ACR Appropriateness Criteria®

Pneumonia in the Immunocompetent Child

EVIDENCE TABLE

Patients/ Study Objective

Reference Study Type Study Results Study Quality
Events (Purpose of Study)
1. World Health Organizaton. Review/Ot N/A No abstract available. No results stated in abstract. 4
Pneumonia. Available at: her-Dx
http://www.who.int/news-room/fact-
sheets/detail/pneumonia.
2. Wardlaw T, Salama P, Johansson EW, Review/Ot N/A No abstract available. No results stated in abstract. 4
Mason E. Pneumonia: the leading her-Dx
killer of children. Lancet.
368(9541):1048-50, 2006 Sep 23.
3. Bradley JS, Byington CL, Shah SS, et Review/Ot N/A To provide guidance in the care of No results stated in abstract 4
al. The management of community- her-Dx otherwise healthy infants and children and
acquired pneumonia in infants and addresses practical questions of diagnosis
children older than 3 months of age: and management of community-
clinical practice guidelines by the acquiredpneumonia (CAP) evaluated in
Pediatric Infectious Diseases Society outpatient (offices, urgent care clinics,
and the Infectious Diseases Society of emergency departments) or inpatient
America. Clin Infect Dis. 53(7):e25- settings in the United States.
76, 2011 Oct.
4. Harris M, Clark J, Coote N, et al. Review/Ot N/A To provide 2002 The British Thoracic No results stated in abstract 4
British Thoracic Society guidelines for her-Dx Society (BTS) management guidelines for
the management of community community acquired pneumonia (CAP) in
acquired pneumonia in children: children.
update 2011. Thorax. 66 Suppl 2:ii1-
23, 2011 Oct.
5. McIntosh K.. Community-acquired Review/Ot N/A No abstract in article. No results stated in abstract. 4
pneumonia in children. [Review] [83 her-Dx
refs]. N Engl J Med. 346(6):429-37,
2002 Feb 07.
6. le Roux DM, Zar HJ. Community- Review/Ot N/A To review the impact of recent No results stated in abstract 4
acquired pneumonia in children - a her-Dx preventative and management advances in
changing spectrum of disease. pneumonia epidemiology, etiology,
[Review][Erratum appears in Pediatr radiologic presentation and outcome in
Radiol. 2017 Dec;47(13):1855; PMID: children.
29110044]. Pediatr Radiol.
47(11):1392-1398, 2017 Oct.

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Reference
7. Bruns AH, Oosterheert JJ, El
Moussaoui R, Opmeer BC,
Hoepelman AI, Prins JM. Pneumonia
recovery: discrepancies in perspectives
of the radiologist, physician and
patient. J Gen Intern Med. 25(3):203-
6, 2010 Mar.
8. American College of Radiology. ACR
Appropriateness Criteria®: Fever
Without Source or Unknown
Origin—Child. Available at:
https://acsearch.acr.org/docs/69438/Na
rrative/.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 119 To compare the radiographic resolution of Radiographic resolution, clinical cure and 2
nal-Dx Patients mild to moderately severe community- normalization of the CAP score were
acquired pneumonia (CAP) to resolution of observed in 30.8%, 93% and 32% of
clinical symptoms as assessed by the patients at day 10, and in 68.4%, 88.9%
physician or rated by the patient. and 41.7% at day 28, respectively. More
severe CAP (PSI score >90) was
independently associated with delayed
radiographic resolution at day 28 (OR 4.7,
95% CI 1.3-16.9). All 12 patients with
deterioration of radiographic findings
during follow-up had clinical evidence of
treatment failure.
Review/Ot N/A Evidence-based guidelines to assist No abstract available. 4
her-Dx referring physicians and other providers in
making the most appropriate imaging or
treatment decision for fever without source
or unknown origin-child.
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Reference
9. Jain S, Williams DJ, Arnold SR, et al.
Community-acquired pneumonia
requiring hospitalization among U.S.
children. N Engl J Med. 372(9):835-
45, 2015 Feb 26.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot 2638 To conduct an active population-based From January 2010 through June 2012, we 4
her-Dx children surveillance for community-acquired enrolled 2638 of 3803 eligible children
pneumonia requiring hospitalization (69%), 2358 of whom (89%) had
among children <18 years in three radiographic evidence of pneumonia. The
hospitals in Memphis, Nashville and Salt median age of the children was 2 years
Lake City. (interquartile range, 1 to 6); 497 of 2358
children (21%) required intensive care, and
3 (<1%) died. Among 2222 children with
radiographic evidence of pneumonia and
with specimens available for bacterial and
viral testing, a viral or bacterial pathogen
was detected in 1802 (81%), one or more
viruses in 1472 (66%), bacteria in 175
(8%), and both bacterial and viral
pathogens in 155 (7%). The annual
incidence of pneumonia was 15.7 cases per
10,000 children (95% confidence interval
[CI], 14.9 to 16.5), with the highest rate
among children younger than 2 years of
age (62.2 cases per 10,000 children; 95%
CI, 57.6 to 67.1). Respiratory syncytial
virus was more common among children
younger than 5 years of age than among
older children (37% vs. 8%), as were
adenovirus (15% vs. 3%) and human
metapneumovirus (15% vs. 8%).
Mycoplasma pneumoniae was more
common among children 5 years of age or
older than among younger children (19%
vs. 3%).
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Reference
10. Cakir Edis E, Hatipoglu ON, Yilmam
I, Eker A, Tansel O, Sut N. Hospital-
acquired pneumonia developed in non-
intensive care units. Respiration.
78(4):416-22, 2009.
11. Chang I, Schibler A. Ventilator
Associated Pneumonia in Children.
[Review]. Paediatr Respir Rev. 20:10-
16, 2016 Sep.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot 154 adult To determine the incidence rate of non- During the study, and not counting those in 4
her-Dx patients ICU HAP, the risk factors associated with the ICU, 45,679 adult patients were
mortality and the survival rates of hospital- hospitalized. Of these, 154 patients
acquired pneumonia (HAP) patients at 6 developed HAP (incidence 3.3cases/1,000
weeks and 1 year. patients). The mean age of those
developing HAP was 64.53 8 14.92 years
(range 15–98). Survival rates at the 3rd,
7th, 14th, 42nd and 365th day were 91, 89,
69, 49 and 29%, respectively. Independent
risk factors associated with 6-week
mortality were: age [relative risk (RR)
1.026; 95% confidence interval (CI)
1.008–1.045], chronic renal failure (RR
1.8; 95% CI 1.087–3.086), aspiration risk
(RR 2.86; 95% CI 1.249–6.564), steroid
use (RR 2.35; 95% CI 1.306–4.257),
andmultilobar infiltration (RR 2.1; 95% CI
1.102–4.113).
Review/Ot N/A To explore the issues surrounding the No results stated in abstract 4
her-Dx definition of Ventilator
Associated Pneumonia (VAP) including
recommendations on how to address the
problem and how to measure success in the
reduction of VAP in your own institution
using strategic guidelines.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE

