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Sonal N. Shah, MD, MPH, discusses the clinical examination for childhood pneumonia.
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Sonal N. Shah, MD, MPH, discusses the clinical examination for childhood pneumonia.
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Language: EN.
Segment:0 .
[ Music ] >> Hello and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of The Rational Clinical Examination Series and Professor of Medicine at the Durham Veterans Affairs Medical Center in Duke University. Today, we're discussing the clinical evaluation for childhood pneumonia.
Joining me to talk about this topic is Dr. Sonal Shah, Assistant Professor of Pediatrics and Emergency Medicine at Harvard Medical School. Dr. Shah, a discussion about childhood pneumonia has to start with an agreement on the ages of children that fall into this category and consensus on what we consider the pragmatic reference standard test in usual clinic practice. Can you define those two things for us? >> Pneumonia is a leading cause of morbidity and mortality in children beyond the neonatal period worldwide.
In United States, the annual outpatient visit rates for pneumonia range from 17 to 22 per thousand population with the highest rates occurring in aged 1 to 5 years. The majority of studies examining the clinical evaluation of pediatric pneumonia involved children aged 5 years and younger. With regards to the reference standard, the true reference standard for diagnosis of pneumonia is an aspirate from bronchoalveolar lavage, but such invasive measures are reserved for children with life-threatening conditions.
A more pragmatic reference standard is the chest radiograph, and although it's true that the chest radiographs don't distinguish bacterial from viral disease, it's widely accepted that alveoli pneumonia represents the radiographic pattern of pneumonia most frequently associated with bacterial infections. So radiograph findings are used to guide therapy for pneumonia. >> As an adult physician, I know that we often get sputum cultures in our patients where we suspect pneumonia. Does that have a role in pediatric pneumonia?
>> In pediatrics, we do not use sputum cultures. Kid's coughs are often not productive. They don't have the ability to produce a sample for us, so we do not use sputum cultures in the pediatric population. >> So as you know, I work at the Veterans Administration Medical Center here in Durum where I don't see too many children other than as visitors, but I do know that most pediatricians and emergency physicians who evaluate children brought in for a cough or a fever evaluation are at least going to have a suspicion of pneumonia.
So what is the pneumonia prevalence among these children? >> The presence of pneumonia varies depending on what region of the world we're discussing. So among kids in Canada and the United States, the prevalence of pneumonia is about 19%, but outside of North America, that prevalence can go up to 37%. >> Dr. Shah, a lot of our advice to patients is given in the absence of patients like during a phone call. So let's say the mother of a 12 or 14-month-old child calls you up, and she's concerned because her child has developed a fever, the overall symptom seems to be getting worse, and the baby has become a little irritable.
What factors would make you think about pneumonia and ask her to bring the child in for an evaluation? >> I think the main things that I would focus on in a conversation over the phone with a parent is the general appearance of the child, if she was concerned about how the child appeared, or more specifically, if she was concerned that the child's breathing pattern looked different to her. If any of those two things existed, I would certainly refer her in to be seen. >> In the emergency room, our patients are going to typically be triaged by a nurse, and when they have, the patient has a cough and fever, we are typically going to look at the vital signs even before we see the patient.
The ones that catch our eye are going to be the degree of the fever itself, and the respiratory rate, and whether there is hypoxemia if the pulse ox was measured. So let's talk about each of these and their diagnostic accuracy for identifying pneumonia among children with cough and/or fever. >> That's absolutely right. We always look at the vital signs right before examining the patient in the emergency room. Interestingly, fever is not strongly associated with pneumonia diagnosis, and that's true for any temperature threshold.
With regards to respiratory rate, in contrast to the WHO guidelines, we did not find that tachypnea was associated with an increased likelihood of pneumonia. What is true, however, is that in children less than 5 years in age, the absence of tachypnea makes pneumonia less likely. Oxygen saturation is the most useful vital sign in identifying children with pneumonia. Children with normal oxygen saturations are less likely to have pneumonia compared with hypoxemic children, and by normal we me mean greater than 96%.
However, the strength of that association is not consistent among those children with hypoxemia. Children with severe hypoxemia that's less than 90%, have a statistically lower likelihood of pneumonia. So in the most hypoxic children, other causes should be considered. >> Wow. That's counterintuitive that a lower oxygen saturation makes childhood pneumonia less likely. Can you tell us about some of the diagnoses we ought to be considering for the child with very low oxygen saturation?
>> So in children with more severe hypoxia, the differential can be more complicated pneumonia, bacterial sepsis. The hypoxia could result from a cardiac etiology or even a pulmonary embolism [assumed spelling]. >> Well, on meeting the child, we tend to focus on how they're breathing and we then auscultate the lungs. Does the observation, the general observation, of watching the child breathing and/or lung auscultation add to the information provided by the vital signs themselves?
>> That's a great question. Among physical exam findings, work of breathing is the most useful for diagnosing pneumonia in pediatric patients. And although often thought of as a hallmark of pneumonia, auscultatory findings were not correlated with the diagnosis of pneumonia, and that's true of any type of auscultatory findings such as crackles, rales, wheeze, or rhonchi. >> Well, that's a little disappointing, but I can live with the data. The range of ages for childhood pneumonia include both verbal and preverbal children.
Do symptoms obtained from an older verbal child help us to identify those with pneumonia? >> Yes, there is some hope there. Among adolescents, chest discomfort is associated with an increased likelihood of pneumonia. >> What do you mean by chest discomfort? >> Patient's report of chest pain has been associated with an increase likelihood of pneumonia with a positive likelihood ratio of anywhere from 1.5 to 5.5. >> So don't get a cardiac cast. Think about pneumonia.
That sounds good for an adult physician to think about, but it sounds like the general appearance of the child and the presence of hypoxemia are more important than the respiratory rate and/or auscultation. What do the guidelines say about the role of radiographs after considering these clinical findings? >> Well, you're absolutely right about hypoxia and the appearance of the child. Among children with cough and fever, a child's general appearance and oxygen saturation are key determinants in evaluating for pneumonia.
Hypoxemia and increase work of breathing outweigh tachypnea and auscultatory findings in identifying children with pneumonia. With respect to the guidelines, the guidelines published in 2011 by the Infectious Disease Society of America and the Pediatric Infectious Disease Society discouraged routine chest radiograph use for children not requiring hospitalization. The guidelines recommend relying upon symptoms and exam findings to diagnose pneumonia. >> Well, thanks Dr. Shah for this interesting discussion.
Is there anything else you would like our listeners to know when evaluating the child with cough and/or fever for pneumonia? >> Just remember there's no single finding that reliably differentiates pneumonia from other cause of childhood respiratory illness, but hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings in attempting to identify patients with pneumonia. >> Well, I'm not going to put my stethoscope away yet, but I believe the data.
More information about this topic is available in the Rational Clinical Examination and on our website JAMAevidence.com where you can listen to our entire roster of podcasts. I'm David Simel, and I'll be back with you soon for another edition of JAMAevidence. [ Music ]
