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The scenario

A4 year old boy with a cough and a fever is referred by his general practitioner. On auscultation of his chest there are focal signs suggestive of a lower respiratory tract infection; a chest x ray examination confirms right lower lobe collapse and consolidation. He is started on oral antibiotics and discharged home within 24 hours. He is given a follow up appointment in four weeks time in the registrar clinic to be reviewed after having a repeat chest x ray examination according to your units protocol. At the follow up appointment he is clinically well and has a normal radiograph. After discharging him you wonder whether the routine exposure to radiation outweighs the detection of persistent radiological changes.

The Questions
1. 2. 3. 4. 5. 6.

Background questions :
What is pneumonia? What are pneumonia symptoms and signs? How to Diagnose? What is the Investigation? What is the Complications? What is the Treatment?

Foreground questions :
In asymptomatic children with prior radiological evidence of pneumonia are routine follow up chest radiographs necessary to confirm complete resolution?

PICO analysis:
Patient 4year child with lobar pneumonia. Intervention follow up chest x-ray. Outcome confirmation of complete resolution.

The Background
What is pneumonia?

inflammatory condition of the lung. It is often characterized as including inflammation of the parenchyma of the lung (that is, the alveoli) and abnormal alveolar filling with fluid (consolidation and exudation)

What are pneumonia symptoms and signs?


The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganisms and by the immune system's response to the infection.

Lobar Pneumonia:
Lobar pneumonia may follow a viral infection or influenza. The onset of this condition is often quite sudden and may start off with chills and fever. Chest pain which may be commonly experienced occurs as a result of pleural involvements.

Congestion in the first 24 hours Red hepatisation or consolidation grey hepatisation resolution (complete recovery)

How to Diagnose?

Bronchial breathing on auscultation with a stethoscope (harsher sounds from the larger airways transmitted through the inflamed and consolidated lung), and rales (or crackles) heard over the affected area during inspiration. Percussion may be dulled over the affected lung, but increased rather than decreased vocal resonance (which distinguishes it from a pleural effusion.

What is the Investigation?


If sputum is available and the patient has not had prior antibiotic treatment then a Gram stain is a good indicator of the causative organisms.

2- complete blood count.

A complete blood count may show a high white blood cell count, indicating the presence of an infection or inflammation.

An important test for pneumonia in unclear situations is a chest x-ray. Chest x-rays can reveal areas of opacity (seen as white) which represent consolidation. Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT (computed tomography) can reveal pneumonia that is not seen on chest x-ray. X-rays can be misleading, because other problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray.] Chest x-rays are also used to evaluate for complications of pneumonia.

Pneumonia as seen on chest x-ray. A: Normal chest x-ray. B: Abnormal chest x-ray with shadowing from pneumonia in the right lung (white area, left side of image).

What is the Treatment?


Oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. Bacterial Antibiotics improve outcomes in those with bacterial pneumonia. Initially antibiotic choice depends on the characteristics of the person affected such as age, underlying health, and location the infection was acquired. Viral No specific treatments exist for most types of viral pneumonia, with the exception of influenza A and influenza B.

What is the Complications?


Respiratory and circulatory failure Pneumonia can also cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. Sepsis and septic shock Sepsis occurs when microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia. Pleural effusion, empyema, and abscess microorganisms infecting the lung will cause fluid (a pleural effusion) to build up in the space that surrounds the lung (the pleural cavity). If the microorganisms themselves are present in the pleural cavity, the fluid collection is called empyema.

Search strategy
Pubmedpneumonia AND radiography AND follow-up480 references (four pertinent articles, three in English). Cochrane Database of Systematic Reviews. Guideline.

The studies
Study type (level of Citation Study group 65 children with pneumonia (history, clinical and radiological diagnosis); Heaton and Arthur (1998) mean age 3.5 years (0.413) Retrospective cohort (level 4) Chest radiograph findings at follow up evidence) Outcome Key results 37/41 children asymptomatic: 35 (95%) normal to 100%) 2 improved (5%) CXR Comments Only 41/65 children followed up fully; 11 were up and a further 13 were lost to follow up 5 patients defaulted follow up.; 7 of the 8 patients with Clinical 77 children with pneumonia (history, clinical Gibson et al (1993) and radiological diagnosis) Prospective cohort (level 4) symptoms, radiograph findings at follow up 59/72 children asymptomatic: CXR CXR 56/70 (80%) children normal 129 children with a radiological diagnosis of pneumonia. (6 Grossman et al (1979) weeks 15 years) Prospective cohort (level 4) Chest radiograph findings at follow up CXR by 4 weeks; 9/9 (100%) children with residual CXR changes at 4 CXR by 3 months 59 were lost to first follow up; no data regarding clinical symptoms and signs was up symptoms, signs, and radiological findings at follow up had pleural original chest x ray

CXR (95% CI 87% not offered follow

signs and chest 51 (87%) normal

8 (13%) improved effusions on their

weeks had normal collected at follow

Our opinion
In asymptomatic children with prior radiological evidence of pneumonia, routine chest radiology provides no benefit.

-- Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z Med J1998;111:31517. -- Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood pneumonia. BMJ1993;307:1117. -- Grossman LK, Wald ER, Nair P, et al. Roentgenographic follow-up of acute pneumonia in children. Pediatrics1979;63:301