio [LR+] 2.1, 95% CI 1.2-3.6, specificity 85%), oxygen saturation < 92% (LR+ 3.6, 95% CI 1.4-8.9, specificity 89%), and grunting (LR+ 2.7, 95% CI 1.6-4.4, pooled specificity 91%). Factors associated with the absence of radiographic pneumonia included lack of fever (negative likelihood ratio [LR-] 0.67, 95% CI 0.52-0.85) and oxygen saturation ≥ 95% (LR- 0.64, 95% CI 0.42-0.98). Tachypnea and auscultatory findings were not associated with radiographic pneumonia. DISCUSSION Heterogeneity across studies limits generalizability. Additionally, all included studies overestimate the rate of radiographic pneumonia given the fact that all subjects had a CXR performed due to clinical suspicion of pneumonia. CONCLUSIONS Radiographic pneumonia occurs in 15% of wheezing children undergoing CXR for pneumonia. Auscultatory findings and tachypnea do not differentiate children with and without pneumonia, and the rate of radiographic pneumonia is very low in the absence of fever and hypoxemia.
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Affiliation(s)
- Sonal N Shah
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Rashid MM, Ahmed S, Owens L, Hu N, Jaffe A, Homaira N. Asthma-community acquired pneumonia co-diagnosis in children: a scoping review. J Asthma 2024; 61:282-291. [PMID: 37943507 DOI: 10.1080/02770903.2023.2280843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE This scoping review investigated the existing literature and identified the evidence gaps related to diagnosis and management in children aged 2-18 years presenting to hospitals with a co-diagnosis of asthma and community-acquired pneumonia. DATA SOURCES We designed a scoping review following Arksey and O'Malley's scoping review framework and PRISMA extension for a scoping review. We searched literature using five electronic databases: PubMed, CINAHL, Scopus, Web of Science, and Embase from 2003 to June 2023. RESULTS A total of 1599 abstracts with titles were screened and 12 abstracts were selected for full review. Separate guidelines including Modified Global Initiative for Asthma (GINA) guidelines; modified Integrated Management of Childhood Illness (IMCI) guidelines; and a consensus guideline developed by the Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) were used for diagnosing asthma and CAP individually. Chest X-rays were used in 83.3% (10/12) of studies to establish the co-diagnosis of asthma-CAP in children. Variations were observed in using different laboratory investigations across the studies. Infectious etiologies were detected in five (41.7%) studies. In 75% (9/12) of studies, children with asthma-CAP co-diagnosis were treated with antimicrobials, however, bacterial etiology was not reported in 44.4% (4/9) of the studies. CONCLUSIONS Our scoping review suggests that chest X-rays are commonly used to establish the co-diagnosis of asthma-CAP and antibiotics are often used without laboratory confirmation of a bacterial etiology. Clinical practice guidelines for the management of asthma and pneumonia in children who present with co-diagnosis may standardize clinical care and reduce variation.
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Affiliation(s)
- Md Mahbubur Rashid
- Faculty of Medicine, School of Clinical Medicine, UNSW, Sydney, Australia
| | - Shamim Ahmed
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Louisa Owens
- Faculty of Medicine, School of Clinical Medicine, UNSW, Sydney, Australia
- Respiratory Department, Sydney Children's Hospital, Sydney, Australia
| | - Nan Hu
- Faculty of Medicine, School of Clinical Medicine, UNSW, Sydney, Australia
| | - Adam Jaffe
- Faculty of Medicine, School of Clinical Medicine, UNSW, Sydney, Australia
- Respiratory Department, Sydney Children's Hospital, Sydney, Australia
| | - Nusrat Homaira
- Faculty of Medicine, School of Clinical Medicine, UNSW, Sydney, Australia
- Respiratory Department, Sydney Children's Hospital, Sydney, Australia
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Sakr M, Al Kanjo M, Balasundaram P, Kupferman F, Al-Mulaabed S, Scott S, Viswanathan K, Basak RB. A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations. Pediatr Qual Saf 2024; 9:e721. [PMID: 38576889 PMCID: PMC10990363 DOI: 10.1097/pq9.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/26/2024] [Indexed: 04/06/2024] Open
Abstract
Background Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. Methods We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. Results The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. Conclusions This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.
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Affiliation(s)
- Mohamed Sakr
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Mohamed Al Kanjo
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Palanikumar Balasundaram
- Division of Neonatology, Department of Pediatrics, Mercy Health - Javon Bea Hospital, Rockford, Ill
| | - Fernanda Kupferman
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Sharef Al-Mulaabed
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Sandra Scott
- Department of Emergency Medicine, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Kusum Viswanathan
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
| | - Ratna B. Basak
- From the Department of Pediatrics, Brookdale University Medical Center, One Brookdale Plaza, Brooklyn, N.Y
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Yu Y, Meng W, Zhu X, Li B, Yang J, Zhang Y, Wang X, Luo J, Wang Y, Xuan Y. Tidal breathing lung function analysis of wheezing and non-wheezing infants with pneumonia: A retrospective observational study. Medicine (Baltimore) 2023; 102:e33507. [PMID: 37058014 PMCID: PMC10101276 DOI: 10.1097/md.0000000000033507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
To compare lung function in wheezing and non-wheezing infants with pneumonia through tidal breathing analysis and explore the correlation between tidal breathing lung function and clinical characteristics. This retrospective observational study included infants with pneumonia hospitalized in the Affiliated Hospital of Guizhou Medical University between January 2018 and December 2018. Medical records were used to obtain the demographic characteristics, clinical characteristics, tidal breathing lung function results before and after a bronchodilator test, and positive remission rates after the bronchodilator test for each patient. Eighty-six wheezing infants (64 males, aged 6.5 [4.8, 9] months) and 27 non-wheezing infants (18 males, aged 7 [5, 12] months) were included. Non-wheezing infants were more likely to have normal airway function compared to wheezing infants (44.4% vs 23.3%, P = .033). Peak tidal expiration flow/tidal expiratory flow (TEF)25 in wheezing infants was significantly higher than that in non-wheezing infants (162.4 [141.2, 200.7] vs 143.3 [131, 178.8], P = .037). The positive remission rate of tidal inspiratory flow (TIF50)/TEF50 (53.5% vs 29.6%, P = .03) and TEF50 (58.1% vs 33.3%, P = .024) were significantly higher in the wheezing infants compared to non-wheezing infants (P = .03 and P = .024, respectively). Furthermore, respiratory rate, tidal volume, peak expiration flow, TEF25, TEF50, and TEF75 were significantly correlated to the age, height, weight, and platelet counts of infants in both the wheezing and non-wheezing infants (all P < .05). Wheezing infants with pneumonia were more likely to have worse tidal breathing lung function compared to non-wheezing infants with pneumonia. The tidal breathing lung function parameter (respiratory rate, tidal volume, peak expiration flow, TEF25, TEF50, and TEF75) were correlated to the age, height, weight, and platelet counts of both wheezing and non-wheezing infants.
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Affiliation(s)
- Yiyi Yu
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Wenjuan Meng
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Xiaoping Zhu
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Bo Li
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Jun Yang
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Yali Zhang
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Xuesong Wang
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Jing Luo
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Youyan Wang
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Yingying Xuan
- Department of Pediatrics, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
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Pittet LF, Glangetas A, Barazzone-Argiroffo C, Gervaix A, Posfay-Barbe KM, Galetto-Lacour A, Stollar F. Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study. PLoS One 2023; 18:e0285626. [PMID: 37200253 DOI: 10.1371/journal.pone.0285626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/26/2023] [Indexed: 05/20/2023] Open
Abstract
The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.
