Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado.
Pediatrics. 2021 May;147(5). doi: 10.1542/peds.2020-041582.
Validated prognostic tools for pediatric community-acquired pneumonia (CAP) do not exist. Thus, clinicians rely on "gestalt" in management decisions for children with CAP. We sought to determine the ability of clinician gestalt to predict severe outcomes.
We performed a prospective cohort study of children 3 months to 18 years old presenting to a pediatric emergency department (ED) with lower respiratory infection and receiving a chest radiograph for suspected CAP from 2013 to 2017. Clinicians reported the probability that the patient would develop severe complications of CAP (defined as respiratory failure, empyema or effusion, lung abscess or necrosis, metastatic infection, sepsis or septic shock, or death). The primary outcome was development of severe complications.
Of 634 children, 37 (5.8%) developed severe complications. Of children developing severe complications after the ED visit, 62.1% were predicted as having <10% risk by the ED clinician. Sensitivity was >90% at the <1% predicted risk threshold, whereas specificity was >90% at the 10% risk threshold. Gestalt performance was poor in the low-intermediate predicted risk category (1%-10%). Clinicians had only fair ability to discriminate children developing complications from those who did not (area under the receiver operator characteristic curve 0.747), with worse performance from less experienced clinicians (area under the receiver operator characteristic curve 0.693).
Clinicians have only fair ability to discriminate children with CAP who develop severe complications from those who do not. Clinician gestalt performs best at very low or higher predicted risk thresholds, yet many children fall in the low-moderate predicted risk range in which clinician gestalt is limited. Evidence-based prognostic tools likely can improve on clinician gestalt, particularly when risk is low-moderate.
目前不存在针对小儿社区获得性肺炎（CAP）的有效预后工具。因此，临床医生在管理 CAP 患儿时主要依赖于“整体印象”。本研究旨在评估临床医生的整体印象预测 CAP 患儿发生严重结局的能力。
我们对 2013 年至 2017 年期间因疑似 CAP 行胸部 X 线检查的 3 个月至 18 岁的小儿急诊科就诊的下呼吸道感染患儿进行了前瞻性队列研究。临床医生报告了患儿发生 CAP 严重并发症（定义为呼吸衰竭、脓胸或胸腔积液、肺脓肿或坏死、转移性感染、脓毒症或感染性休克或死亡）的概率。主要结局为发生严重并发症。
634 例患儿中，37 例（5.8%）发生严重并发症。在急诊科就诊后发生严重并发症的患儿中，62.1%的患儿被急诊科临床医生预测为发生严重并发症的风险<10%。在预测风险<1%的阈值时，敏感性>90%，而特异性>90%在预测风险为 10%的阈值时。预测风险为 1%~10%的患儿中，临床医生的整体印象评估结果较差。临床医生区分发生并发症与未发生并发症的患儿的能力一般（接受者操作特征曲线下面积 0.747），经验较少的临床医生的区分能力更差（接受者操作特征曲线下面积 0.693）。
临床医生区分发生 CAP 严重并发症与未发生严重并发症的患儿的能力一般。临床医生的整体印象在极低或较高预测风险阈值时的预测效果最佳，但许多患儿处于预测风险较低至中等的范围内，此时临床医生的整体印象存在局限性。基于证据的预后工具可能优于临床医生的整体印象，尤其是当风险处于较低至中等水平时。
