Transcript Chest X-Ray - York College of Pennsylvania

The Value of a Chest X-Ray in Diagnosing Pneumonia in SIRS Patients
Lacking Respiratory Symptoms in York Hospital’s Emergency Department
Michelle Lynch
Department of Biological Sciences, York College of Pennsylvania
http://www.wellspan.org/body.cfm?id=91
Radiologyinfo.org
Introduction
Systemic Inflammatory Response Syndrome (SIRS)
•Bodily response caused by a wide variety of issues
•Related to sepsis, which is SIRS specifically caused by
infection
•Requires two or more of the following symptoms:
* Tachycardia [>90 bpm]
* Hypo/Hyperthermia [<96.0 °F or >100.4 °F ]
* High Respiratory Rate [>20 breaths/minute]
* Low/High WBC [<4,000/μL or >12,000/μL]
Methods
Results
• Retroactive chart review of York Hospital Emergency
Table 1. Effectiveness of methods in the diagnosis of pneumonia
Department patients receiving a chest x-ray in Dec. 2010
• Those with at least two SIRS criteria were included
• Pediatric and DNR/comfort care only patients and those with
known pneumonia or a chronic abnormal chest x-ray were
excluded
• Charts were reviewed to determine:
History and Physical
100%
(95% CI: 82-100%)
Chest X-Ray
65%
(95% CI: 43-83%)
23%
(95% CI: 17-30%)
86%
(95% CI: 80-91%)
+ Likelihood Ratio 1.3
(95% CI: 1.2-1.4)
4.6
(95% CI: 2.9-7.4)
- Likelihood Ratio 0
(95% CI: 0-0.8)
0.4
(95% CI: 0.2-0.7)
Sensitivity
Specificity
* Presence or absence of respiratory symptoms at ED
presentation
Respiratory Symptom (RS): Dyspnea, Tachypnea, Cough,
Chest Pain, Hypoxia, and Focal Lung Findings
* Radiology interpretation of ED chest x-ray
* Discharge Diagnosis (Gold standard for pneumonia
diagnosis )
http://emedicine.medscape.com/article/168402-overview
Pneumonia
•Infection in one or more lobes of the lungs
•Symptoms include: cough, fever, shortness of breath
•5.6 million cases per year in U.S., 1/5 requiring
hospitalization
•Leading cause of death by infectious disease
Chest X-Ray
•Required in the diagnosis of pneumonia
•Infection infiltrates are seen as white opaque patches
•Benefits: clear indicator of infiltrates
•Drawbacks: costly ($50-$400), radiation exposure
• Fisher’s exact test and descriptive statistics were used
1053 charts
reviewed
860 Excluded
193 charts included
Conclusion
154 with one or more RS
39 with no RS
Objectives
To determine the prevalence of pneumonia and the
predictive properties of a chest x-ray in the
evaluation of SIRS for patients with and without
respiratory symptoms
23 (14.9%) with
Pneumonia
0 (0%) with
Pneumonia
References
Hypothesis: Patients with SIRS criteria and no
respiratory symptoms have a lower prevalence of
pneumonia and do not require a chest x-ray on initial
work up
Bone, R., et al. 1992. American College of Chest Physicians/Society of Critical Care Medicine Consensus
Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies
in sepsis. Chest 101:1644-55.
Lutfiyya, M., et al. 2006. Diagnosis and treatment of community-acquired pneumonia. Am. Family
Physician 73:442-450.
Verma, V., et al. 2011. The utility of routine admission chest X-ray films on patient care. European Journal
of Internal Medicine 22:286–288.
A history and physical was more effective in
diagnosing pneumonia than a chest x-ray (sensitivity
100% and 65% respectively)
None of the patients with SIRS lacking respiratory
symptoms were diagnosed with pneumonia and
Chest X-rays were not necessary in their diagnosis
Combined with supportive findings from additional
studies, chest x-rays can be used more judiciously to
limit radiation exposure and reduce medical costs
Acknowledgements
Thank you to Dr. Kochert, Dr. Ryles, Dr. Lalani, and Mrs. Stahlman from York Hospital
and Dr. Kaltreider and Dr. Boehmler from York College