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The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–9, 2013
Copyright Ó 2013 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2013.04.041

International
Emergency Medicine

OXYGEN SATURATION CAN PREDICT PEDIATRIC PNEUMONIA IN


A RESOURCE-LIMITED SETTING

Payal Modi, MD, MPH,* Richard B. Mark Munyaneza, MD,† Elizabeth Goldberg, MD,* Garry Choy, MD,‡
Randheer Shailam, MD,‡ Pallavi Sagar, MD,‡ Sjirk J. Westra, MD,‡ Solange Nyakubyara, BSN,§
Mathias Gakwerere, MD,§ Vanessa Wolfman, MD, MPH,jj{ Alexandra Vinograd, MD,jj Molly Moore, MD,jj{ and
Adam C. Levine, MD, MPH*
*Department of Emergency Medicine, Brown University Medical School, Providence, Rhode Island, †Department of Community Health,
Rwanda Ministry of Health, Kigali, Rwanda, ‡Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts, §Butaro Hospital, Rwanda Ministry of Health, Burera District, Rwanda, jjPartners in Health/Inshuti Mu Buzima, Rwinkwavu,
Rwanda, and {Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
Reprint Address: Payal Modi, MD, MPH, Department of Emergency Medicine, Brown University Medical School, 593 Eddy St, Claverick 274,
Providence, RI 02903

, Abstract—Background: The World Health Organiza- ROC curve (AUC) of 0.675 (95% confidence interval [CI]
tion (WHO) recommends using age-specific respiratory 0.581–0.769 and p = 0.001). Respiratory rate had an AUC
rates for diagnosing pneumonia in children. Past studies of 0.528 (95% CI 0.428–0.627 and p = 0.588). Conclusion:
have evaluated the WHO criteria with mixed results. Objec- Oxygen saturation was the best clinical predictor for pediat-
tive: We examined the accuracy of clinical and laboratory ric pneumonia and should be further studied in a prospective
factors for diagnosing pediatric pneumonia in resource- sample of children with respiratory symptoms in a resource-
limited settings. Methods: We conducted a retrospective limited setting. Ó 2013 Elsevier Inc.
chart review of children under 5 years of age presenting
with respiratory complaints to three rural hospitals in , Keywords—pediatric; pneumonia; developing coun-
Rwanda who had received a chest radiograph. Data were tries; international; child; diagnosis
collected on the presence or absence of 31 historical, clinical,
and laboratory signs. Chest radiographs were interpreted
by pediatric radiologists as the gold standard for diagnosing INTRODUCTION
pneumonia. Overall correlation and test characteristics
were calculated for each categorical variable as compared Pneumonia kills more children under the age of 5 years
to the gold standard. For continuous variables, we created than any other illness; it is responsible for over two mil-
receiver operating characteristic (ROC) curves to determine lion pediatric deaths each year (1). In the developing
their accuracy for predicting pneumonia. Results: Between world, about 29% of children under 5 years of age, or
May 2011 and April 2012, data were collected from 147
about 151 million children each year, will develop clini-
charts of children with respiratory complaints. Approxi-
mately 58% of our sample had radiologist-diagnosed pneu-
cal pneumonia. Nearly 10% of those, or 14 million chil-
monia. Of the categorical variables, a negative blood smear dren, will go on to have severe disease requiring
for malaria (c2 = 6.21, p = 0.013) and the absence of history hospitalization (1). Over 97% of new pneumonia cases
of asthma (c2 = 4.48, p = 0.034) were statistically associated each year occur among children living in low- and
with pneumonia. Of the continuous variables, only oxygen middle-income countries, and nearly two-thirds of those
saturation had a statistically significant area under the cases are in children living in Southeast Asia and

RECEIVED: 13 October 2012; FINAL SUBMISSION RECEIVED: 15 March 2013;


ACCEPTED: 30 April 2013

1
2 P. Modi et al.

