Radiographic Patterns Of Pneumonia
Numerous radiographic patterns are consistent with pneumonia and a multitude of other pathologic processes. A synthesis of all available information and careful consideration of the differential diagnosis is essential to establishing the diagnosis, although empiric antimicrobial treatment usually cannot be deferred because of an inability to prospectively exclude the diagnosis.
Generalized hyperinflation with patchy infiltrates suggests partial airway obstruction from particulate or inflammatory debris, although the contribution of positive airway pressure from respiratory support must be considered. Pneumatoceles and prominent pleural fluid collections also support the presence of infectious processes.
Chest radiographs of infants infected with organisms in utero or via the maternal genital tract may demonstrate a ground-glass appearance and air bronchograms. Diffuse, relatively homogeneous infiltrates that resemble the ground-glass pattern of respiratory distress syndrome are suggestive of a hematogenous process, although aspiration of infected fluid with subsequent seeding of the bloodstream cannot be excluded.
Patchy, irregular densities that obscure normal margins are suggestive of antepartum or intrapartum aspiration, especially if such opacities are distant from the hilus. Patchy, irregular densities in dependent areas that are more prominent on the right side are more consistent with postnatal aspiration.
Guidelines For Imaging In Suspected Community
National guidance on community-acquired pneumonia from the United Kingdom and the United States indicates that chest radiographs are not recommended routinely in uncomplicated cases . However, there are defined situations where chest radiographs might be helpful in making the diagnosis , such as when there is pyrexia with only mild respiratory symptoms . The main reason why chest radiography is not routinely recommended in the ambulatory setting is that there is no evidence of a substantial impact on clinical outcomes , which is also true for developing countries . This is because radiography cannot reliably differentiate viral from bacterial pneumonia and therefore does not impact on choice of treatment with antibiotics .
How Can I Care For My Child With Pneumonia At Home
If your child is miserable because of pain or fever, you can give paracetamol to make them more comfortable. You must follow the dosage instructions on the bottle. It is dangerous to give more than the recommended dose.
Your child will need rest to help them recover from pneumonia. Encourage them to drink fluids and eat healthy small meals.
If your doctor has given your child antibiotics, make sure they take all the doses until finished.
It is wise to keep your child with pneumonia away from other children, to limit the spread of infection.
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When Do I Need To See A Doctor Urgently
You should see a doctor urgently if your child:
- is under 3 months old
- is breathing fast, has noisy breathing and is having to use extra effort to breathe
- is having less than half their normal feeds
- looks pale and unwell
- doesn’t seem to be getting better from a mild illness
- suddenly gets worse after beginning to get better
Follow Up Chest Radiography In Paediatric Pneumonia: Is It Avoidable
Dear Sir Pneumonia is a common paediatric condition with estimated incidence 14.7 in 10,000 in children aged 016years1. Evidence for benefit of follow-up chest radiograph is inconclusive2-4. We therefore set out to examine the outcomes and timing of follow-up CXR in a group of paediatric patients and whether there is a link between blood tests and radiological evidence of pneumonia. We studied 161 patients admitted to paediatric ward with radiological evidence of consolidation between 1st January 2016 and 30th October 2016. Mean age was 55.9 months. Of these, 38 had atelectasis and 24 had pleural effusion. Of 161 patients, 93 had a follow-up CXR, of whom 24 had both consolidation and atelectasis. Mean duration between initial and follow-up CXR was significantly longer in those with normal follow-up CXR findings , compared to those with persistent residual changes .
Of 161 patients, 120 had normal serum platelet count , 82 experienced normal WCC and 61 had normal neutrophil values . Moreover, 15 exhibited CRP < 5mg/L . Whilst some patients had normal single blood markers, when aggregated WCC, CRP and neutrophil counts every child had at least one abnormality. Of 161 patients, 141 had blood cultures, positive in two patients.
