Acute Respiratory Illness in Immunocompetent Patients
EVIDENCE TABLE
Patients/ Study Objective Study
Reference Study Type Study Results Events (Purpose of Study) Quality 1. Benacerraf BR, McLoud TC, Rhea JT, Review/Other- 1,102 To assess the value of CXR in patients with Although in patients over 40 years old, chest 4 Tritschler V, Libby P. An assessment of Dx consecutive chest complaints to identify selective symptoms are a sufficient indication for CXR, the contribution of chest radiography in patients indications for CXR in this population with 96% of the patients below age 40 had a outpatients with acute chest complaints: a relation to the patient's age, the symptoms, normal physical examination of the chest, no prospective study. Radiology. 1981; and the results of physical examination. hemoptysis, and no acute radiographic 138(2):293-299. abnormalities. If CXRs in the below-40 group had been limited to patients with abnormal physical examinations and/or hemoptysis, 58% of the patients in that group would have been spared the examination. Under these conditions, 2.3% of the acute radiographic abnormalities in the entire population of patients under 40 would have gone undetected. 2. Heckerling PS. The need for chest Review/Other- 464 patients To study the predictive values of several Of 464 patients who received a CXR, 129 4 roentgenograms in adults with acute Dx clinical variables for the presence or absence (27.8%) had pneumonia. None of the respiratory illness. Clinical predictors. of pneumonia in adults with acute respiratory symptoms, signs, or laboratory findings Arch Intern Med. 1986; 146(7):1321- complaints. evaluated could reliably predict the presence 1324. of pneumonia. The absence of abnormal auscultatory findings on lung examination, however, excluded pneumonia with >95% certainty. Among the 106 patients who presented with acute asthma, only 2 (1.9%) had pneumonia. Among the 33 patients with underlying organic brain syndrome, 25 (75.8%) had pneumonia. Incorporating these findings into a diagnostic strategy for ordering CXRs could have reduced the number obtained by 54% and spared 72% of patients without pneumonia unnecessary radiation exposure. 3. Okimoto N, Yamato K, Kurihara T, et al. Observational- 79 To identify sensitive clinical predictors for the A total of 24 patients (30.4%) had radiological 4 Clinical predictors for the detection of Dx outpatients detection of community-acquired pneumonia evidence of pneumonia. In total, 22 presented community-acquired pneumonia in adults in adults as a guide to when to order a CXR. with 4 clinical signs: fever, cough, sputum and as a guide to ordering chest radiographs. coarse crackles. The sensitivity and the Respirology. 2006; 11(3):322-324. specificity of detecting pneumonia based on these 4 clinical signs mentioned was 91.7% and 92.7%, respectively.
Reference Study Type Study Results Events (Purpose of Study) Quality 4. Butcher BL, Nichol KL, Parenti CM. High Observational- 221 patients To assess the yield of CXR among a group of New clinically important radiographic 3 yield of chest radiography in walk-in Dx symptomatic adults presenting to a walk-in abnormalities, defined as those necessitating clinic patients with chest symptoms. J Gen clinic. acute intervention and/or follow-up Intern Med. 1993; 8(3):115-119. evaluation, were identified for 77 (34.8%) of the 221 patients studied. Abnormalities included 39 (17.6%) cases of infiltrates, 23 (10.4%) cases of nodules or mass lesions, and 19 (8.6%) cases of cardiomegaly or congestive heart failure. Evaluation of clinical data obtained during the triage interview revealed no statistically significant difference between those patients with and those without new radiographic abnormalities on their CXRs. 5. Speets AM, Hoes AW, van der Graaf Y, Observational- 192 patients To assess the diagnostic yield of CXR in Pneumonia was diagnosed by general 3 Kalmijn S, Sachs AP, Mali WP. Chest Dx primary-care patients suspected of pneumonia. practitioners in 35 (18%) patients, of whom radiography and pneumonia in primary 27 (14%) patients had a positive CXR, and 8 care: diagnostic yield and consequences (4%) patients a negative CXR, but with an for patient management. Eur Respir J. assumed high probability of pneumonia by the 2006; 28(5):933-938. general practitioner. CXR clearly influenced the diagnosis of pneumonia by the general practitioner in 53% of the patients. CXR ruled out pneumonia in 47% and the probability of pneumonia substantially increased in 6% of the patients. Patient management changed after CXR in 69% of the patients, mainly caused by a reduction in medication prescription (from 43% to 17%) and more frequent reassurance of the patient (from 8% to 35%).