Patients/ Study Objective

Reference
12. Darby JB, Singh A, Quinonez R.
Management of Complicated
Pneumonia in Childhood: A Review of
Recent Literature. Rev Recent Clin
Trials. 12(4):253-259, 2017.
13. Andronikou S, Goussard P, Sorantin
E. Computed tomography in children
with community-acquired pneumonia.
[Review]. Pediatr Radiol.
47(11):1431-1440, 2017 Oct.
Study Type
Events (Purpose of Study)
Review/Ot N/A To review recently published literature to
her-Tx inform clinician about the most up to date
management of complicated pneumonia in
children.
Review/Ot N/A To outline the situations where CT needs
her-Dx to be considered in community-acquired
pneumonia, describe the imaging features
of the parenchymal and pleural
complications, discuss how CT may have a
larger role to play in developing countries
where HIV and tuberculosis are prevalent,
note the role of CT scanning whenthere is a
possibility of foreign body aspiration and
address radiation concerns.
Study Results Study Quality
Narrow spectrum antibiotics including 4
ampicillin and azithromycin remain
important first line agents, but directed
therapy towards causative pathogens is the
ideal standard practice. Novel DNA
isolation technologies hold promise for
raising the diagnostic yield of pleural fluid.
Surgical interventions are often required
and new literature further supports the use
of fibrinolytics and minimally invasive
chest tube thoracostomy. Not to be
overlooked is the importance of supportive
measuresincluding oxygen therapy and
adequate fluid, electrolyte and nutrition
support. The use of other adjunctive
therapies such as steroids in pediatric
complicated pneumonia remains
controversial.
No results stated in abstract 4

