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Rapid Responses: Rapid Responses published:
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fast breathing and x-ray chest
- Jayendra R Gohil, Ahmedabad, India 380016 (22 August 2006)
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"Pneumonia"
- Sanjiv Lewin (22 September 2006)
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Chest radiography in children aged 2-59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan
- Tabish Hazir, Shamim A Qazi, Yasir Bin Nisar (23 September 2006)
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Childhood pneumonia in developing countries.
- David A Green (26 September 2006)
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simple but effective algorithm needed
- vijayashankara Nanjegowda (27 September 2006)
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Re: Childhood pneumonia in developing countries.
- Dr. Tabish Hazir, Shamim A Qazi, Yasir Bin Nisar (30 September 2006)
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Jayendra R Gohil, Pediatrician BJMedical college, Ahmedabad, India 380016
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The reason WHO included cough and fast breathing only as a sign to diagnose pneumonia in 0-5 yr age group is precisely because the x-rays were normal in majority in such children with bacteremia proven by blood culture. The cases of wheeze and viral pneumonias will also recieve antibiotics as mentioned in the article. This strategy is to be field based to pick up cases of pneumonia early from fast breathing by health workers other than pediatricians (even they too miss) and to refer them early on or treat them early. There is not a pediatrician who would not use antibiotics in an infant breathing at 80/ min with a normal x-ray. WHO has only facilitated this process by allowing health workers to pick up fast breathing early under the IMNCI- integrated management of neonatal and childhood illnesses. If they had termed it as fast- breathing rather than pneumonia in the algorithm, this argument would have been unnecessary by authors. Competing interests: None declared |
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Sanjiv Lewin, Clinical Associate, Pediatrician AIDS Relief - Zambia (UoMd-IHV); Professor St. John's Medical College Hospital, Bangalore, 560 034
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A very interesting study! I am sure the authors know that the term "Pneumonia" used in the WHO public health guidelines does not actually mean the term "Pneumonia" as clinicians would routinely use in clinical practice. It indicates a respiratory problem involving the parenchyma/lower airways probably due to viral or bacterial etiology. In the absence of means to differentiate the two and considering the morbidity/ mortality associated with missing bacterial respiratory tract infections, the guidelines lean towards the use of oral antibiotics based on a criteria of fast breathing without retractions/ danger signs. Many have shown that this approach in resource limited settings has lowered child mortality/morbidity. Many may agree with the opinion that the radiological identification of a 'pneumonia' is probably a most conflicting, at best subjective, and should not be used as a gold standard of "Pneumonia". Yes, it is another matter that we have no better means of confirming an "early" pneumonia! It would be prudent to continue to propogate the WHO ARI approach to identify 'Pneumonia' (or if others prefer...."an ARI needing an antibiotic") as it does rationalize (relatively speaking) the use of antibiotics and reduces morbidity and mortality. Competing interests: Author routinely uses the WHO criteria during outpatient and emergency practice-teaching in rural and urban, both in India and Zambia and is an enthusiastic supporter! |
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Tabish Hazir, Principal Investigator ARI Research Cell, Children's Hospital, Pakistan Institute of medical sciences, Islamabad, Pakistan, Shamim A Qazi, Yasir Bin Nisar
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The authors are grateful to Jayendra R Gohil and Sanjiv Lewin for highlighting some of the issues regarding diagnosis and management of pneumonia in developing countries. First of all, there are no competing interests since the authors are staunch supporters of WHO ARI standard case management (SCM) guidelines and have not only been practising but preaching it to their trainees for over 17 years now. The authors are fully aware of the rationale of ARI SCM guidelines and the impact these guidelines have had on child mortality in certain communities. But the authors strongly believe that an effort must be made constantly to improve these guidelines. There is a need to identify gaps in knowledge and then generate scientific evidence which can serve as the basis for making amendments in the existing guidelines. It must be remembered that WHO ARI SCM guidelines were developed in the early 80s and were based on the evidence available at that time. A lot of work has been done since then, and a number of amendments were proposed by the panel of experts for the existing guidelines in a consultative meeting held at WHO Geneva in November 2003. We must not forget that WHO ARI SCM guidelines are a living document and there can not be a greater injustice done to a living document than by treating it as word of gospel. It is the intention of the authors to make a constant effort to identify areas within the existing guidelines which have a room for improvement and then to carry out operational research in order to find answers. The only purpose is to improve the case management of pneumonia with the objective of not only bringing down mortality rates but also to rationalize the use of antibiotics to deal with the menacing problem of rising antimicrobial resistance. The authors cannot agree more with the comments made by esteemed critics regarding the usefulness or the lack of chest x-rays in the management of childhood pneumonia in developing countries. The authors have highlighted these arguments amply in the publication. Dr. Gohil and Dr. Lewin are advised to go back to the article to verify this fact. Due to the limitations of chest x-rays and the lack of availability of this facility in most of the developing communities, the authors conclude that the WHO guidelines are perfectly justified in not recommending the routine use of x-ray chest. At the same time we concluded that there is a need to improve the specificity of case definitions and we staunchly stick to both the recommendations. Competing interests: None declared |
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David A Green, Consultant Paediatrician West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK
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World Health Organisation (WHO) Guidelines for the Diagnosis of Pneumonia in Children under 5 years are based on studies that compared the sensitivity and specificity of clinical signs with radiographic evidence of pneumonia. Hazir et al 1 expressed concern about false positives (i.e. low specificity) if tachypnoea is used as the only physical sign. However their study of childhood pneumonia does not include a group with a normal respiratory rate. Although this is understandable, as such children do not usually warrant a chest radiograph on clinical grounds, in the absence of this group one cannot make a valid comment on the specificity of the WHO criteria for the classification of pneumonia. The positive predictive value of the WHO criteria would of course depend on the prevalence of pneumonia in the target population. In the editorial comment in the same issue 2 it is stated that chest radiographs have a very low specificity for pneumonia in young children. In the study quoted 3 the tables were turned (quite literally) because the performance of the chest radiograph was measured against the gold standard of the clinical examination, whereas the reverse was true in the studies on which the WHO guidelines were based. The vast majority of patients recruited had been those who had fulfilled the integrated management of childhood illnesses (IMCI) criteria for the diagnosis of pneumonia. There were very few in the normal group, which in this case were patients with upper respiratory tract infections, and it is from this latter group that specificity is calculated. If the same numbers were looked at the other way round then we could arrive at the specificity of the IMCI criteria against the gold standard of the chest radiograph. However the vast majority of patients in this study had pneumonia by IMCI criteria and such selective recruitment would decrease the specificity mathematically by increasing the number of false positives in the same way that specificity can decrease as patients are referred from primary on to secondary and tertiary care. Hazir et al 1 have shown a low positive predictive value for tachypnoea. It is not valid to infer a low specificity from this. Specificity and positive predictive values are distinct entities. Specificity is negativity in health and as such it is measured exclusively in the healthy population. In this context the healthy population consists of children without pneumonia by gold standard investigation, which in the earlier studies quoted was the chest radiograph. These studies did show a high specificity for tachypnoea. A high specificity is reflected in a high positive likelihood ratio, which can be thought of as the power of confirmation. References 1. Hazir T, Bin Nisar Y, Qazi SA, Khan SF, Raza M, Zameer S, et al. Chest radiography in children aged 2-59 months diagnosed with non-severe pneumonia as defined by the World Health Organization: descriptive multicentre study in Pakistan. BMJ 2006; 333: 629-31, doi: 10.1136/bmj.38915.673322.80 2. Bhutta ZA. Childhood pneumonia in developing countries. BMJ 2006;333: 612-613, doi:10.1136/bmj.38975.602836.BE 3. Nizami SQ, Bhutta ZA, Hasan R, Husen YA. Role of chest X-ray in the diagnosis of lower respiratory tract infections in children less than five years of age in community. Pak J Med Sci 2005;21: 471-21. Competing interests: None declared |
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vijayashankara Nanjegowda, senior specialist, pediatrics sohar new hospital, sohar, oman
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sir, I would like to congratulate Hazir et all for attempting to clarify certain issues in the management of childhood pneumonia. The diagnosis of pneumonia is fraught with many pitfalls, resulting in unnescessry morbity and mortality. The WHO criteria overdiagnoses the pneumonia resulting in needless referals; the use of co-trimazole orally in sick children may not achieve the desired results. The management stratgey should include oxygen supplementation and maintainance of fluid balance,which are not usually available at the community level and in institutions in developing countries which lack the basic amenities due to poor budget allocation. our own observations while working in India, correlates with the findings of Hazir et all. The diferentiation between bacterial and viral pnemonias is difficult, but most of the viral pnemonias follows an upper respiratory illness. The presence of rhinitis, eye congestion or a rash definitely points towards a viral etiology. The presence of wheeze indicates bronchiolitis partcularly if it is associated with rhinitis and eye congestion. Reactive airway disease is more likely when there is a family history of atopy, if it is a recurring event and shows a very good response to bronchodilators. we have used total blood count and neutrophil count to decide upon antibiotics, but that is possible only in institutions. Be as it may the management at community level with simpler algorithm and sufficient funds for oxygen and fluids is the urgent need and we pediatricians have to work towards that aim. Competing interests: None declared |
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Dr. Tabish Hazir, Principal Investigator ARI Research Cell, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Shamim A Qazi, Yasir Bin Nisar
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Authors are grateful to Dr. David A Green for his comments. The point that he has raised is valid and authors have no disagreement regarding the technical merit of his argument. We fully agree that positive predictive value and specificity are distinct entities. If our manuscript does not have clarity on this issue, we apologize for the ambiguity, which obviously is inadvertent. In that case certain clarifications are in order. This is a descriptive analysis of the chest radiographs of children diagnosed to have WHO defined non-severe pneumonia. It shows that 82% of the chest radiographs were normal. Authors conclude that it is quite possible that some of these children may not have bacterial pneumonia and, therefore, the use of antibiotics in these children may be unnecessary and could result in exacerbating the problem of increasing antimicrobial resistance in the community. At no stage did authors claim to have embarked upon the task of validating the specificity of tachypnoea. Nowhere in the article authors make a statement on the specificity of tachypnoea, since, as pointed out by my learned colleague, such an inference cannot be made based on the results of this study. However, as Dr. Green must have noticed that in our conclusion we suggest “The clinical assessment of pneumonia needs to be more specific”. Based on the results of our analysis it is a perfectly justified suggestion. For this purpose we do suggest that we need to re-visit the case definitions of pneumonia in order to improve the antibiotic prescribing practices. As we understand this can only be achieved by carrying out operational research to generate greater evidence base and by identifying better and cheaper technology to better understand the etiology of pneumonia in developing countries. These suggestions in no way are meant to be unquestionable inferences and hence, should be taken in that spirit only. Competing interests: None declared |
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