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Affiliation(s)
- Laure F Pittet
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
- Unit of Pediatric Infectious Diseases, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Alban Glangetas
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Constance Barazzone-Argiroffo
- Unit of Pediatric Pulmonology, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Alain Gervaix
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Klara M Posfay-Barbe
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
- Unit of Pediatric Infectious Diseases, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Annick Galetto-Lacour
- Division of Pediatric Emergency, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
| | - Fabiola Stollar
- Division of General Pediatrics, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and University of Geneva's Faculty of Medicine, Geneva, Switzerland
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Akcan Yildiz L, Demirci B, Gunes A, Yakut HI, Dibek Misirlioglu E. A Self-criticism of Diagnostic and Therapeutic Decision Making in Children Admitted With Acute Lower Respiratory Infection at a Single Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e839-e843. [PMID: 34101685 DOI: 10.1097/pec.0000000000002474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute bronchiolitis and community-acquired pneumonia are the most common acute lower respiratory infections (LRIs) leading to emergency admission and hospitalization in children. The aim of this study is to investigate clinical, laboratory, and radiology findings; diagnostic and therapeutic decisions; and the relationships between them in patients younger than 2 years of age, hospitalized for LRI. METHODS Patients hospitalized for acute LRI (aged 28 days to 24 months) between November 1, 2017, and March 31, 2018, at a referral hospital were included. Patients' characteristics, clinical, laboratory, and radiologic findings and diagnostic and therapeutic decisions, along with reason for hospitalization, were recorded retrospectively. Chest x-rays were reinterpreted by the pediatric radiologist. Associations of these data with the radiologic signs and treatment modalities including antibiotics, bronchodilators, and high-flow oxygen therapy (HFOT) were assessed. RESULTS One hundred eighty-two patients were included. One hundred sixty (87.9%) had at least one of the following criteria for hospitalization: dehydration, feeding difficulties, young age (<12 weeks), and hypoxia. One hundred forty-five (79.6%) and 71 (39.0%) patients were administered antibiotic and antiviral therapy, respectively. Twenty-three patients (13.7%) were given HFOT, and 179 (99.4%) were given bronchodilators. None of the complaints, physical signs, or laboratory parameters had statistically significant associations with radiologic findings (P > 0.05). History of wheezing and presence of rales and dehydration in physical examination were associated with antibiotic use (P < 0.001). CONCLUSIONS The decision of hospitalization was generally appropriate. However, laboratory and radiologic tests and treatments including HFOT, bronchodilator, antibiotic, and antiviral therapies were used excessively and inefficiently. Physicians' decisions were not based on evidence or on the clinical findings of the patient. The results of this study should prompt investigations into the reasons underlying these clinical decisions and development of practice models that can provide solutions specifically targeting the decision-making processes of physicians caring for young children with LRI at the emergency department.
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Affiliation(s)
| | - Busra Demirci
- Division of Pediatrics, Ankara City Hospital, University of Health Sciences
| | - Altan Gunes
- Division of Pediatric Radiology, Ankara City Hospital
| | | | - Emine Dibek Misirlioglu
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Abstract
BACKGROUND The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia. METHODS We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia. RESULTS Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73). CONCLUSIONS In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.
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Hudgins JD, Neuman MI, Monuteaux MC, Porter J, Nelson KA. Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments. Pediatr Emerg Care 2021; 37:507-512. [PMID: 30624420 DOI: 10.1097/pec.0000000000001706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. METHODS Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. RESULTS More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. CONCLUSIONS Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.
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Affiliation(s)
- Joel D Hudgins
- From the Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
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Majerus CR, Tredway TL, Yun NK, Gerard JM. Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain. Pediatr Emerg Care 2021; 37:e372-e375. [PMID: 30256317 DOI: 10.1097/pec.0000000000001615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Previous studies have not evaluated the utility of obtaining chest radiographs (CXR) in patients with acute asthma exacerbation reporting chest pain. The aims of this study were to evaluate the symptom of chest pain as a predictor for clinicians obtaining a CXR in these patients and to evaluate chest pain as a predictor of a positive CXR finding. METHODS This was a retrospective chart review of patients, ages 2 to 18 years, presenting for acute asthma exacerbation to the emergency department from August 1, 2014, to March 31, 2016. Data collected included demographics, clinical data, provider type, and CXR results. Chest radiographs were classified as positive if they showed evidence of pneumonia, pneumothorax, or pneumomediastinum. Multivariate logistic regression models were developed with dependent variables of "obtaining a CXR" and "a positive CXR finding." RESULTS Seven hundred ninety-three subjects were included in the study. Two hundred thirty-one (29.1%) reported chest pain. Chest radiographs were obtained in 184 patients (23.2%). Of those, 74 patients (40.2%) had chest pain and 21 (11.4%) had a positive CXR. Providers were more likely to obtain CXRs in patients who reported chest pain (odds ratio = 2.2 [95% confidence interval = 1.5-3.2]). Patients reporting chest pain were more likely to have a positive CXR although this difference was not statistically significant (odds ratio = 2.0 [95% confidence interval = 0.7-5.6]). CONCLUSIONS Providers are more likely to obtain CXRs in asthmatic patients complaining of chest pain; however, these CXRs infrequently yield positive findings. This further supports limiting the use of chest radiography in patients with acute asthma exacerbation.
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Affiliation(s)
- Chelsea R Majerus
- From the Department of Pediatrics, Division of Pediatric Emergency Medicine, Saint Louis University School of Medicine and SSM Health Cardinal Glennon Children's Hospital, Saint Louis, MO
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10
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Ozdemır B, Yalçın SS. The role of body temperature on respiratory rate in children with acute respiratory infections. Afr Health Sci 2021; 21:640-646. [PMID: 34795718 PMCID: PMC8568237 DOI: 10.4314/ahs.v21i2.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The World Health Organization (WHO) recommends the use of tachypnea as a proxy to the diagnosis of pneumonia. Objective The purpose of this study was to examine the relationship between body temperature alterations and respiratory rate (RR) difference (RRD) in children with acute respiratory infections(ARI). Methods This cross-sectional study included 297 children with age 2–60 months who presented with cough and fever at the pediatric emergency and outpatient clinics in the Department of Pediatrics, Baskent University Hospital, from January 2016 through June 2018. Each parent completed a structured questionnaire to collect background data. Weight and height were taken. Body temperature, respiratory rate, presence of the chest indrawing, rales, wheezing and laryngeal stridor were also recorded. RRD was defined as the differences in RR at admission and after 3 days of treatment. Results Both respiratory rate and RRD were moderately correlated with body temperature (r=0.71, p<0.001 and r=0.65, p<0.001; respectively). For every 1°C increase in temperature, RRD increased by 5.7/minutes in overall, 7.2/minute in the patients under 12 months of age, 6.4/minute in the female. The relationship between body temperature and RRD wasn't statistically significant in patients with rhonchi, chest indrawing, and low oxygen saturation. Conclusion Respiratory rate should be evaluated according to the degree of body temperature in children with ARI. However, the interaction between body temperature and respiratory rate could not be observed in cases with rhonchi and severe pneumonia.
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Affiliation(s)
- Beril Ozdemır
- Department of Pediatrics, Baskent University Faculty of Medicine, Ankara, Turkey
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Kong K, Ding Y, Wu B, Lu M, Gu H. Clinical Predictors of Wheezing Among Children Infected With Mycoplasma Pneumoniae. Front Pediatr 2021; 9:693658. [PMID: 34631611 PMCID: PMC8492963 DOI: 10.3389/fped.2021.693658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mycoplasma pneumoniae (MP) not only was a common pathogen of respiratory tract infections, but also could trigger the exacerbation of asthmatic symptoms in children with or without asthma. Objective: This study aimed to identify possible risk factors associated with wheezing among children diagnosed with MP infection. Methods: A retrospective analysis of medical records of children aged 28 days to 18 years old who visited the Shanghai Children's Hospital between January 2019 and January 2020 was carried out, and all children were then classified into three groups: two wheezing groups (with or without MP infection) and a non-wheezing group with MP infection. Information including patient's demographics, clinical features, laboratory data, and radiography findings was extracted from the electronic medical record system. Chest radiographs were reviewed independently by two board-certified, blinded pediatric radiologists. Results: A total of 1,512 patients were included in our study, and 21.9% of them belonged to the wheezing group without MP infection. Among 1,181 patients with MP infection, 295 people (25.0%) suffered from wheezing, and males accounted for 61%. Through the multivariable logistic regression analyses, we found that six variables were positively associated with wheezing attacks in children with MP infection: male gender (likelihood ratio [LR] = 2.124, 95% confidence interval [CI]: 1.478-3.053), history of allergy (LR= 3.301, 95% CI: 2.206-4.941), history of wheezing (LR = 7.808, 95% CI: 5.276-11.557), autumn in reference to summer (LR = 2.414, 95% CI: 1.500-3.885), non-end-point infiltration in reference to consolidation or pleural effusion (LR = 1.982, 95% CI: 1.348-2.914), and infiltration scope (LR = 1.773, 95% CI: 1.293-2.432). However, the model showed that the probability of wheezing after MP infection decreased as age increased (LR = 0.257, 95% CI: 0.196-0.337). Moreover, the area under the curve (AUC) of the regression model was as high as 0.901 (0.847-0.955). Conclusion: The model integrated with factors including gender, age, season, radiological patterns, infiltration scope, and history of allergy performed well in predicting wheezing attack after MP infection in children.