sub-Saharan Africa (1). Because it is the primary cause predictors of pneumonia in children than respiratory
for one in every five child deaths, prompt identification rate alone.
and treatment of pneumonia remains integral to achieving
the fourth Millennium Development Goal of reducing the METHODS
under-5 mortality by two-thirds before 2015.
Study Design
To address the disease burden caused by pneumonia
and other common childhood diseases such as malnutri-
We conducted a retrospective chart review of children ad-
tion, diarrhea, and malaria, the World Health Organiza-
mitted with respiratory complaints (cough or difficulty
tion (WHO) released the Integrated Management of
breathing) to three rural hospitals in Rwanda. The re-
Childhood Illnesses (IMCI) guidelines to establish a stan-
search was approved by both the Rwanda National Ethics
dardized protocol for the diagnosis and management of
Committee and the Lifespan (Rhode Island Hospital) In-
common and often fatal pediatric diseases (2). Given
stitutional Review Board, both of which waived informed
that in most resource-limited settings where child mortal-
consent for this study given its retrospective nature and
ity remains high and access to advanced diagnostic mo-
the difficulty in contacting rural villagers up to a year af-
dalities such as chest radiography are often limited, the
ter their child’s admission to the hospital.
IMCI guidelines appropriately focus on simple clinical
measures for diagnosing and treating these common pedi-
atric diseases. Although a recent evaluation of the impact Setting
of IMCI in five countries found relatively consistent
improvements in health worker skills, community knowl- This study was conducted at three rural, government hos-
edge, and care-seeking behavior with the implementation pitals in Rwanda. Rwinkwavu Hospital is located in
of IMCI, the studies were mixed with regards to improve- Kayonza District and Kirehe Hospital is located in Kirehe
ments in child mortality (3–7). Although the IMCI District, both in the Eastern Province of the country. Bu-
guidelines have proved to be both an effective and taro Hospital is located in Burera District in the Northern
cost-effective tool for improving pediatric care in Province. All three hospitals serve relatively impover-
resource-limited settings, there is still room for further ished populations and are supported by Partners in
improvement and refinement of the guidelines to bring Health/Inshuti Mu Buzima (PIH/IMB), an international
about more significant reductions in child mortality. non-government organization. Each hospital sees about
Specifically with regards to pneumonia, the IMCI 15–25 pediatric patients per day in its outpatient clinic
guidelines recommend separating children with cough and Emergency Department, with a census of 25–45 pa-
or difficulty breathing into one of three categories: chil- tients on the inpatient pediatric ward at any given time.
dren with chest indrawing (subcostal retractions) should Pneumonia is one of the most common reasons for pedi-
be considered to have severe pneumonia; children with atric admissions to each of the three hospitals. Together,
rapid respiratory rate (tachypnea) alone should be treated these three hospitals serve a catchment area that includes
as having non-severe pneumonia; and children without approximately 750,000 people, about 16% of which are
tachypnea should be treated as having no pneumonia (es- children under 5 years of age (8).
sentially as having a viral upper respiratory infection).
According to the IMCI guidelines, children with severe Patient Selection
pneumonia should be given intravenous antibiotics and
admitted to a hospital; children with non-severe pneumo- We reviewed all medical charts for children admitted with
nia should be treated as outpatients with oral antibiotics; respiratory symptoms to the pediatric wards of our three
and children with no pneumonia should be treated as out- study hospitals in Rwanda between May 2011 and April
patients without antibiotics (2). 2012. Charts were included for children who presented
As part of a preliminary analysis for a larger study to with respiratory complaints, including cough or difficulty
develop a clinical prediction rule for pediatric pneumo- breathing, regardless of their final discharge diagnosis.
nia, we conducted a retrospective chart review of children We excluded charts for children over 5 years of age be-
under 5 presenting with respiratory complaints to three cause the IMCI guidelines focus on children under 5. Ad-
rural hospitals in Rwanda. We developed a list of candi- ditionally, this is the population at highest risk for death
date clinical variables that were associated with our out- from pneumonia, in whom an accurate diagnosis is
come of interest: the presence of pneumonia on chest most important. We also excluded charts for those chil-
radiograph. Based on our review of the literature and ex- dren who did not receive a chest X-ray study during their
perience treating children with respiratory disease in rural admission, because chest radiography was used as the
Rwanda, we hypothesized that other clinical signs and gold standard for determining pneumonia in our study.
symptoms, including oxygen saturation, may be better In all cases, the decision to obtain a chest radiograph
Oxygenation Predicts Pneumonia 3