Reference Study Type Study Results Events (Purpose of Study) Quality 6. Aagaard E, Maselli J, Gonzales R. Review/Other- 300 adults To examine which clinical factors contribute Clinician suspicion of pneumonia was low in 4 Physician practice patterns: chest x-ray Dx to the clinician suspicion of pneumonia, as the majority of patients presenting for ordering for the evaluation of acute cough well as the relationship between clinical evaluation of cough (63%). Higher clinician illness in adults. Med Decis Making. 2006; factors, clinician suspicion of pneumonia, and suspicion of pneumonia was predicted by 26(6):599-605. ordering CXR. advanced patient age (OR: 4.6; 95% CI, [1.2- 18.1]), shortness of breath (2.4; [1.0-6.0]), fever (5.5; [1.8-17.5]), tachycardia (3.8; [1.1- 13.1]), rales (23.8; [5.7-98.7]), and rhonchi (14.6; [5.2-40.5]). CXRs were ordered in 19% of patients presenting with acute cough. Intermediate clinician suspicion of pneumonia (OR: 7.9; 95% CI, [2.8, 22.5]) (vs low suspicion), advanced patient age (≥65 years) (9.2; [2.7, 31.6]) (vs ages 18-44 years), and decreased breath sounds on examination (5.1; [1.8, 14.3]) are independent predictors of ordering a CXR. Among patients with a clinical diagnosis of pneumonia (n=31), CXRs were ordered in only 61%.
Reference Study Type Study Results Events (Purpose of Study) Quality 7. Basi SK, Marrie TJ, Huang JQ, Majumdar Review/Other- 2,706 adults To describe the prevalence of patients One third (n=911) of patients admitted with 4 SR. Patients admitted to hospital with Dx admitted to hospital with a diagnosis of pneumonia had their initial radiograph suspected pneumonia and normal chest community-acquired pneumonia who have reported as “no pneumonia.” Independent radiographs: epidemiology, microbiology, normal CXRs; the extent to which patients review found that only 7% (6/92) of and outcomes. Am J Med. 2004; actually had pneumonia on radiographs; and radiographs developed an opacity that 117(5):305-311. to compare presentation and outcomes in confirmed pneumonia. Characteristics were patients with a lower respiratory tract similar among admitted patients irrespective infection and those whose clinical diagnosis of radiographic findings, although patients of pneumonia was confirmed by radiography. without pneumonia on radiograph were older (mean [+/- SD] age, 73 +/- 15 years vs 68 +/- 19 years, P<0.001) and had greater pneumonia-specific severity-of-illness scores (104 +/- 32 vs 99 +/- 37, P=0.004). Patients without radiographic confirmation of pneumonia had similar rates of positive sputum cultures (32% [87/271] vs 30% [208/706], P=0.42) and blood cultures (6% [35/576] vs 8% [100/1241], P=0.13), but microbiology results differed, with a shift away from Streptococcus pneumoniae towards other streptococci species and gram- negative aerobic bacilli. In-hospital mortality was similar for both groups of patients (8% [64/911] in the unconfirmed pneumonia group vs 10% [165/1795] in the confirmed group, adjusted P=0.09). 8. O'Brien WT, Sr., Rohweder DA, Lattin Observational- 350 patients To develop a prediction rule for the use of The data show that vital sign and physical 2 GE, Jr., et al. Clinical indicators of Dx CXRs in evaluating for CAP based on examination findings are useful screening radiographic findings in patients with presenting signs and symptoms. parameters for CAP, demonstrating a suspected community-acquired sensitivity of 95%, a specificity of 56%, and pneumonia: who needs a chest x-ray? J an OR of 24.9 [corrected] in the presence of Am Coll Radiol. 2006; 3(9):703-706. vital sign or physical examination abnormalities. In light of these results, the authors developed a prediction rule for low- risk patients with reliable follow-up, which states that CXRs are unnecessary in the presence of normal vital signs and physical examination findings.
