HHS Public Access Author manuscript Author Manuscript
JAMA Pediatr. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: JAMA Pediatr. 2016 August 01; 170(8): 803–805. doi:10.1001/jamapediatrics.2016.0310.
Pneumonia in Children Presenting to the Emergency Department With an Asthma Exacerbation
Author Manuscript
Todd A. Florin, MD, MSCE, Hannah Carron, BS, Guixia Huang, MS, Samir S. Shah, MD, MSCE, Richard Ruddy, MD, and Lilliam Ambroggio, PhD, MPH Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Florin, Ruddy); Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (Florin, Carron, Shah, Ruddy, Ambroggio); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Huang, Ambroggio); Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Shah, Ambroggio); Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Shah)
Author Manuscript
Asthma and pneumonia are 2 of the most common reasons children visit the emergency department.1 These conditions have overlapping features and can occur concomitantly. Subsequently, physicians often obtain chest radiographs to diagnose pneumonia in children with asthma, although less than 5% of children have pneumonia that can be radiographically confirmed (hereafter referred to as radiographic pneumonia).2 The consequences of the overuse of radiography include increased time in the hospital, unnecessary radiation exposure, increased costs, and inappropriate antibiotic use due to equivocal imaging findings.3 Given the high rate of normal chest radiographs and the consequences of unnecessary radiographs, more accurate criteria are needed to identify children with asthma who are at increased risk for pneumonia. This study aims to identify risk factors for pneumonia in children with asthma exacerbations.
Methods This is a retrospective cohort study of children 2 to 18 years of age who presented to the emergency department of the Cincinnati Children’s Hospital Medical Center between
Author Manuscript
Corresponding Author: Todd A. Florin, MD, MSCE, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229 ([email protected]). Author Contributions: Dr Florin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Florin, Carron, Ruddy, Ambroggio. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Florin. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Florin, Carron, Huang, Ambroggio. Obtained funding: Ambroggio. Administrative, technical, or material support: Ambroggio. Study supervision: Florin, Shah, Ruddy, Ambroggio. Conflict of Interest Disclosures: None reported. Disclaimer: Dr Shah is the JAMA Pediatrics Clinical Challenge Editor but was not involved in the editorial review or decision to accept the manuscript for publication.
Florin et al.
Page 2
Author Manuscript
January 1, 2010, and December 31, 2013, with an asthma exacerbation. Children were identified using a validated algorithm of an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for asthma (code 493.X) in the first 3 diagnosis positions and receipt of 1 or more doses of albuterol sulfate in the emergency department.4 We excluded children who were younger than 2 years of age to minimize including infants with bronchiolitis. The Cincinnati Children’s Hospital Medical Center institutional review board approved this study. Informed consent was not required because the data were deidentified.
Author Manuscript
Data were abstracted from the electronic health record (Epic Systems Corporation). Potential factors associated with pneumonia included demographics, medical history, medications, and vital signs (Table 1). The primary outcome was radiographic pneumonia as determined by 2 investigators who manually reviewed the final radiologist reports using a coding manual. Meetings to clarify disagreements occurred weekly. Abnormal radiographs were classified as definite atelectasis, favoring atelectasis, atelectasis vs pneumonia, favoring pneumonia, and definite pneumonia. Radiographic pneumonia was present if the radiologist favored or definitively diagnosed pneumonia.2 Less than 1.9% of data were missing from any variable, so a complete case analysis was performed. The t test and the χ2 test were performed to examine the relationship between each potential risk factor and radiographic pneumonia. Variables with P ≤ .20 in the univariable analysis were included in a multivariable logistic regression model to determine the association of risk factors with radiographic pneumonia.
Results Author Manuscript
There were 14 007 emergency department visits for asthma exacerbation; chest radiography was performed during 4708 of 14 007 emergency department visits (33.6%). Radiographic pneumonia was present in 280 of the 4708 children who underwent chest radiography (5.9%). Factors independently associated with pneumonia included an age of 5 years or older, female sex, fever, and an oxygen saturation of less than 90% (Table 1 and Table 2).
Discussion
Author Manuscript
Less than 2% of patients with an asthma exacerbation had radiographic pneumonia, yet onethird underwent chest radiography. Being 5 years of age or older, female, febrile, and/or hypoxic was statistically associated with radiographic pneumonia. A previous study reported that 4.9% of children with wheezing (many .99
.28
.53
JAMA Pediatr. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: JAMA Pediatr. 2016 August 01; 170(8): 803–805. doi:10.1001/jamapediatrics.2016.0310.