was at the discretion of the treating physician, although and the proportion of children from each of the three
the vast majority of patients admitted with respiratory districts. We then summarized the data for each of the
complaints to our study hospitals received a chest X-ray 31 historical symptoms, clinical signs, and basic labora-
study. tory tests included in our data abstraction tool, as well
as the Rwandan provider’s interpretation of the chest ra-
Data Collection diograph when available. Finally, we summarized clinical
outcome data for each patient, including mortality and
We created a data abstraction tool based on our review of final clinical discharge diagnosis.
the published literature and in consultation with local Based on the final consensus among our three pediatric
physicians to capture all available data from the medical radiologists, we calculated the proportion of children
chart relevant to the diagnosis of pneumonia in our set- with radiologist-confirmed pneumonia. As a secondary
ting. Research assistants at each of the study hospitals outcome, we also calculated the proportion of children
were trained to use the tool and to collect data from pa- with radiographic evidence of other diseases that com-
tient charts. Clinical data collected included basic demo- monly cause respiratory symptoms in our setting, includ-
graphic measures (age and sex), clinical symptoms ing tuberculosis, pulmonary edema (due to congenital or
(cough, wheezing, dyspnea, fever, feeding intolerance, rheumatic heart disease), or hyperexpansion (due to
vomiting, diarrhea, and duration of symptoms), past his- asthma or bronchiolitis).
tory (immunization status, mother’s human immunodefi- Finally, for each of the categorical clinical and labora-
ciency virus [HIV] status, tuberculosis [TB] contact, prior tory variables collected by our data abstraction tool, we
asthma diagnosis), vital signs (temperature, pulse, respi- assessed its correlation with our outcome of interest,
ratory rate, and oxygen saturation), physical examination radiologist-confirmed pneumonia using chi-squared
signs (weakness, cyanosis, pallor, intercostal or subcostal analysis. We also calculated its test characteristics, in-
retractions, grunting, nasal flaring, wheezing, crepita- cluding sensitivity and specificity, as well as positive
tions, or decreased breath sounds), and basic laboratory and negative likelihood ratios for predicting pneumonia.
tests (white blood cell count, hemoglobin, C-reactive pro- For continuous variables, we constructed receiver
tein, erythrocyte sedimentation rate, and malaria blood operating characteristic (ROC) curves as compared to
smear). We also collected data on the treating physician’s radiologist-confirmed pneumonia, and calculated the
initial clinical suspicion for pneumonia before chest area under the ROC curve for each continuous variable
X-ray study. All clinical data were collected from the ad- to determine its accuracy for predicting pneumonia.
mitting physician’s note on the patient’s first day of hos- Finally, we calculated the test characteristics for respira-
pitalization, whereas laboratory and radiologic tests were tory rate using the pre-determined, age-specific cutoffs
collected from their first appearance in the chart. recommended by the WHO.
In addition to collecting clinical data, research assis-
tants also recorded the interpretation of chest radiography
RESULTS
as documented by the Rwandan general practice physi-
cian caring for the patient. Chest radiographs at our study Demographics
hospitals were generally limited to a single, anterior-
posterior view of the chest usually conducted with the We identified 178 charts of children admitted to the pedi-
child upright (small children who cannot stand are usu- atric wards of our three study hospitals between May
ally held up for the chest radiograph). Digital images of 2011 and April 2012. Of these charts, 147 (87%) were
all chest radiographs were also obtained by the research for children under age 5 years who received chest radio-
assistant and transmitted to the United States to be inter- graphs, and we limited our analysis to this group. The me-
preted by two fellowship-trained pediatric radiologists. dian age of children in our sample was 10 months, and
Any discrepancy in interpretation between the two radiol- 51% were male. All three districts were about evenly rep-
ogists was reconciled by a third pediatric radiologist, and resented, with 32% from Kayonza District, 26% from
the final consensus among the three pediatric radiologists Kirehe District, and 42% from Burera District. Figure 1
on the presence or absence of pneumonia was considered demonstrates the dates of admission for children included
the gold standard for pneumonia in our study, as recom- in our sample.
mended by the WHO Radiology Working Group (9).
Outcomes
Data Analysis
Based on the consensus of our pediatric radiologists,
We summarized basic demographic measures for our about 58% of children in our sample presenting with re-
population including age, gender, date of admission, spiratory symptoms had pneumonia, and 42% did not.
4 P. Modi et al.

between clinical suspicion for pneumonia (as charted by


the physician on admission before chest X-ray study or
laboratory tests) and radiologist-confirmed pneumonia
(c2 = 1.54, p = 0.215). Overall, there was a strong corre-
lation between the Rwandan general practitioner and ra-
diologist chest X-ray study interpretation for the presence
of pneumonia (c2 = 7.68, p = 0.006). The overall case fa-
tality ratio for children admitted with respiratory symp-
toms to our study hospitals during this time period was
2.3% (1.5% in children with radiologist-confirmed pneu-
monia and 3.9% in children without radiologist-
confirmed pneumonia).