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Reference
14. Byington CL, Spencer LY, Johnson
TA, et al. An epidemiological
investigation of a sustained high rate
of pediatric parapneumonic empyema:
risk factors and microbiological
associations. Clin Infect Dis.
34(4):434-40, 2002 Feb 15.
15. Dorman RM, Vali K, Rothstein DH.
Trends in treatment of infectious
parapneumonic effusions in U.S.
children's hospitals, 2004-2014. J
Pediatr Surg. 51(6):885-90, 2016 Jun.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 540 To examine the increasing incidence of Of 540 children hospitalized with 2
nal-Dx Children paediatric empyema during the 1990s at community-acquired bacterial pneumonia
Primary Children's Medical Center in Salt (CAP) who were discharged from 1 July
Lake City, Utah, USA 1993 through 1 July 1999, 153 (28.3%)
had empyema. The annual population
incidence of empyema increased during the
study period from 1 to 5 cases per 100 000
population aged <19 years. Streptococcus
pneumoniae was identified as the most
common cause of CAP with or without
empyema; serotype 1 accounted for 50% of
the cases of pneumococcal empyema.
Patients with empyema were more likely to
be >3 years old, to have =7 days of fever,
to have varicella, and to have received
antibiotics and ibuprofen before admission
to the hospital, compared with patients
without empyema (P<0.0001 for each
factor). The increasing incidence of
empyema was associated with infection
due to S. pneumoniae serotype 1,
outpatient treatment with certain
antibiotics, ibuprofen use, and varicella.
Observatio 5569 To examine trends in the treatment of 5569 patientswere included in the final 3
nal-Dx patients patients with infectious parapneumonic analysis. The proportion of patients
effusions in U.S. children's hospitals over treatedwith antibiotics alone increased
the past decade. from 62% to 74% from 2004 to 2014 (p <
0.001). Among patients requiring pleural
space drainage, the frequency of VATS
peaked in 2009 (50.8%), dropping to
36.4% in 2014 (p < 0.001),while tube
thoracostomy, usually with fibrinolytics,
rose from 39.0% in 2009 to 53.2% in 2014
(p < 0.001).
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Reference
16. James CA, Braswell LE, Pezeshkmehr
AH, Roberson PK, Parks JA, Moore
MB. Stratifying fibrinolytic dosing in
pediatric parapneumonic effusion
based on ultrasound grade correlation.
Pediatr Radiol. 47(1):89-95, 2017 Jan.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 32 patients To evaluate experience with lower Of 32 patients with parapneumonic 3
nal-Dx fibrinolytic dose for parapneumonic effusion, all except one received at least
effusions and to assess potential dose some 1-mg tPA doses. Dosing was solely
stratification based on a simple ultrasound 1-mg tPA in 81% of subjects; 19% of
grading system. subjects also received 2-mg tPA doses.
Mean fibrinolytic duration was 3.1 days for
grade 1 effusions compared to 5.4 days for
grade 2 effusions. A second pleural
procedure was required in 15.6% of
children. Pleural drainage with fibrinolytic
therapy was successful in 97%; only one
child required surgical drainage. Grade 2
US differed significantly from grade 1 US,
with grade 2 occurring in younger patients
(P< 0.0001), smaller patients (P < 0.0001),
those needing a second procedure (P=
0.001), those with positive pleural culture
or polymerase chain reaction test (P=
0.006), and those with longer treatment
duration (P=0.03).
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Reference
17. Lai JY, Yang W, Ming YC. Surgical
Management of Complicated
Necrotizing Pneumonia in Children.
Pediatr neonatol. 58(4):321-327, 2017
Aug.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 56 patients To report the outcomes of surgery for Thirty-one cases were uncomplicated and 2
nal-Tx necrotizing pneumonia (NP) in a single 25 were complicated. Operative procedures
institution. included 38 decortications (31
uncomplicated and seven complicated), 14
wedge resections, and four lobectomies
(complicated only). Preoperatively,
patients with complicated necrotizing
pneumonia had a higher incidence of
pneumothorax (32% vs. 14.3%; p = 0.001),
endotracheal intubation (44% vs. 9.7%; p =
0.008), and hemolytic uremic syndrome
(20% vs. 3.2%; p = 0.01). These patients
also had higher incidences of
intraoperative transfusion (68% vs. 9.7%; p
= 0.03), major postoperative complications
(16% vs. 0%; p = 0.02), reoperations(16%
vs. 0%; p = 0.02), and longer postoperative
stay (19.8 +- 24.2 days vs. 11.2 +- 5.8
days; p = 0.03). Four complicated patients,
who initially had decortications and limited
resections, underwent reoperations.
Compared with uncomplicated patients,
those who underwent decortications and
wedge resection required longer
postoperative stays (23.6 +- 9.9 days, p <
0.01 and 21.1 += 30.7 days, p = 0.04,
respectively), whereas patients who had
lobectomy had a similar duration of
recovery (9.0 +- 2.1 days, p = 0.23). All
patients improved significantly at follow-
up.
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Reference
18. Redden MD, Chin TY, van Driel ML.
Surgical versus non-surgical
management for pleural empyema.
[Review]. Cochrane Database Syst
Rev. 3:CD010651, 2017 Mar 17.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot 8 RCT, 391 To assess the effectiveness and safety of There was no difference in the proportion 4
her-Tx participants surgical versus non-surgical treatments for of patients of all ages who survived
complicated parapneumonic effusion or empyema in relation to surgical or non-
pleuralempyema. surgical treatment.However, this finding
was based on limited data: one study
reported one death with each treatment
option, and seven studies reportedno
deaths. There was no difference in rates of
complications between patients treated
with surgical or non-surgical options.There
was limited evidence to suggest that VATS
reduced length of stay in hospital
compared to non-surgical treatments.
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Reference
19. Hodina M, Hanquinet S, Cotting J,
Schnyder P, Gudinchet F. Imaging of
cavitary necrosis in complicated
childhood pneumonia. Eur Radiol.
12(2):391-6, 2002 Feb.
20. Montella S, Corcione A, Santamaria F.
Recurrent Pneumonia in Children: A
Reasoned Diagnostic Approach and a
Single Centre Experience. [Review].
Int. j. mol. sci.. 18(2), 2017 Jan 29.
21. Brand PL, Hoving MF, de Groot EP.
Evaluating the child with recurrent
lower respiratory tract infections.
[Review]. Paediatr Respir Rev.
13(3):135-8, 2012 Sep.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot 9 patients To illustrate the chest radiographs (CR) Chest radiographs showed consolidations 4
her-Dx and CT imaging features and sequential in 8 of the 9 patients. On CT examination,
findings of cavitary necrosis in cavitary necrosis was localized to 1 lobe in
complicated childhood pneumonia. 2 patients and 7 patients showed multilobar
or bilateral areas of cavitary necrosis. In 3
patients of 9, the cavitary necrosis was
initially shown on CT and visualization by
CR was delayed by a time span varying
from 5 to 9 days. In all patients with
cavities, a mean number of five cavities
were seen on antero-posterior CR,
contrasting with the multiple cavities seen
on CT. Parapneumonic effusions were
shown by CR in 3 patients and in 5 patients
by CT. Bronchopleural fistulae were
demonstrated by CT alone ( n=3). No
purulent pericarditis was demonstrated.
The CT scan displayed persistent residual
pneumatoceles of the left lower lobe in 2
patients. Computed tomography is able to
define a more specific pattern of
abnormalities than conventional CR in
children with necrotizing pneumonia and
allows an earlier diagnosis of this rapidly
progressing condition. Lung necrosis and
cavitation may also be associated with
Aspergillus or Legionella pneumonia in the
pediatric population.
Review/Ot N/A To discuss a reasoned diagnostic approach No results stated in abstract 4
her-Dx to recurrent pneumonia (RP) in childhood.
Review/Ot N/A To discuss the approach to diagnosis and No results stated in abstract 4
her-Dx management of children presenting with
recurrent lower respiratory tract infections
from a clinician’spoint of view.
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Reference
22. American College of Radiology.
ACR–NASCI–SIR–SPR Practice
Parameter for the Performance and
Interpretation of Body Computed
Tomography Angiography (CTA).
Available at: https://www.acr.org/-
/media/ACR/Files/Practice-
Parameters/body-cta.pdf.
23. Cao AM, Choy JP, Mohanakrishnan
LN, Bain RF, van Driel ML. Chest
radiographs for acute lower respiratory
tract infections. [Review]. Cochrane
Database Syst Rev. (12)CD009119,
2013 Dec 26.
24. Andronikou S, Lambert E, Halton J, et
al. Guidelines for the use of chest
radiographs in community-acquired
pneumonia in children and
adolescents. [Review]. Pediatr Radiol.
47(11):1405-1411, 2017 Oct.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot N/A Guidance document to promote the safe No abstract available. 4
her-Dx and effective use of diagnostic and
therapeutic radiology by describing
specific training, skills and techniques.
Review/Ot 2024 To assess the effectiveness of chest Two RCTs involving 2024 patients (1502 4
her-Tx patients, 2 radiographs in addition to clinical adults and 522 children) were included in
RCTs judgement, compared to clinical judgement this review. Both RCTs excluded patients
alone, in themanagement of acute LRTIs in with suspected severe disease. It was not
children and adults. possible to pool the results due to
incomplete data. Both included trials
concluded that the use of chest radiographs
did not result in a better clinical outcome
(duration of illness and of symptoms) for
patients with acute LRTIs. In the study
involving children in South Africa, the
median time to recovery was seven days
(95% confidence interval (CI) six to eight
days (radiograph group) and six to nine
days (control group)), P value = 0.50, log-
rank test) and the hazard ratio for recovery
was 1.08 (95% CI 0.85 to 1.34). In the
study with adult participants in the USA,
the average duration of illness was 16.9
days versus 17.0 days (P value > 0.05) in
the radiograph and no radiograph groups
respectively. This result was not
statistically significant and there were no
significant differences in patient outcomes
between the groups with or without chest
radiograph.
Review/Ot N/A To discuss current perspectives on No results stated in abstract 4
her-Dx paediatric chest radiograph referral practice
and radiographic findings in children with
suspected community-acquiredpneumonia
in different clinical settings.
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Reference
25. Pereda MA, Chavez MA, Hooper-
Miele CC, et al. Lung ultrasound for
the diagnosis of pneumonia in
children: a meta-analysis. [Review].
Pediatrics. 135(4):714-22, 2015 Apr.
26. Stadler JAM, Andronikou S, Zar HJ.
Lung ultrasound for the diagnosis of
community-acquired pneumonia in
children. [Review]. Pediatr Radiol.
47(11):1412-1419, 2017 Oct.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Meta- 8 studies To summarize evidence on the diagnostic Five studies (63%) reported using highly Good
analysis accuracy of lung ultrasound (LUS) for skilled sonographers. Overall
childhood pneumonia. methodologic quality was high, but
heterogeneity was observed across studies.
LUS had a sensitivity of 96% (95%
confidence interval [CI]: 94%–97%) and
specificity of 93% (95% CI: 90%–96%),
and positive and negative likelihood ratios
were 15.3 (95% CI: 6.6–35.3) and 0.06
(95% CI: 0.03–0.11), respectively. The
area under the receiver operating
characteristic curve was 0.98. Limitations
included the following: most studies
included in our analysis had a low number
of patients, and the number of eligible
studies was also small.
Review/Ot N/A To give an overview of the equipment and No results stated in abstract 4
her-Dx techniques used to perform lung
Ultrasound (US) in children with suspected
pneumonia and the interpretation of
relevant sonographic findings
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Reference
27. Xin H, Li J, Hu HY. Is Lung
Ultrasound Useful for Diagnosing
Pneumonia in Children?: A Meta-
Analysis and Systematic Review.
Ultrasound Quarterly. 34(1):3-10,
2018 Mar.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Meta- 51 articles To summarize the diagnostic usefulness of Our search identified 1038 articles, and we Good
analysis Lung ultrasonography (LUS) for childhood selected 51 of these for detailed review.
pneumonia Eight studies containing 1013 patients met
all the inclusion criteria and were included
in the final meta-analysis. The pooled
sensitivity and specificity for the diagnosis
of pneumonia using LUS were 93.0%
(95% confidence interval, 88.0%–96.0%)
and 96.0% (95% confidence interval,
92.0%–98.0%), respectively. The pooled
positive likelihood ratio, negative
likelihood ratio, and diagnostic odds ratio
were 25.8 (11.0, 60.4), 0.07 (0.05, 0.12),
and 344 (104, 1140), respectively. In
addition, the summary receiver operating
characteristic area under the curve was