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Affiliation(s)
- Kaimeng Kong
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Ding
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Beirong Wu
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Min Lu
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Haoxiang Gu
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Homma T, Kawahara T, Mikuni H, Uno T, Sato H, Fujiwara A, Uchida Y, Fukuda Y, Manabe R, Ida H, Kuwahara N, Kimura T, Hirai K, Miyata Y, Jinno M, Yamaguchi M, Kishino Y, Murata Y, Ohta S, Yamamoto M, Watanabe Y, Yamaguchi H, Kusumoto S, Suzuki S, Tanaka A, Yokoe T, Ohnishi T, Sagara H. Beneficial Effect of Early Intervention with Garenoxacin for Bacterial Infection-Induced Acute Exacerbation of Bronchial Asthma and Chronic Obstructive Pulmonary Disease. Int Arch Allergy Immunol 2019; 178:355-362. [PMID: 30759444 DOI: 10.1159/000495761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) and asthma have similar clinical features and are both exacerbated by airway infection. OBJECTIVE To determine whether garenoxacin mesylate hydrate (GRNX) added to the standard care for bacterial infection-induced acute exacerbation of asthma or COPD in adults has clinical benefits. METHOD This single-arm clinical trial was conducted from January 2015 to March 2016. Adults with a history of asthma or COPD for more than 12 months were recruited within 48 h of presentation with fever and acute deterioration of asthma or COPD requiring additional intervention. Participants were administered 400 mg GRNX daily for 7 days without additional systemic corticosteroids or other antibiotics. The primary outcome was efficacy of GRNX based on clinical symptoms and blood test results after 7 days of treatment. Secondary outcomes were: (1) comparison of the blood test results, radiograph findings, and bacterial culture surveillance before and after treatment; (2) effectiveness of GRNX after 3 days of administration; (3) analyzation of patient symptoms based on patient diary; and (4) continued effectiveness of GRNX on 14th day after the treatment (visit 3). RESULTS The study included 44 febrile patients (34 asthma and 10 COPD). Frequently isolated bacteria included Moraxella catarrhalis (n = 6) and Klebsiella pneumoniae (n = 4). On visit 2, 40 patients responded, and no severe adverse events were observed. All secondary outcomes showed favorable results. CONCLUSION GRNX effectively treated asthma and COPD patients with acute bacterial infection without severe adverse events. Further research with a larger study population is needed.
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Affiliation(s)
- Tetsuya Homma
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan,
| | - Tomoko Kawahara
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hatsuko Mikuni
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomoki Uno
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Haruna Sato
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akiko Fujiwara
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoshitaka Uchida
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yosuke Fukuda
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Ryo Manabe
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hitomi Ida
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Naota Kuwahara
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomoyuki Kimura
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kuniaki Hirai
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoshito Miyata
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Megumi Jinno
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Munehiro Yamaguchi
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yasunari Kishino
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yasunori Murata
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shin Ohta
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Mayumi Yamamoto
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoshio Watanabe
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hirofumi Yamaguchi
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Sojiro Kusumoto
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shintaro Suzuki
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akihiko Tanaka
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuya Yokoe
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tsukasa Ohnishi
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hironori Sagara
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
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Hirsch AW, Monuteaux MC, Neuman MI, Bachur RG. Estimating Risk of Pneumonia in a Prospective Emergency Department Cohort. J Pediatr 2019; 204:172-176.e1. [PMID: 30293642 DOI: 10.1016/j.jpeds.2018.08.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/17/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To improve the prediction of pediatric pneumonia by developing a series of models based on clinically distinct subgroups. We hypothesized that these subgroup models would provide superior estimates of pneumonia risk compared with a single pediatric model. STUDY DESIGN We conducted a secondary analysis of a prospective cohort being evaluated for radiographic pneumonia in an urban pediatric emergency department (ED). Using multivariate modeling, we created 4 models across subgroups stratified by age and presence of wheezing to predict the risk of pneumonia. RESULTS A total of 2351 patients were included in the study. In this series, the prevalence of pneumonia was 8.5%, and 21.6% were hospitalized. The highest prevalence of pneumonia was in children aged >2 years without wheezing (13.3%). Children aged <2 years with wheezing had the lowest prevalence of pneumonia (4.0%). The most accurate model was for children aged <2 years with wheezing (area under the curve [AUC], 0.80), and the poorest performing model was for those aged <2 years without wheezing (AUC, 0.64). The AUC of a combination of the 4 subgroup models was 0.76 (95% CI, 0.72-0.80). The precision of the models' estimates (expected vs observed) was ± 3.7%. CONCLUSIONS Using 4 complementary prediction models for pediatric pneumonia, an accurate risk of pneumonia can be calculated. These models can provide the basis for clinical decision making support to guide the use of chest radiographs and promote antibiotic stewardship.
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Affiliation(s)
- Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Lipsett SC, Monuteaux MC, Bachur RG, Neuman MI. Caregiver Valuation of Chest Radiography for the Diagnosis of Pneumonia in Children. Clin Pediatr (Phila) 2018; 57:1103-1106. [PMID: 29027476 DOI: 10.1177/0009922817736768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Wasser CD, Grushevsky A, Johnson ST, Smith SR. Asthmonia: A clinical definition of a commonly used colloquial term. J Asthma 2017; 55:1237-1241. [PMID: 29283705 DOI: 10.1080/02770903.2017.1409235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the clinical characteristics of pediatric asthmonia, a syndrome in which children have both an acute asthma exacerbation and a concomitant diagnosis of community acquired pneumonia. METHODS A retrospective chart review was conducted on children admitted to Connecticut Children's Medical Center in the pediatric emergency department from January 1, 2012 to December 31, 2012. Children with asthma and pneumonia were identified using ICD-9 codes 493 (asthma) or 482 (pneumonia). In this study, we defined asthmonia, a third group, based on the following criteria: (1) history of asthma based on documentation in the past medical history section of the chart, (2) documented wheezing on presentation, (3) administration of bronchodilator(s), and (4) new focal infiltrate on chest radiograph during ED visit. The three nonoverlapping groups (asthma, pneumonia, and asthmonia) were described. RESULTS Three hundred and sixty-eight children were identified for our study population. In the study population, 66.0% (N = 243) had asthma, 20.4% (N = 75) pneumonia, and 13.6% (N = 50) met our definition of asthmonia. We found that 84.0% (N = 42) of children who met asthmonia criteria in our study were treated with antibiotic therapies. Also, 28.0% (N = 14) of children who met asthmonia criteria had documented fever during admission or by parent report. CONCLUSIONS This study defined clinical features of the coexistence of pneumonia in children with asthma. Overall, these children frequently presented with fever and were treated with antibiotics. More studies are needed to better elucidate this clinical entity and its ramifications.