Predictors of Pneumonia

Of all the historical categorical variables studied, only


Figure 1. Date of admission.
history of asthma was significantly associated with the
absence of pneumonia (c2 = 4.48, p = 0.034) on chest ra-
Those without pneumonia on their chest X-ray study had diograph. Of all the categorical clinical signs and labora-
a range of other radiologic diagnoses, including hyperex- tory tests studied, only a positive blood smear for malaria
pansion (4%), tuberculosis (3%), pulmonary edema/car- was statistically associated with the absence of pneumo-
diomegaly (1%), or normal chest X-ray studies (34%). nia (c2 = 6.21, p = 0.013). Table 1 shows the sensitivity,
There was a statistically significant correlation between specificity, and positive and negative likelihood ratios as
a final clinical discharge diagnosis of pneumonia in the compared to our gold standard diagnosis of radiologist-
chart and radiologist-confirmed pneumonia (c2 = 5.68, confirmed pneumonia for each of the categorical vari-
p = 0.017). However, there was no significant correlation ables collected by our data abstraction tool.

Table 1. Test Characteristics of Categorical Variables for Predicting Pneumonia

Symptoms Sensitivity Specificity Likelihood Ratio Positive (95% CI) Likelihood Ratio Negative (95% CI)

Respiratory distress 0.93 0.06 1.00 (0.85–1.18) 0.90 (0.08–9.26)


Dyspnea 1 0.03 1.03 (0.97–1.09) 0 (0–0)
Cough 0.98 0.01 1.00 (0.95–1.05) 0.68 (0.04–10.7)
Wheezing 0.81 0 0.81 (0.61–1.08) 0 (0–0)
Fever 0.93 0.06 0.99 (0.90–1.10) 1.00 (0.23–4.27)
Feeding tolerance 0.31 0.84 2.03 (0.46–8.81) 0.81 (0.54–1.21)
Vomiting 0.75 0.38 1.22 (0.82–1.81) 0.63 (0.27–1.47)
Diarrhea 0.66 0.29 0.94 (0.60–1.46) 1.14 (0.44–2.95)
Past medical history
Vaccinated 0.98 0.04 1.02 (0.96–1.09) 0.36 (0.03–3.94)
Mother HIV positive 0.11 0.90 1.29 (0.20–8.27) 0.97 (0.78–1.20)
Prior TB contact 0 0.8 0 (0–0) 1.25 (0.80–1.93)
History of asthma 0.27 0.2 0.34 (0.14–0.82) 3.61 (0.61–21.3)
Clinical signs
Weakness 0.80 0.26 1.10 (0.85–1.41) 0.71 (0.31–1.66)
Cyanosis 0 0.5 0 (0–0) 2 (0.50–7.99)
Pallor 0.21 0.57 0.49 (0.18–1.32) 1.36 (0.91–2.04)
Intercostal retractions 0.85 0.08 0.93 (0.73–1.19) 1.71 (0.19–14.7)
Subcostal retractions 0.81 0.11 0.91 (0.65–1.27) 1.68 (0.20–13.9)
Grunting 0.4 1 0 (0–0) 0.6 (0.29–1.22)
Nasal flaring 0.91 0.18 1.12 (0.82–1.51) 0.45 (0.07–2.84)
Wheezing 0.44 0.4 0.74 (0.26–2.05) 1.38 (0.40–4.71)
Crepitations/decreased breath sounds 0.70 0.38 1.13 (0.86–1.50) 0.77 (0.45–1.30)
Suspicion of PNA 0.88 0.18 1.09 (0.94–1.26) 0.60 (0.26–1.35)
Studies
HIV 0 0.94 0 (0–0) 1.05 (0.94–1.17)
Positive malaria smear 0 0.90 0 (0–0) 1.10 (1.00–1.21)
CRP 0.65 0.38 1.07 (0.68–1.68) 0.88 (0.41–1.90)
GP CXR read 0.55 0.72 2.06 (1.16–3.68) 0.60 (0.42–0.85)

HIV = human immunodeficiency virus; TB = tuberculosis; PNA = pneumonia; CRP = C-reactive protein; GP = general practitioner; CXR =
chest X-ray study; CI = Confidence Interval.
Oxygenation Predicts Pneumonia 5

