Can chest X-ray predict pneumonia severity?

Clinical Implications of the Obstructive Pattern on Chest Radiography in Children Aged 3-59 Months With Severe Lower Respiratory Tract Infections

OBJECTIVES

To investigate the clinical implications of the obstructive pattern on plain chest radiography, defined as peribronchial cuffing or hyperinflation, in young children with severe lower respiratory tract infections (LRTIs).

METHODS

We reviewed all children aged 3‒59 months with LRTIs who underwent radiography and polymerase chain reaction in a Korean emergency department from 2016 through 2020. The radiographs were read as consolidation, peribronchial cuffing, or hyperinflation, with each interrater reliability computed. As per the obstructive pattern, we compared their clinical features, therapeutic interventions, outcomes, and microbiology.

RESULTS

Among 599 children with LRTIs, 465 were enrolled, of whom 98 (21.1%) had consolidation (κ = 0.60; 95% confidence interval, 0.50‒0.70), and 367 (78.9%) had peribronchial cuffing (0.55; 0.46‒0.65) or hyperinflation (0.59; 0.52‒0.67). The obstructive pattern was significantly associated with more frequent wheezing (obstructive, 28.6% vs. consolidation, 10.2%) and the use of inhaled albuterol or systemic steroids (39.0% vs. 23.5%), and lower median values or frequencies of age (22.0 vs. 35.0 months), crackle or diminished breath sound (42.0% vs. 61.2%), C-reactive protein (1.4 vs. 2.9 mg/dL), antibiotic therapy (72.2% vs. 93.9%), length of hospital stay (4.0 vs 5.0 days), fever lasting 3 days or longer (7.9% vs. 29.6%), and complications (0.5% vs. 9.2%). Microbiologically, viruses, such as respiratory syncytial virus, were more frequently detected in children with the obstructive pattern or at a younger age.

CONCLUSIONS

This study confirms an association of the obstructive pattern on radiography with viral infection and inflammatory airway obstruction-relieving therapy in young children with severe LRTIs.

Assessing Severity in Pediatric Pneumonia: Predictors of the Need for Major Medical Interventions

OBJECTIVE

The aim of this study was to determine potential predictors of the need for major medical interventions in the context of assessing severity in pediatric pneumonia.

METHODS

This was a prospective, cohort study of previously healthy children and adolescents younger than 18 years presenting to the pediatric emergency room with clinically suspected pneumonia and examining both the full cohort and those with radiologically confirmed pneumonia. The presence of hypoxemia (peripheral oxygen saturation ≤92%), age-specific tachypnea, high temperature (≥38.5°C), chest retraction score, modified Pediatric Early Warning Score, age, C-reactive protein, white blood cell (WBC) count, and chest radiograph findings at first assessment were analyzed by univariate and multivariate analyses to examine their predictive ability for the need for major medical interventions: supplemental oxygen, supplemental fluid, respiratory support, intensive care, or treatment for complications during admission.

RESULTS

Fifty percent of the 394 cases of suspected pneumonia and 60% of the 265 cases of proven pneumonia were in need of 1 or more medical interventions. In multivariate logistic regression, only the presence of hypoxemia (odds ratios, 3.66 and 3.83 in suspected and proven pneumonia, respectively) and chest retraction score (odds ratios, 1.21 and 1.31, respectively for each 1-point increase in the score) significantly predicted the need for major medical interventions in both suspected and proven pneumonia. Specificity of 94% or greater, positive likelihood ratio of 6.4 or greater, and sensitivity of less than 40% were found for both hypoxemia and chest retraction score in predicting major medical interventions. C-reactive protein and white blood cell count were not associated with the need for these interventions, whereas multifocal radiographic changes were.

CONCLUSIONS

Hypoxemia and an assessment of chest retractions were the predictors significantly able to rule in more severe pneumonia, but with a limited clinical utility given their poor ability to rule out the need for major medical interventions. Future validation of these findings is needed.

Factors Associated With Pneumonia Severity in Children: A Systematic Review

Community-acquired pneumonia in children is associated with significant morbidity and mortality; however, data are limited in predicting which children will have negative outcomes, including clinical deterioration, severe disease, or development of complications. The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) pediatric pneumonia guideline includes criteria that were modified from adult criteria and define pneumonia severity to assist with resource allocation and site-of-care decision-making. However, the PIDS/IDSA criteria have not been formally developed or validated in children. Definitions for mild, moderate, and severe pneumonia also vary across the literature, further complicating the development of standardized severity criteria. This systematic review summarizes (1) the current state of the evidence for defining and predicting pneumonia severity in children as well as (2) emerging evidence focused on risk stratification of children with pneumonia.

