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Paediatrica Indonesiana

VOLUME 52 July  NUMBER 4

Original Article

Chest x-ray findings and outcomes of children with


suspected ventilator-associated pneumonia
Neni Sumarni1, Muhammad Sholeh Kosim1, Mohamad Supriatna1, Eddy Sudijanto2

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Abstract HQWLODWRUDVVRFLDWHG SQHXPRQLD  9$3 
Background 9HQWLODWRUDVVRFLDWHG SQHXPRQLD 9$3  LV D is the second most common nosocomial
nosocomial infection in patients who have received mechanical LQIHFWLRQLQ3,&8SDWLHQWVLQWKH8QLWHG
ventilation (MV), either by endotracheal intubation or 6WDWHV9$3LVDQRVRFRPLDOSQHXPRQLD
WUDFKHRVWRP\IRUPRUHWKDQKRXUV9$3UHSUHVHQWVRI
DOO KRVSLWDODFTXLUHG SQHXPRQLDV 9$3 LQFLGHQFH YDULHV IURP
in patients who have been mechanically ventilated for
 7KH PRGLILHG FOLQLFDO SXOPRQDU\ LQIHFWLRQ VFRUH !48 hours, who develop signs of new lower respiratory
LVDFULWHULDIRUGLDJQRVLQJVXVSHFWHG9$3DQGW\SLFDOO\LQFOXGHV tract infection. Despite advances in supportive care,
UDGLRJUDSKLF HYLGHQFH 9$3 LV DVVRFLDWHG ZLWK VLJQLILFDQW antimicrobial therapies, and mechanical ventilation,
morbidity and mortality.
9$3UHPDLQVDPDMRUWKUHDWWR,&8SDWLHQWV,QDGXOWV
Objective To determine the relationship between chest x-ray
ILQGLQJVDQGRXWFRPHVLQFKLOGUHQZLWKVXVSHFWHG9$3
WKH UHSRUWHG LQFLGHQFH RI 9$3 UDQJHV IURP  WR
Methods7KLVUHWURVSHFWLYHVWXG\ZDVKHOGLQ'U.DULDGL+RVSLWDO 28% worldwide.3,47KHLQFLGHQFHRI9$3LQSHGLDWULF
IURP-DQXDU\'HFHPEHU'DWDZDVFROOHFWHGIURPPHGLFDO SDWLHQWV YDULHV IURP  The National
UHFRUGVRISHGLDWULF,&8 3,&8 SDWLHQWVZLWKVXVSHFWHG9$3 1RVRFRPLDO ,QIHFWLRQV 6XUYHLOODQFH 11,6  V\VWHP
&KHVW[UD\ILQGLQJVDQGSDWLHQWRXWFRPHVZHUHUHFRUGHG;UD\ RI WKH &HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQ
ILQGLQJVZHUHDVVHVVHGE\WKHRQGXW\UDGLRORJLVW&KLVTXDUHWHVW
was used for statistical analysis.
&'&  UHSRUWHG D PHDQ 9$3 UDWH RI  SHU 
Results6XEMHFWVZHUHFKLOGUHQFRQVLVWLQJRIPDOHVDQG YHQWLODWRUGD\VIRUSDUWLFLSDWLQJ3,&8VLQWKH8QLWHG
IHPDOHV3DWLHQWRXWFRPHVZHUHSDWLHQWVVXUYLYHGDQGSDWLHQWV 6WDWHV 7KH (XURSHDQ 0XOWLFHQWHU 6WXG\ *URXS
died. Chest x-ray findings were categorized into the following IRXQGWKHPRVWFRPPRQ3,&8QRVRFRPLDOLQIHFWLRQ
JURXSVDQGFRPSDUHGWRSDWLHQWVXUYLYDELOLW\GLIIXVHLQILOWUDWHV to be pneumonia, at 53% of all infections.8 Adult
 25 3 &,WR ORFDOL]HG
LQILOWUDWHV 25 3 &,WR 
SDWLHQWVZKRDFTXLUH9$3KDYHZRUVHRXWFRPHVDQG
DQGQRLQILOWUDWHV 25 3 &,WR
 1RQHRIWKH[UD\ILQGLQJVKDGDVLJQLILFDQWFRUUHODWLRQ
to patient outcomes.
Conclusion There was no significant relationship between chest )URPWKH'HSDUWPHQWRI&KLOG+HDOWK, and Department of Radiology2,
'LSRQHJRUR8QLYHUVLW\0HGLFDO6FKRRO'U.DULDGL+RVSLWDO6HPDUDQJ
[UD\ ILQGLQJV DQG RXWFRPHV LQ FKLOGUHQ ZLWK VXVSHFWHG 9$3
Indonesia.
[Paediatr Indones. 2012;52:233-8].
Reprint requests to: 1HQL 6XPDUQL 'HSDUWPHQW RI &KLOG +HDOWK
Keywords: chest x-ray, outcome, ventilator- 'LSRQHJRUR 8QLYHUVLW\ 0HGLFDO 6FKRRO 'U .DULDGL +RVSLWDO -O 'U
6RHWRPR QR  6HPDUDQJ  ,QGRQHVLD 7HO 
associated pneumonia (PDLO neni_thea@yahoo.com

