Wheeze

Pulmonology and Respiratory Research ISSN 2053-6739 Short report Open Access Analysis of clinical & radiological findings in children with acute wheeze Lakshmi Muthukrishnan* and Radhika Raman *Correspondence: vcmlck@yahoo.co.in Kanchi Kamakoti CHILDS Trust Hospital, CHILDS Trust Medical Research Foundation, Chennai, Tamil Nadu, India. Abstract Objective: To analyze the indications for chest (CXR) radiography, radiological abnormalities and the clinical predictors for pneumonia in children who present with acute wheeze to the pediatric emergency department. Methods: This prospective study was conducted in the emergency department of a tertiary care pediatric referral hospital between July and December 2012. Children between 6 months to 18 years of age presenting with acute wheeze were included in the study. Results: Of a total of 126 children included in the study, the most common indication for CXR was temperature > 100 0F at presentation (65%). The most common radiological abnormality was prominent bronchovascular markings in 67%. Ten children (8.7%) had radiological evidence of pneumonia, seven of them were <5years of age. Presence of fever during triage (p=0.006), hypoxia (p=0.01) and localised chest findings on auscultation (p=0.001) were statistically significant clinical predictors for pneumonia. Conclusion: The incidence of radiographically confirmed pneumonia among children with wheezing is uncommon. Definite clinical criteria should be defined to avoid unwarranted chest radiography in children with acute wheeze. Keywords: Acute, wheeze, children, pneumonia, chest radiography Introduction Wheeze is a common paediatric emergency. Children with viral respiratory infection often present with fever and acute wheeze and a chest radiograph is often performed as it is difficult to identify pneumonia by clinical examination alone. Identifying clinical parameters which are more likely to be associated with pneumonia in children who present with acute wheeze can possibly prevent unwarranted radiography. Aim The aim of our study was to analyse the radiological abnormalities, indications for chest radiography and the clinical predictors for pneumonia in children who present with an acute wheeze to the paediatric emergency department. findings on chest radiography were continually abstracted from medical records throughout the study period. Severity of wheeze was determined by the Pulmonary score index (PSI) [1]. PSI 0 – 3 was mild, 4 - 6 moderate and > 6 was considered as severe wheeze. The variables included in pulmonary score index are respiratory rate, wheeze and accessory muscle activity. All radiographs were reviewed by a qualified pediatric radiologist for the presence (as evidenced by consolidation) or absence of pneumonia. Results A total of 126 children were included the study of which 70% were males and 73% were between 1- 5 years of age. Ninety two children (73%) had a PSI score of 4 - 6. Children with PSI > 6 (n=13) required admission to the intensive care unit. Of the Materials and methods 115 children who had a CXR, sixty had previously undergone This prospective study at the emergency department of a tertiary chest radiography for wheeze (n=52, single & n=8, multiple care paediatric referral hospital was conducted between July times). On analysis it was found that 65% of children had a CXR to December 2012. Children who presented with acute wheeze as they were febrile. The other indications being 1st episode aged between 6 months to 18 years were included. Children of wheeze (25%) suspected foreign body (5%), persistent with chronic lung disease, history of tracheostomy, complex hypoxemia (3.5%) and suspected cardiac pathology (0.85%) congenital heart disease, underlying immunodeficiency and (Figure 1). Radiological abnormalities (reported were as follows, malignancy were excluded from study. The decision to obtain prominent bronchovascular markings (67%), hyperaerated a chest x ray (CXR) was left to the discretion of pediatric post lungs (21%), consolidation (8.7%), atelectasis (3.5%) and graduates, fellows in emergency medicine, registrars and foreign body (0.8%) (Figure 2). Out of 10 children (8.7%) who paediatric consultants in the emergency room who was blinded had radiological evidence for pneumonia majority (n=7) to the ongoing study. Clinical parameters (Table 1) such as fever, were in the age group of 1 to 5 years. The clinical predictors chest retractions, tachypnea, focal lung signs, oxygen saturation for pneumonia were triage temperature = or > 1010F (10/10), (SpO2), age, the need for intensive care unit admission and hypoxia (4/10), localised chest findings (7/10) (Figure 3A-3C). Chi © 2013 MuthuKrishnan et al; licensee Herbert Publications Ltd. This is an Open Access article distributed under the terms of Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0). This permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. MuthuKrishnan et al. Pulmonology & Respiratory Research 2013, http://www.hoajonline.com/journals/pdf/2053-6739-1-1.pdf doi: 10.7243/2053-6739-1-1 Table 1. Demographic characteristics of the study population (N=126). Prominent BVM-67% Patient Characteristics n (%) Age <1 yr 26 (21) 1-5 yr 92 (73) >5 yr 8 (6.3) Male 87 (70) History of wheezing 60 (48) Hyperaeration-21% Consolidation-8.7% Sub segmental Atelectasis-3.5% Triage temperature >1010F 14 (11) <1010F 61 (48) Foreign body-0.8% Pulmonary Score Index (PSI) 0-3 (mild) 13 (10) 4-6 (moderate) 89 (71) >6 (severe) 24 (19) Admission in PICU 13 Admission in ward 11 Figure 2. Findings on chest radiography. 