Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis

Jennifer H. Chao, Raymond Chou Jui Lin, Shashidhar Marneni, Shreya Pandya, Sana Alhajri, Richard Sinert

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Background: An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%–23% of cases. Despite national guidelines stating “current evidence does not support routine radiography in children with bronchiolitis”; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. Objectives: We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis. Methods: We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, “What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?”: Patients—pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention—H&P and VS; Comparator—a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome—operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR−). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test–treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection. Results: We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR– to significantly decrease the pretest probability of finding a +CXR. Our test–treatment threshold model showed that hypoxia (O2 Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O2 Sat < 95%) and respiratory failure requiring ventilatory support. Conclusion: No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.

Original languageEnglish (US)
Pages (from-to)1107-1118
Number of pages12
JournalAcademic Emergency Medicine
Volume23
Issue number10
DOIs
StatePublished - Oct 1 2016

Fingerprint

Bronchiolitis
Meta-Analysis
Hospital Emergency Service
Thorax
X-Rays
Vital Signs
Bacterial Pneumonia
Anti-Bacterial Agents
Pulmonary Atelectasis

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis : A Systematic Review and Meta-analysis. / Chao, Jennifer H.; Lin, Raymond Chou Jui; Marneni, Shashidhar; Pandya, Shreya; Alhajri, Sana; Sinert, Richard.

In: Academic Emergency Medicine, Vol. 23, No. 10, 01.10.2016, p. 1107-1118.

Research output: Contribution to journalArticle

Chao, Jennifer H. ; Lin, Raymond Chou Jui ; Marneni, Shashidhar ; Pandya, Shreya ; Alhajri, Sana ; Sinert, Richard. / Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis : A Systematic Review and Meta-analysis. In: Academic Emergency Medicine. 2016 ; Vol. 23, No. 10. pp. 1107-1118.
@article{b18c18ec164c4f62ac056789ed7cf805,
title = "Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis",
abstract = "Background: An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7{\%}–23{\%} of cases. Despite national guidelines stating “current evidence does not support routine radiography in children with bronchiolitis”; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. Objectives: We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis. Methods: We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, “What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?”: Patients—pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention—H&P and VS; Comparator—a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome—operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR−). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test–treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection. Results: We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7{\%} to 23{\%}. An oxygen saturation < 95{\%} was the predictor with highest LR+ of 2.3 (95{\%} confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR– to significantly decrease the pretest probability of finding a +CXR. Our test–treatment threshold model showed that hypoxia (O2 Sat < 95{\%}) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O2 Sat < 95{\%}) and respiratory failure requiring ventilatory support. Conclusion: No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.",
author = "Chao, {Jennifer H.} and Lin, {Raymond Chou Jui} and Shashidhar Marneni and Shreya Pandya and Sana Alhajri and Richard Sinert",
year = "2016",
month = "10",
day = "1",
doi = "10.1111/acem.13052",
language = "English (US)",
volume = "23",
pages = "1107--1118",
journal = "Academic Emergency Medicine",
issn = "1069-6563",
publisher = "Wiley-Blackwell",
number = "10",

}

TY - JOUR

T1 - Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis

T2 - A Systematic Review and Meta-analysis

AU - Chao, Jennifer H.

AU - Lin, Raymond Chou Jui

AU - Marneni, Shashidhar

AU - Pandya, Shreya

AU - Alhajri, Sana

AU - Sinert, Richard

PY - 2016/10/1

Y1 - 2016/10/1

N2 - Background: An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%–23% of cases. Despite national guidelines stating “current evidence does not support routine radiography in children with bronchiolitis”; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. Objectives: We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis. Methods: We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, “What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?”: Patients—pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention—H&P and VS; Comparator—a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome—operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR−). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test–treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection. Results: We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR– to significantly decrease the pretest probability of finding a +CXR. Our test–treatment threshold model showed that hypoxia (O2 Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O2 Sat < 95%) and respiratory failure requiring ventilatory support. Conclusion: No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.

AB - Background: An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%–23% of cases. Despite national guidelines stating “current evidence does not support routine radiography in children with bronchiolitis”; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. Objectives: We performed a systematic review and meta-analysis to describe potential predictors of a CXR with airspace disease in patients with bronchiolitis. Methods: We searched the medical literature from 1965 to June 2015 in PubMed/EMBASE using the following PICO formulation of our clinical question, “What characteristic(s) of history/physical examination (H&P) and vital signs (VS) in a child with bronchiolitis should prompt the physician to order a CXR?”: Patients—pediatric emergency department (ED) patients (<2 years) with clinical bronchiolitis; Intervention—H&P and VS; Comparator—a CXR positive for airspace disease (+CXR), defined as atelectasis versus infiltrate or infiltrate/consolidation; and Outcome—operating characteristics of H&P and VS predicting an +CXR were calculated: sensitivity, specificity, and likelihood ratios (LR+ or LR−). The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). We created a test–treatment threshold model based on the operating characteristics of the CXR to accurately identify a child with bronchiolitis and a superimposed bacterial pneumonia while accounting for the risks of a CXR and risks of treating patients with and without a bacterial infection. Results: We found five studies including 1,139 patients meeting our inclusion/exclusion criteria. Prevalence of a +CXR ranged from 7% to 23%. An oxygen saturation < 95% was the predictor with highest LR+ of 2.3 (95% confidence interval = 1.3 to 3.07) to predict a +CXR. None of the H&P and VS variables were found to have sufficiently low LR– to significantly decrease the pretest probability of finding a +CXR. Our test–treatment threshold model showed that hypoxia (O2 Sat < 95%) alone complicating bronchiolitis did not show a benefit to obtaining a CXR. Our model only suggested that a CXR maybe indicated for a child with hypoxia (O2 Sat < 95%) and respiratory failure requiring ventilatory support. Conclusion: No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.

UR - http://www.scopus.com/inward/record.url?scp=84990195275&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84990195275&partnerID=8YFLogxK

U2 - 10.1111/acem.13052

DO - 10.1111/acem.13052

M3 - Article

C2 - 27426736

AN - SCOPUS:84990195275

VL - 23

SP - 1107

EP - 1118

JO - Academic Emergency Medicine

JF - Academic Emergency Medicine

SN - 1069-6563

IS - 10

ER -