Does This Child Really Need an XR

1
Does This Child Really Need an XR?

• Tanuja Kodeeswaran, MD
• June 7, 2009

2
Disclosure
I do not have an affiliation (financial or
otherwise) with any commercial organization that
may have a direct or indirect connection to the
content of my presentation.
3
The Radiograph

• 1895
• Wilhelm Roentgen
• Battlefield physicians imaging wounded soldiers
  to locate bullets
• Today, easily accessible

4
The Pitfalls

• Overuse
• Unnecessary radiation
• Increased health care expenditures
• Increased wait time

5
Are children really that different when it comes
to imaging?
6
Hurdles and the Decision to XR the Pediatric
Patient

• The Parental Historian
• The Uncooperative Patient
• The Preverbal Patient
• The Growing Child

7
Objectives

• Review current recommendations regarding
  radiographic evaluation for diagnosis of
  sinusitis in children.
• Discuss rationale for radiographic imaging in
  children with suspected community acquired
  pneumonia.
• Review current literature surrounding use of
  radiographs in bronchiolitis.
• Outline current literature available for clinical
  decision rules for imaging in pediatric ankle
  injuries.

8
Case 1

• 5 yo presents to the ED after a 12 day history of
  upper respiratory symptoms and yesGREEN nasal
  discharge.
• Should you consider sinus XRs to confirm your
  suspected diagnosis of sinusitis?

9
Sinus Development
Aeration begins at 7- 8 years old
10
Cold vs ABS

• Children average 6-8 URTI/year
• 7 may be complicated by a secondary bacterial
  sinusitis
• Peak age of ABS lt6 yo

11

• Bacterial infection of paranasal sinuses lasting
  less than 30 days in which symptoms resolve
  completely

ABS
AAP, Pediatrics 2001
12
The Parental Historian
13
(No Transcript)
14
Clinical Manifestations ABS

• Past studies shown large variance
• However current recommendations indicate
  diagnosis on clinical basis
• in the presence of a constellation of signs and
  symptoms
• 10 days duration without improvement

15
Likelihood Ratios for Clinical Signs/Symptoms of
ABS in Children
16
Physical exam

• Physical examination does NOT generally
  contribute to diagnosis of ABS in children
• Facial tenderness unreliable
• Sinus transillumination also unreliable

17

• The colour, green or otherwise,
• A sinusitis does not make!
• Aitken, Arch Pediatr Adolesc Med 1998

18
Sinus XR
19
The Uncooperative Patient
20
Paranasal Sinus XRs

• Difficult to perform in young children
• Incorrect positioning may overestimate or
  underestimate diagnoses
• Waters (occipitomental) or Caldwell views do not
  illustrate ethmoid involvement well
• Lateral views of little use in lt 4 yo

21
Acute Bacterial Sinusitis Guideline Team,
Cincinnati Childrens Hospital, 2006
22
Overestimation

• 97 of children with colds within 2 weeks had
  abnormalities on cranial CT scan performed for
  another indication

Glaser et al, J. Pediatr 1989
23
Abnormal XR inflammation Not necessarily
bacterial infection
24
American College of Radiology, 2000

• Diagnosis of pediatric ABS should be clinical not
  on basis of imaging alone
• If ABS diagnosed appropriately treated, no
  imaging studies indicated if resolved
• If symptoms persist gt10d, despite appropriate
  therapy, and in whom imaging evaluation is
  desired, ? coronal CT scan
• Use of XR discouraged unless exceptional
  circumstances

25

• In the lt 6 year old

Abnormal XR
Positive History

75 sinus positive aspirate
Positive History
Abnormal XR

26

• Imaging studies are NOT necessary to confirm
  clinical sinusitis
• in children 6 yo.
• AAP, 2001

27
Bottom Line Sinusitis and XR

• If clinically suspected through adequate history
  and physical examination, treat on speculation
  without need for XR in lt 6 years old.

28
Case 2

• The parents are expecting an XR.
• Does this sound familiar?

29
Pediatric Pneumonia

• Incidence varies 4-36 per 1000/yr

30
Diagnosis of Pneumonia

• Limited studies ( 1990s)
• Most in developing countries
• No single clinical finding predictive of
  pneumonia
• In children with cough, fever and respiratory
  distress, only 7-19 positive CXR

31
The Preverbal Patient
32

• N 510, cohort
• Examined single or
• combined
• signs/symptoms
• Gold standard CXR

33

• lt12 mth, absence of
• Tachypnea ( 50)
• Nasal Flaring
• Hypoxia (O2 sats96)

Spec 98
34
Best Negative Predictor

• Current evidence still supports Absence of
  Tachypnea obviates need for CXR.

Essential oil of Ylang Ylang slows fast breathing
35
Jury still out!

• More research needed examining clinical
  predictors used to identify those with pneumonia
  in gt12 mth

36
CXR Pneumonia

• Radiographic findings are poor indicators of
  etiology
• High intra/inter-observer agreement variation
  amongst radiologists

BTS Guidelines, Thorax 200251
37
Indications for CXR

• Clinical findings ambiguous
• Complication suspected (ie pleural effusion)
• Prolonged symptoms
• Unresponsive to antimicrobials
• CAP Guideline Team, Cincinnati Childrens
  Hospital, 2005

38

• N 522, 2 -59 mths
• WHO defn of pneumonia cough tachypnea
  (drinking well and no WOB /cyanosis)
• Exclusions cough gt14d, TB contact, localized
  wheeze or cardiac failure

Cochrane Review 2009
39

• Randomized to CXR or no CXR
• Analysis of intention to treat
• 1 Outcome time to recovery (blinded assessment)
• 46 recovered 7d no difference between groups

Cochrane Review 2009
40
(No Transcript)
41
No change in clinical outcome
42
Bottom Line

• Age good predictor of likely pathogens
• Absence of Tachypnea in lt 1yo ?no CXR
• Imaging generally does not change clinical
  outcomes
• CXR should not be performed routinely in children
  with mild uncomplicated acute LRTI

43
Case 3

• 8 mth fever, cough 1st episode wheezing.
  Diagnosed bronchiolitis does not require oxygen
  but needs supportive management with a short stay
  admission at a nearby community hospital.
• Prior to transfer, the receiving MD is inquiring
  if a CXR was done.
• Do you order one before transfer?

