PEM Pearl: Pneumonia and wheezing
As asthma is becoming more and more common, the wheezing child has become an extremely common presentation to the Peds ED. We all know that the most common cause of asthma exacerbation is a simple URI (the kid is not sick) however sticking to PEM Rule Number I “its not the patient’s job to prove that they are sick, its your job to prove that they are NOT” some children may have actual Pneumonia (kid is sick) and will need a CXR. CXR is one of my favorite tests to do. It is one of the very few tests that meets the two conditions an ED tests MUST have.
1. It gives you an answer (pneumonia, no pneumonia) AND….
2. The answer changes the management (abx no abx).
So of the many children we see with wheezing, who needs an x ray to r/o pneumonia? This study answers exactly that question. Which tools can we use to “predict” pneumonia.
I like this study because it answers a very important question, a very common problem and uses appropriate patient population (age) we see all the time.
Some Bottom lines: (Table 2)
1. Among the “historical Features”, Fever was the only one that was statistically significant AND had a positive LR. - so asking the parents about fever is important.
2. Among the examination findings - Respiratory distress was useless (not statistically significant) but the higher temp clearly correlated with findings of Pneumonia on CXR. (Look at the P value and the value of the LR)
3. Triage oxygen sat also correlated with pneumonia (if the pt was less than 92% or 90%).
Interestingly the lowest sat obtained (during the visit) was not statistically significant. So once you give tons of albuterol (which you should cause the only way albuterol can kill a child is if he drowns in a pool full of it) and created the VQ mismatch dont be alarmed to get the CXR if the pt was not initially hypoxic. That hypoxia is your fault. :-)
So next time you see a wheezing child who is hypoxic right at the start, had a fever (by history at home) and in your ED consider a CXR to r/o pneumonia.
If you find one, remember resistant pneumococcus is still the exception so sprinkling the child with some Amox (outpatient) or Ampicillin (inpatient) is still the first choice.
As always, keep in mind…..
“Getting unnecessary tests is like picking your nose in public. What are you going to do if you find something???
1. It gives you an answer (pneumonia, no pneumonia) AND….
2. The answer changes the management (abx no abx).
So of the many children we see with wheezing, who needs an x ray to r/o pneumonia? This study answers exactly that question. Which tools can we use to “predict” pneumonia.
I like this study because it answers a very important question, a very common problem and uses appropriate patient population (age) we see all the time.
Some Bottom lines: (Table 2)
1. Among the “historical Features”, Fever was the only one that was statistically significant AND had a positive LR. - so asking the parents about fever is important.
2. Among the examination findings - Respiratory distress was useless (not statistically significant) but the higher temp clearly correlated with findings of Pneumonia on CXR. (Look at the P value and the value of the LR)
3. Triage oxygen sat also correlated with pneumonia (if the pt was less than 92% or 90%).
Interestingly the lowest sat obtained (during the visit) was not statistically significant. So once you give tons of albuterol (which you should cause the only way albuterol can kill a child is if he drowns in a pool full of it) and created the VQ mismatch dont be alarmed to get the CXR if the pt was not initially hypoxic. That hypoxia is your fault. :-)
So next time you see a wheezing child who is hypoxic right at the start, had a fever (by history at home) and in your ED consider a CXR to r/o pneumonia.
If you find one, remember resistant pneumococcus is still the exception so sprinkling the child with some Amox (outpatient) or Ampicillin (inpatient) is still the first choice.
As always, keep in mind…..
“Getting unnecessary tests is like picking your nose in public. What are you going to do if you find something???
