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BioMed Research International
Volume 2019, Article ID 6202405, 8 pages
https://doi.org/10.1155/2019/6202405
Research Article

Radiologic Diagnosis and Hospitalization among Children with Severe Community Acquired Pneumonia: A Prospective Cohort Study

1Adare General Hospital, Pediatrics Unit, Hawassa, Ethiopia
2Hawassa University, College of Medicine and Health Sciences, Department of Pediatrics and Child health, Hawassa, P.O. Box 1560, Ethiopia
3Hawassa University, College of Medicine and Health Sciences, School of Pharmacy, Department of Pharmacology and Toxicology, Hawassa, P.O. Box 1560, Ethiopia
4Bete-Abrham Primary Hospital, Department of Radiology, Hawassa, P.O. Box 851, Ethiopia
5Alatyon General Hospital, Department of Radiology, Hawassa, P.O. Box 1267, Ethiopia
6Hawassa University, College of Medicine and Health Sciences, Department of Radiology, Hawassa, P.O. Box 1560, Ethiopia
7Hawassa University, College of Medicine and Health Sciences, School of Laboratory Medicine, Hawassa, P.O. Box 1560, Ethiopia
8Hawassa University, College of Medicine and Health Sciences, Department of Gynecology and Obstetrics, Hawassa, P.O. Box 1560, Ethiopia

Correspondence should be addressed to Birkneh Tilahun Tadesse; moc.liamg@nuhalithenkrib

Received 15 November 2018; Revised 13 December 2018; Accepted 20 December 2018; Published 9 January 2019

Academic Editor: Jonathan Muraskas

Copyright © 2019 Meiron Hassen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives. This study was designed to assess the role of chest radiography for the diagnosis of pneumonia and assess the association of clinical characteristics with radiologic findings and predictors of hospitalization among children with severe community acquired pneumonia. Methods. A prospective study was conducted on 122 children between ages of 3 month and 14 years admitted to pediatric emergency unit with diagnosis of severe pneumonia from September to November , 2017. Eligible children were subjected to chest radiography which was read by two senior radiologists independently (R1 and R2). Disagreements between R1 and R2 were resolved by a third senior radiologist (R3). Level of agreement between radiologists was assessed using Cohen’s kappa coefficient. Clinical and laboratory parameters which could explain the variability in the duration of hospital stay were assessed using a linear regression mode. Independent predictors were assessed using multiple linear regression. Results. The median age of the cohort was 10.0 months (interquartile range (IQR): 6.75–24.0); 76 (62.3%) were male. Nearly half, 63 (51.6%) did not have radiologic evidence of pneumonia. There was low level of agreement between R1 and R2 in reporting consolidation (kappa=0.435, p-value≤0.001), haziness (kappa=0.375, p-value≤0.001), and infiltration (kappa=0.267, p-value=0.008). Children with higher recorded temperature were more likely to have radiologic abnormalities suggesting pneumonia (p-value=0.033). The median duration of hospitalization was 3 days (IQR: 1-4 days); 118 (96.7%) were discharged with improvement. Height-for-age z-score (Coef.=0.203, R2=0.041, p-value=0.027); and hemoglobin level (Coef.=-0.249, R2=0.062, p-value=0.006) explained 4.1% and 6.2% of the variability in the duration of hospital stay, respectively. Conclusion. Radiologic evidence of pneumonia was absent in half of the children with severe pneumonia. There was low agreement between senior radiologists in reporting chest radiographic findings, potentially necessitating harmonization activities to uniformly implement the WHO guidelines in reading chest radiographs.

1. Background

Worldwide, pneumonia was responsible for 15% of childhood deaths in 2016, with highest incidence in developing countries [1]. The global annual incidence of pneumonia is 150 to 156 million cases, accounting for approximately 10-20 million hospitalizations [1]. In Ethiopia, acute respiratory tract infections, particularly pneumonia, are the leading causes of child mortality and morbidity. Pneumonia accounts for 18% of childhood deaths in Ethiopia [2]. Typically, cough, pleuritic chest pain, fever, fatigue, and loss of appetite are presenting symptoms of pneumonia. Children and the elderly with pneumonia have varying presenting features, which include headache, nausea, abdominal pain, and absence of one or more of the prototypical symptoms [3, 4].

The diagnosis of pneumonia is based mainly on clinical parameters including respiratory symptoms and signs, which incur no cost and are sensitive, but are also nonspecific and could lead to unnecessary prescription of antibiotics and drug resistance. According to World Health Organization (WHO) guidelines, severe pneumonia is diagnosed when there is cough and fast breathing (defined based on respiratory rate for age) with one or two of the severity signs including chest in-drawing (in infants <2 months of age), grunting, cyanosis, inability to feed, lethargy, or convulsion [5]. Chest X-ray (CXR) has been the main stay modality in the investigation of chest infection since its invention in the late century, despite the advances in imaging modalities [6]. The WHO recommends CXR for all patients clinically diagnosed with severe pneumonia at tertiary centers [711]. Chest radiograph improves the diagnosis of pediatric community acquired pneumonia to a certain degree and may prevent overtreatment with antibiotics [12]. However, it is important to understand that interpretation is subject to perceptual and cognitive limitation and errors [13].