Pneumonia in Children Presenting to the Emergency Department With an Asthma Exacerbation
Author Manuscript
Todd A. Florin, MD, MSCE, Hannah Carron, BS, Guixia Huang, MS, Samir S. Shah, MD, MSCE, Richard Ruddy, MD, and Lilliam Ambroggio, PhD, MPH Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Florin, Ruddy); Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (Florin, Carron, Shah, Ruddy, Ambroggio); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Huang, Ambroggio); Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Shah, Ambroggio); Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Shah)
Author Manuscript
Asthma and pneumonia are 2 of the most common reasons children visit the emergency department.1 These conditions have overlapping features and can occur concomitantly. Subsequently, physicians often obtain chest radiographs to diagnose pneumonia in children with asthma, although less than 5% of children have pneumonia that can be radiographically confirmed (hereafter referred to as radiographic pneumonia).2 The consequences of the overuse of radiography include increased time in the hospital, unnecessary radiation exposure, increased costs, and inappropriate antibiotic use due to equivocal imaging findings.3 Given the high rate of normal chest radiographs and the consequences of unnecessary radiographs, more accurate criteria are needed to identify children with asthma who are at increased risk for pneumonia. This study aims to identify risk factors for pneumonia in children with asthma exacerbations.
Methods This is a retrospective cohort study of children 2 to 18 years of age who presented to the emergency department of the Cincinnati Children’s Hospital Medical Center between
Author Manuscript
Corresponding Author: Todd A. Florin, MD, MSCE, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229 ([email protected]). Author Contributions: Dr Florin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Florin, Carron, Ruddy, Ambroggio. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Florin. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Florin, Carron, Huang, Ambroggio. Obtained funding: Ambroggio. Administrative, technical, or material support: Ambroggio. Study supervision: Florin, Shah, Ruddy, Ambroggio. Conflict of Interest Disclosures: None reported. Disclaimer: Dr Shah is the JAMA Pediatrics Clinical Challenge Editor but was not involved in the editorial review or decision to accept the manuscript for publication.
Florin et al.
Page 2
Author Manuscript
January 1, 2010, and December 31, 2013, with an asthma exacerbation. Children were identified using a validated algorithm of an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for asthma (code 493.X) in the first 3 diagnosis positions and receipt of 1 or more doses of albuterol sulfate in the emergency department.4 We excluded children who were younger than 2 years of age to minimize including infants with bronchiolitis. The Cincinnati Children’s Hospital Medical Center institutional review board approved this study. Informed consent was not required because the data were deidentified.
Author Manuscript
Data were abstracted from the electronic health record (Epic Systems Corporation). Potential factors associated with pneumonia included demographics, medical history, medications, and vital signs (Table 1). The primary outcome was radiographic pneumonia as determined by 2 investigators who manually reviewed the final radiologist reports using a coding manual. Meetings to clarify disagreements occurred weekly. Abnormal radiographs were classified as definite atelectasis, favoring atelectasis, atelectasis vs pneumonia, favoring pneumonia, and definite pneumonia. Radiographic pneumonia was present if the radiologist favored or definitively diagnosed pneumonia.2 Less than 1.9% of data were missing from any variable, so a complete case analysis was performed. The t test and the χ2 test were performed to examine the relationship between each potential risk factor and radiographic pneumonia. Variables with P ≤ .20 in the univariable analysis were included in a multivariable logistic regression model to determine the association of risk factors with radiographic pneumonia.
Results Author Manuscript
There were 14 007 emergency department visits for asthma exacerbation; chest radiography was performed during 4708 of 14 007 emergency department visits (33.6%). Radiographic pneumonia was present in 280 of the 4708 children who underwent chest radiography (5.9%). Factors independently associated with pneumonia included an age of 5 years or older, female sex, fever, and an oxygen saturation of less than 90% (Table 1 and Table 2).
Discussion
Author Manuscript
Less than 2% of patients with an asthma exacerbation had radiographic pneumonia, yet onethird underwent chest radiography. Being 5 years of age or older, female, febrile, and/or hypoxic was statistically associated with radiographic pneumonia. A previous study reported that 4.9% of children with wheezing (many .99
.28
.53