Table 2. Area under ROC Curve for Continuous Variables breaths/min for children 2 months to 1 year, and above
for Predicting Pneumonia
40 breaths/min for children over 1 year), respiratory
95% Confidence Interval rate in our sample failed to demonstrate a statistical asso-
Continuous Area under ciation with the presence of pneumonia on the chest ra-
Variables ROC Curve Lower Bound Upper Bound
diograph (c2 = 1.26, p = 0.261). Using the WHO
Symptom duration 0.556 0.457 0.654 cutoffs, respiratory rate had a sensitivity of 37%, a speci-
Oxygen saturation 0.675 0.581 0.769 ficity of 72%, a positive likelihood ratio of 1.33 (95% CI
Respiratory rate 0.528 0.428 0.627
Temperature 0.480 0.379 0.581
0.80–2.21), and a negative likelihood ratio of 0.87 (95%
WBC 0.558 0.444 0.671 CI 0.69–1.10) for predicting pneumonia.
Hemoglobin 0.530 0.424 0.636 Based on our ROC curve for oxygen saturation, we de-
ESR 0.522 0.259 0.786
termined the best cut-point for the prediction of pneumo-
ROC = receiver operating characteristic; WBC = white blood cell nia to be an oxygen saturation below 93%. Using this
count; ESR = erythrocyte sedimentation rate. cut-point, oxygen saturation was significantly associated
with the presence of pneumonia on the chest radiograph
Table 2 demonstrates the area under the ROC curves (c2 = 9.87, p = 0.002). Additionally, oxygen saturation
and 95% confidence intervals (CI) for each of the contin- below 93% was found to have a sensitivity of 76%, a spec-
uous variables studied. Of all the continuous variables ificity of 51%, a positive likelihood ratio of 1.54 (95% CI
studied, only oxygen saturation had an area under the 1.14–2.06), and a negative likelihood ratio of 0.47 (95%
ROC curve (AUC) statistically different from the refer- CI 0.29–0.76) for predicting pneumonia. A cut-point of
ence line (i.e., better than chance), with an AUC of oxygen saturation below 90% had a sensitivity of 61%
0.675 (95% CI 0.581–0.769 and p = 0.001). Respiratory and specificity of 68%, and oxygen saturation below
rate, on the other hand, had an AUC of 0.528 (95% CI 96% had a sensitivity of 86% and specificity of 28%.
0.428–0.627 and p = 0.588), not significantly different
from the reference line. Figure 2 demonstrates the ROC DISCUSSION
curves for respiratory rate and oxygen saturation,
respectively. The accuracy and reliability of respiratory rate and other
Using the age-specific cutoffs for respiratory rate clinical indicators for the diagnosis of pneumonia is of far
recommended by the WHO IMCI guidelines for the more than just academic importance; the use of inaccu-
diagnosis of pneumonia (respiratory rate above 60 rate or unreliable means for diagnosing pneumonia in
breaths/min in children under 2 months, above 50 children can have significant negative impacts on both

Figure 2. Oxygen saturation and respiratory rate receiver operating characteristic curve.
6 P. Modi et al.