7KLV VWXG\ ZDV SUHVHQWHG DW WKH $VLD 2FHDQLD 6RFLHW\ IRU 3HGLDWULFV
5DGLRORJ\&RQJUHVV.XWD%DOL1RYHPEHU

Paediatr Indones, Vol. 52, No. 4, July 2012 233


Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

have longer ICU and hospital stays than children.3 respiratory patients were eligible for enrollment if their
2IDGXOWSDWLHQWVZKRUHTXLUHPHFKDQLFDOYHQWLODWLRQ clinical status improved. This study was approved by
IRUKRXUVDFTXLUH9$3ZLWKPRUWDOLW\ the institutional review board.
UDWHVRIWR8,9&KLOGUHQZLWK9$3KDYHQHHG Data collected from medical records included
for prolonged mechanical ventilation, longer ICU demographic data (age at time of intubation, gender,
stays and higher mortality rates. and admission diagnosis), clinical signs (maximum
The modified clinical pulmonary infection temperature, presence of endotracheal secretions
VFRUH &3,6  LV XVHG WR GLDJQRVH VXVSHFWHG 9$3 defined as non-purulent, purulent, or absent,
in children. 'HILQLWLYH 9$3 PD\ EH GLDJQRVHG ),2DWWLPHRIWKHORZHVW3D2 ODERUDWRU\GDWD
by bronchoscopic bronchoalveolar lavage (BAL) PD[LPXP ZKLWH FHOO FRXQW ORZHVW 3D2 IURP
culture.   &3,6 KDV D VHQVLWLYLW\ RI  DQG arterial source), chest radiograph data (development
VSHFLILFLW\ RI  Chest x-ray finding is one of of new infiltrates, diffuse infiltrates, localized
WKH&3,6YDULDEOHVGHILQHGDVGLIIXVHORFDOL]HGRU infiltrates or no infiltrates) and culture data (results
no infiltrates. Localized infiltrates score higher points of endotracheal tube, blood, urine, and other tissue
than that of diffuse infiltrates. FXOWXUHV 'DWDDQDO\VLVLQFOXGHG&3,6VFRUHVFKHVW
&KHVW [UD\ ILQGLQJV DV WKH\ UHODWH WR 9$3 radiograph data (diffuse, localized or no infiltrates),
outcomes are not as well documented in pediatric and patient outcomes defined as survived or died.
SDWLHQWVDVWKH\DUHLQDGXOWV9$3LQDGXOWVKDVEHHQ Chest x-rays findings were determined as by the on-
associated with prolonged duration of mechanical duty radiologist.
ventilation, as well as increased length of ICU stay, :H XVHG WKH PRGLILHG &3,6 VFRUH WR GLDJQRVH
hospital stay, hospital cost, and absolute mortality.3 VXVSHFWHG9$3IRUZKLFKWKHVHQVLWLYLW\LVDQG
3,&8SDWLHQWVQRWRQO\HQFRPSDVVDZLGHUDQJHRIDJHV VSHFLILFLW\LV&3,6FRQVLVWVRIYDULDEOHVRQHRI
different from adult ICU patients, but also differ in which is radiologic findings as shown in Table 1.
their developmental physiology, underlying disorders, &KLVTXDUHZDVXVHGWRDQDO\]HWKHUHODWLRQVKLS
DQGWUHDWPHQWQHHGV0RUHSHGLDWULF9$3VWXGLHVDUH EHWZHHQWKHFKHVW[UD\ILQGLQJV&3,6DQGRXWFRPHV
needed to elucidate these factors. Logistic regression analysis was not used to assess a
:H FRQGXFWHG D FURVVVHFWLRQDO VWXG\ LQ 'U correlation between chest x-ray findings and outcomes
.DULDGL+RVSLWDOWRHYDOXDWHWKHUHODWLRQVKLSEHWZHHQ VLQFHWKH&KLVTXDUHDQDO\VLVVKRZHGQRVLJQLILFDQW
chest x-ray findings and outcomes of children with FRUUHODWLRQ6WDWLVWLFDODQDO\VHVZHUHSHUIRUPHGZLWK
VXVSHFWHG9$3 6366VRIWZDUHYHUVLRQ

