The Value of a Chest X-Ray in Diagnosing Pneumonia in SIRS Patients Lacking Respiratory Symptoms in York Hospital’s Emergency Department

Michelle Lynch Department of Biological Sciences, York College of Pennsylvania

ResultsMethods

Objectives

Conclusion

To determine the prevalence of pneumonia and the predictive properties of a chest x-ray in the evaluation of SIRS for patients with and without respiratory symptoms

Hypothesis: Patients with SIRS criteria and no respiratory symptoms have a lower prevalence of pneumonia and do not require a chest x-ray on initial work up

A history and physical was more effective in diagnosing pneumonia than a chest x-ray (sensitivity 100% and 65% respectively)

None of the patients with SIRS lacking respiratory symptoms were diagnosed with pneumonia and Chest X-rays were not necessary in their diagnosis

Combined with supportive findings from additional studies, chest x-rays can be used more judiciously to limit radiation exposure and reduce medical costs

Systemic Inflammatory Response Syndrome (SIRS)•Bodily response caused by a wide variety of issues•Related to sepsis, which is SIRS specifically caused by infection•Requires two or more of the following symptoms:

* Tachycardia [>90 bpm]* Hypo/Hyperthermia [<96.0 °F or >100.4 °F ]* High Respiratory Rate [>20 breaths/minute]* Low/High WBC [<4,000/μL or >12,000/μL]

Pneumonia •Infection in one or more lobes of the lungs•Symptoms include: cough, fever, shortness of breath•5.6 million cases per year in U.S., 1/5 requiring hospitalization•Leading cause of death by infectious disease

Chest X-Ray•Required in the diagnosis of pneumonia•Infection infiltrates are seen as white opaque patches•Benefits: clear indicator of infiltrates•Drawbacks: costly ($50-$400), radiation exposure

AcknowledgementsThank you to Dr. Kochert, Dr. Ryles, Dr. Lalani, and Mrs. Stahlman from York Hospital

and Dr. Kaltreider and Dr. Boehmler from York College

Radiologyinfo.org

• Retroactive chart review of York Hospital Emergency Department patients receiving a chest x-ray in Dec. 2010

• Those with at least two SIRS criteria were included

• Pediatric and DNR/comfort care only patients and those with known pneumonia or a chronic abnormal chest x-ray were excluded

• Charts were reviewed to determine:* Presence or absence of respiratory symptoms at ED

presentation Respiratory Symptom (RS): Dyspnea, Tachypnea, Cough, Chest Pain, Hypoxia, and Focal Lung Findings

* Radiology interpretation of ED chest x-ray* Discharge Diagnosis (Gold standard for pneumonia

diagnosis )

• Fisher’s exact test and descriptive statistics were used

1053 charts reviewed

23 (14.9%) with Pneumonia

0 (0%) with Pneumonia

39 with no RS154 with one or more RS

193 charts included

860 Excluded

Introduction

History and Physical Chest X-RaySensitivity 100%

(95% CI: 82-100%)65% (95% CI: 43-83%)

Specificity 23% (95% CI: 17-30%)

86% (95% CI: 80-91%)

+ Likelihood Ratio 1.3 (95% CI: 1.2-1.4)

4.6 (95% CI: 2.9-7.4)

- Likelihood Ratio 0(95% CI: 0-0.8)

0.4 (95% CI: 0.2-0.7)

http://emedicine.medscape.com/article/168402-overview

http://www.wellspan.org/body.cfm?id=91

Table 1. Effectiveness of methods in the diagnosis of pneumonia

ReferencesBone, R., et al. 1992. American College of Chest Physicians/Society of Critical Care Medicine Consensus

Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:1644-55.

Lutfiyya, M., et al. 2006. Diagnosis and treatment of community-acquired pneumonia. Am. Family Physician 73:442-450.

Verma, V., et al. 2011. The utility of routine admission chest X-ray films on patient care. European Journal of Internal Medicine 22:286–288.