Chest Radiographic Findings and Outcomes of Pneumonia Among Children in Botswana

BACKGROUND

Chest radiography is increasingly used to diagnose pneumonia in low-income and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings.

METHODS

This is a hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by 2 pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes.

RESULTS

From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months, and 58% were male. Chest radiograph classifications were primary endpoint pneumonia (35%), other infiltrate/abnormality (42%) or no significant pathology (22%). The prevalence of endpoint consolidation was higher in children with HIV infection (P = 0.0005), whereas endpoint pleural effusions were more frequent among children with moderate or severe malnutrition (P = 0.0003). Ninety-one (37%) children failed treatment, and 12 (4.8%) children died. Primary endpoint pneumonia was associated with an increased risk of treatment failure at 48 hours (P = 0.002), a requirement for more days of respiratory support (P = 0.002) and a longer length of stay (P = 0.0003) compared with no significant pathology. Primary endpoint pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P = 0.004).

CONCLUSIONS

Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.

Admission chest radiographs predict illness severity for children hospitalized with pneumonia

OBJECTIVE

To assess whether radiographic findings predict outcomes among children hospitalized with pneumonia.

METHODS

This retrospective study included children <18 years of age from 4 children's hospitals admitted in 2010 with clinical and radiographic evidence of pneumonia. Admission radiographs were categorized as single lobar, unilateral or bilateral multilobar, or interstitial. Pleural effusions were classified as absent, small, or moderate/large. Propensity scoring was used to adjust for potential confounders, including need for supplemental oxygen, intensive care, and mechanical ventilation, as well as hospital length of stay and duration of supplemental oxygen.

RESULTS

There were 406 children (median age, 3 years). Infiltrate patterns included: single lobar, 61%; multilobar unilateral, 13%; multilobar bilateral, 16%; and interstitial, 10%. Pleural effusion was present in 21%. Overall, 63% required supplemental oxygen (median duration, 31.5 hours), 8% required intensive care, and 3% required mechanical ventilation. Median length of stay was 51.5 hours. Compared with single lobar infiltrate, all other infiltrate patterns were associated with need for intensive care; only bilateral multilobar infiltrate was associated with need for mechanical ventilation (adjusted odds ratio [aOR]: 3.0, 95% confidence interval [CI]: 1.2-7.9). Presence of effusion was associated with increased length of stay and duration of supplemental oxygen; only moderate/large effusion was associated with need for intensive care (aOR: 3.2, 95% CI: 1.1-8.9) and mechanical ventilation (aOR: 14.8, 95% CI: 9.8-22.4).

CONCLUSIONS

Admission radiographic findings are associated with important hospital outcomes and care processes and may help predict disease severity.

Severity of childhood community-acquired pneumonia and chest radiographic findings

To assess if chest radiographic findings present on admission are associated with severity of childhood community-acquired pneumonia (CAP), a total of 161 children hospitalized with pulmonary infiltrate were enrolled in the study; 48 (30%) patients were excluded because of presence of bilateral chest radiographic alterations (33; 20%) and presence of underlying diseases (15; 9%). According to WHO and BTS criteria, severe CAP was present in 57 (50%) and in 96 (85%) cases, respectively; 29 (26%) were aged less than 1 year. The median age (months) was 22 (mean 24 +/- 14, range 2-58). Overall, radiographic finding was right-sided in 77 (68%) cases and the upper lobe was compromised in 36 (32%) cases. By analyzing data stratified to age, the frequency of upper lobe involvement was significantly higher among severe cases (WHO criteria) only for those patients aged > or =1 year (13/35 [37%] vs. 7/45 [16%], P = 0.03, OR [95% CI] 3.2 [1.1-9.2]). The specificity and positive predictive value of upper lobe involvement for severity among the latter group of patients were 84% (95% CI 70-93%) and 65% (95% CI 41-84%), respectively. No association was found by using the BTS criteria. The admission chest radiography was useful to predict severity of children aged > or =1 year hospitalized with CAP.