Khan N, Whitla L, Kenosi M, Coghlan D, Nadeem M Department of Paediatrics, NCH, Tallaght, Dublin 24
Corresponding author: Dr Montasser Nadeem, Paediatric Consultant, NCH, Tallaght, Dublin 24, Ireland
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Distinguishing Between Viral And Bacterial Infections
Differentiating between viral and bacterial pneumonia continues to be a major clinical challenge, whether it be based on clinical findings, diagnostic tests or both . Comparable, well-designed studies that have used credible reference standards such as lung aspiration or comprehensive panels of laboratory investigations to establish the viral or bacterial origin of radiologically diagnosed pneumonia are limited in number. This is further compounded by the increasing description of multi-organism infection or detection for a single clinical episode with the use of molecular diagnostic methods such as polymerase chain reaction. Increasingly, viral-viral, viral-bacterial and bacterial-bacterial interactions in the pathogenesis of respiratory infections are recognised with in-vitro and in-vivo animal and human studies . Thus, although viruses may initiate the respiratory infection, secondary bacterial infection may occur and simply identifying a virus at presentation may not indicate the sole aetiology of the childs acute clinical presentation. This is exemplified on a large-scale in previous influenza epidemics where deaths were caused by secondary bacterial pneumonia rather than the influenza infection .
Limitations Of Cxr Patterns
Other than for complicated pneumonia, there are limitations to this pattern approach, particularly at an individual level in the clinical setting where host factors such as age, comorbidities and immunologic status can modify the radiologic manifestations of pneumonia. In some settings there is wide variation in the use of CXRs in emergency departments but no corresponding association with the proportion of children diagnosed with pneumonia . The utility of clinical signs and symptoms present at the time of CXR to predict a radiological diagnosis of pneumonia, particularly in non-severe cases, varies across studies . In addition, the interpretation of CXR findings is dependent on the quality of the film and the expertise of the reader, with several studies demonstrating varying degrees of concordance between clinicians , between clinicians and radiologists and between radiologists . Despite the frequency of use of CXRs, there is limited evidence to support its routine use in distinguishing between viral and bacterial infections and its ongoing use in clinical management once a diagnosis of pneumonia has been made.
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Pediatric Pneumonia: Sensitivity Of Lung Ultrasound Vs Chest Radiography
Lung ultrasound was more effective in diagnosing pediatric community-acquired pneumonia than chest radiography, with significantly better sensitivity and similar specificity, according to the results of a meta-analysis published in Pediatric Pulmonology.
Although pCAP is diagnosed clinically, radiologic confirmation is often used in complicated or uncertain cases. Chest radiography has a high false-negative rate, exposes patients to ionizing radiation, and can be difficult to obtain in areas with limited resources. Computed tomography of the chest exposes children to considerable radiation and is expensive. Provider-performed point-of-care lung ultrasound is a promising alternative: portable and radiation-free.
Daniel S. Balk, MD, from the Department of Emergency Medicine, Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues conducted a systematic review of PubMed, EMBASE, and Web of Science and included all literature through August 2017. The investigators identified 12 studies, which included a total of 1510 patients.
Lung ultrasound had a pooled sensitivity of 95.5% and a pooled specificity of 95.3%, and it had a positive predictive value of 99.0% and a negative predictive value of 63.1%. In contrast, chest radiography had a pooled sensitivity of 86.8% and a pooled specificity of 98.2%, whereas the positive predictive value for chest radiography was 99.6%, and the negative predictive value was 43.6%.
Indications For Chest Radiography
Chest radiography is indicated in an infant or toddler who presents with fever and any of the following:
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Tachypnea
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Respiratory distress
In older children and adolescents, the diagnosis of pneumonia is often based on clinical presentation and chest x-rays may not be necessary to make the diagnosis.
Chest radiography also helps to confirm the diagnosis of active tuberculosis in a child with positive Mantoux test results. If the chest radiography findings are positive or if the child has other symptoms consistent with the diagnosis of tuberculosis, an attempt should be made to isolate the tuberculous bacilli from early-morning gastric aspirates, cerebrospinal fluid, sputum, urine, pleural fluid, or biopsy specimens.
Chest radiography is indicated in complicated cases in which treatment fails to elicit a response, in patients with respiratory distress, or in those who require hospitalization. Obtain frontal and lateral radiographs, particularly in cases in which the clinical examination findings are equivocal.
In complicated cases of pneumonia, perform chest radiography 6 weeks after treatment to verify resolution of the pneumonia and to screen for any underlying predisposing conditions, such as sequestration.