calculated to be 0.98 (0.97, 0.99). A Fagan
plot analysis demonstrated that when
pretest probabilities were 25%, 50%, and
75%, the positive posttest probabilities
were 90%, 96%, and 99%, respectively,
and the negative posttest probabilities were
2%, 7%, and 18%, respectively. Four
clinical signs were most
frequentlyobserved using LUS in the
screening of children with pneumonia:
pulmonary consolidation, positive air
bronchogram, abnormal pleural line, and
pleural effusion.
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Reference
28. Zhan C, Grundtvig N, Klug BH.
Performance of Bedside Lung
Ultrasound by a Pediatric Resident: A
Useful Diagnostic Tool in Children
With Suspected Pneumonia. Pediatric
Emergency Care. 2016 Oct 04.
29. Jones BP, Tay ET, Elikashvili I, et al.
Feasibility and Safety of Substituting
Lung Ultrasonography for Chest
Radiography When Diagnosing
Pneumonia in Children: A
Randomized Controlled Trial. Chest.
150(1):131-8, 2016 Jul.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 82 children To investigate how beside lung ultrasound A total of 82 children underwent both chest 3
nal-Dx performed by a pediatric resident radiography and lung ultrasound (57%
compared with chest radiography in boys; median [interquartile range] age, 1.5
children with suspected pneumonia. [1.1-2.5] years). The lung ultrasound took
7 to 20 minutes to perform, and 10% were
of suboptimal quality due to an uneasy
child. The prevalence of consolidations by
chest radiography was 50%. Lung
ultrasound had a sensitivity of 40% (95%
confidence interval [CI], 30%-51%),
specificity of 91% (95% CI, 83%-96%),
positive likelihood ratio of 4.71 (95% CI,
2.21-10.04), and negative likelihood ratio
of 0.65 (95% CI, 0.54-0.79).
Observatio 191 To determine the feasibility and safety of There was a 38.8% reduction (95% CI, 1
nal-Tx patients substituting Lung ultrasonography (LUS) 30.0%-48.9%) in CXR among
for Chest radiography (CXR) when investigational subjects compared with no
evaluating children suspected of having reduction (95% CI, 0.0%-3.6%) in the
pneumonia. control group. Novice and experienced
physician-sonologists achieved 30.0% and
60.6% reduction in CXR use, respectively.
There were no cases of missed pneumonia
among all study participants
(investigational arm, 0.0%: 95% CI, 0.0%-
2.9%; control arm, 0.0%: 95% CI, 0.0%-
3.0%), or differences in adverse events, or
subsequent unscheduled health-care visits
between arms.
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Reference
30. Soudack M, Plotkin S, Ben-Shlush A,
et al. The Added Value of the Lateral
Chest Radiograph for Diagnosing
Community Acquired Pneumonia in
the Pediatric Emergency Department.
Isr Med Assoc J 2018;20:5-8.
31. Islam S, Calkins CM, Goldin AB, et
al. The diagnosis and management of
empyema in children: a
comprehensive review from the APSA
Outcomes and Clinical Trials
Committee. [Review]. J Pediatr Surg.
47(11):2101-10, 2012 Nov.
32. King S, Thomson A. Radiological
perspectives in empyema. [Review]
[35 refs]. Br Med Bull. 61:203-14,
2002.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 451 To determine the value of the frontal and Findings consistent with bacterial 3
nal-Dx children lateral chest radiographs compared to pneumonia were diagnosed in 94 (20.8%)
frontal view stand-alone images for the of the frontal stand-alone radiographs and
management of children with suspected in 109 (24.2%) of the combined frontal and
community acquired pneumonia seen in a lateral radiographs. The sensitivity,
pediatric emergency department. specificity, positive predictive value, and
negative predictive value of the frontal
radiograph alone were 86.2%, 93.9%,
81.7%, and 95.5%, respectively. False
positive and false negative rates were 15%
and 21%, respectively, for the frontal view
alone. The number of lateral radiographs
needed to diagnose one community
acquired pneumonia was 29.
Review/Ot N/A To review the current evidence on the No results stated in abstract 4
her-Dx diagnosis and management of empyema.
Review/Ot N/A To summarize the imaging investigations No results stated in abstract. 4
her-Dx in children with empyema, provide an
overview of the risks and benefits of these
techniques, and discuss the appearances of
empyema on imaging studies.
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Reference
33. Lichtenstein D, Goldstein I, Mourgeon
E, Cluzel P, Grenier P, Rouby JJ.
Comparative diagnostic performances
of auscultation, chest radiography, and
lung ultrasonography in acute
respiratory distress syndrome.
Anesthesiology. 100(1):9-15, 2004
Jan.
34. Calder A, Owens CM. Imaging of
parapneumonic pleural effusions and
empyema in children. [Review] [28
refs]. Pediatr Radiol. 39(6):527-37,
2009 Jun.
35. Donnelly LF, Klosterman LA. The
yield of CT of children who have
complicated pneumonia and
noncontributory chest radiography.
AJR Am J Roentgenol. 170(6):1627-
31, 1998 Jun.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 32 patients To assess whether lung ultrasonography Auscultation had a diagnostic accuracy of 2
nal-Dx could be an alternative to bedside chest 61% for pleural effusion, 36% for alveolar
radiography for assessing the presence and consolidation, and 55% for
extent of alveolar consolidation, alveolar–interstitial syndrome. Bedside
alveolar–interstitial syndrome, and pleural chest radiography had a diagnostic
effusion in ventilated patients with acute accuracy of 47% for pleural effusion, 75%
respiratory distress syndrome (ARDS). for alveolar consolidation, and 72% for
alveolar–interstitial syndrome. Lung
ultrasonography had a diagnostic accuracy
of 93% for pleural effusion, 97% for
alveolar consolidation, and 95% for
alveolar–interstitial syndrome. Lung
ultrasonography, in contrast to auscultation
and chest radiography, could quantify the
extent of lung injury. Interobserver
agreement for the ultrasound findings as
assessed by the ? statistic was satisfactory:
0.74, 0.77, and 0.73 for detection of
alveolar–interstitial syndrome, alveolar
consolidation, and pleural effusion,
respectively.
Review/Ot N/A To review the pathophysiology, treatment No results stated in abstract. 4
her-Dx options and imaging findings of
complicated parapneumonic effusion and
empyema in children.
Observatio 56 CT To investigate the usefulness of CT in One hundred ten CT findings, not revealed 4
nal-Dx scans and evaluating children who donot respond by radiography, were seen on 56 CTscans
radiographs appropriately to treatment for pneumonia, (2.0 per CT scan): parenchymal
when chest radiography is noncontributory. complications (n = 40), pleural
complications (n = 37),
inaccurateestimation of cause of chest
opacity on radiography (n = 20),
pericardial effusion (n =13). All CT scans
showed at least one significant finding
(100% yield) not seen on radiography.
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ACR Appropriateness Criteria®
Reference
36. Pinotti KF, Ribeiro SM, Cataneo AJ.
Thorax ultrasound in the management
of pediatric pneumonias complicated
with empyema. Pediatr Surg Int.
22(10):775-8, 2006 Oct.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 52 children To prospectively study the value of From August 2001 to July 2003, 52 2
nal-Dx thoracic ultrasound (US) before pleural children were examined. US was
drainage in children with parapneumonic performed on 48 of these children, of
effusion (PPE). whom 35 received chest tube drainageand
13 only received clinical treatment. US
identified 38 patients with free flowing and
10 with loculated pleural fluid. About 25 of
the free flowing(65.8%) and 10 (100%) of
the loculated patients received chest tube
drainage. Echogenicity was anechoic in 13,
echoic without septations in 17 and
echoicwith septations in 18. Chest tube
drainage was required in 6 anechoic
(46.15%), 14 echoic without septations
(82.35%), and 15 echoic with septations
(83.33%).Quantity of fluid estimated by
US varied from 20 to 860 ml. Effusion
volume was higher in patients that were
echoic with septations and loculated
effusions.Pleural glucose and pH were
lower, and LDH was higher in loculated
PPE patients.
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ACR Appropriateness Criteria®
Reference
37. Donnelly LF, Klosterman LA. CT
appearance of parapneumonic
effusions in children: findings are not
specific for empyema. AJR Am J
Roentgenol. 169(1):179-82, 1997 Jul.
38. Chen IC, Lin MY, Liu YC, et al. The
role of transthoracic ultrasonography
in predicting the outcome of
community-acquired pneumonia in
hospitalized children. PLoS ONE.
12(3):e0173343, 2017.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 30 patients To compare the CT findings of Thirty patients were identified as having a 3
nal-Dx (14 boys, paraneumonic effusions with the results of paraneumonic pleural effusion revealed on
16 girls) thoracentesis, thoracscopy, or both to contrast-enhanced CT scans and by pleural
determine whether these CT findings can fluid analysis. Twenty-one of these
reliably differentiate empyemas from parapneumonic effusions met the clinical
transudative paraneumonic effusions in criteria for empyema, and nine were
children. considered not to be empyemas. Neither
any individual CT finding nor the CT score
accurately differentiated empyema from
transudative paraneumonic effusions (p>
.1): pleural enhancement (empyema 100%,
transudative effusion 89%), pleural
thickening (empyema 57%, transudative
effusion 56%), abnormal extrapleural
space (empyema 66%, transudative
effusion 67%), extracostal chest wall
edema (empyema 33%, transudative
effusion 56%), and average CT score
(empyema 2.5, transudative effusion 2.3).
Observatio 142 To assess the association between The study enrolled 142 patients (median 3
nal-Dx patients transthoracic ultrasound (TUS) findings age, 60 months): 28 (19.7%) required ICU
and clinical outcome in children with admission, 14 (9.89%) underwent tube
community-acquired pneumonia (CAP). thoracotomy, and 26 (18.3%) had a
hospital stay > 9 days. Multifocal
involvement seen by TUS were
independently associated with ICU
admission, a prolonged hospital stay, and
tube thoracotomy (p = 0.0027, p = 0.02,
and p = 0.0262, respectively). A pleural
effusion and fluid bronchogram were
independent predictors of a longer hospital
stay (p = 0.003 and p = 0.006,
respectively). In addition, a fluid
bronchogram was an independent predictor
of tube thoracotomy (p = 0.0262).
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Reference
39. Kurian J, Levin TL, Han BK, Taragin
BH, Weinstein S. Comparison of
ultrasound and CT in the evaluation of
pneumonia complicated by
parapneumonic effusion in children.
AJR Am J Roentgenol. 193(6):1648-
54, 2009 Dec.
40. Gorkem SB, Coskun A, Yikilmaz A,
Zurakowski D, Mulkern RV, Lee EY.
Evaluation of pediatric thoracic
disorders: comparison of unenhanced
fast-imaging-sequence 1.5-T MRI and
contrast-enhanced MDCT. AJR Am J
Roentgenol. 200(6):1352-7, 2013 Jun.
41. Liszewski MC, Gorkem S, Sodhi KS,
Lee EY. Lung magnetic resonance
imaging for pneumonia in children.
[Review]. Pediatr Radiol.
47(11):1420-1430, 2017 Oct.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 19 children To compare chest ultrasound and chest CT Eighteen of 19 patients had an effusion on 3
nal-Dx in children with complicated pneumonia both chest ultrasound and chest CT. The
and parapneumonic effusion. findings of effusion loculation as well as
parenchymal consolidation and necrosis or
abscess were similar between the two
techniques. Chest ultrasound was better
able to visualize fibrin strands within the
effusions. Of the 14 patients who
underwent video-assisted thoracoscopy,
five had surgically proven parenchymal
abscess or necrosis. Preoperatively, chest
ultrasound was able to show parenchymal
abscess or necrosis in four patients,
whereas chest CT was able to show
parenchymal abscess or necrosis in three.
Observatio 71 To investigate the efficacy of thoracic MRI With MDCT as the reference standard, 51 2
nal-Dx pediatric with fast imaging sequences without of 71 (72%) patients had abnormal findings
patients contrast administration at 1.5 T for on MDCT studies, including infections in
evaluating thoracic abnormalities by 21 (42%) cases, neoplasms in 19 (37%)
comparing MRI findings with contrast- cases, interstitial lung disease in seven
enhanced MDCT findings. (14%) cases, pleural effusion in three (6%)
cases, and congenital bronchogenic cyst in
one (2%) case. The overall diagnostic
accuracy, sensitivity, and specificity of
MRI for detecting thoracic abnormalities
were 69 of 71 (97%), 49 of 51 (96%), and
20 of 20 (100%). Two undiagnosed
findings with MRI that were detected with
MDCT were mild bronchiectasis and small
pulmonary nodule (3 mm). Almost perfect
interobserver agreement was found
between two reviewers with 70 of 71
agreements (? = 0.97; 95% CI, 0.92–1.00;
p < 0.001).
Review/Ot N/A To provide up-to-date MR imaging No results stated in abstract 4
her-Dx techniques that can be implemented in
most radiology departments to evaluate
pneumonia in children.
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EVIDENCE TABLE