Methods Results
7KLVFURVVVHFWLRQDOVWXG\ZDVKHOGDWWKH'U.DULDGL Thirty-four patients met the inclusion criteria, but
+RVSLWDO 8QLYHUVLW\ RI 'LSRQHJRUR 6HPDUDQJ RQO\  ZHUH HQUROOHG GXH WR WKHLU ),2  
Indonesia. This tertiary-care hospital receives referrals The outcomes of patients were survived (23 out of
IURPWKH:HVW-DYDUHJLRQ  FKLOGUHQ  DQG GLHG   6XEMHFWVFRQVLVWHGRI
All pediatric and neonatal patients admitted to PDOHVDQGIHPDOHV7KHPHDQDJHRIWKHPDOHV
'U.DULDGL+RVSLWDOIURP-DQXDU\WR'HFHPEHU ZDV 6' PRQWKVDQGRIWKHIHPDOHVZDV
ZHUH VFUHHQHG IRU VWXG\ HQUROOPHQW :H LQFOXGHG 6' PRQWKV
SDWLHQWV ZKR ZHUH PHFKDQLFDOO\ YHQWLODWHG IRU  :HGLYLGHG&3,6VFRUHVLQWRJURXSVWKRVHZLWK
48 hours and not diagnosed with pneumonia prior VFRUHVRI SDWLHQWV IRUZKLFKWKHGHDWKUDWH
WR 3,&8 DGPLVVLRQ 3DWLHQWV ZHUH H[FOXGHG LI WKHLU ZDVDQGWKRVHZLWK&3,6VFRUHV SDWLHQWV 
UHVSLUDWRU\VWDWXVZDVXQVWDEOH LHUHTXLUHGIUDFWLRQ IRUZKLFKWKHGHDWKUDWHZDV:HIRXQGVLJQLILFDQW
RILQVSLUHGR[\JHQ>),2@RUKLJKIUHTXHQF\ UHODWLRQVKLSVEHWZHHQ&3,6DQGRXWFRPHVLQWKHILUVW
oscillatory ventilation), support was withdrawn JURXS 25 3 &,WR 
or declaration of death was imminent. Unstable DQGWKHVHFRQGJURXS 25 3 

234Paediatr Indones, Vol. 52, No. 4, July 2012


Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

Table 16JGOQFKGFENKPKECNRWNOQPCT[KPHGEVKQPUEQTG12
CPIS parameters 0 1 2
6TCEJGCNUGETGVKQPU Rare Abundant CDWPFCPV RWTWNGPV
%JGUVZTC[KPNVTCVGU 0QKPNVTCVGU &KHHWUG Localized
6GORGTCVWTG 36.5 and 38.4 38.5. and 38.9 39 or 36
Leukocyte count, per mm3 4,000 and 11,000 <4,000 or >11,000 QT  DCPFHQTOU
500
PAO2/FIO2, mmHg >240 or ARDS CPFPQGXKFGPEGQH#4&5
Microbiology Negative Positive

