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Presenting Signs and Symptoms of Rapidly Progressing Severe Pneumonia in the Pediatric Emergency Department

Porter Moore C, Craig Huang, Adriana Rodriguez, Robert Wiebe and Jane Siegel

Background: Children with pneumonia are often diagnosed in the emergency department based on clinical and/or radiographic findings. Many of these patients can be treated as outpatients. However, patients with severe pneumonia often require Intensive Care Unit (ICU) admission and have significant morbidity. There is no published data to aide in rapid identification of children with severe pneumonia who require ICU admission.

Objectives: To identify clinical variables, laboratory and radiographic data that may predict the need for ICU admission.

Methods: Retrospective analysis of ED patients aged 0 to 18 years, admitted to a tertiary pediatric hospital with a diagnosis of severe pneumonia between 2002 and 2007 was performed. Severe pneumonia was defined as: empyema and/or pleural effusion. Patients were assigned into two cohorts: 1) admitted to the ICU and 2) admitted to general inpatient unit. Patients with significant past medical history were excluded. Demographic information, signs, symptoms, laboratory, and radiographic data were collected and compared. The Student t-test was used to compare the means for continuous variables and Chi Square for categorical variables.

Results: Patients admitted to ICU (n=113) had similar symptoms compared with the non ICU admission group (n=180), however the ICU cohort presented with a more acute onset of illness with significantly fewer days of fever and cough prior to presentation. They were also significantly more tachypenic and tachycardic on presentation. Laboratory analysis found the ICU patients had significantly greater bandemia with mean band count of 20.4 (95% CI 17.0, 23.8) compared to 11.8, (95% CI 9.8, 13.7). The general inpatient pneumonia patients had significantly higher mean platelet counts at 389 (95% CI 364,414) versus the ICU patients at 304 (95% CI 276, 332) as well as ESR values at 79 (95% CI 73, 85) versus the ICU patients at 58 (95% CI 49, 67).

Conclusions: This data suggest that children with severe pneumonia with rapid illness onset and bandemia are at higher risk for ICU admission. More insidious onset, elevated platelet counts and ESR may predict a more stable course of illness. Continued analysis of these variables may be helpful in constructing a diagnostic algorithm for pediatric pneumonia patients at presentation, facilitating earlier detection, treatment, and appropriate in-patient disposition.