3A Triage oxygen saturation <92% 17 (13) >92% 109 (87) Localised chest findings 13 (10) Children who had CXR 115 (91) Clinical predictors - fever Children who had previous CXR Once 52 (41) Multiple 8 (6) Radiographic pneumonia 10 (8) No fever fever No pneumonia (65/116) Fever- 65% 3B pneumonia (10/10) Hypoxia 1st wheeze- 25% ForeignBody- 5% Spo2< 92% Hypoxia- 3.5% Spo2- Nr Cardic- 0.85% Figure 1. Indications for chest radiography. No pneumonia (13/116) 3C pneumonia (4/10) Localised chest finding square test was applied and p value of <0.05 was considered significant. Presence of fever (p=0.006), hypoxia (p=0.01) and localised chest findings (p=0.001) were statistically significant (Table 2). PSI of more than 6 was not associated with pneu-monia. Localised finding Discussion The criteria for ordering a chest x ray for children with acute wheeze are not well defined. Chest x rays are performed frequently in children who present with acute wheeze, as it is difficult to rule out pneumonia based on history and clinical examination alone. Pneumonia in children with acute wheeze is uncommon and imaging adds to the health No local finding No pneumonia (6/116) pneumonia (7/10) Figure 3A-3C. Clinical predictors of pneumonia. 2 MuthuKrishnan et al. Pulmonology & Respiratory Research 2013, http://www.hoajonline.com/journals/pdf/2053-6739-1-1.pdf Table 2. Parameters predictive of pneumonia. Variables No Pneumonia Pneumonia P value By Chi Square Test (n=116) (n=10) P< 0.05 = Significant Temp≥1010F 65 10 0.006 Hypoxia 13 4 0.01 Localised chest findings 6 7 0.001 Moderate PSI score 82 7 0.75 care cost and exposure of children to ionizing radiation all of which can be avoided. Analysis of CXR taken for children with acute exacerbation of wheeze in the emergency department suggests that in most instances it does not alter the diagnosis or management. We found a low rate (8.7%) of radiographic pneumonia in our study population which is comparable to 4.9% in a study from Boston [2]. The prevalence of pneumonia in previous investigations varied widely, ranging from 8.6% to 35% [3-5]. In our study all children (100%) who had radiological evidence for pneumonia had triage temperature ≥ 1010F (p=0.006). A study from Pakistan also concludes that temperature of > 1000F was highly specific for poor response to bronchodilator and susequent deterioration. The overall positive predictive value was best for temperature of > 1000F [6]. We also observed in our study that in addition to temperature, hypoxia (p=0.01) and localised chest findings (p=0.001) were also statistically significant variables associated with pneumonia. The difference in Pulmonary score index in children without radiological pneumonia was not stastically significant as PSI mainly includes respiratory rate, wheeze and work of breathing. This observation is similar to a prospective study which reported that, among infants < 18 months of age, grunting on examination and oxygen saturation of < 93% were predictors of radiographic pneumonia, whereas fever and tachypnea were not associated with pneumonia risk [7]. In a study from Brazil, absence of pulmonary infiltrates was associated with the complaint of difficulty in breathing (P=0.04) and wheezing (P=0.001) [8]. It is also difficult to distinguish a viral process from bacterial pneumonia on chest radiographs, and radiographic pneumonia does not necessarily indicate a bacterial infection leading to overuse of antibiotics. Conclusion Majority of children with acute wheeze are subjected to chest radiography as they are febrile, though the occurrence of radiographic pneumonia is as low as (8.7%). Triage temperature of ≥ 1010F, hypoxia and localized chest findings were predictors of pneumonia in children with acute wheeze. Definite criteria have to be defined through larger studies to avoid unnecessary chest radiography. doi: 10.7243/2053-6739-1-1 data and preparation of manuscript. Radhika Raman conceived, designed and critically analysed the study. Acknowledgement S. Muralinath, Consultant radiologist. Publication history Editor: Chunbin Zou, University of Pittsburgh, USA. EIC: Victor J. Thannickal, University of Alabama at Birmingham, USA. James R. Seibold, Scleroderma Research Consultants, LLC, USA. Received: 13-May-2013 Revised: 13-Jun-2013 Accepted: 21-Jun-2013 Published: 11-Jul-2013 References 1. Smith SR and Strunk RC. Acute asthma in the pediatric emergency department. Pediatr Clin North Am. 1999; 46:1145-65. | Article | PubMed 2. Mathews B, Shah S, Cleveland RH, Lee EY, Bachur RG and Neuman MI. Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009; 124:e29-36. | Article | PubMed 3. Leventhal JM. Clinical predictors of pneumonia as a guide to ordering chest roentgenograms. Clin Pediatr (Phila). 1982; 21:730-4. | Article | PubMed 4. Lynch T, Gouin S, Larson C and Patenaude Y. Does the lateral chest radiograph help pediatric emergency physicians diagnose pneumonia? A randomized clinical trial. Acad Emerg Med. 2004; 11:625-9. | Article | PubMed 5. Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, Donnelly LF, Bracey SE, Duma EM, Mallory ML and Slap GB. 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Pulmonol Respir Res. 2013; 1:1. http://dx.doi.org/10.7243/2053-6739-1-1 Competing interests The authors declare that they have no competing interests. Authors’ contributions Lakshmi Muthukrishnan did the collection, analysis of 3