Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
Children's Health Ireland, Temple Street, Dublin, Ireland.
Arch Pediatr. 2024 Aug;31(6):380-386. doi: 10.1016/j.arcped.2024.04.003. Epub 2024 Jul 16.
Fever is a common presenting complaint to the pediatric emergency department (PED), especially among oncology patients. While bacteremia has been extensively studied in this population, pneumonia has not. Some studies suggest that chest X-ray (CXR) does not have a role in the investigation of neutropenic fever in the absence of respiratory symptoms, yet non-neutropenic pediatric oncology patients were excluded from these studies.
We aimed to determine the incidence of CXRs ordered for febrile pediatric oncology patients, irrespective of their absolute neutrophil count (ANC), and to evaluate the rates of radiographic pneumonia as well as predictors of the latter in this group.
This study was conducted in the PED at the American University of Beirut Medical Center (AUBMC), an Eastern Mediterranean tertiary-care hospital. We conducted a retrospective cohort study of acutely febrile pediatric cancer patients, younger than 18 years, presenting to a tertiary center from 2014 to 2018. We included one randomly selected febrile visit per patient. Fever was defined as a single oral temperature ≥38 °C within 24 h of presentation. We collected data on patient characteristics and outcomes. Our primary outcome was radiographic pneumonia; our secondary outcome was whether a CXR was done or not. We defined radiographic pneumonia as a consolidation, pleural effusion, infiltrate, pneumonia, "infiltrate vs. atelectasis," or possible pneumonia mentioned by the radiologist. SPSS was used for the statistical analysis.
We reviewed a total of 664 medical charts and included data from 342 febrile pediatric patients in our analysis. Of these, 64 (18.7%) had a CXR performed. Overall, 16 (25%) had radiographic pneumonia while 48 (75%) did not. Patients were significantly more likely to have a CXR performed if they presented with upper respiratory tract symptoms, cough (p < 0.001 for both), or abnormal lung auscultation at the bedside (p = 0.004). Patients were also less likely to have a CXR done if they were asymptomatic upon admission to the PED (p < 0.001). However, neither cough nor shortness of breath nor abnormal lung examinations were significant predictors of a positive CXR (p = 0.17, 0.43, and 0.669, respectively). Patients with radiographic pneumonia were found to be significantly younger (4.29 vs. 6 years, p = 0.03), with a longer time since their last chemotherapy (15 vs. 7 days, p = 0.005), and were given intravenous (IV) bolus in the PED (87.5% vs. 56.3%, p = 0.02). Interestingly, patients with higher white blood cell (WBC) counts were more likely to have radiographic pneumonia (4850 vs. 1750, p = 0.01). Having a cough and an abnormal lung examination on presentation increased the odds of having a CXR (adjusted odds ratio [aOR]: 6.6; 95% confidence interval [CI]: 3.4-12.8 and aOR: 4.5; 95% CI: 1.1-18.3, respectively). Returning to the PED for the same complaint within 2 weeks was associated with lower odds of a CXR at the index visit (aOR: 0.3; 95% CI: 0.1-0.6). For every year the child is older, the odds of having radiographic pneumonia decreased by 0.8 (95% CI: 0.6-0.98). However, for every day since the last chemotherapy session, the odds increased by 1.1 (95% CI: 1.01-1.12).
In our sample, CXR was not commonly performed in the initial assessment of febrile cancer patients in the PED, unless respiratory symptoms or an abnormal lung examination was noted. However, these were not significant predictors of radiographic pneumonia. Further studies are needed to identify better predictors of pneumonia in this high-risk population.
发热是儿科急诊（PED）常见的就诊主诉，尤其是肿瘤患者。虽然菌血症在该人群中得到了广泛研究，但肺炎尚未得到研究。一些研究表明，在没有呼吸道症状的情况下，中性粒细胞减少性发热的胸部 X 线（CXR）检查没有作用，但这些研究排除了非中性粒细胞减少性儿科肿瘤患者。
我们旨在确定儿科肿瘤发热患者 CXR 检查的发生率，而不论其绝对中性粒细胞计数（ANC）如何，并评估该组患者中放射性肺炎的发生率以及后者的预测因素。
本研究在贝鲁特美国大学医学中心（AUBMC）的 PED 进行，这是一家东地中海的三级保健医院。我们对 2014 年至 2018 年在三级中心就诊的 18 岁以下急性发热的儿科癌症患者进行了回顾性队列研究。我们为每位患者随机选择一次发热就诊。发热定义为 24 小时内单次口腔温度≥38°C。我们收集了患者特征和结局的数据。我们的主要结局是放射性肺炎；我们的次要结局是是否进行了 CXR。我们将放射性肺炎定义为实变、胸腔积液、浸润、肺炎、“浸润与肺不张”或放射科医生提到的可能肺炎。使用 SPSS 进行统计分析。
我们共回顾了 664 份病历，并对 342 例发热儿科患者的数据进行了分析。其中，64 例（18.7%）进行了 CXR 检查。总体而言，16 例（25%）有放射性肺炎，48 例（75%）没有。如果患者出现上呼吸道症状、咳嗽（两者均<0.001）或床边肺部听诊异常（p=0.004），则更有可能进行 CXR 检查。如果患者在 PED 就诊时无症状（p<0.001），则不太可能进行 CXR 检查。然而，咳嗽或呼吸急促或肺部检查异常均不是阳性 CXR 的显著预测因素（p=0.17、0.43 和 0.669）。有放射性肺炎的患者明显更年轻（4.29 岁 vs. 6 岁，p=0.03），距上次化疗时间更长（15 天 vs. 7 天，p=0.005），在 PED 中接受静脉（IV）推注（87.5% vs. 56.3%，p=0.02）。有趣的是，白细胞计数较高的患者更有可能出现放射性肺炎（4850 对 1750，p=0.01）。就诊时有咳嗽和肺部检查异常会增加进行 CXR 的几率（调整后的优势比[aOR]：6.6；95%置信区间[CI]：3.4-12.8 和 aOR：4.5；95% CI：1.1-18.3）。在索引就诊时，在两周内因同一主诉返回 PED 与 CXR 检查的几率较低（aOR：0.3；95% CI：0.1-0.6）。儿童每增加 1 岁，发生放射性肺炎的几率就会降低 0.8（95% CI：0.6-0.98）。然而，自上次化疗以来，每天的几率会增加 1.1（95% CI：1.01-1.12）。
在我们的样本中，在 PED 中对发热的癌症患者进行初始评估时，CXR 通常不常进行，除非注意到呼吸道症状或肺部检查异常。然而，这些并不是放射性肺炎的显著预测因素。需要进一步的研究来确定该高危人群中肺炎的更好预测因素。