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Expected Clinical Course And Follow
Clinical improvement should be evident within 48 h of starting antibiotic therapy with bacterial pneumonia. However, improvement may be slower with viral pneumonia. If the patient does not show clinical improvement or worsens within the expected time frame, a chest radiograph or ultrasound should be repeated to look for evidence of a complication . Other reasons for lack of clinical resolution may include a foreign body aspiration, reactive airways disease with atelectasis, a congenital pulmonary anomaly, tuberculosis or unrecognized immunodeficiency with an opportunistic infection.
Radiographic resolution in most uncomplicated pneumonia cases may take up to four to six weeks. Repeat radiographs when children are otherwise well are not indicated to document improvement.
Rsnas Ai Pneumonia Detection Challenge
The Radiological Society of North America is conducting a competition for the development of a software algorithm that can automatically locate lung opacities. Chest radiographs are the most commonly performed diagnostic imaging study, but interpretation can be complicated by many factors. The organization stated that it sees the potential for ML to automate initial detection of potential pneumonia cases in order to prioritize and expedite their review.2
The RSNA challenge states, While common, accurately diagnosing pneumonia is a tall order. It requires review of a chest radiograph by highly trained specialists and confirmation through clinical history, vital signs and laboratory exams. Pneumonia usually manifests as an area or areas of increased opacity on CXR. However, the diagnosis of pneumonia on CXR is complicated because of a number of other conditions in the lungs such as fluid overload , bleeding, volume loss , lung cancer, or post-radiation or surgical changes. Outside of the lungs, fluid in the pleural space also appears as increased opacity on CXR.
Winners of the challenge will be presenting their artificial intelligence models and technologies during an award ceremony at the forthcoming RSNA Annual Meeting being held November 25-30th in Chicago.
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Pleural Effusion Empyema And Abscess
In pneumonia, a collection of fluid may form in the space that surrounds the lung. Occasionally, microorganisms will infect this fluid, causing an empyema. To distinguish an empyema from the more common simple parapneumonic effusion, the fluid may be collected with a needle , and examined. If this shows evidence of empyema, complete drainage of the fluid is necessary, often requiring a drainage catheter. In severe cases of empyema, surgery may be needed. If the infected fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity. If the fluid is sterile, it must be drained only if it is causing symptoms or remains unresolved.
In rare circumstances, bacteria in the lung will form a pocket of infected fluid called a lung abscess. Lung abscesses can usually be seen with a chest X-ray but frequently require a chest CT scan to confirm the diagnosis. Abscesses typically occur in aspiration pneumonia, and often contain several types of bacteria. Long-term antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.
What Puts My Child At Risk Of Getting Pneumonia
Anyone can get pneumonia, but some children are more likely to than others. A child will be at greater risk of getting pneumonia if they:
- are very young
- making a grunting sound with breathing
- putting a lot of extra effort into breathing
Your child with pneumonia is usually very tired and looks unwell.
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Previous Adverse Events With Penicillin Or Other Antibiotic Therapy
If a patient experienced a nonurticarial rash after previous use of a penicillin or amoxicillin, they can safely be started on ampicillin or amoxicillin therapy.
It is now recognized that the cross-reactivity rate between penicillins and second- or third-generation cephalosporins is extremely low. Therefore, cefuroxime, cefprozil or ceftriaxone can be prescribed for penicillin-allergic patients. However, if the reaction to a penicillin included rapid onset of urticaria, angioedema, hypotension or bronchospasm following the dose of penicillin, the patient should be observed for 30 min following the first dose of cephalosporin in a setting where epinephrine is available. Clarithromycin or azithromycin may also be used, but pneumococcal resistance to these antimicrobials is increasingly common and careful follow-up must be ensured. Although rare, a history of a serious nonimmunoglobulin E-mediated reactions attributed to an antibiotic is also a contraindication to using related antibiotics. In such cases, a different class of drug should be selected.