Table 2. 6JGTGNCVKQPUJKRDGVYGGP%2+5CPFQWVEQOGU
Cases Survived Died
CPIS score OR 95% CI P
n n n
6-7 22 20 2 0.06 0.008 to 0.461 0.007
 8 3 5 16.67 2.167 to 128.17 0.007

Table 32CVJQIGPUEWNVWTGFHTQOGPFQVTCEJGCNVWDGU Diffuse infiltrates was found in all region of the


Pathogens n
lung for most patients and this contributed one point
Acinetobacter baumanni 4
RI &3,6 SDUDPHWHU Figure 1). Most of them were
Enterobacter aerogenes 4 survived.
Pseudomonas aeruginosa 15 Localized infiltrates was found in certain region of
Staphylococcus aureus 2 the lung and the most common location was in the right
Klebsiella pneumoniae 3 upper region of the lung (Figure 2). These chest x-ray
No pathogen growth 2
findings were found in less number of patients than

Table 4.6JGTGNCVKQPUJKRDGVYGGPEJGUVZTC[PFKPIUCPFQWVEQOGU
Case Survived Died
%JGUVZTC[ OR 95% CI P
% % %
&KHHWUGKPNVTCVGU 76.7 60 16.6 0.694 0.102 to 4.717 0.532
.QECNK\GFKPNVTCVGU 13.3 6.7 6.7 4.200 0.470 to 37.499 0.225
0QKPNVTCVGU 10 10 0 1.222 0.222 to 6.730 0.581

&,WR DVVKRZQLQTable 2. those with diffuse infiltrates, but contributed to more


2QHSDUDPHWHURIWKH&3,6VFRUHLVPLFURELRORJ\ SRLQWRI&3,6SDUDPHWHU/RFDOL]HGLQILOWUDWHILQGLQJV
meaning pathogens found in endotracheal cultures. was significantly more common in patients with positive
In our study, Pseudomonas aeruginosa was the most BAL (bronchoalveolar lavage) culture.
common isolated pathogenic microorganism, found
LQHQGRWUDFKHDOFXOWXUHV2WKHUSDWKRJHQVZHUH
Acinetobacter baumanni in 4 samples, Enterobacter Discussion
aerogenes in 4 samples, Staphylococcus aureus in 2
samples and Klebsiella pneumoniae in 3 samples. No 9$3 LV SQHXPRQLD WKDW GHYHORSV DIWHU !48 hours
pathogens were found in 3 endotracheal cultures of mechanical ventilation provided by way of an
(Table 3). HQGRWUDFKHDOWXEHRUWUDFKHRVWRP\9$3UHVXOWVIURP
The chest x-ray findings in our study of diffuse the invasion of the lower respiratory tract and lung
LQILOWUDWHV 25 3 &,WR  parenchyma by microorganisms. In our study,
ORFDOL]HGLQILOWUDWHV 25 3 &, WKH GHDWK UDWH ZDV  RXW RI  SDWLHQWV  
WR DQGQRLQILOWUDWHV 25 3  within the mortality rate range from an adult study
&,WR KDGQRVLJQLILFDQWUHODWLRQVKLSVZLWK WKDW UHSRUWHG WKH FUXGH PRUWDOLW\ UDWH IRU 9$3
patient outcomes as shown in Table 4. WR EH 2XWFRPHV RI 9$3 KDYH QRW EHHQ

