Accident & Emergency Department, Tuen Mun Hospital, Hong Kong.
Accident & Emergency Department, Princess Margaret Hospital, Hong Kong.
Am J Emerg Med. 2020 Dec;38(12):2557-2563. doi: 10.1016/j.ajem.2019.12.041. Epub 2020 Jan 3.
It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph.
This was a multicenter prospective study in 3 emergency departments. Children younger than 6 years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios.
Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever <3 days (0 points), 3-4 days (2 points), 5-6 days (4 points), ≥7 days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpO ≤96% or tachypnea (3 points). The Area under ROC curve of the PAFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. A PAFRI score of ≥0 gives a sensitivity of 91.7% and negative predictive value of 97.7%.
PAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation.
WHAT'S KNOWN ON THIS SUBJECT: It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients.
The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.
对于医生来说，识别患有急性发热性呼吸道症状的肺炎患者是一项常见的挑战，尤其是对于没有呼吸窘迫的稳定儿科患者。需要一种决策规则来辅助判断是否需要开具胸部 X 光检查单。
这是一项在 3 个急诊中心进行的多中心前瞻性研究。招募了急性发热且伴有呼吸道症状的 6 岁以下儿童。采用拆分样本方法对儿科急性发热性呼吸道疾病规则（PAFRI 规则）进行推导和验证。PAFRI 是基于调整后的优势比进行逻辑回归加权得到的。
在评估的 967 名儿童中，530 名接受了胸部 X 光检查，其中 91 名患儿的 X 光片显示有肺炎证据。PAFRI 规则是通过逻辑回归得到的，其中有 5 个加权预测因子：发热持续时间<3 天（0 分）、3-4 天（2 分）、5-6 天（4 分）、≥7 天（5 分）、寒战（2 分）、鼻部症状（-2 分）、异常胸部检查（3 分）、SpO₂≤96%或呼吸急促（3 分）。PAFRI 规则、Bilkis 决策规则和 Bilkis 简化规则的 ROC 曲线下面积分别为 0.733、0.600 和 0.579。PAFRI 评分≥0 时，其灵敏度为 91.7%，阴性预测值为 97.7%。
PAFRI 规则可作为指导儿科患者是否需要进行胸部 X 光检查的参考工具。虽然很有前景，但 PAFRI 规则仍需要进一步验证。
对于急性发热伴有呼吸道症状的儿童，尤其是那些没有呼吸窘迫的稳定儿童，医生常常难以确定是否患有肺炎。开具胸部 X 光检查单的决定基于临床评估，且实践存在差异。因此，对于没有呼吸窘迫迹象的发热稳定儿童，一项有效的、经过验证的临床预测规则来指导开具胸部 X 光检查单，将有助于管理这群患者。
PAFRI 规则基于临床床边评估的参数，可以作为指导儿科患者转诊或使用胸部 X 光检查的参考工具，并对临床护理的优先级进行分类。