Patients/ Study Objective

Reference
42. Sodhi KS, Khandelwal N, Saxena AK,
et al. Rapid lung MRI in children with
pulmonary infections: Time to change
our diagnostic algorithms. Journal of
Magnetic Resonance Imaging.
43(5):1196-206, 2016 May.
43. Yikilmaz A, Koc A, Coskun A, Ozturk
MK, Mulkern RV, Lee EY. Evaluation
of pneumonia in children: comparison
of MRI with fast imaging sequences at
1.5T with chest radiographs. Acta
Radiol. 2011;52(8):914-919.
44. Peltola V, Ruuskanen O, Svedstrom E.
Magnetic resonance imaging of lung
infections in children. Pediatr Radiol.
2008;38(11):1225-1231.
45. Seo H, Kim TJ, Jin KN, Lee KW.
Multi-detector row computed
tomographic evaluation of
bronchopleural fistula: correlation
with clinical, bronchoscopic, and
surgical findings. J Comput Assist
Tomogr. 34(1):13-8, 2010 Jan.
Study Type
Events (Purpose of Study)
Experiment 75 patients To determine the diagnostic utility of a
al-Dx new rapid MRI protocol, as compared with
computed tomography (CT) for the
detection of various pulmonary and
mediastinal abnormalities in children with
suspected pulmonary infections.
Observatio 40 patients To investigate the efficacy of chest MRI
nal-Dx with fast imaging sequences at 1.5T for
evaluating pneumonia in children by
comparing MRI findings with those of
chest radiographs.
Review/Ot N/A To illustrate MRI findings in children with
her-Dx pneumonia caused by Mycoplasma
pneumoniae, Streptococcus pneumoniae,
and other pathogens.
Review/Ot 24 patients To evaluate the usefulness of multi-
her-Dx detector row computed tomography (CT)
in the diagnosis of bronchopleural fistula
(BPF) and to correlate CT features with
clinical, bronchoscopic, and surgical
findings.
Study Results Study Quality
MRI with a new rapid MRI protocol 2
demonstrated sensitivity, specificity, PPV,
and NPV of 100% for detecting pulmonary
consolidation, nodules (>3 mm),
cyst/cavity, hyperinflation, pleural
effusion, and lymph nodes. The kappa-test
showed almost perfect agreement between
MRI and multidetector CT (MDCT) in
detecting thoracic abnormalities (k = 0.9).
No statistically significant difference was
observed between MRI and MDCT for
detecting thoracic abnormalities by the
McNemar test (P = 0.125).
All consolidation, lung necrosis/abscess, 3
bronchiectasis, and pleural effusion
detected with chest radiographs were also
detected with MRI. There was statistically
substantial agreement between chest
radiographs and MRI in detecting
consolidation (k = 0.78) and bronchiectasis
(k = 0.72) in children with pneumonia. The
agreement between chest radiographs and
MRI was moderate for detecting
necrosis/abscess (k = 0.49) and fair for
detecting pleural effusion (k = 0.30).
No results stated in abstract. 4
Computed tomography demonstrated 4
fistulous tract (central type, 3; peripheral
type, 11) or indirect signs of BPF (central
type, 3; peripheral type, 6), whereas
bronchoscopy demonstrated 2 fistula
openings (all central type) and indirect
signs of BPF (central type, 2; peripheral
type, 1).