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Affiliation(s)
- Caleb D Wasser
- a Department of Pediatrics , University of Connecticut School of Medicine, Connecticut Children's Medical Center , Hartford , CT , USA
| | - Anna Grushevsky
- a Department of Pediatrics , University of Connecticut School of Medicine, Connecticut Children's Medical Center , Hartford , CT , USA
| | - Stephanie T Johnson
- b Department of Research , Connecticut Children's Medical Center , Hartford , CT , USA
| | - Sharon R Smith
- a Department of Pediatrics , University of Connecticut School of Medicine, Connecticut Children's Medical Center , Hartford , CT , USA
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17
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Allie EH, Dingle HE, Johnson WN, Birnbaum JR, Hilmes MA, Singh SP, Arnold DH. ED chest radiography for children with asthma exacerbation is infrequently associated with change of management. Am J Emerg Med 2017; 36:769-773. [PMID: 29137905 DOI: 10.1016/j.ajem.2017.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information. OBJECTIVE To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic. DESIGN/METHODS Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes. RESULTS Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p>0.11). Crackles were associated with antibiotic administration (p=0.03), but not PNA on CXR (p=0.07). Only previous antibiotic use within 7days had both significant univariate associations (p=0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3). CONCLUSION CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles.
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Affiliation(s)
- Evan H Allie
- Pediatric Emergency Medicine, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States.
| | - Henry E Dingle
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Jeffrey R Birnbaum
- Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Melissa A Hilmes
- Pediatric Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Sudha P Singh
- Pediatric Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States
| | - Donald H Arnold
- Pediatric Emergency Medicine, Vanderbilt University Medical Center, Monroe Carell Jr. Childrens' Hospital, Nashville, TN, United States; Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, TN, United States
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Nazif JM, Taragin BH, Azzarone G, Rinke ML, Liewehr S, Choi J, Esteban-Cruciani N. Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis. Clin Pediatr (Phila) 2017; 56:1054-1059. [PMID: 28871880 DOI: 10.1177/0009922817698802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.
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Affiliation(s)
- Joanne M Nazif
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin H Taragin
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gabriella Azzarone
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael L Rinke
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sheila Liewehr
- 3 Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Jaeun Choi
- 2 Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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20
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Florin TA, Carron H, Huang G, Shah SS, Ruddy R, Ambroggio L. Pneumonia in Children Presenting to the Emergency Department With an Asthma Exacerbation. JAMA Pediatr 2016; 170:803-5. [PMID: 27270612 PMCID: PMC5358794 DOI: 10.1001/jamapediatrics.2016.0310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Hannah Carron
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Guixia Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio4Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio5Division of Infectious Diseases, Cincinnati Children’s Hospital Medical
| | - Richard Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio3Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio4Division of Hospital Medicine, Cincinnati Children’s Hospi
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Abstract
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.
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Mace SE, Gemme SR, Valente JH, Eskin B, Bakes K, Brecher D, Brown MD, Brown MD, Brecher D, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Ingalsbe GS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah K, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Wolf SJ, Cantrill SV, O’Connor RE, Whitson RR, Mitchell MA. Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever. Ann Emerg Med 2016; 67:625-639.e13. [DOI: 10.1016/j.annemergmed.2016.01.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Varshney T, Mok E, Shapiro AJ, Li P, Dubrovsky AS. Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze. Emerg Med J 2016; 33:603-10. [PMID: 27107052 DOI: 10.1136/emermed-2015-205302] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 03/25/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Characterise lung ultrasound (LUS) findings, diagnostic accuracy and agreement between novice and expert interpretations in young children with respiratory tract infections and wheeze. METHODS Prospective cross-sectional study in a paediatric ED. Patients ≤2 years with a respiratory tract infection and wheeze at triage were recruited unless in severe respiratory distress. Prior to clinical management, a novice sonologist performed the LUS using a six-zone scanning protocol. The treating physician remained blinded to ultrasound findings; final diagnoses were extracted from the medical record. An expert sonologist, blinded to all clinical information, assessed the ultrasound video clips at study completion. Positive LUS was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. RESULTS Ninety-four patients were enrolled (median age 11.1 months). LUS was positive in 42% (39/94) of patients (multiple B-lines in 80%, consolidation in 64%, pleural abnormalities in 23%). The proportion of positive LUS, along with their diagnostic accuracy (sensitivity (95% CI), specificity (95% CI)), were as follows for children with bronchiolitis, asthma, pneumonia and asthma/pneumonia: 46% (45.8% (34.0% to 58.0%), 72.7% (49.8% to 89.3%)), 0% (0% (0.0% to 23.3%), 51.3% (39.8% to 62.6%)), 100% (100% (39.8% to 100.0%), 61.1% (50.3% to 71.2%)), 50% (50% (6.8% to 93.2%), 58.9% (48.0% to 69.2%)), respectively. There was good agreement between the novice and expert sonographers for a positive LUS (kappa 0.68 (95% CI 0.54 to 0.82)). CONCLUSIONS Among children with respiratory tract infections and wheeze, a positive LUS seems to distinguish between clinical syndromes by ruling in pneumonia and ruling out asthma. If confirmed in future studies, LUS may emerge as a point-of-care tool to guide diagnosis and disposition in young children with wheeze.
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Affiliation(s)
- Terry Varshney
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Elise Mok
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Adam J Shapiro
- Department of Pediatric Respirology, Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada
| | - Patricia Li
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada Departments of Pediatrics, Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada
| | - Alexander S Dubrovsky
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada Department of Pediatric Emergency Medicine, Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada
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Levine GK, Datta S, Babbitt CJ. Infections and Asthma in the Pediatric Intensive Care Unit: Prevalence and Contribution to Disease Severity. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2016. [DOI: 10.1089/ped.2015.0586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Glenn K. Levine
- Pediatric Critical Care, Miller Children's and Women's Hospital Long Beach, Long Beach, California
| | - Sumit Datta
- Pediatric Critical Care, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Christopher J. Babbitt
- Pediatric Critical Care, Miller Children's and Women's Hospital Long Beach, Long Beach, California
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Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice Pattern Variation in the Care of Children With Acute Asthma. Acad Emerg Med 2016; 23:166-70. [PMID: 26766222 DOI: 10.1111/acem.12857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/30/2015] [Accepted: 08/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pediatric asthma is a highly prevalent disease, affecting over 7 million U.S. children and accounting for 750,000 annual emergency department (ED) visits. Guidelines from the National Asthma Education and Prevention Program recommend limited use of chest radiography (CXR), complete blood counts (CBCs), and antibiotics when managing acute exacerbations of asthma. However, studies suggest frequent overutilization of these resources. The objective was to evaluate differences between pediatric and general EDs in rates of CXRs, CBCs, and use of antibiotics for pediatric asthma exacerbations. METHODS This was a repeated cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2000 through 2010 of CXR, CBCs, and antibiotics during ED visits for pediatric acute asthma exacerbations. Multivariable logistic regression was performed to identify differences in asthma management by ED type (pediatric vs. general) after adjusting for demographic covariates. RESULTS There were 3,313 observations, representing an estimated 10.9 million (95% confidence interval [CI] = 9.7 to 12.1 million) ED visits for acute asthma without bacterial coinfection. Of these, 17.4% occurred in pediatric EDs. Multivariable logistic regression revealed that visits to pediatric EDs were less likely to include CXRs (adjusted odds ratio [AOR] = 0.39; 95% CI = 0.25 to 0.60), CBCs (AOR = 0.42; 95% CI = 0.22 to 0.80), and antibiotics (AOR = 0.50; 95% CI = 0.31 to 0.82) after adjustment for race/ethnicity, triage level, academic ED, metropolitan statistical area, and geographic region. CONCLUSIONS There are substantial differences in diagnostic testing and antibiotic usage for management of acute exacerbations of asthma by ED type, suggesting potential resource overuse in general EDs. Future studies should focus on evaluating the effect of quality improvement efforts for ED asthma management.
