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Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? A prospective observational study in four Indian hospitals
  1. Vishwanath Gowraiah1,
  2. Shally Awasthi2,
  3. Rashmi Kapoor3,
  4. Devdas Sahana4,
  5. Pushpalatha Venkatesh5,
  6. Belvadi Gangadhar4,
  7. Aradhana Awasthi3,
  8. Anilkumar Verma2,
  9. Nanditha Pai4,
  10. Michael Seear1
  1. 1Divisions of Respiratory Medicine, BC's Children's Hospital, Vancouver, Canada
  2. 2Department of Paediatrics, King George Medical University, Lucknow, India
  3. 3Department of Pediatrics, Regency Hospital, Kanpur, India
  4. 4Department of Paediatrics, Vanivilas Hospital, Bangalore Medical College & Research Centre, Bangalore, India
  5. 5Department of Paediatrics, Bowring and Lady Curzon Hospital, Bangalore Medical College & Research Centre, Bangalore, India
  1. Correspondence to Dr Michael Seear, Division of Respiratory Medicine, Children's Hospital, Vancouver, British Columbia, Canada V6H 3V4; mseear{at}cw.bc.ca

Abstract

Background Acute respiratory infections are the commonest cause of mortality and morbidity in children worldwide. A quarter of all deaths occur in India alone. In order to reduce this disease burden, there is a need for better diagnostic criteria, particularly ones allowing early detection of high-risk children.

Methods We enrolled 516 under 5 year olds, in four Indian hospitals, who met WHO age-dependent tachypnoea criteria for pneumonia at presentation. Patients underwent a protocolised examination assessing 29 items, including history, examination, O2 saturation, plus scores for chest X-ray, auscultation and conscious level. Treatment was determined by the emergency room (ER) physician. All children were reviewed at day 4 by a paediatrician and placed into four diagnostic categories: pneumonia, wheezy disease, mixed and non-respiratory.

Results The majority had wheezy diseases (42.8%). The remainder had pneumonia (35.9%), mixed disease (18.6%) and non-respiratory (2.7%). Best diagnostic predictors for wheezy disease were (auscultation/previous similar episodes) and for pneumonia (auscultation/CXR score). Mortality was 1.6%. Best disease severity predictors were conscious level, weight/age z score and respiratory/pulse rates.

Interpretation Current tachypnoea-based algorithms significantly overdiagnose pneumonia in children and underdiagnose wheezy diseases. Diagnostic accuracy can be improved by various combinations of clinical variables, but the best single diagnostic predictor is auscultation. Simple criteria can also be defined that reliably detect which tachypnoeic children are at high risk of death or deterioration. Management plans based on these protocols could reduce unnecessary antibiotic use, improve the management of wheezy diseases and reduce mortality by earlier identification of high-risk children.

Keywords
  • pneumonia
  • wheezy diseases
  • developing countries
  • children

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