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EVIDENCE TABLE

Patients/ Study Objective

Reference
46. Ramgopal S, Ivan Y, Medsinge A,
Saladino RA. Pediatric Necrotizing
Pneumonia: A Case Report and
Review of the Literature. [Review].
Pediatr Emerg Care. 33(2):112-115,
2017 Feb.
47. Lai SH, Wong KS, Liao SL. Value of
Lung Ultrasonography in the
Diagnosis and Outcome Prediction of
Pediatric Community-Acquired
Pneumonia with Necrotizing Change.
PLoS ONE. 10(6):e0130082, 2015.
48. Nair A, Godoy MC, Holden EL, et al.
Multidetector CT and postprocessing
in planning and assisting in minimally
invasive bronchoscopic airway
interventions. [Review].
Radiographics. 32(5):E201-32, 2012
Sep-Oct.
Study Type
Events (Purpose of Study)
Review/Ot 1 case To review the literature and describe the
her-Dx report clinical presentation, diagnosis,
microbiological etiology, and management
of necrotizing pneumonia in children.
Observatio 236 To investigate the value of lung
nal-Dx children ultrasonography in diagnosing pediatric
necrotizing pneumonia and its role in
predicting clinical outcomes.
Review/Ot N/A To review existing and novel
her-Dx bronchoscopic techniques and highlight
pertinent multidetector CT and
postprocessing techniques that enhance the
evaluation, planning, and monitoring of
such procedures for various
tracheobronchial, peripheral airway, and
parenchymal conditions.
Study Results Study Quality
No results stated in abstract 4
Our results showed a high correlation 2
between the degree of impaired perfusion
in ultrasonography and the severity of
necrosis in computed tomography (r =
0.704). The degree of impaired perfusion
can favorably be used to predict massive
necrosis in computed tomography (area
under the receiver operating characteristic
curve, 0.908). The characteristics of
impaired perfusion and hypoechoic lesions
in ultrasonography were associated with an
increasedrisk of pneumatocele formation
(odds ratio (OR), 10.11; 95% CI,
2.95–34.64) and the subsequent
requirement for surgical lung resection
(OR, 8.28; 95% CI, 1.86–36.93).
Furthermore, a longer hospital stay would
be expected if moderate-to-massive pleural
effusion was observed in addition to
impaired perfusion in ultrasonography
(OR, 3.08; 95% CI, 1.15–8.29).
No results stated in the abstract. 4