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Affiliation(s)
- James M. Chamberlain
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Stephen J. Teach
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Katie L. Hayes
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Gia Badolato
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Monika K. Goyal
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
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Simbalista R, Andrade DC, Borges IC, Araújo M, Nascimento-Carvalho CM. Differences upon admission and in hospital course of children hospitalized with community-acquired pneumonia with or without radiologically-confirmed pneumonia: a retrospective cohort study. BMC Pediatr 2015; 15:166. [PMID: 26496953 PMCID: PMC4619036 DOI: 10.1186/s12887-015-0485-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 10/13/2015] [Indexed: 11/28/2022] Open
Abstract
Background The use of chest radiograph (CXR) for the diagnosis of childhood community-acquired pneumonia (CAP) is controversial. We assessed if children with CAP diagnosed on clinical grounds, with or without radiologically-confirmed pneumonia on admission, evolved differently. Methods Children aged ≥ 2 months, hospitalized with CAP diagnosed on clinical grounds, treated with 200,000 IU/Kg/day of aqueous penicillin G for ≥ 48 h and with CXR taken upon admission, without pleural effusion, were included in this retrospective cohort. One researcher, blinded to the radiological diagnosis, collected data on demographics, clinical history and physical examination on admission, daily hospital course during the first 2 days of treatment, and outcome, all from medical charts. Radiological confirmation of pneumonia was based on presence of pulmonary infiltrate detected by a paediatric radiologist who was also blinded to clinical data. Variables were initially compared by bivariate analysis. Multi-variable logistic regression analysis assessed independent association between radiologically-confirmed pneumonia and factors which significantly differed during hospital course in the bivariate analysis. The multi-variable analysis was performed in a model adjusted for age and for the same factor present upon admission. Results 109 (38.5 %) children had radiologically-confirmed pneumonia, 143 (50.5 %) had normal CXR and 31 (11.0 %) had atelectasis or peribronchial thickening. Children without radiologically-confirmed pneumonia were younger than those with radiologically-confirmed pneumonia (median [IQR]: 14 [7–28 months versus 21 [12–44] months; P = 0.001). None died. The subgroup with radiologically-confirmed pneumonia presented fever on D1 (33.7 vs. 19.1; P = 0.015) and on D2 (31.6 % vs. 16.2 %; P = 0.004) more frequently. The subgroup without radiologically-confirmed pneumonia had chest indrawing on D1 (22.4 % vs. 11.9 %; P = 0.027) more often detected. By multi-variable analysis, Fever on D2 (OR [95 % CI]: 2.16 [1.15-4.06]) was directly and independently associated with radiologically-confirmed pneumonia upon admission. Conclusion The compared subgroups evolved differently.
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Affiliation(s)
- Raquel Simbalista
- Postgraduate Program in Pathology, Federal University of Bahia School of Medicine, Salvador, Brazil.
| | - Dafne C Andrade
- Postgraduate Program in Health Sciences, Federal University of Bahia School of Medicine, Salvador, Brazil.
| | - Igor C Borges
- Postgraduate Program in Health Sciences, Federal University of Bahia School of Medicine, Salvador, Brazil.
| | - Marcelo Araújo
- Image Diagnosis, Image Memorial Unit and Bahia Hospital, Salvador, Brazil.
| | - Cristiana M Nascimento-Carvalho
- Postgraduate Program in Pathology, Federal University of Bahia School of Medicine, Salvador, Brazil. .,Postgraduate Program in Health Sciences, Federal University of Bahia School of Medicine, Salvador, Brazil. .,Department of Paediatrics, Federal University of Bahia School of Medicine, Salvador, Brazil.
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Ecochard-Dugelay E, Beliah M, Perreaux F, de Laveaucoupet J, Bouyer J, Epaud R, Labrune P, Ducou-Lepointe H, Gajdos V. Clinical predictors of radiographic abnormalities among infants with bronchiolitis in a paediatric emergency department. BMC Pediatr 2014; 14:143. [PMID: 24906343 PMCID: PMC4053285 DOI: 10.1186/1471-2431-14-143] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute viral respiratory exacerbation is one of the most common conditions encountered in a paediatric emergency department (PED) during winter months. We aimed at defining clinical predictors of chest radiography prescription and radiographic abnormalities, among infants with bronchiolitis in a paediatric emergency department. METHODS We conducted a prospective cohort study of children less than 2 years of age with clinical bronchiolitis, who presented for evaluation at the paediatric emergency department of an urban general hospital in France. Detailed information regarding historical features, examination findings, and management were collected. Clinical predictors of interest were explored in multivariate logistic regression models. RESULTS Among 410 chest radiographs blindly interpreted by two experts, 40 (9.7%) were considered as abnormal. Clinical predictors of chest radiography achievement were age (under three months), feeding difficulties, fever over 38°C, hypoxia under than 95% of oxygen saturation, respiratory distress, crackles, and bronchitis rales. Clinical predictors of radiographic abnormalities were fever and close to significance hypoxia and conjunctivitis. CONCLUSION Our study provides arguments for reducing chest radiographs in infants with bronchiolitis. For infants with clinical factors such as age less than three months, feeding difficulties, respiratory distress without hypoxia, isolated crackles or bronchitis rales, careful clinical follow-up should be provided instead of chest radiography.
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Narayanan S, Magruder T, Walley SC, Powers T, Wall TC. Relevance of chest radiography in pediatric inpatients with asthma. J Asthma 2014; 51:751-5. [PMID: 24673123 DOI: 10.3109/02770903.2014.909459] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The goals of this study are to identify factors associated with ordering of chest radiographs (CXR's) in children hospitalized with acute asthma exacerbations and determine the overall clinical impact of these CXR's. METHODS A retrospective study was performed with children ≥ 2 years of age admitted from our emergency department (ED) between 6/1/2011 and 5/31/2012 with a primary diagnosis of acute asthma exacerbation or status asthmaticus. Patients were excluded if they had been on antibiotics prior to the emergency visit, received continuous albuterol or intravenous magnesium during the hospitalization, or had another chronic disease affecting lung function. RESULTS 180 of the 405 children in the study (44%) had CXR's ordered, of which 18 (10%) had imaging that altered the patient's treatment plan. There were six cases of radiologist-diagnosed pneumonia, nine cases of atelectasis treated with antibiotics and three cases of pneumothorax. Factors associated with CXR ordering were: fever at home or in the ED (OR 4.5, 95% CI 2.8-7.4), triage oxygen saturation less than or equal to 92% (OR 1.8, 95% CI 1.2-2.7) and age 4 years or less (OR 2.3, 95% CI 1.4-3.7). Patients with treatment-altering CXR's were more likely to have oxygen saturations less than or equal to 92% (OR 4.2, 95% CI 1.4-13.0; p = 0.006) or fever in the ED (OR 3.8, 95% CI 1.0-13.6; p < 0.05). No patients with triage oxygen saturation above 96% had a treatment-altering CXR. CONCLUSIONS The majority of CXR's ordered in pediatric inpatients with asthma exacerbation do not provide clinically relevant information.
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Ecochard-Dugelay E, Beliah M, Boisson C, Perreaux F, de Laveaucoupet J, Labrune P, Epaud R, Ducou-Lepointe H, Bouyer J, Gajdos V. Impact of chest radiography for children with lower respiratory tract infection: a propensity score approach. PLoS One 2014; 9:e96189. [PMID: 24788944 PMCID: PMC4008561 DOI: 10.1371/journal.pone.0096189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 04/03/2014] [Indexed: 11/26/2022] Open
Abstract
Background Management of acute respiratory tract infection varies substantially despite this being a condition frequently encountered in pediatric emergency departments. Previous studies have suggested that the use of antibiotics was higher when chest radiography was performed. However none of these analyses had considered the inherent indication bias of observational studies. Objective The aim of this work was to assess the relationship between performing chest radiography and prescribing antibiotics using a propensity score analysis to address the indication bias due to non-random radiography assignment. Methods We conducted a prospective study of 697 children younger than 2 years of age who presented during the winter months of 2006–2007 for suspicion of respiratory tract infection at the Pediatric Emergency Department of an urban general hospital in France (Paris suburb). We first determined the individual propensity score (probability of having a chest radiography according to baseline characteristics). Then we assessed the relation between radiography and antibiotic prescription using two methods: adjustment and matching on the propensity score. Results We found that performing a chest radiography lead to more frequent antibiotic prescription that may be expressed as OR = 2.3, CI [1.3–4.1], or as an increased use of antibiotics of 18.6% [0.08–0.29] in the group undergoing chest radiography. Conclusion Chest radiography has a significant impact on the management of infants admitted for suspicion of respiratory tract infection in a pediatric emergency department and may lead to unnecessary administration of antibiotics.
