Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
Durham Veterans Medical Center, Durham, North Carolina.
JAMA. 2017 Aug 1;318(5):462-471. doi: 10.1001/jama.2017.9039.
Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse.
To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia.
MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria.
Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes.
Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia.
Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67]).
Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.
肺炎是儿童发病率和死亡率的主要原因。识别与肺炎相关的临床症状和体格检查结果对于改善及时诊断、预防严重发病和限制抗生素过度使用非常重要。
系统回顾症状和体格检查结果在识别有放射影像学肺炎的儿童中的准确性。
检索了 MEDLINE 和 Embase（1956 年至 2017 年 5 月），并从检索到的文章的参考文献中查找了涵盖广泛年龄范围的儿科肺炎的诊断研究，必须包括 5 岁以下儿童（尽管一些研究纳入了年龄达 19 岁的儿童）；共确定了 3644 篇独特的文章，其中 23 篇符合纳入标准。
两名作者独立提取原始数据并评估了方法学质量。第三名作者解决了争议。
计算了单个症状和体格检查结果在诊断肺炎中的似然比（LR）、敏感性和特异性。胸部 X 射线检查的浸润被认为是肺炎诊断的参考标准。
纳入了 23 项可能患有肺炎的儿童前瞻性队列研究（N = 13 833）（8 项来自北美），每项研究的患者人数为 78 至 2829 例。北美研究中放射影像学肺炎的患病率为 19%（95%CI，11%-31%），北美以外地区为 37%（95%CI，26%-50%）。没有单一的症状与肺炎有很强的关联；然而，在包括青少年的 2 项研究中出现胸痛与肺炎相关（LR，1.5-5.5；敏感性，8%-14%；特异性，94%-97%）。生命体征异常，如发热（体温>37.5°C [LR 范围，1.7-1.8]；敏感性，80%-92%；特异性，47%-54%）和呼吸急促（呼吸频率>40 次/分钟；LR，1.5 [95% CI，1.3-1.7]；敏感性，79%；特异性，51%）与肺炎诊断的关联并不强。同样，听诊结果与肺炎诊断也无关联。存在中度低氧血症（氧饱和度≤96%；LR，2.8 [95% CI，2.1-3.6]；敏感性，64%；特异性，77%）和呼吸功增加（呼噜声、鼻翼煽动和肋间隙凹陷；阳性 LR，2.1 [95% CI，1.6-2.7]）是与肺炎最相关的体征。存在正常氧合（氧饱和度>96%）降低了肺炎的可能性（LR，0.47 [95% CI，0.32-0.67]）。
尽管没有单一的发现能可靠地区分肺炎与儿童其他呼吸系统疾病，但低氧血症和呼吸功增加比呼吸急促和听诊结果更重要。