The interpretation of radiographs is difficult in young children and is affected by the radiographer’s experience and the amount of clinical information available. Additionally, chest radiography cannot reliably distinguish between viral and bacterial pneumonia and is often unable to detect early changes of pneumonia [6, 11, 14]. Other drawbacks of chest radiography include exposure to ionizing radiation, cost, the time and space used, and the need to wait from the radiograph and to see the clinician again. Moreover, chest radiography has a low sensitivity compared to advanced imaging tools like lung ultrasound, computed tomography, and magnetic resonance imaging [1416].

Timely diagnosis and management of severe pneumonia, and shorter hospital stay is crucial to decrease childhood morbidity and mortality in resource limited settings. Prolonged hospitalization could be associated with unfavorable outcomes and is also a cost burden to the public [1721]. Several preventable risk factors have been reported to be associated with prolonged hospitalization among children with severe community acquired pneumonia. Failing to exclusively breastfeed for the first 6 months, inappropriate complimentary feeding, anemia, malnutrition, exposure to parental smoking, inadequate antibiotic use, lack of awareness of parents, overuse of nonsteroidal anti-inflammatory drugs, and indoor air pollution contribute to prolonging duration of hospitalization [22, 23]. History of full vaccination on the other hand decreased length of stay in the hospital [24].

Ethiopia is one of the high burden countries for childhood morbidity and mortality associated with severe pneumonia. It is common practice for clinicians working in hospitals to routinely request CXR for the diagnosis of pneumonia. Chest radiographic films are usually read by radiologists. However, there are no data to assess the validity of the readings by the radiologists and the role of CXR in treating children with pneumonia. In the current study three clinical questions were posed: (1) What is the level of agreement between two radiologists in reading CXR films of children with severe pneumonia? (2) What is the magnitude and predictors of radiologic pneumonia in children? (3) What are the predictors of duration of hospitalization among children with severe pneumonia in Ethiopia?

2. Methods and Materials

2.1. Study Setting, Design, and Research Questions

The study was conducted in Hawassa University Specialized Comprehensive Hospital (HUCSH), which is found in the southern region of Ethiopia. HUSCH is the first referral hospital established in the region serving as a teaching hospital for the College of Medicine and Health Science of Hawassa University, with a catchment population of 10-12 million. It receives about 43,384 patients annually. The hospital gives free service for patients with high priority pediatric conditions, including severe pneumonia.

A prospective short cohort study was conducted from September to November , 2017. Children with a clinical diagnosis of severe community acquired pneumonia were followed from admission until discharge. All pediatric patients between ages 3 months and 14 years, who presented to the pediatric emergency department and were diagnosed with severe community acquired pneumonia as per WHO guidelines, were included. All patients fulfilling inclusion criteria during the study period were enrolled consecutively.

There were three primary objectives of the study, which included (1) assessing the pattern of CXR abnormalities among children with a clinical diagnosis of severe community acquired pneumonia; (2) assessing the level of agreement among senior radiologists (MD + Radiology) on the WHO classification of CXR findings among children with severe community acquired pneumonia; and (3) assessing the determinants of duration of hospitalization of children with severe community acquired pneumonia.

2.2. Exclusion Criteria

Children with congestive heart failure, hospitalization within 14 days of a prior hospitalization episode or onset of pneumonia within 4 days of hospitalization, those diagnosed with tuberculosis, and children with foreign body aspiration or aspiration pneumonia were excluded from participating in the study.

2.3. Diagnosis and Management of Severe Community Acquired Pneumonia

In this study, the diagnosis of severe community acquired pneumonia was considered if the children presented with cough and/or with tachypnea defined by respiratory rate count of more than cut off for age (i.e., >/= 50 for those between ages of 3 months and 1 year; >/= 40 for children between the ages of 1-5 years) and the presence of one of intercostal and/or subcostal recessions, chest in-drawing, grunting, cyanosis, or altered mental status [5].

Treatment of severe community acquired pneumonia involves respiratory support—including oxygen administration via a nasal catheter or prong, antipyretics if fever >38.5°Celsius and antibiotics—intravenous crystalline penicillin in four divided doses until the child can take oral antibiotics. Additionally, any environmental, nutritional, or socioeconomic risk factors are carefully assessed and modifiable factors are addressed.

2.4. CXR Diagnosis of Pneumonia

Based on the WHO guidelines [8], the standard criteria for the radiologic diagnosis of pneumonia in a two view plain chest radiograph are defined as follows:Endpoint consolidation: a dense or fluffy opacity that occupies the whole lobe of the lung or the entire lung often containing air bronchogram.Nonend point consolidation: linear and patchy densities in a lacy pattern involving both lungs, featuring peribronchial thickening and multiple areas of atelectasis.Pleural effusion: presence of fluid in the lateral pleural space evidenced by obliterating the costophrenic angle between the lung and chest wall.

Initially, CXR was independently read by two senior radiologists (MD + 3-Year Radiology Specialty)—referred to as R1 and R2—following a checklist adopted from the WHO guidelines (Table 1). Findings and conclusion in which both radiologists agreed were taken as final and did not require reading by a third senior radiologist, R3 who was used as a tie breaker for the study. Chest X-ray films with discordant readings in the initial evaluation were arbitrated by R3. The finding which was reported by two radiologists (R1 and R3 or R2 and R3) was considered as a final CXR finding.
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