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Affiliation(s)
- Emmanuelle Ecochard-Dugelay
- Inserm, CESP Centre for research in Epidemiology and Population Health, U1018, Reproduction and Child Development Team, Le Kremlin Bicêtre, France
| | - Muriel Beliah
- APHP, Paediatric Department, Hopital Antoine Béclère, Clamart, France
| | - Caroline Boisson
- APHP, Paediatric Department, Hopital Antoine Béclère, Clamart, France
| | - Francis Perreaux
- APHP, Paediatric Department, Hopital Antoine Béclère, Clamart, France
| | | | - Philippe Labrune
- APHP, Paediatric Department, Hopital Antoine Béclère, Clamart, France
- Université Paris Sud 11, Kremlin Bicêtre, France
| | - Ralph Epaud
- APHP, Paediatric Department, Centre Hospitalier Intercommunal, Créteil, France
- Université Paris Est, Créteil, Val de Marne, France
| | - Hubert Ducou-Lepointe
- APHP, Paediatric Radiology Department, Hôpital Trousseau, Paris, France
- Université Paris 6, Paris, France
| | - Jean Bouyer
- Inserm, CESP Centre for research in Epidemiology and Population Health, U1018, Reproduction and Child Development Team, Le Kremlin Bicêtre, France
- Université Paris Sud 11, Kremlin Bicêtre, France
| | - Vincent Gajdos
- Inserm, CESP Centre for research in Epidemiology and Population Health, U1018, Reproduction and Child Development Team, Le Kremlin Bicêtre, France
- APHP, Paediatric Department, Hopital Antoine Béclère, Clamart, France
- Université Paris Sud 11, Kremlin Bicêtre, France
- * E-mail:
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Williams HS, Zenel JA. Commentary: when doing less is best. Pediatr Rev 2013; 34:423-8. [PMID: 24085790 DOI: 10.1542/pir.34-10-423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- H Stephen Williams
- Department of Pediatrics, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
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Abstract
Asthma continues to be one of the most common reasons for emergency department visits and a leading cause of hospitalization. Acute management involves severity-based treatment of bronchoconstriction and underlying airway inflammation. Optimal treatment has been defined and standardized through randomized controlled trials, systematic reviews, and consensus guidelines. Implementation of clinical practice guidelines may improve clinical, quality, and safety outcomes. Asthma morbidity is disproportionately high in poor, urban, and minority children. Children treated in emergency departments commonly have persistent chronic severity, significant morbidity, and infrequent follow-up and primary asthma care, and prescription of inhaled corticosteroids is appropriate.
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Affiliation(s)
- Kyle A Nelson
- Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Quinonez RA, Garber MD, Schroeder AR, Alverson BK, Nickel W, Goldstein J, Bennett JS, Fine BR, Hartzog TH, McLean HS, Mittal V, Pappas RM, Percelay JM, Phillips SC, Shen M, Ralston SL. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value. J Hosp Med 2013; 8:479-85. [PMID: 23955837 DOI: 10.1002/jhm.2064] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 04/01/2013] [Accepted: 04/15/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results. METHODS A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.
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Affiliation(s)
- Ricardo A Quinonez
- Department of Pediatrics, Section of Pediatric Hospital Medicine, Baylor College of Medicine, Houston, Texas
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Williams DJ, Shah SS, Myers A, Hall M, Auger K, Queen MA, Jerardi K, McClain L, Wiggleton C, Tieder JS. Identifying pediatric community-acquired pneumonia hospitalizations: Accuracy of administrative billing codes. JAMA Pediatr 2013; 167:851-8. [PMID: 23896966 PMCID: PMC3907952 DOI: 10.1001/jamapediatrics.2013.186] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Community-acquired pneumonia (CAP) remains one of the most common indications for pediatric hospitalization in the United States, and it is frequently the focus of research and quality studies. Use of administrative data is increasingly common for these purposes, although proper validation is required to ensure valid study conclusions. OBJECTIVE To validate administrative billing data for hospitalizations owing to childhood CAP. DESIGN AND SETTING Case-control study of 4 tertiary care, freestanding children’s hospitals in the United States. PARTICIPANTS A total of 998 medical records of a 25% random sample of 3646 children discharged in 2010 with at least 1 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code representing possible pneumonia were reviewed. Discharges (matched on date of admission) without a pneumonia-related discharge code were also examined to identify potential missed pneumonia cases. Two reference standards, based on provider diagnosis alone (provider confirmed) or in combination with consistent clinical and radiographic evidence of pneumonia (definite), were used to identify CAP. EXPOSURE Twelve ICD-9-CM–based coding strategies, each using a combination of primary or secondary codes representing pneumonia or pneumonia-related complications. Six algorithms excluded children with complex chronic conditions. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, and negative and positive predictive values (NPV and PPV, respectively) of the 12 identification strategies. RESULTS For provider-confirmed CAP (n = 680), sensitivity ranged from 60.7% to 99.7%; specificity, 75.7% to 96.4%; PPV, 67.9% to 89.6%; and NPV, 82.6% to 99.8%. For definite CAP (n = 547), sensitivity ranged from 65.6% to 99.6%; specificity, 68.7% to 93.0%; PPV, 54.6% to 77.9%; and NPV, 87.8% to 99.8%. Unrestricted use of the pneumonia-related codes was inaccurate, although several strategies improved specificity to more than 90% with a variable effect on sensitivity. Excluding children with complex chronic conditions demonstrated the most favorable performance characteristics. Performance of the algorithms was similar across institutions. CONCLUSIONS AND RELEVANCE Administrative data are valuable for studying pediatric CAP hospitalizations. The strategies presented here will aid in the accurate identification of relevant and comparable patient populations for research and performance improvement studies.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Samir S. Shah
- Divisions of Infectious Diseases and Hospital Medicine, Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Angela Myers
- Division of Infectious Diseases, Children’s Mercy Hospital and Clinics and the University of Missouri School of Medicine, Kansas City, MO
| | - Matthew Hall
- The Children’s Hospital Association, Overland Park, KS
| | - Katherine Auger
- Robert Wood Johnson Foundation Clinical Scholars Fellow and the Division of General Pediatrics, University of Michigan, Ann Arbor, MI
| | - Mary Ann Queen
- Section of Hospital Medicine, Children’s Mercy Hospital and Clinics and the University of Missouri School of Medicine, Kansas City, MO
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lauren McClain
- The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Catherine Wiggleton
- Division of Hospital Medicine, The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Joel S. Tieder
- Division of Hospital Medicine, Seattle Children’s Hospital and the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Ishimine P. Risk Stratification and Management of the Febrile Young Child. Emerg Med Clin North Am 2013; 31:601-26. [DOI: 10.1016/j.emc.2013.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Williams DJ, Shah SS. Community-Acquired Pneumonia in the Conjugate Vaccine Era. J Pediatric Infect Dis Soc 2012; 1:314-28. [PMID: 26619424 PMCID: PMC7107441 DOI: 10.1093/jpids/pis101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/05/2012] [Indexed: 12/27/2022]
Abstract
Community-acquired pneumonia (CAP) remains one of the most common serious infections encountered among children worldwide. In this review, we highlight important literature and recent scientific discoveries that have contributed to our current understanding of pediatric CAP. We review the current epidemiology of childhood CAP in the developed world, appraise the state of diagnostic testing for etiology and prognosis, and discuss disease management and areas for future research in the context of recent national guidelines.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, The Monroe Carell Jr Children's Hospital at Vanderbilt, and,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Divisions of,Corresponding Author: Derek J. Williams, MD, MPH, 1161 21st Ave. South, CCC 5311 Medical Center North, Nashville, TN 37232. E-mail: derek.
| | - Samir S. Shah
- Infectious Diseases and,Hospital Medicine, Cincinnati Children's Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
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Frequency and trajectory of abnormalities in respiratory rate, temperature and oxygen saturation in severe pneumonia in children. Pediatr Infect Dis J 2012; 31:863-5. [PMID: 22531236 PMCID: PMC3399926 DOI: 10.1097/inf.0b013e318257f8ec] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The frequency or trajectory of vital sign abnormalities in children with pneumonia has not been described. In a cohort of 2714 patients with severe pneumonia identified and treated as per the World Health Organization definition and recommendations, tachypnea, fever and hypoxia were found in 68.9%, 23.6% and 15.5% of children, respectively. Median oxygen saturation returned to a normal range by 10 hours following initiation of treatment, followed by temperature at 12 hours and respiratory rate at 22 hours for subjects <12 months and at 48 hours for those ≥ 12 months of age.
