ArticlesRandomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children
Introduction
When available, chest radiographs are frequently used in the management of ambulatory acute lower-respiratory-tract infections in children.1 In developing countries radiograph facilities are often not available, and WHO guidelines for the case management of acute lower-respiratory infections in developing countries do not recommend the use of a chest radiograph.2 These recommendations are however designed for countries with an infant mortality rate above 40 per 1000 live births. In relatively wealthier developing countries with a lower infant-mortality rate and where radiograph facilities are available the use of chest radiographs could result in improved clinical outcome but any benefit would need to be balanced against other priorities.
The benefit of chest radiography in such cases of pneumonia is not known. The interpretation of the radiograph is difficult in young children and varies with the interpreter's experience and the amount of clinical information available,3, 4, 5 and chest radiography does not reliably distinguish viral from bacterial pneumonia.6 Drawbacks of ordering a chest radiograph include exposure to ionising radiation, cost (especially if travel to another facility is necessary), the time and space used waiting for the radiograph and the need to be seen again by a clinician.
We did not find any studies on the impact of chest radiograph on clinical outcome in acute lower-respiratory infections in children. We found three studies that examined a less important outcome measure—the frequency with which chest radiographs result in a change in diagnosis and management in acute lower-respiratory infections in children.7, 8, 9 Diagnosis was changed in 21–34% of cases, use of antibiotics in 13–22%, and plans for hospital admission in 1–12%. All three studies followed an uncontrolled before-after design which assumes that the clinicians' stated management plans and actual clinical behaviour will match, and that all improvements in health over time are due to the intervention. These studies thus overestimate the impact of radiographs on practice, as compared with randomised controlled trials.10
The aim of this study was to quantify the effect of the use of chest radiographs on management and clinical outcome in children with ambulatory acute lower-respiratory infection, and to determine whether any such effect was dependent on the experience of the clinician.
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Study population
Children aged 2 to 59 months who presented to the Red Cross Children's Hospital as their first contact were eligible for this study if they met the WHO case definition for pneumonia (ie, cough and tachypnoea but drinking well and without chest indrawing, cyanosis, abnormal level of consciousness or stridor).2 WHO case-management guidelines recommend that this group of children be treated with an antibiotic at home. Tachypnoea was defined as a respiratory rate of 50 breaths or more/min in
Results
Of the 581 eligible patients identified by the registered nurse, 59 (26 contactable by telephone) were excluded by the clinicians before randomisation (table 1). The remaining 522 patients were randomly allocated, 259 to the radiograph group and 263 to the control group. Four (1·5%) patients in the radiograph group did not receive the intervention whereas 7 (2·7%) of the control group had a radiograph on the day of randomisation.
Details of follow-up are shown in figure 1. 295 (77·5%) of the
Discussion
This randomised controlled trial is, to our knowledge, the first to be done on the impact of chest radiographs on the diagnosis, treatment, follow-up, and clinical outcome of children with acute-respiratory infections.
The principal and the subsidiary clinical outcomes were not affected by the intervention. The effect of chest radiographs was not modified by age, weight for age, duration of symptoms before presentation, respiratory rate and the clinicians' perception of the need for a chest
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