Paediatr Indones, Vol. 52, No. 4, July 2012 235


Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

Figure 1%JGUVZTC[PFKPIUQHFKHHWUGKPNVTCVGU

Figure 2.%JGUVZTC[PFKPIU
QHNQECNK\GFKPNVTCVGU

236Paediatr Indones, Vol. 52, No. 4, July 2012


Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

documented as well in pediatric patients as in adults. References


1HYHUWKHOHVV6ULQLYDVDQet al. found that children
ZLWK9$3KDGLQFUHDVHGDEVROXWHKRVSLWDOPRUWDOLW\  5LFKDUGV0-(GZDUGV-5&XOYHU'+*D\QHV531DWLRQDO
RIFRPSDUHGWRWKRVHZLWKRXW9$3 1RVRFRPLDO ,QIHFWLRQV 6XUYHLOODQFH 6\VWHP 1RVRFRPLDO
:H XVHG WKH PRGLILHG &3,6 VFRUH WR GLDJQRVH infections in pediatric intensive care units in the United
VXVSHFWHG9$3IRUZKLFKWKHVHQVLWLYLW\LVDQG 6WDWHV3HGLDWULFV
VSHFLILFLW\LV:HIRXQGDVLJQLILFDQWUHODWLRQVKLS  3RU]HFDQVNL,%RZWRQ'/'LDJQRVLVDQGWUHDWPHQWRIYHQ-
EHWZHHQ&3,6DQGRXWFRPHVLQWKHILUVWJURXSZLWK WLODWRUDVVRFLDWHGSQHXPRQLD&KHVW
VFRUHV RI  25   3   &,   &KDVWUH-)DJRQ-<9HQWLODWRUDVVRFLDWHGSQHXPRQLD$P-
WR DQGLQWKHVHFRQGJURXSZLWKVFRUHV 5HVSLU&ULW&DUH0HG
25 3 &,WR   5HOOR-2OOHQGRUI'$2VWHU*9HUD/ORQFK0%HOOP/
:HDOVRIRXQGWKDWWKHPRVWFRPPRQSDWKRJHQ Redman R, et al. Epidemiology and outcomes of ventilator-
cultured was Pseudomonas aeruginosa  6LPLODUO\ DVVRFLDWHG SQHXPRQLD LQ D ODUJH 86 GDWDEDVH &KHVW
WKH 11,6 LQ WKH 8QLWHG 6WDWHV DQG WKH (XURSHDQ 
0XOWLFHQWHU6WXG\*URXSIRXQGSQHXPRQLDLQWKHLU  6KDUPD+6LQJK'3RRQL30RKDQ8$VWXG\SURILOHRI
pediatric populations to be most often associated YHQWLODWRUDVVRFLDWHG SQHXPRQLD LQ FKLOGUHQ LQ 3XQMDE -
with Pseudomonas aeruginosa   DQG S. aureus 7URS3HGLDWU
  In contrast, Tripathi et al. reported that  $VHPEHUJLHQH-*XUNLV9.HYDODV59DOLQWHOLHQH51RVRFR-
the most common bacteria isolated from endotracheal mial infection in pediatric intensive care units in Lithuania.
DVSLUDWHV RI 9$3 1,&8 SDWLHQWV ZDV Klebsiella spp 0HGLFLQD .DXQDV 
(32.8%). 7KLV GLIIHUHQFH PD\ EH GXH WR SDWLHQWV  1DWLRQDO1RVRFRPLDO,QIHFWLRQV6XUYHLOODQFH6\VWHP1D-
encountering resistant Enterobacter, Pseudomonas WLRQDO1RVRFRPLDO,QIHFWLRQV6XUYHLOODQFH6\VWHP5HSRUW
and Acinetobacter VSHFLHV LQ ODWH RQVHW 9$3 DIWHU GDWDVXPPDU\IURP-DQXDU\WKURXJK-XQHLVVXHG
5 days of hospitalization), while the etiologic agent 2FWREHU$P-,QIHFW&RQWURO
RI EDFWHULDO FRPPXQLW\DFTXLUHG SQHXPRQLD GLIIHUV  5D\PRQG - $XMDUG < 1RVRFRPLDO LQIHFWLRQV LQ SHGLD-
by age which the most common bacterial cause of WULF SDWLHQWV D (XURSHDQ PXOWLFHQWHU SURVSHFWLYH VWXG\