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Diagnosis of childhood pneumonia: clinical assessment without radiological confirmation may lead to overtreatment. Pediatr Emerg Care 2012; 28:646-9. [PMID: 22743749 DOI: 10.1097/pec.0b013e31825cfd53] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Consensus guidelines discourage the use of routine radiologic confirmation of clinically diagnosed pneumonia in children. The goal of the present study was to assess the degree of antibiotic overtreatment resulting from this approach. DESIGN This was a prospective data collection. SETTING This was performed in 5 urgent care clinics in Jerusalem, Israel. PARTICIPANTS This study was composed of previously healthy children between 2 months and 18 years of age who presented with a chief complaint of fever, cough, or dyspnea between August 1, 2007, and March 15, 2008, by for whom chest x-rays were obtained because of clinical suspicion of pneumonia. OUTCOME MEASURES Outcome measure was percentage of children with clinical findings associated with pneumonia (hypoxia, tachypnea, rales, dyspnea) who did not have radiological findings of pneumonia. RESULTS With the exception of wheezing, 55% to 65% of children with specific signs and symptoms did not have radiologic pneumonia. A similar range of children with a combination of the signs did not have radiologic pneumonia. For wheezing, alone or in combination, the percentages were higher. On multivariate analysis, only fever was found to be predictive of pneumonia. Wheezing was found to be negatively predictive. CONCLUSIONS Treatment of childhood pneumonia on the basis of clinical parameters alone with no chest x-ray confirmation may lead to a large portion of children receiving unnecessary antibiotic therapy. In an era when the emphasis is to decrease antibiotic resistance, radiological confirmation of pneumonia should be obtained when possible.
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Wingerter SL, Bachur RG, Monuteaux MC, Neuman MI. Application of the world health organization criteria to predict radiographic pneumonia in a US-based pediatric emergency department. Pediatr Infect Dis J 2012; 31:561-4. [PMID: 22333702 DOI: 10.1097/inf.0b013e31824da716] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The World Health Organization (WHO) established guidelines that rely on simple clinical signs for the diagnosis of childhood pneumonia in resource-limited settings. Our objective was to evaluate the test characteristics of the WHO criteria for the diagnosis of radiographic pneumonia in the emergency department setting. METHODS We prospectively collected clinical information from children ≤5 years of age presenting to a US-based pediatric emergency department who had a chest radiograph performed for suspicion of pneumonia. Patients were classified as meeting the WHO case definition of pneumonia if they had both 1) cough or difficulty breathing and 2) age-specific WHO-defined tachypnea. The primary outcome was radiographic pneumonia based on the final radiology report. Among children with cough or with difficulty breathing, receiver operator characteristic curve analysis was used to evaluate the test characteristics of triage respiratory rate, temperature and oxygen saturation for the diagnosis of radiographic pneumonia. RESULTS Two thousand eight children were enrolled. Median age was 19 months, and 28.5% had tachypnea based upon age-specific respiratory rate thresholds. Of the 324 children with radiographic pneumonia, 111 met the WHO case definition of pneumonia (sensitivity = 34.3%, 95% confidence interval: 29.1-39.7). Triage respiratory rate demonstrated an area under the curve of 0.54 for the diagnosis of radiographic pneumonia. The area under the curve for triage temperature and oxygen saturation was 0.56 and 0.60, respectively. CONCLUSIONS The WHO criteria demonstrated poor sensitivity for the diagnosis of radiographic pneumonia in a US-based pediatric emergency department. Compared with respiratory rate, oxygen saturation offered slightly improved test characteristics. Although applied to a different target population, these findings suggest the WHO criteria may not be a sensitive screening tool for the diagnosis of pneumonia in children.
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Affiliation(s)
- Sarah L Wingerter
- Division of Emergency Medicine, Children's Hospital Boston, Boston, Boston, MA 02115, USA.
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Abstract
Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.
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Affiliation(s)
- Joseph Choi
- McGill University FRCP Emergency Medicine Residency Program, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.62, Montreal, Quebec, Canada H3A 1A1.
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Neuman MI, Lee EY, Bixby S, Diperna S, Hellinger J, Markowitz R, Servaes S, Monuteaux MC, Shah SS. Variability in the interpretation of chest radiographs for the diagnosis of pneumonia in children. J Hosp Med 2012; 7:294-8. [PMID: 22009855 DOI: 10.1002/jhm.955] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 05/09/2011] [Accepted: 06/11/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although chest radiography is commonly used to establish the diagnosis of pneumonia in children, the reliability of radiographic findings among radiologists is not well described. OBJECTIVE We sought to evaluate the inter-rater and intra-rater reliability of radiographic features commonly described by radiologists in childhood pneumonia. METHODS Prospective case-based study. One hundred and ten radiographs of children evaluated in a pediatric emergency department for suspicion of pneumonia were interpreted by six radiologists at two academic children's hospitals. Radiologists were blinded to the clinical history. Reliability of standardized radiographic features was evaluated using the kappa statistic. RESULTS The radiographic finding of an alveolar infiltrate demonstrated substantial reliability among radiologists (κ = 0.69). The presence of 'any infiltrate' and pleural effusion demonstrated moderate reliability (κ = 0.47 and k=0.45, respectively). Other radiographic features were less reliable: air bronchograms (κ = 0.32), hilar adenopathy (κ = 0.21), and interstitial infiltrate (κ = 0.14). Similarly, the finding of alveolar infiltrate demonstrated substantial intra-rater reliability upon review of ten duplicate radiographs, whereas interstitial infiltrate was less reliable. CONCLUSION The radiographic finding of an alveolar infiltrate is very reliable among pediatric radiologists, whereas the finding of an interstitial infiltrate is less reliable.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Children's Hospital, Boston, Boston, Massachusetts 02115, USA.
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Respiratory Tract Symptom Complexes. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2012. [PMCID: PMC7152091 DOI: 10.1016/b978-1-4377-2702-9.00021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lynch BA, Fenta Y, Jacobson RM, Li X, Juhn YJ. Impact of delay in asthma diagnosis on chest X-ray and antibiotic utilization by clinicians. J Asthma 2011; 49:23-8. [PMID: 22149172 DOI: 10.3109/02770903.2011.637596] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the effect of the timeliness of asthma diagnosis on chest X-ray (CXR) and antibiotic utilization in children. PATIENTS AND METHODS This was a retrospective cohort study of 276 asthmatic children aged 5-12 years from Rochester, Minnesota. From the time when children met our predetermined asthma criteria, the frequency of CXR and antibiotic utilizations for respiratory illnesses were collected from medical records until age 18 years. Using a Poisson regression model, the frequency of CXR and antibiotic utilizations were compared in children with timely, delayed, or no clinician diagnosis of asthma. RESULTS Of the 276 asthmatic patients, 97 (35%) had a timely diagnosis, 122 (44%) had a delayed diagnosis, while 57 patients (21%) had no clinician diagnosis of asthma. There was no significant difference in CXR or antibiotic utilization for respiratory illness between these groups. In addition, this was true for the comparison between the timely diagnosed group and the delayed diagnosed group combining both the group with a delay in asthma diagnosis and the group who never had asthma diagnosis. CONCLUSIONS A delay in the diagnosis of asthma in children is common and overall it may not influence antibiotic and CXR utilization for respiratory symptoms by clinicians. However, its impact on access to asthma-related therapies and other healthcare utilizations could be possible and was not assessed in this study. Given the limitations of our study, a larger prospective study needs to be considered.