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Reference
49. Chen HJ, Yu YH, Tu CY, et al.
Ultrasound in peripheral pulmonary
air-fluid lesions. Color Doppler
imaging as an aid in differentiating
empyema and abscess. Chest.
135(6):1426-1432, 2009 Jun.
50. Wu HD, Yang PC, Lee LN.
Differentiation of lung abscess and
empyema by ultrasonography. J
Formos Med Assoc. 90(8):749-54,
1991 Aug.
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EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 34 patients To reevaluate the clinical significance of Among the sonographic characteristics, 2
nal-Dx sonographic appearances, in particular the complex-septated effusions and passive
application of color Doppler ultrasound atelectasis were specific for empyema, but
imaging, in discriminating peripheral air- the sensitivity was only 40% (n =12 of 30)
fluid lung abscess from empyema. and 47% (n =14 of 30), respectively. The
identification of color Doppler ultrasound
vessel signals in pericavitary consolidation
was the most useful and specific for
identifying lung abscesses. In our series, if
we define the identification of color
Doppler ultrasound vessel signals in a
pericavitary consolidation as a predictorfor
peripheral lung abscess, we can achieve
sensitivity, specificity, positive predictive
value, and negative predictive value of
94%, 100%, 100%, and 94%, respectively.
Observatio 50 patients To assess the value of chest The total scores for the four features were 3
nal-Dx with lung ultrasonography in the differentiation then assessed. Ninety-six percent of the
abscesses between a lung abscess and empyema, 50 empyema cases scored 2 or more, while
or patients, including 24 cases of lung abscess 96% of the lung abscess cases scored 1 or
empyema and 26 cases of empyema, were studied. zero. The efficacy of differential diagnosis
was 96%. We conclude that chest
ultrasonography is a useful tool in the
differentiation between lung abscess and
empyema and that ultrasonography alone is
sufficient to make a correct diagnosis in
most cases.
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Reference
51. Yang PC, Luh KT, Lee YC, et al.
Lung abscesses: US examination and
US-guided transthoracic aspiration.
Radiology. 180(1):171-5, 1991 Jul.
52. Tonson la Tour A, Spadola L, Sayegh
Y, et al. Chest CT in
bronchopulmonary dysplasia: clinical
and radiological correlations. Pediatric
Pulmonology. 48(7):693-8, 2013 Jul.
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EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 35 patients To evaluate lung abscesses and to guide Twenty-five abscesses (71%) had local 4
nal-Dx with lung transthoracic aspiration. adhesion to parietal pleura (lesion-pleura
abscesses symphysis). Ultrasound guided
transthoracic needle aspiration of fluid
from the abscess cavity was performed
successfully in 31 of 33 patients (94%). A
total of 65 pathogens were isolated from 31
aspuates (41 anaerobes and 24 aerobes),
notwithstanding the fact that 23 of the
patients had been previously treated with
antibiotics. Only two of 65 pathogens (3%)
could be recovered from blood culture,
seven (11 % ) from sputum culture, and
two from bronchoalveolar lavage (3%).
Two patients developed minimal
pneumothorax.
Observatio 19 infants To investigate whether there is a All CT scans showed abnormalities. The 2
nal-Dx correlation between radiological most frequent lesion was bronchial wall
pulmonary lesions and relevant BPD thickening observed in all patients,
clinical data (gestational age, type and followed by linear (89.5%) and subpleural
duration of mechanical ventilation, and (89.5%) opacities. Areas of decreased
severity of BPD) and assess the usefulness attenuation were found in 68.4%.
of a CT score in evaluating clinical Bullae/emphysema and bronchiectasis
severity. were the less frequent item described
(26.3% and 21.1%, respectively). The
presence of areas of decreased attenuation
significantly correlated with BPD severity
(P = 0.03). However, there was no
significantcorrelation between the CT
score and clinical data.
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Reference
53. Montella S, Maglione M, Bruzzese D,
et al. Magnetic resonance imaging is
an accurate and reliable method to
evaluate non-cystic fibrosis paediatric
lung disease. Respirology. 17(1):87-
91, 2012 Jan.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 50 subjects To assess the accuracy and reliability of Bronchiectasis, mucous plugging, 2
nal-Dx MRI compared with high-resolution peribronchial wall thickening,
computed tomography (HRCT) in children consolidation, bullae, abscesses and
with non-cystic fibrosis (CF) chronic lung emphysema were detected by HRCT in 72,
disease. 68,66, 60, 10, 8 and 8% of subjects,
respectively. Sensitivity, specificity,
accuracy and positive and negative
likelihood ratios for MRI were good or
excellent formost of the changes that were
assessed. Median total Helbich scores for
HRCT and MRI were 10 (range 0–20) and
10 (range 0–18), respectively. There
wasgood-to-excellent agreement between
the two techniques for all scores (r >= 0.8).
A Bland–Altman plot confirmed this
agreement between total scores (biasvalue:
0.2 +- 1.18; 95% limits of agreement of
mean difference: -2.12–2.52).
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Reference
54. Lee EY, Tracy DA, Mahmood SA,
Weldon CB, Zurakowski D, Boiselle
PM. Preoperative MDCT evaluation of
congenital lung anomalies in children:
comparison of axial, multiplanar, and
3D images. AJR. American Journal of
Roentgenology. 196(5):1040-6, 2011
May.
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EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 46 To compare the preoperative diagnostic The final study cohort consisted of 46 2
nal-Dx pediatric accuracy of axial, multiplanar, and 3D pediatric patients (28 males and 18
patients MDCT images for evaluating congenital females; mean age, 5.6 ± 6 [SD] months;
lung anomaliesin pediatric patients and to range, 1 day–50 months). Histopathologic
assess the potential added diagnostic value diagnoses included congenital pulmonary
of multiplanar and 3D MDCT images in airway malformation (n = 19, 41%),
this setting. sequestration (n = 15, 33%), congenital
lobar emphysema (n = 7, 15%), and
bronchogenic cyst (n = 5, 11%). Both
independent reviewers correctly diagnosed
types, location, associated mass effect, and
associated anomalous arteries of all
congenital lung anomalies with high
accuracy (100%) and confidence level
(mean confidence level < 1.2) on each type
of image display (axial, multiplanar, and
3D). However, for the detection of
anomalous veins, multiplanar and 3D
images were associated with greater
diagnostic accuracy and higher confidence
level than axial images alone. Specifically,
diagnostic accuracy for the detection of
anomalous veins (n = 15; 33%) was 60%
(9/15 cases) for axial MDCT images, 80%
(12/15) for multiplanar MDCT images, and
100% (15/15) for 3D MDCT images
(Friedman test, p = 0.011). Confidence
levels for the detection of anomalousveins
were significantly higher with 3D MDCT
images (mean level = 1.0) and multiplanar
MDCT images (mean level = 1.5)
compared with axial MDCT images alone
(mean level = 2.6) (Friedman test, p <
0.01). Both multiplanar and 3D MDCT
images were found to provide added
diagnostic value for accurately detecting
anomalous veins associated with congenial
lung anomalies (paired Student t tests, p <
0.012).
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ACR Appropriateness Criteria®
Reference
55. Saeed A, Kazmierski M, Khan A,
McShane D, Gomez A, Aslam A.
Congenital lung lesions: preoperative
three-dimensional reconstructed CT
scan as the definitive investigation and
surgical management. European
Journal of Pediatric Surgery. 23(1):53-
6, 2013 Feb.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 38 children To review postnatal investigations and A total of 38 children were identified 3
nal-Dx management of congenital lung lesions. between January 2000 and December
2011; 22 were males and 16 were females.
The mean gestational age at diagnosiswas
21 weeks (range18 to 26 weeks). Five
children showed complete resolution
antenatally. Four children were
symptomatic at birth. Postnatal CXR
showed anabnormality in only 17 infants.
CT scan with three-dimensional (3D)
reconstructions was performed at the mean
age of 7.7 months (range 1 day to 42
months). CT scan correlated well with per-
operative findings and provided adequate
anatomical information r = 0.98. Open
thoracotomy and lobectomy/excision was
performed in 23, and 15 had thoracoscopic
lobectomy/excision. The mean age of
operation was 18 months (range 2 days to
96 months). Twenty patients had signs of
recurrent preoperative infection with
pleural adhesions and hilar thickening
resulting in conversion of 10 thoracoscopic
cases to open surgery. Histology confirmed
26 congenital cystic adenomatoid
malformations, 2 hybrid lesions, 7
sequestrations, and 3 bronchopulmonary
malformations.
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EVIDENCE TABLE

Patients/ Study Objective

Reference
56. Griffin N, Devaraj A, Goldstraw P,
Bush A, Nicholson AG, Padley S. CT
and histopathological correlation of
congenital cystic pulmonary lesions: a
common pathogenesis?. Clinical
Radiology. 63(9):995-1005, 2008 Sep.
57. Shimohira M, Hara M, Kitase M, et al.
Congenital pulmonary airway
malformation: CT-pathologic
correlation. Journal of Thoracic
Imaging. 22(2):149-53, 2007 May.
Study Type
Events (Purpose of Study)
Observatio 24 patients To determine whether similarities exist in
nal-Dx both the imaging and histopathological
features of congenital cystic lung lesions
and whether a more appropriate
classification would be to adopt the theory
of ‘‘malinosculation’’.
Observatio 13 patients To correlate computed tomography (CT)
nal-Dx findings with those of pathologic
examination and evaluated the
predictability of the Congenital pulmonary
airway malformation (CPAM) subtype.
Study Results Study Quality
There were five type 1 congenital cystic 2
adenomatoid malformations (CCAMs), six
type 2 CCAMs, one type 4CCAM, one
bronchial atresia, four pleuropulmonary
blastomas (PPBs), and seven
sequestrations. CCAMs(types 1, 2 and
4),sequestrations and PPBs appeared as
cystic lesions, with cyst size less than 2 cm
in type 2 CCAMs. Sequestrations
weredistinguished radiologically from
CCAMs by systemic vessels. Reduced
pulmonary attenuation was seen in
bronchial atresia,type 2 CCAMs and in
sequestrations. Histopathology showed an
overlap in entities with sequestrations
demonstratingCCAMtype 2 histology and
segmental atresia noted in both type 2
CCAMsand sequestrations. PPBs showed
histological andimaging overlap with type
4 CCAMs and were distinguished on
histology by the presence of blastematous
proliferation.
Eight, 3, and 2 cases were diagnosed as 3
groups A, B, and C, respectively. All of the
8 cases diagnosed as group A
wereStocker’s type 1. One of the 3 cases
diagnosed as group B was type 2, but the
remaining 2 were type 1 and type 4,
respectively.One of the 2 cases diagnosed
as group C was type 3 but the other was
type 2.