Reference Study Type Study Results Events (Purpose of Study) Quality 9. Hagaman JT, Rouan GW, Shipley RT, Review/Other- 105 patients To determine the percentage of patients with a 21% (22/105) of patients with a clinical 4 Panos RJ. Admission chest radiograph Dx clinical diagnosis of CAP who did not have diagnosis of CAP had negative CXRs at lacks sensitivity in the diagnosis of radiographic opacifications and compare this presentation. Demographic, clinical, and community-acquired pneumonia. Am J group with patients with CAP and laboratory data were the same in both groups. Med Sci. 2009; 337(4):236-240. radiographic infiltrates. 55% of patients with initially negative CXRs who had follow-up studies developed an infiltrate within 48 hours. 10. Wilson KC, Saukkonen JJ. Acute Review/Other- N/A To review acute respiratory failure from No results stated in abstract. 4 respiratory failure from abused Dx abused substances. substances. J Intensive Care Med. 2004; 19(4):183-193. 11. Mandell LA, Wunderink RG, Anzueto A, Review/Other- N/A Infectious Diseases Society of N/A 4 et al. Infectious Diseases Society of Dx America/American Thoracic Society America/American Thoracic Society consensus guidelines on the management of consensus guidelines on the management community-acquired pneumonia in adults. of community-acquired pneumonia in adults. Clin Infect Dis. 2007; 44 Suppl 2:S27-72. 12. Hayden GE, Wrenn KW. Chest Review/Other- 26 patients To determine, in an emergency department Of the 1,057 patients diagnosed with 4 radiograph vs. computed tomography scan Dx had either population, the incidence of pneumonia pneumonia, both CXR and CT were in the evaluation for pneumonia. J Emerg negative diagnosed on thoracic CT in the setting of performed in 97 cases. Of this group, there Med. 2009; 36(3):266-270. CXR or negative or nondiagnostic CXRs. were 26 patients (27%), in whom the CXR nondiagnosti was either negative or nondiagnostic, but the c CT noted an infiltrate/consolidation consistent with pneumonia. The authors find that in 27% of cases in which both a CXR and a CT scan were performed in the workup of varied chief complaints, pneumonia was demonstrated on CT in the face of a negative or nondiagnostic CXR. 13. Baber CE, Hedlund LW, Oddson TA, Review/Other- 13 patients To determine the value of CT in After CT, 8 patients were diagnosed as having 4 Putman CE. Differentiating empyemas Dx differentiating empyemas and peripheral abscesses and 5 as having empyemas. and peripheral pulmonary abscesses: the pulmonary abscesses. Abscesses had an irregular shape and a value of computed tomography. relatively thick wall which was not uniformly Radiology. 1980; 135(3):755-758. wide and did not have a discrete boundary between the lesion and lung parenchyma. In contrast, empyemas had a regularly shaped lumen, a smooth inner surface, and a sharply defined border between the lesion and lung. CT studies can help to distinguish between empyemas and abscesses, and treatment can be started sooner in difficult cases.
Reference Study Type Study Results Events (Purpose of Study) Quality 14. Ito I, Ishida T, Togashi K, et al. Observational- 181 patients To determine the potential of thin-section CT Among 183 CAP episodes (181 patients, 125 2 Differentiation of bacterial and non- Dx in differentiating bacterial and non-bacterial men and 56 women, mean age+/-S.D.: 61.1+/- bacterial community-acquired pneumonia pneumonia. 19.7) examined by thin-section CT, the by thin-section computed tomography. etiologies of 125 were confirmed (94 bacterial Eur J Radiol. 2009; 72(3):388-395. pneumonia and 31 non-bacterial pneumonia). Centrilobular nodules were specific for non- bacterial pneumonia and airspace nodules were specific for bacterial pneumonia (specificities of 89% and 94%, respectively) when located in the outer lung areas. When centrilobular nodules were the principal finding, they were specific but lacked sensitivity for non-bacterial pneumonia (specificity 98% and sensitivity 23%). To distinguish the two types of pneumonias, centrilobular nodules, airspace nodules and lobular shadows were found to be important by multivariate analyses. ROC curve analysis discriminated bacterial pneumonia from non- bacterial pneumonia among patients without underlying lung diseases, yielding an optimal point with sensitivity and specificity of 86% and 79%, respectively, but was less effective when all patients were analyzed together (70% and 84%, respectively). 15. Petheram IS, Kerr IH, Collins JV. Value Observational- 117 patients To assess the value of CXRs in determining 92 (70%) of the admission 3 of chest radiographs in severe acute Dx the frequency and importance of radiological radiographs were abnormal. Patients with asthma. Clin Radiol. 1981; 32(3):281-282. abnormalities in adults with severe acute radiographic signs of over-inflation had more asthma. severe pulsus paradoxus (P<0.01 X2), faster heart rates (P<0.025 X 2) and lower FEV1 (P<0.025 X2). Over-inflation was common and correlated significantly with tachycardia, pulsus paradoxus and decrease in FEV1. Bronchial wall thickening was common and prominence of hilar vessels was also noted in a few patients. CXR is strongly recommended in severe exacerbations of asthma and anteroposterior views are adequate for interpretation.