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Affiliation(s)
- Brian A Lynch
- Division of Community Pediatric and Adolescent Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH, Moore MR, St Peter SD, Stockwell JA, Swanson JT. 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. Clin Infect Dis 2011; 53:e25-76. [PMID: 21880587 PMCID: PMC7107838 DOI: 10.1093/cid/cir531] [Citation(s) in RCA: 991] [Impact Index Per Article: 76.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/08/2011] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- John S Bradley
- Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, California, USA.
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Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr 2011; 48:191-218. [PMID: 21478555 DOI: 10.1007/s13312-011-0051-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Scaling up of evidence based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action. OBJECTIVE To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps. METHODS A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. RESULTS Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care. CONCLUSION The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.
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Neuman MI, Monuteaux MC, Scully KJ, Bachur RG. Prediction of pneumonia in a pediatric emergency department. Pediatrics 2011; 128:246-53. [PMID: 21746723 DOI: 10.1542/peds.2010-3367] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography. METHODS We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis. RESULTS Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O₂ saturation >92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4). CONCLUSION Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, 300 Longwood Ave, Boston, MA 02115.
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Abstract
OBJECTIVES We sought to examine the utilization of chest radiography among children with pneumonia and other respiratory illnesses and to investigate interinstitution chest radiograph (CXR) utilization to identify if there is a relationship between CXR utilization and rate of pneumonia. METHODS This is a retrospective study of children evaluated in an emergency department at 25 institutions contributing information to the Pediatric Health Information System database from 2003 to 2008. The use of chest radiographs was determined for patients with a diagnosis of pneumonia, upper respiratory tract illness, wheeze, and fever. RESULTS Over a 6-year period, pneumonia accounted for 2.1% of all visits to an emergency department. Comparing institutions, the proportion of children with a diagnosis of pneumonia who had a CXR obtained ranged from 38% to 88%. There was no observed association between CXR utilization rate and the proportion of patients with a diagnosis of pneumonia between institutions. There was also a wide variation in the use of CXR for other diagnoses (upper respiratory tract infection [range, 9%-36%], wheeze [14%-56%], fever [7%-41%]). Eighty-percent of children hospitalized with pneumonia had a radiograph obtained, compared with 76% of children with pneumonia discharged from the ED (P = 0.28). However, the rate of utilization of CXR for patients hospitalized with other diagnoses was higher than respective rates of CXR use for discharged patients (upper respiratory tract infection, 68% vs 16% [P < 0.001]; wheeze, 57% vs 23% [P < 0.001]; and fever, 45% vs 18% [P < 0.001]). CONCLUSIONS The use of CXR varies widely among pediatric emergency departments but does not appear to influence the institution-specific rate of pneumonia.
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Paul IM, Maselli JH, Hersh AL, Boushey HA, Nielson DW, Cabana MD. Antibiotic prescribing during pediatric ambulatory care visits for asthma. Pediatrics 2011; 127:1014-21. [PMID: 21606155 DOI: 10.1542/peds.2011-0218] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE National guidelines do not recommend antibiotics as an asthma therapy. We sought to examine the frequency of inappropriate antibiotic prescribing during US ambulatory care pediatric asthma visits as well as the patient, provider, and systemic variables associated with such practice. PATIENTS AND METHODS Data from the National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Survey were examined to assess office and emergency-department asthma visits made by children (aged < 18 years) for frequencies of antibiotic prescription. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to assess the presence of coexisting conditions warranting antibiotics. Multivariable logistic regression models assessed associations with the prescription of antibiotics. RESULTS From 1998 to 2007, an estimated 60.4 million visits occurred for asthma without another ICD-9 code justifying antibiotic prescription. Antibiotics were prescribed during 16% of these visits, most commonly macrolides (48.8%). In multivariate analysis, controlling for patient age, gender, race, insurance type, region, and controller medication use, systemic corticosteroid prescription (odds ratio [OR]: 2.69 [95% confidence interval (CI): 1.68-4.30]) and treatment during the winter (OR: 1.92 [95% CI: 1.05-3.52]) were associated with an increased likelihood of antibiotic prescription, whereas treatment in an emergency department was associated with decreased likelihood (OR: 0.48 [95% CI: 0.26-0.89]). A second multivariate analysis of only office-based visits demonstrated that asthma education during the visits was associated with reduced antibiotic prescriptions (OR: 0.46 [95% CI: 0.24-0.86]). CONCLUSIONS Antibiotics are prescribed during nearly 1 in 6 US pediatric ambulatory care visits for asthma, ~ 1 million prescriptions annually, when antibiotic need is undocumented. Additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma.
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Affiliation(s)
- Ian M Paul
- Department of Pediatrics, HS83, Penn State College of Medicine, Hershey, PA 17033, USA.
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Singhi SC, Mathew JL, Jindal A. Clinical pearls in respiratory diseases. Indian J Pediatr 2011; 78:603-8. [PMID: 21153894 DOI: 10.1007/s12098-010-0270-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 10/05/2010] [Indexed: 01/01/2023]
Abstract
In this section, the authors present some common and some uncommon respiratory cases that have diagnostic and/or therapeutic challenges. First case is of an eight- yr- old child having Acute onset Wheeze and fever, second one is of a 1.5- yr- old Wheezing child not responding to inhaled bronchodilators and corticosteroids, third of a 4-yr- old with Respiratory distress and wheezing with underlying ventricular septal defect, and fourth of a 5-yr- old with fever for 1 month, epistaxis from right nostril for 15 days, polyuria for 10 days, impaired consciousness and discoloration of right orbit. Each one had some unique pointers to correct diagnosis and management. The authors share clinical learning points from these cases with a concise review of the topic.
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Affiliation(s)
- Sunit C Singhi
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Key NK, Araujo-Neto CA, Cardoso M, Nascimento-Carvalho CM. Characteristics of radiographically diagnosed pneumonia in under-5 children in Salvador, Brazil. Indian Pediatr 2011; 48:873-7. [PMID: 21555804 DOI: 10.1007/s13312-011-0142-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 09/27/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the association of demographic and clinical aspects with radiographically diagnosed pneumonia. DESIGN By active surveillance, the admitted pneumonia cases by the pediatrician on duty were identified in a 2 year period. Demographic, clinical and radiographic data were registered into standardized forms. SETTING A public university pediatric hospital in Salvador, Northeast Brazil. PATIENTS Children <5 years-old. MAIN OUTCOME MEASURES Radiographically diagnosed pneumonia based on detection of pulmonary infiltrate/ consolidation. RESULTS 301 cases had the chest X-ray evaluated by a pediatric radiologist blinded to clinical information, among whom pulmonary infiltrate and consolidation were described in 161 (54%) and 119 (40%), respectively. Chest X-ray was read normal for 140 cases. Overall, the median age was 17 months (mean 20±14, range 12 days-59 months). Pulmonary infiltrate was less frequently described among patients aged under 1 year (41.3% vs 59.9%, P=0.002, OR [95% CI] = 0.47 [0.29-0.76]) and hyperinflation was significantly more frequent in this age group (27.9% vs 4.1%, P<0.001, OR [95% CI] = 9.14 [4.0-20.9]). By multiple logistic regression, fever on admission was independently associated with pulmonary infiltrate (OR [95% CI] = 1.68 [1.03-2.73]) or consolidation (1.79 [1.10-2.92]), wheezing was independently associated with absence of pulmonary infiltrate (0.53 [0.33-0.86]) or of consolidation (0.53 [0.33-0.87]). The positive likelihood ratio of fever on examination for pulmonary infiltrate and consolidation was 1.49 (95% CI:1.11-1.98) and 1.49 (95% CI: 1.14-1.94), respectively. CONCLUSION Presence of fever enhanced 2.5 times the chance of children hospitalized with lower respiratory tract disease to have radiographically diagnosed pneumonia.
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Affiliation(s)
- N K Key
- Department of Pediatrics, Federal University of Bahia School of Medicine, Salvador, Brazil.
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