The Value of a Chest X-Ray in Diagnosing Pneumonia in SIRS Patients Lacking Respiratory Symptoms in York Hospital’s Emergency Department Michelle Lynch Department of Biological Sciences, York College of Pennsylvania Radiologyinfo.org http://www.wellspan.org/body.cfm?id=91 Introduction Methods Results Systemic Inflammatory Response Syndrome (SIRS) Bodily response caused by a wide variety of issues Related to sepsis, which is SIRS specifically caused by infection Requires two or more of the following symptoms: Tachycardia [>90 bpm] Hypo/Hyperthermia [<96.0 °F or >100.4 °F ] High Respiratory Rate [>20 breaths/minute] Low/High WBC [<4,000/μL or >12,000/μL] Pneumonia Infection in one or more lobes of the lungs Symptoms include: cough, fever, shortness of breath 5.6 million cases per year in U.S., 1/5 requiring hospitalization Leading cause of death by infectious disease Chest X-Ray Required in the diagnosis of pneumonia Infection infiltrates are seen as white opaque patches Benefits: clear indicator of infiltrates Drawbacks: costly ($50-$400), radiation exposure Retroactive chart review of York Hospital Emergency Department patients receiving a chest x-ray in Dec. 2010 Those with at least two SIRS criteria were included Pediatric and DNR/comfort care only patients and those with known pneumonia or a chronic abnormal chest x-ray were excluded Charts were reviewed to determine: Presence or absence of respiratory symptoms at ED presentation Respiratory Symptom (RS): Dyspnea, Tachypnea, Cough, Chest Pain, Hypoxia, and Focal Lung Findings Radiology interpretation of ED chest x-ray Discharge Diagnosis (Gold standard for pneumonia diagnosis ) Fisher’s exact test and descriptive statistics were used Table 1. Effectiveness of methods in the diagnosis of pneumonia History and Physical Chest X-Ray Sensitivity 100% (95% CI: 82-100%) 65% (95% CI: 43-83%) Specificity 23% (95% CI: 17-30%) 86% (95% CI: 80-91%) + Likelihood Ratio 1.3 (95% CI: 1.2-1.4) 4.6 (95% CI: 2.9-7.4) - Likelihood Ratio (95% CI: 0-0.8) 0.4 (95% CI: 0.2-0.7) http://emedicine.medscape.com/article/168402-overview 1053 charts reviewed 23 (14.9%) with Pneumonia 0 (0%) with Pneumonia 39 with no RS 154 with one or more RS 193 charts included 860 Excluded Conclusion A history and physical was more effective in diagnosing pneumonia than a chest x-ray (sensitivity 100% and 65% respectively) None of the patients with SIRS lacking respiratory symptoms were diagnosed with pneumonia and Chest X-rays were not necessary in their diagnosis Combined with supportive findings from additional studies, chest x-rays can be used more judiciously to limit radiation exposure and reduce medical costs Objectives To determine the prevalence of pneumonia and the predictive properties of a chest x-ray in the evaluation of SIRS for patients with and without respiratory symptoms Hypothesis: Patients with SIRS criteria and no respiratory symptoms have a lower prevalence of pneumonia and do not require a chest x-ray on initial work up References Bone, R., et al. 1992. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:1644-55. Lutfiyya, M., et al. 2006. Diagnosis and treatment of community-acquired pneumonia. Am. Family Physician 73:442-450. Verma, V., et al. 2011. The utility of routine admission chest X-ray films on patient care. European Journal of Internal Medicine 22:286–288. Acknowledgements Thank you to Dr. Kochert, Dr. Ryles, Dr. Lalani, and Mrs. Stahlman from York Hospital and Dr. Kaltreider and Dr. Boehmler from York College