the effectiveness and cost-effectiveness of pediatric care Finally, the sensitivity and specificity of respiratory
in resource-limited settings. For instance, the low speci- rate alone for the diagnosis of pneumonia can also be af-
ficity of respiratory rate alone for diagnosing pneumonia fected by the prevalence of other diseases in the pediatric
in certain settings can mean that many children are population (18). For instance, if all children enrolled in
treated unnecessarily with antibiotics, increasing antibi- a particular study with cough or shortness of breath
otic resistance and wasting health care resources. Far have either pneumonia or a viral upper respiratory infec-
more important, however, is that children mistakenly di- tion, then respiratory rate may be an accurate means of
agnosed with pneumonia due to an increased respiratory predicting which children will have pneumonia and
rate alone may not be evaluated and treated appropriately which will not. However, if significant numbers of chil-
for other life-threatening childhood diseases that also dren in the population studied have other diseases that
present with tachypnea such as malaria or asthma. This cause rapid breathing, such as bronchiolitis, asthma, ma-
is evidenced by the trend toward higher mortality in chil- laria, heart failure, or tuberculosis, then respiratory rate
dren in our sample without pneumonia as compared to will have far lower specificity for the diagnosis of pneu-
those with pneumonia. Finally, the low sensitivity of re- monia. This was clearly true in our population of children
spiratory rate alone for the diagnosis of pneumonia in where lack of prior asthma diagnosis and negative blood
certain pediatric populations, such as those with severe smear for malaria were significant predictors of pneumo-
malnutrition, can mean that antibiotics may be inappro- nia, whereas respiratory rate was not. Similarly, in popu-
priately withheld from those children who truly need lations where severe malnutrition is common (as it is in
them. ours, according to a recent Rwanda Demographic and
Based on the IMCI guidelines, the diagnosis of pneu- Health Survey), many children with pneumonia may
monia in children hinges on the assessment of respiratory not be able to mount an increased respiratory drive, mak-
rate by community health workers, nurses, or doctors ing rapid breathing a less sensitive predictor of pneumo-
working at first-level health facilities. Whereas a review nia (8).
of several early pneumonia diagnostic studies found respi- In this study, we retrospectively assessed more than
ratory rate itself to be a moderately good predictor of two dozen clinical signs and symptoms for the presence
pneumonia in children under the age of 5 years, with pos- of pneumonia in a population of children presenting
itive likelihood ratios ranging from 1.5 to 3.2 and negative with cough or difficulty breathing to three rural, Rwandan
likelihood ratios ranging from .32 to .75, several more re- hospitals, and found that oxygen saturation was the most
cent studies have not found respiratory rate alone to be an predictive clinical indicator of radiologist-confirmed
accurate predictor of pneumonia in children (10–13). In pneumonia. Although many prior studies have analyzed
particular, studies have found respiratory rate to be the accuracy of other clinical signs for predicting hypoxia
a less accurate predictor of pneumonia in children over in children diagnosed with pneumonia, no prior studies
12 months, those suffering from severe malnutrition or have analyzed the accuracy of oxygen saturation itself
HIV, and those presenting with wheezing (14–18). for detecting pneumonia in children, either alone or in
The significant variability in the diagnostic accuracy combination with other clinical signs (22–25). Finally,
of respiratory rate for predicting pneumonia in children whereas most prior diagnostic studies of pneumonia in
can be explained in three ways: 1) variability in the children have been conducted at single urban referral
method of measurement of respiratory rate; 2) variability hospitals, our research was conducted in several front-
in the gold standard used for diagnosing pneumonia; and line rural hospitals in a low-income African country, in-
3) variability in the prevalence of other diseases in chil- creasing the generalizability of our results to children
dren that cause tachypnea. Prior studies for instance, living across sub-Saharan Africa.
have found high variability in measured respiratory rate
in children depending on the method of counting (i.e., ob- Limitations
servation vs. auscultation), the duration of the counting
period (i.e., 30 vs. 60 s), and the state of the child (i.e., The primary limitation of this study is its retrospective
sleeping, agitated, or feeding) (19,20). Perhaps even nature. This means that in studying the association of var-
more important than the inter-study variability in the ious clinical signs and symptoms for the presence of
method of determining respiratory rate in children is pneumonia on chest radiography, we were limited by
the inter-study variability in the gold standard used for the data primary providers chose to record, or failed to re-
the detection of pneumonia. A recent review found no cord, in the chart. The problem of missing data was great-
less than 11 different gold standards used in 25 different est for certain historical symptoms and past medical
diagnostic studies assessing various clinical and labora- history, such as history of feeding intolerance, history
tory predictors for pneumonia in children (21). of asthma, and history of TB contact, which were missing
Oxygenation Predicts Pneumonia 7