SQHXPRQLD DPRQJ FKLOGUHQ EHWZHHQ  ZHHNV DQG (XURSHDQ 6WXG\ *URXS ,QIHFW &RQWURO +RVS (SLGHPLRO
older was Streptococcus pneumonia. 
$QRWKHU SDUDPHWHU IRU &3,6 LV FKHVW [UD\  0HOVHQ:*5RYHUV00%RQWHQ0-9HQWLODWRUDVVRFLDWHG
finding, defined as diffuse, localized or no infiltrates. SQHXPRQLDDQGPRUWDOLW\DV\VWHPDWLFUHYLHZRIREVHUYDWLR-
Localized infiltrates score higher points than diffuse QDOVWXGLHV&ULW&DUH0HG
infiltrates. In our study, we did not find a significant  6ULQLYDVDQ 5 $VVHOLQ - *LOGHQJRULQ * :LHQHU.URQLVK
relationship between chest x-ray findings and patient - )ORUL +5 $ SURVSHFWLYH VWXG\ RI YHQWLODWRUDVVRFLDWHG
RXWFRPHV6LPLODUO\6DFKGHYet al. reported that of SQHXPRQLDLQFKLOGUHQ3HGLDWULFV
WKH ILYH YDULDEOHV XVHG IRU &3,6 RQO\ WHPSHUDWXUH  (OZDUG $0 :DUUHQ '. )UDVHU 9- 9HQWLODWRUDVVRFLDWHG
DQG3D22)L22 ratio were significant for assessing the SQHXPRQLD LQ SHGLDWULF LQWHQVLYH FDUH XQLW SDWLHQWV ULVN
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A limitation of our study was that we were  6DFKGHY $ &KXJJK . 6HWKL 0 *XSWD ' :DWWDO &
XQDEOHWRSHUIRUPD.DSSDWHVWIRUWKHLQWUDREVHUYHU 0HQRQ*&OLQLFDOSXOPRQDU\LQIHFWLRQVFRUHWRGLDJQRVH
agreement between radiologists, since this was a YHQWLODWRUDVVRFLDWHGSQHXPRQLDLQFKLOGUHQ,QGLDQ3HGLDWU
retrospective study. Also, our small sample size may 
KDYHFRQWULEXWHGWRWKHODFNRIYDULDEOHDVVRFLDWLRQV  3XJLQ-$XFNHQWKDOHU50LOL1-DQVVHQV-3/HZ3'6XWHU
A large, multicenter study should be done to better 30'LDJQRVLVRIYHQWLODWRUDVVRFLDWHGSQHXPRQLDE\EDF-
assess a relationship between chest x-ray findings teriologic analysis of bronchoscopic and nonbronchoscopic
DQG RXWFRPHV RI FKLOGUHQ ZLWK VXVSHFWHG 9$3 ,Q blind bronchoalveolar lavage fluid. Am Respir Crit Med.
conclusion, we found no significant relationship 
between chest x-ray findings and outcomes of children  *DXYLQ)'DVVD&&KDLERX03URXO[))DUUHOO&$/DFURL[
ZLWKVXVSHFWHG9$3 - 9HQWLODWRUDVVRFLDWHG SQHXPRQLD LQ LQWXEDWHG FKLOGUHQ

Paediatr Indones, Vol. 52, No. 4, July 2012 237


Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

FRPSDULVRQ RI GLIIHUHQW GLDJQRVWLF PHWKRGV 3HGLDWU &ULW  &RRN '- :DOWHU 6' &RRN 5- *ULIILWK /( *X\DWW *+
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 )DUWNRXWK00DLWUH%+RQRUH6&HUI&=DKDU-5%UXQ associated pneumonia in critically ill patients. Ann Intern
Buisson C. Diagnosing pneumonia during mechanical ven- 0HG
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a8 3HGLDWULFV

238Paediatr Indones, Vol. 52, No. 4, July 2012