44
Bronchiolitis

• Self-limited, acute inflammatory disease of LRT,
  initiated by viral infection
• Median duration12d
• 18 remain ill after 21 days
• 9 remain ill after 28 days
• Swingler, Arch Pediatr Adoles Med, 2000

45
Overall 72 of 17397 hospitalized pts
46
Use of CXR in Bronchiolitis

• Benefit identifying diagnoses inconsistent with
  bronchiolitis (ie pneumonia lobar consolidation)
• Risk many studies have shown an increased use
  of antibiotics
• Swingler et al, Lancet 1998
• Christakis et al, Pediatrics 2005

47

• CXR does not discriminate between bronchiolitis
  and other forms of lower respiratory tract
  infections

Arch Pediatr Adoles Med, 2004
48

• Prospective study
• 265 patients
• 2-23 mths diagnosed with bronchiolitis
• All patients had RDAI
• All patients had CXR

J Pediatr 2007 150429-33
49
RDAI

• validated score in bronchiolitis
• 17 point ordinal scale
• expiratory wheezing (0-4)
• inspiratory wheezing(0-2)
• location of wheezing (0-2)
• Supraclavicular retractions (0-3)
• Intercostal retractions (0-3)
• subcostal retractions (0-3)

50

• Simple XR peribronchial markings/peribronc
  hial infiltrates airway disease
• Complex airway disease adjacent airspace
  disease
• Inconsistent lobar consolidation/
  cardiomegaly/other incompatible

51
3.9x ? likely for simple CXR if O2satgt92
RDAI gt10
J Pediatr 2007 150429-33
52
(No Transcript)
53
5x ?
J Pediatr 2007 150429-33
54

• Intended
• pre- post-XR disposition was the same in 97.4

55
Bottom Line

• XR not warranted in patients suspected of
  bronchiolitis with mild disease
• CXR can be useful in patients with unusual
  clinical courses or severe disease
• Bordley et al, Arch Pediatr Adoles Med 2004

56
Case 4

• At busy adult ED, a 12 yo injured her R ankle
  while on trampoline with 2 other children.
• The triage nurse asks if you would like an XR
  done, prior to assessing the patient.
• Do you order the XR?

57
Pediatric Ankle Injuries

• 2 of children present to ED with acute
  ankle/foot injuries
• Difficult assessment in children
• Unreliable history and physical exam
• Need to weight bear on command
• Presence of epiphyseal growth plates
• Use of XR varies from 64-100
• OAR have been shown to be highly sensitive in
  adult and pediatric populations

58
Steill et al, Ottawa Ankle Rules
59
Steill et al, Ottawa Ankle Rules
60
The Growing Child
61

• Meta-analysis
• N 12 studies
• 4 prospective, 8 retrospective
• Pediatric population, 3130 patients
• 671 fractures with a prevalence of 21.4

Acad Emerg Med, 2009
62

• Pooled sensitivity of 98 (95 CI-97.3-99.2)

Acad Emerg Med, 2009
63

• 10/ 3130
• missed fractures
• 1 SH-I
• 1 SH-IV
• 2 insignificant fractures SH-1 or avulsion
  lt3mm
• 6 were not described

64

• Missed Fracture Rate (1-NPV)
• 1.2 (95 CI 0.6-2.3)

65
What is the acceptable threshold?
66
Do OAR detect SH-1 Fractures?

• SH-1 Fractures are typically diagnosed clinically
• XR would exclude more significant fracture
• Treatment variations
• Consequently more studies required to examine
  clinical significance of SH-1 OAR

67

• XR reduction rates ranged from 5-44 with pooled
  estimate of 24.8
• (95 CI 23.3-26.3)

68
Bottom Line

• OAR is a reliable tool to exclude fractures in
  6 yo
• Applied with caution and pt/parent education that
  a small percentage still can be missed by both
  OAR and initial XR
• May warrant close followup /- delayed XR if
  symptoms persist

69
Summary

• Imaging studies not necessary to confirm clinical
  sinusitis in 6 yo.
• CXR should not be performed routinely in children
  with mild uncomplicated acute LRTI.
• XR not warranted in patients suspected of
  bronchiolitis with mild disease.
• OAR is a reliable tool to exclude fractures in
  6 yo.

70

• Kids are different.
• Awareness enhances clinical decision making.

71
Questions?
72
References

• Engels et al, J Clin Epi 53 2000 852-862
• American Academy of Pediatrics, 2001
• http//www.cincinnatichildrens.org
• Mahabee-Gitttens et al,Clin Ped 200544427-35
• Margolis JAMA 1998279(4)308-313
• Swingler et al, Lancet 1998351404-408
• Cochrane Database of Systematic Review, 2009
• Christakis 2005115878-884
• Schuh et al, J Ped 2007150429-433
• S. Dowling et al, Acad Emerg 200916277-87

73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76

• N 522, 2 -59 mths
• WHO defn of pneumonia cough tachypnea
  (drinking well and no WOB /cyanosis)
• Exclusions cough gt14d, TB contact, localized
  wheeze or cardiac failure
• randomized to CXR or no CXR
• Analysis of intention to treat
• 1 Outcome time to recovery, blinded assessment
• 46 recovered 7d no difference between groups

Cochrane Review 2009