from a majority of charts. These missing data likely com- the use of chest radiography as our gold standard may
promised the power of our study to detect significant as- have biased our sample towards sicker children, who
sociations between these historical signs and the presence were more likely to receive a chest radiograph. However,
of pneumonia (though history of asthma did still demon- of all children admitted with respiratory symptoms to the
strate a significant association). Similarly, a number of pediatric wards at our study hospitals, 87% were children
clinical signs were also frequently missing from the under 5 years of age who received a chest radiograph. Of
charts, including the presence or absence of cyanosis, the small percentage of children who did not receive
grunting, or wheezing. However, vital signs, including a chest radiograph in our sample, most of these cases
temperature, respiratory rate, and oxygen saturation, seemed to be due to malfunctioning of the X-ray ma-
were recorded in all charts, though we cannot verify the chine, a common occurrence at rural hospitals in our set-
precise methods used by providers to collect each of these ting. However, as this is essentially a random event, it
variables. A future, prospective study will be necessary to should not bias our results.
ensure that all data are collected for all children enrolled
in a consistent manner, increasing the power to detect as- CONCLUSION
sociations between the various clinical predictors and the
presence of pneumonia. In addition, this study was con- Pneumonia is a major cause of morbidity and mortality
ducted at hospitals supported by Partners in Health, among children in resource-limited settings. Currently,
which may have somewhat better resources and provider the IMCI guidelines rely on respiratory rate as the primary
training than government hospitals not supported by an indicator of pneumonia in children and advise initiating
outside organization. or withholding treatment based on this variable alone.
Another potential limitation is our decision to utilize However, the low specificity of respiratory rate may
chest radiography as our gold standard for the diagnosis lead to overtreatment with antibiotics while missing other
of pneumonia. Although the ‘‘perfect’’ gold standard for important diagnoses in children, and the low sensitivity
bacterial pneumonia would likely be culture of an aspi- dictates that antibiotics may be withheld from children
rate from the lower respiratory track obtained by bron- requiring them. Better-performing clinical variables that
choalveolar lavage or lung puncture, this is incredibly can be easily collected in resource-limited settings, such
invasive and rarely used in studies of pediatric pneumo- as oxygen saturation, could improve diagnostic accuracy
nia, whether in the developed or developing world. In- and thereby resource utilization. As pulse oximeters be-
stead, a number of different gold standards have been come increasingly available in resource-limited settings
used for diagnostic studies of pneumonia in children, over the coming years, they have the potential to be a rel-
with the most common in the published literature being atively inexpensive method for diagnosing pneumonia in
chest radiography and blood cultures (21). Of these these settings. We recommend a prospective study to de-
two, only chest radiography is available in our setting rive a clinical prediction rule for the diagnosis of pneumo-
in rural Rwanda. Furthermore, the largest meta-analysis nia in children under age 5 years in resource-limited
of clinical indicators of pneumonia in children included settings that incorporates oxygen saturation and other
only studies utilizing chest radiography as the reference clinical variables found to be predictive of pneumonia.
standard, as this was felt to be the most practical and valid
gold standard for pneumonia in children (10). As such, Acknowledgments—We would like to thank the Rwanda Minis-
we have chosen to use chest radiography, interpreted by try of Health and Partners in Health/Inshuti Mu Buzima for their
fellowship-trained pediatric radiologists, as the reference support of this project.
standard for pneumonia in our study. A particular strength
of our study was that we had digital images of each chest
radiograph reviewed by two separate pediatric radiolo- REFERENCES
gists, with any discrepancy in their reads resolved by
a third pediatric radiologist. This is recommended by 1. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H.
the WHO Radiology Working Group, given the inherent Epidemiology and etiology of childhood pneumonia. Bull World
Health Organ 2008;86:408–16.
inter-rater variability they found in chest radiograph in- 2. World Health Organization. Integrated management of childhood
terpretation for the presence of pneumonia in children illness. Geneva: World Health Organization; 2005.
in resource-limited settings, due to the poor quality of 3. Amaral J, Gouws E, Bryce J, Leite AJ, Cunha AL, Victora CG. Ef-
fect of Integrated Management of Childhood Illness (IMCI) on
many chest X-ray studies in these settings (9). health worker performance in Northeast-Brazil. Cad Saude Publica
A final limitation of this study is that it only included 2004;20(Suppl 2):S209–19.
hospitalized children. Unfortunately, as in most rural 4. Bryce J, Victora CG, Habicht JP, Black RE, Scherpbier RW. Pro-
grammatic pathways to child survival: results of a multi-country
areas of sub-Saharan Africa, medical charts are only evaluation of Integrated Management of Childhood Illness. Health
kept for hospitalized children in our setting. In addition, Policy Plan 2005;20(Suppl 1):i5–17.
8 P. Modi et al.

