Physical Exam and Historical Patient Factors Associated with Diagnosis of Pneumonia

Background: The use of chest radiography (CXR) to aid in the diagnosis of pneumonia varies among pediatric emergency physicians. Recent guidelines recommend clinical assessment to diagnose community-acquired pneumonia. Objective: To study the association between historical and physical exam findings in children who were diagnosed with pneumonia in the pediatric emergency department (PED). Design/Methods: A retrospective chart review of patients (birth-18 years of age) who presented with symptoms suspicious for pneumonia in an urban PED was conducted between 01/01/10-12/31/11. Symptoms suggestive of pneumonia included chief complaints of fever, respiratory/difficulty breathing, or cough. Children were excluded if they had chronic lung diseases (i.e. asthma), and non-infectious etiologies (i.e. costochondritis). Children with a PED physician discharge diagnosis of pneumonia were compared to those with the same symptoms but without a diagnosis of pneumonia. Variables analyzed included: tachypnea, fever, duration of fever, chest pain, history of cough, any retractions, oxygen saturation, and physician documented abnormal breath sounds. Chi-square analysis was performed and a logistic regression model was used. CXRs were interpreted by a board certified pediatric radiologist. Results: 497 children met inclusion criteria (51% female, 31% Caucasian, mean age 5.8 yrs). 266 children with a diagnosis of pneumonia were compared to 231 without. 91% (242/266) of those diagnosed with pneumonia had a CXR compared to 13% (27/231) without. The following were significant independent predictors of physician diagnosed pneumonia controlled for CXR performed: abnormal breath sounds OR 12.4 (95% CI: 5.7-26.9), cough OR 3.1 (95% CI: 1.5-6.3), and duration of fever >2 days OR 2.9 (95% CI: 2.0-4.1). Tachypnea, retractions, and oxygen saturations below 95% were not associated with the diagnosis of pneumonia. In children 5 years and older chest pain was a significant predictor with OR 29.5 (95% CI: 6.8-127.2). Conclusion: Clinical predictors of pneumonia for children 2 years and older included abnormal breath sounds, cough, and fever > 2 days. Chest pain was also a significant predictor in children older than 5 years.