Guidelines for the use of chest radiographs in community-acquired pneumonia in children and adolescents

Abstract

National guidance from the United Kingdom and the United States on community-acquired pneumonia in children states that chest radiographs are not recommended routinely in uncomplicated cases. The main reason in the ambulatory setting is that there is no evidence of a substantial impact on clinical outcomes. However clinical practice and adherence to guidance is multifactorial and includes the clinical context (developed vs. developing world), the confidence of the attending physician, the changing incidence of complications (according to the success of immunisation programs), the availability of alternative imaging (and its relationship to perceived risks of radiation) and the reliability of the interpretation of imaging. In practice, chest radiographs are performed frequently for suspected pneumonia in children. Time pressures facing clinicians at the front line, difficulties in distinguishing which children require admission, restricted bed numbers for admissions, imaging-resource limitations, perceptions regarding risk from procedures, novel imaging modalities and the probability of other causes for the child's presentation all need to be factored into a guideline. Other drivers that often weigh in, depending on the setting, include cost-effectiveness and the fear of litigation. Not all guidelines designed for the developed world can therefore be applied to the developing world, and practice guidelines require regular review in the context of new information. In addition, radiologists must improve radiographic diagnosis of pneumonia, reach consensus on the interpretive terminology that clarifies their confidence regarding the presence of pneumonia and act to replace one imaging technique with another whenever there is proof of improved accuracy or reliability.

Keywords: Children; Community-acquired pneumonia; Guidelines; Radiography; Ultrasound.

Fig. 1

Anteroposterior chest radiograph requested in a malnourished 1-year-2-month-old boy presenting at a Médecins Sans Frontières site in the Central African Republic with an acute cough and lung crepitations. There was a specific request for the tele-reader to comment on any signs of pulmonary infection or signs of tuberculosis. The report read: “Infiltrates throughout the right lung and in the left upper lobe. Small cavity in the right lower lobe. Right hilar adenopathy narrows the right bronchus (white arrow) and mediastinal adenopathy slightly narrows the trachea (black arrow). Findings are highly indicative of primary TB”. Effusion on the right was not commented on

Fig. 2

Imaging in a 6-year-old boy presenting with cough, dyspnoea, hepatosplenomegaly and oedema at a Médecins Sans Frontières site in the Democratic Republic of Congo. a, b Anteroposterior (a) and lateral (b) chest radiographs. The report read: “CXR shows widespread consolidation — there are many causes for multifocal pneumonia like this. TB is also possible as there is a small left basal pleural effusion (black arrow) and probable mediastinal adenopathy”. A round lucency in the right lower zone was reported as aerated lung and not a cavity

Fig. 3

Imaging in an 8-year-old girl at a Médecins Sans Frontières site in the Democratic Republic of Congo referred for tele-reporting. Presenting symptoms were cough and fever, and the girl was not responsive to antibiotic treatment for suspected pneumonia. The request indicated that pneumonia and tuberculosis were being considered despite no known contact history. a Anteroposterior chest radiograph demonstrates calcified lymphadenopathy at the right paratracheal (white arrow) and right hilar regions (black arrow), consistent with primary pulmonary tuberculosis. b Lateral radiograph confirms the calcified paratracheal (white arrow) and hilar lymphadenopathy (black arrow)