Symptoms And Signs Of Acute Pneumonia
The symptoms of pneumonia may be nonspecific, especially in infants and younger children. Acute onset of fever, cough, difficulty breathing, poor feeding or vomiting, and lack of interest in normal activities are common symptoms. Chest or abdominal pain may also be prominent features. Abrupt onset of rigors favours a bacterial cause. M pneumoniae is typically characterized by malaise and headache for seven to 10 days before the onset of fever and cough, which then predominate. During annual influenza season, influenza as a cause of pneumonia should be strongly considered. Influenza infections may be heralded by the sudden onset of systemic symptoms such as diffuse myalgias and fever, which are then followed by cough, sore throat or other respiratory symptoms.
Children typically experience fever and tachypnea . Indrawing, retractions and/or a tracheal tug indicate respiratory distress . Measurement of oxygen saturation with pulse oximetry is indicated in all patients presenting to a hospital or with significant illness because hypoxemia may not be clinically apparent and cyanosis is only associated with severe hypoxemia. However, a normal oxygen saturation does not exclude the possibility of pneumonia.
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Can You Catch Pneumonia
Yes, you can catch the viruses that cause viral pneumonia – they can spread easily between people. Most children and adults with a virus just get a cold. Only a few will get pneumonia. Viral infections, including viral pneumonia, are more common in winter.
Bacterial pneumonia does not usually spread between people.
Because it’s difficult to tell whether pneumonia is viral or bacterial, it is wise to keep your child with pneumonia away from others.
Extending Who Epc To Clinical Studies
Figure 3
Example of chest radiograph discordant for the diagnosis of pneumonia between a paediatric pulmonologist and WHO radiological criteria when applied in the clinical context.
Note: Chest radiograph of left upper lobe pneumonia diagnosed by a paediatric pulmonologist in a 12 month old child hospitalised for pneumonia. Clinical signs of tachypnoea, chest-indrawing and crackles on admission. This film was classified as negative according to WHO radiological criteria.
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Patterns Of Cxr Abnormalities
There is a spectrum of radiological appearances that are consistent with the clinical and pathological diagnosis of pneumonia, ranging from complicated pneumonia , simple or uncomplicated pneumonia to mild interstitial changes . The characteristics of childhood pneumonia on CXRs generally assume a pattern approach based on pathologic and radiologic characteristics .
Lobar pneumonia is usually considered to be associated with specific bacterial infections such as Haemophilus influenzae type b , S. pneumoniae and Klebsiella pneumoniae . Features on CXRs are a non-segmental, homogenous consolidation predominantly involving one lobe with air bronchograms . Multilobar pneumonia can occur with a number of different bacteria and is associated with more severe disease .
Figure 1
Bronchopneumonia is thought to be usually associated with infections due to gram-negative bacteria, Staphylococcus aureus and some fungi . The radiological appearance of bronchopneumonia varies depending on the severity of disease. Mild disease can manifest as peribronchial thickening and poorly defined air-space opacities inhomogeneous patchy areas of consolidation involving several lobes reflect more severe disease. When confluent, bronchopneumonia may resemble lobar pneumonia .
Figure 2
Guidelines For Referral To Hospital Or Hospital Admission
Most children with pneumonia can be managed as outpatients. Specific paediatric criteria for admission are not available. Hospitalization is generally indicated if a child has inadequate oral intake, is intolerant of oral therapy, has severe illness or respiratory compromise , or if the pneumonia is complicated. There should be a lower threshold for admitting infants younger than six months of age to hospital because they may need more supportive care and monitoring, and it can be difficult to recognize subtle deterioration clinically.
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Limitations Of Chest Radiography
Chest radiography is not always necessary, or even useful, as an aid in determining the etiology of the infection.
Several studies, in fact, have demonstrated that chest radiography is 42-73% accurate in predicting the etiology of a case of pneumonia. For example, in a study of 168 children with pneumonia, 2 radiologists who independently evaluated all chest radiographs were unable to distinguish whether the agent involved was bacterial, viral, or unidentified.
A retrospective cohort study that included 4708 children who presented to the emergency department with an asthma exacerbation reported that radiographic confirmation of pneumonia was present in only 5.9% of the 4708 children who underwent chest radiography.
Given the frequency of nonspecific findings obtained with imaging, clinical presentation and other laboratory findings must be considered in the diagnosis of pneumonia and in the determination of the etiologic agent.