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Reference
58. Thakkar HS, Durell J, Chakraborty S,
et al. Antenatally Detected Congenital
Pulmonary Airway Malformations:
The Oxford Experience. European
Journal of Pediatric Surgery.
27(4):324-329, 2017 Aug.
59. Buyukoglan H, Mavili E, Tutar N, et
al. Evaluation of diagnostic accuracy
of computed tomography to assess the
angioarchitecture of pulmonary
sequestration. Tuberkuloz ve Toraks.
59(3):242-7, 2011.
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Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Review/Ot 91 patients To offer surgery to mitigate the risk of A total of 64 (73%) patients underwent 4
her-Dx infection and possible malignancy in surgery with the most common lesions
antenatally detected congenital pulmonary being congenital pulmonary airway
airway malformations. malformations (CPAMs) (24), hybrid
lesions (19), and pulmonary sequestrations
(12). The median age at surgery was 5
months (1 day to 17 months). Using a
minimal access approach, 41 (64%) cases
were completed with 17 performed open
from the onset. Open surgery was indicated
in neonates who became symptomatic
within the first few weeks of life as well as
patients in respiratory distress that would
not tolerate either single-lung ventilation or
gas insufflation. There were six further
conversions to open from minimal access
surgery due to poor visualization or
technical difficulties. One patient needed a
perioperative blood transfusion and one
patient had a more prolonged stay due to
persistent air leak managed conservatively.
Among asymptomatic patients, evidence of
microscopic disease was seen, which
included infection as well as two cases of
tumors, one pleuropulmonary blastoma
seen as part of a CPAM, and one
rhabdomyomatous dysplasia seen in the
CPAM component of a hybrid lesion.
Observatio 8 patients To evaluate the accuracy of No results stated in abstract. 4
nal-Dx (6 males, 2 multidetector computed tomography
females) (MDCT) in demonstrating the feeding
artery and draining veins.
Revised 2019 Page 28
ACR Appropriateness Criteria®
Reference
60. Long Q, Zha Y, Yang Z. Evaluation of
pulmonary sequestration with
multidetector computed tomography
angiography in a select cohort of
patients: A retrospective study. Clinics
(Sao Paulo, Brazil). 71(7):392-8, 2016
Jul.
See Last Page for Key
Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 43 patients To evaluate the role of multidetector Multidetector computed tomography 2
nal-Dx computed tomography angiography in successfully detected all pulmonary
diagnosing patients with pulmonary sequestrations in the 43 patients (100%).
sequestration. This included 40 patients (93.0%) with
intralobar sequestration and 3 patients
(7.0%) with extralobar sequestration. The
locations of pulmonary sequestration were
left lower lobe (28 cases, 70% ofintralobar
sequestrations), right lower lobe (12 cases,
30% of intralobar sequestrations) and
costodiaphragmatic sulcus (3 cases). Cases
of sequestered lung presented as mass
lesions (37.2%), cystic lesions (32.6%),
pneumonic lesions (16.3%), cavitary
lesions (9.3%) and bronchiectasis (4.6%).
The angioarchitecture of pulmonary
sequestration, including feeding arteries
from the thoracic aorta (86.1%), celiac
truck (9.3%), abdominal aorta (2.3%) and
left gastric artery (2.3%) and venous
drainage into inferior pulmonary veins
(86.0%) and the azygos vein system
(14.0%), was visualized on multidetector
computed tomography. Finally, the
multidetector computed tomography
angiography results of the sequestered
lungs and angioarchitectures were
surgically confirmed in all the patients.
Revised 2019 Page 29
ACR Appropriateness Criteria®
Reference
61. Ren JZ, Zhang K, Huang GH, et al.
Assessment of 64-row computed
tomographic angiography for
diagnosis and pretreatment planning in
pulmonary sequestration. Radiologia
Medica. 119(1):27-32, 2014 Jan.
62. Yoon HM, Kim EA, Chung SH, et al.
Extralobar pulmonary sequestration in
neonates: The natural course and
predictive factors associated with
spontaneous regression. European
Radiology. 27(6):2489-2496, 2017
Jun.
See Last Page for Key
Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 45 patients To evaluate the clinical implications and Digital subtraction angiography and/or 3
nal-Dx results of a prospective protocol using 64- surgery revealed PS in 38 patients, and 7
row computed tomographic angiography patients had no PS. The patient-based
(CTA) for diagnosis and pre-treatment evaluation yielded an accuracy of 97.8 %,
planning in pulmonary sequestration (PS). sensitivity of 97.4 %, specificity of 100 %,
PPV of 100 % and NPV of 87.5 %, in the
detection of PS. CTA clearly depicted the
PS in all 38 patients, and the aberrant
systemic artery was accurately
demonstrated in 37 out of 38 patients
where endovascular treatment was
possible. Working views for endovascular
treatment were found in all patients with
PS, and the choice of coil was correct in 37
out of 38 patients using CTA.
Observatio 51 To describe the natural course of extralobar Fifty-one neonates were included. The 3
nal-Dx neonates pulmonary sequestration (EPS) and cumulative proportions of patients reaching
identify factors associated with PDV>50 % and PDD>50 % were 93.0 %
spontaneous regression of EPS. and 73.3 % at 4 years, respectively. Tissue
attenuation was significantly associated
with PDV rate (B=-21.78, P<.001). The
tissue attenuation (B=-22.62, P=.001) and
diameter of the largest systemic feeding
arteries (B=-48.31, P=.011) were
significant factors associated with PDD
rate.
Revised 2019 Page 30
ACR Appropriateness Criteria®
Reference
63. Yue SW, Guo H, Zhang YG, Gao JB,
Ma XX, Ding PX. The clinical value
of computer tomographic angiography
for the diagnosis and therapeutic
planning of patients with pulmonary
sequestration. European Journal of
Cardio-Thoracic Surgery. 43(5):946-
51, 2013 May.
64. American College of Radiology. ACR
Appropriateness Criteria® Radiation
Dose Assessment Introduction.
Available at: https://www.acr.org/-
/media/ACR/Files/Appropriateness-
Criteria/RadiationDoseAssessmentIntr
o.pdf.
See Last Page for Key
Pneumonia in the Immunocompetent Child
EVIDENCE TABLE
Patients/ Study Objective
Study Type Study Results Study Quality
Events (Purpose of Study)
Observatio 43 patients To evaluate the clinical value of computed Digital subtraction angiography and/or 2
nal-Dx (26 male tomographic (CT) angiography for surgery confirmed pulmonary
patients 17 diagnosis and therapeutic planning in sequestration in 37 patients; six patients
female patients with pulmonary sequestration. had no pulmonary sequestration. The
patients) diagnostic performance of CT angiography
for pulmonary sequestration in the patient-
based evaluation yielded an accuracy of
97.7%, sensitivity of 97.3%, specificity of
100%, positive predictive value (PPV) of
100% and negative predictive value (NPV)
of 85.7%. The aberrant systemic artery-
based evaluation yielded an accuracy of
98.0%, sensitivity of 97.8%, specificity of
100%, PPV of 100% and NPV of 85.7%.
Treatments could be correctly planned
using CT angiography with 100%
accuracy, sensitivity, specificity, PPV and
NPV according to the aneurysm-based
evaluation.
Review/Ot N/A To provide evidence-based guidelines on No abstract available. 4
her-Dx exposure of patients to ionizing radiation.
Revised 2019 Page 31
ACR Appropriateness Criteria®

Evidence Table Key Abbreviations Key

Study Quality Category Definitions Dx = Diagnostic

• Category 1 The study is well-designed and accounts for common biases. Tx = Treatment
• Category 2 The study is moderately well-designed and accounts for most common
biases.
• Category 3 There are important study design limitations.
• Category 4 The study is not useful as primary evidence. The article may not be a
clinical study or the study design is invalid, or conclusions are based on expert
consensus. For example:
a. The study does not meet the criteria for or is not a hypothesis-based clinical study
(e.g., a book chapter or case report or case series description);
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;
c. The study is an expert opinion or consensus document.
• Meta-analysis
a. Good quality – the study design, methods, analysis, and results are valid and the
conclusion is supported.
b. Inadequate quality – the study design, analysis, and results lack the methodological
rigor to be considered a good meta-analysis study.

ACR Appropriateness Criteria® Evidence Table Key