有哮喘症狀兒童 放射線檢查證實肺炎並不常見


  July 10, 2009 — 根據一項發表於7月號小兒醫學期刊的前瞻性世代研究結果,有哮喘症狀但沒有發燒的兒童,放射線檢查證實肺炎的病例並不常見,因此,並不鼓勵常規性地建議進行放射線檢查。
  
  來自麻州波士頓哈佛醫學院與波士頓兒童醫院的Bonnie Mathews醫師與其同事們寫到,診斷有哮喘症狀兒童的肺炎並不容易,因為臨床病史與聽診檢查可能不容易區分出那些沒有罹患肺炎的兒童。這項研究的目的在於找出那些至急診室就診的哮喘症狀兒童,與放射線檢查證實罹患肺炎之間有關的因子。
  
  這項研究的樣本包括526位年齡小於21歲,至急診室就診的兒童病患,這些兒童病患在檢查時都有哮喘的症狀,且因為可能罹患肺炎而接受放射線檢查。在得知胸部放射線檢查結果之前,主治醫師會得到病患的醫療史,以及進行並記錄理學檢查。接著,再由兩位不同的放射科醫師判讀胸部放射線檢查。
  
  在納入病患中,平均年齡為1.9歲(四分位間距介於0.7-4.5歲),其中47%有哮喘病史、36%病患住院、而4.9%(95%信賴區間[CI]為3.3%-7.3%)經放射線檢查證實罹患肺炎。沒有發燒的哮喘病童,定義為體溫低於38°C,罹患肺炎的機率非常低(2.2%;95% CI為1.0%-4.7%)。
  
  與放射線檢查證實肺炎有關的因子,包括在家發燒病史(陽性預測值[LR]為1.39;95% CI為1.08-7.54),有腹痛病史(陽性LR為2.85;95%CI為1.08-7.54),檢傷分類時體溫超過38°C(陽性LR為1.48-2.49),最後是檢傷分類時氧氣飽和度低於92%(陽性LR為3.06;95% CI為1.15-8.16)。
  
  這項研究的限制包括有時間限制、未能收納所有符合條件的病童、放射科醫師未知病患分派下的判讀、由照護病患的主治醫師醫囑放射學檢查,可能造成選擇性誤差。這項發現無法應用到所有哮喘病童,可能高估了肺炎機率。
  
  研究作者們寫到,有哮喘症狀病童,經放射線檢查證實罹患肺炎的機率並不高。病史上與臨床因子可以用於決定是否需要對哮喘兒童進行胸部放射線檢查。常規對有哮喘但沒有發燒兒童進行胸部放射線檢查是不應該被鼓勵的。
  
  研究作者們表示沒有相關資金上的往來。
  

Radiographic Pneumonia Uncommon in Children With Wheezing

By Laurie Barclay, MD
Medscape Medical News

July 10, 2009 — Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.

"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "Limited data exist regarding predictors of pneumonia among children with wheezing. The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting."

The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.

Among the included patients, median age was 1.9 years (interquartile range, 0.7 - 4.5 years), 47% had a history of wheezing, 36% were hospitalized, and 4.9% (95% confidence interval [CI], 3.3% - 7.3%) had radiographic pneumonia. Children with wheezing who were afebrile, defined as a temperature of less than 38°C, had a very low rate of pneumonia (2.2%; 95% CI, 1.0% - 4.7%).

Factors linked to an increased risk for radiographic pneumonia were a history of fever at home (positive likelihood ratio [LR], 1.39; 95% CI, 1.13 - 1.70), a history of abdominal pain (positive LR, 2.85; 95% CI, 1.08 - 7.54), triage temperature of 38°C or higher (positive LR, 2.03; 95% CI, 1.34 - 3.07), maximal temperature in the ED of 38°C or higher (positive LR, 1.92; 95% CI, 1.48 - 2.49), and triage oxygen saturation of less than 92% (positive LR, 3.06; 95% CI, 1.15 - 8.16).

Limitations of this study include time constraints, preventing enrollment of all eligible children; reliance on blinded radiologist review; and chest radiographs ordered at the discretion of the physicians caring for the patients, which may have introduced selection bias. The findings are not generalizable to all children with wheezing, and the rate of pneumonia may have been overestimated.

"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:e29-e36.

    
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