Reference Study Type Study Results Events (Purpose of Study) Quality 16. Findley LJ, Sahn SA. The value of chest Review/Other- 90 CXRs To determine the frequency of There was no significant correlation between 4 roentgenograms in acute asthma in adults. Dx roentgenographic abnormalities in adults with CXR interpretation and hospitalization. The Chest. 1981; 80(5):535-536. acute asthma seen in an emergency room and data show that the incidence of specific to assess its value in guiding management. abnormalities on CXR in adults with uncomplicated acute asthma is low and suggests that the information obtained from the roentgenogram is rarely helpful to outpatient management. CXRs probably are indicated only when there is clinical evidence of pneumonia, a complication of asthma, or a pulmonary disorder that mimics asthma. 17. White CS, Cole RP, Lubetsky HW, Austin Review/Other- 54 patients To review the impact of admission CXR on Major radiographic abnormalities were found 4 JH. Acute asthma. Admission chest Dx in-hospital management of patients with acute in 20 (34%) of 58 occasions. These radiography in hospitalized adult patients. asthma. abnormalities included focal parenchymal Chest. 1991; 100(1):14-16. opacities, increased interstitial markings, enlarged cardiac silhouette, pulmonary vascular congestion, new solitary pulmonary nodule and pneumothorax. Subsequent antibiotic use correlated with radiographic focal opacities or increased interstitial markings, even in afebrile patients, but did not correlate with elevated blood leukocyte count. Based on the evidence of in-hospital alteration of management independent of elevated blood leukocyte count and body temperature, the authors recommend that CXRs be obtained for all adult patients admitted because of acute asthma. 18. Sherman S, Skoney JA, Ravikrishnan KP. Review/Other- 242 patients To determine the value of routine CXRs in Routine admission CXRs were abnormal in 35 4 Routine chest radiographs in Dx patients with an acute exacerbation of chronic (14%) of 242 patients hospitalized with an exacerbations of chronic obstructive obstructive pulmonary disease. exacerbation of chronic obstructive pulmonary disease. Diagnostic value. Arch pulmonary disease and resulted in Intern Med. 1989; 149(11):2493-2496. management changes that were appropriate and clinically significant in only 11 cases (4.5%). The authors propose the following indications for admission CXRs in patients with an acute exacerbation of chronic obstructive pulmonary disease: white blood cell count above 15 x 10(9)/L and polymorphonuclear leukocyte count above 8 x 10(9)/L, history of congestive heart failure, history of coronary artery disease, chest pain, or edema. * See Last Page for Key 2013 Review Kirsch Page 7 ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompetent Patients EVIDENCE TABLE
Patients/ Study Objective Study
Reference Study Type Study Results Events (Purpose of Study) Quality 19. Okada F, Ando Y, Nakayama T, et al. Review/Other- 109 patients To assess the clinical and pulmonary thin- Among the 109 patients, 34 had community- 4 Pulmonary thin-section CT findings in Dx section CT findings in patients with acute M. acquired and 75 had nosocomial infections. acute Moraxella catarrhalis pulmonary catarrhalis pulmonary infection. Underlying diseases included pulmonary infection. Br J Radiol. 2011; emphysema (n=74), cardiovascular disease 84(1008):1109-1114. (n=44) or malignant disease (n=41). Abnormal findings were seen on CT scans in all patients and included ground-glass opacity (n=99), bronchial wall thickening (n=85) and centrilobular nodules (n=79). These abnormalities were predominantly seen in the peripheral lung parenchyma (n=99). Pleural effusion was found in 8 patients. No patients had mediastinal and/or hilar lymph node enlargement.
* See Last Page for Key 2013 Review Kirsch
Page 8 ACR Appropriateness Criteria®
Evidence Table Key Abbreviations Key
Study Quality Category Definitions CAP = Community acquired pneumonia Category 1 The study is well-designed and accounts for common biases. CI = Confidence interval Category 2 The study is moderately well-designed and accounts for most CT = Computed tomography common biases. CXR = Chest radiograph Category 3 There are important study design limitations. H1N1 = Influenza A virus Category 4 The study is not useful as primary evidence. The article may not be HRCT = High-resolution computed tomography a clinical study or the study design is invalid, or conclusions are based on expert consensus. For example: MDCT = Multidetector computed tomography a) the study does not meet the criteria for or is not a hypothesis-based clinical NPV = Negative predictive value study (e.g., a book chapter or case report or case series description); OR = Odds ratio b) the study may synthesize and draw conclusions about several studies such as a literature review article or book chapter but is not primary evidence; PPV = Positive predictive value c) the study is an expert opinion or consensus document. ROC = Receiver-operator characteristic SARS = Severe acute respiratory syndrome Dx = Diagnostic SD = Standard deviation Tx = Treatment S-OIV = Swine-origin influenza A