5. Arifeen SE, Hoque DM, Akter T, et al. Effect of the Integrated Man- 15. Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T.
agement of Childhood Illness strategy on childhood mortality and Pneumonia in severely malnourished children in developing
nutrition in a rural area in Bangladesh: a cluster randomised trial. countries – mortality risk, aetiology and validity of WHO clinical
Lancet 2009;374:393–403. signs: a systematic review. Trop Med Int Health 2009;14:1173–89.
6. Huicho L, Davila M, Gonzales F, Drasbek C, Bryce J, Victora CG. 16. Urganci N, Polat T, Ozer N, Kayaalp N. The presence of clinical
Implementation of the Integrated Management of Childhood Illness signs in malnourished infants with acute lower respiratory tract in-
strategy in Peru and its association with health indicators: an eco- fections. Paediatr Child Health 2003;8:83–6.
logical analysis. Health Policy Plan 2005;20(Suppl 1):i32–41. 17. Hazir T, Qazi S, Nisar YB, et al. Assessment and management of
7. Armstrong Schellenberg J, Bryce J, de Savigny D, et al. The effect children aged 1-59 months presenting with wheeze, fast breathing,
of Integrated Management of Childhood Illness on observed quality and/or lower chest indrawing; results of a multicentre descriptive
of care of under-fives in rural Tanzania. Health Policy Plan 2004;19: study in Pakistan. Arch Dis Child 2004;89:1049–54.
1–10. 18. Graham SM, English M, Hazir T, Enarson P, Duke T. Challenges to
8. National Institute of Statistics of Rwanda (NISR). Rwanda demo- improving case management of childhood pneumonia at health fa-
graphic and health survey 2010. Calverton, MD: NISR and ORC cilities in resource-limited settings. Bull World Health Organ 2008;
Macro; 2011. 86:349–55.
9. Cherian T, Mulholland EK, Carlin JB, et al. Standardized interpre- 19. Berman S, Simoes EA, Lanata C. Respiratory rate and pneumonia in
tation of paediatric chest radiographs for the diagnosis of pneumo- infancy. Arch Dis Child 1991;66:81–4.
nia in epidemiological studies. Bull World Health Organ 2005;83: 20. Simoes EA, Roark R, Berman S, Esler LL, Murphy J. Respiratory
353–9. rate: measurement of variability over time and accuracy at different
10. Margolis P, Gadomski A. The rational clinical examination. Does counting periods. Arch Dis Child 1991;66:1199–203.
this infant have pneumonia? JAMA 1998;279:308–13. 21. Lynch T, Bialy L, Kellner JD, et al. A systematic review on the di-
11. Puumalainen T, Quiambao B, Abucejo-Ladesma E, et al. Clinical agnosis of pediatric bacterial pneumonia: when gold is bronze.
case review: a method to improve identification of true clinical PLoS One 2010;5:e11989.
and radiographic pneumonia in children meeting the World Health 22. Weber MW, Usen S, Palmer A, Jaffar S, Mulholland EK. Predictors
Organization definition for pneumonia. BMC Infect Dis 2008;8:95. of hypoxaemia in hospital admissions with acute lower respiratory
12. Shah S, Bachur R, Kim D, Neuman MI. Lack of predictive value of tract infection in a developing country. Arch Dis Child 1997;76:
tachypnea in the diagnosis of pneumonia in children. Pediatr Infect 310–4.
Dis J 2010;29:406–9. 23. Usen S, Weber M, Mulholland K, et al. Clinical predictors of hypo-
13. Hazir T, Nisar YB, Qazi SA, et al. Chest radiography in children xaemia in Gambian children with acute lower respiratory tract in-
aged 2–59 months diagnosed with non-severe pneumonia as defined fection: prospective cohort study. BMJ 1999;318:86–91.
by World Health Organization: descriptive multicentre study in 24. Lodha R, Bhadauria PS, Kuttikat AV, et al. Can clinical symptoms
Pakistan. BMJ 2006;333:629. or signs accurately predict hypoxemia in children with acute lower
14. Redd SC, Vreuls R, Metsing M, Mohobane PH, Patrick E, respiratory tract infections? Indian Pediatr 2004;41:129–35.
Moteetee M. Clinical signs of pneumonia in children attending 25. Basnet S, Adhikari RK, Gurung CK. Hypoxemia in children with
a hospital outpatient department in Lesotho. Bull World Health Or- pneumonia and its clinical predictors. Indian J Pediatr 2006;73:
gan 1994;72:113–8. 777–81.
Oxygenation Predicts Pneumonia 9

ARTICLE SUMMARY
1. Why is this topic important?
Pediatric pneumonia is the leading cause of death in
children under 5 years of age worldwide. Improved
methods of diagnosis are necessary as the current World
Health Organization guidelines have had mixed diagnos-
tic results.
2. What does this study attempt to show?
This study attempts to find new clinical indicators that
can predict pneumonia.
3. What are the key findings?
Of all the variables studied, a positive blood smear for
malaria and a history of asthma were statistically associ-
ated with the absence of pneumonia. Of the continuous
variables, only oxygen saturation had a statistically signif-
icant area under the receiver operating characteristic
curve, whereas respiratory rate did not.
4. How is patient care impacted?
By finding better methods of diagnosing pneumonia in
children, possibly with the use of oxygen saturation, we
can initiate early treatment and hopefully reduce the mor-
bidity and mortality worldwide.

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