title: Additional markers to refine the World Health Organization algorithm for diagnosis of pneumonia.
abstract: BACKGROUND
  WHO guidelines for primary care of children with tachypnea indicate that all should receive antibiotics for presumed pneumonia. These guidelines have led to excessive antibiotic use.
  
  
  OBJECTIVE
  To examine the value of history of previous respiratory distress, chest indrawing and fever, and response to bronchodilator(BD) to refine these guidelines.
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  Urban tertiary care hospital.
  
  
  METHODS
  Children, between the ages of 6 and 59 months, presenting with cough and tachypnea.
  
  
  METHODS
  182 children were enrolled. Each child had a chest X-ray that was read by two blinded, independent radiologists. Discordance between the two radiologists led to excluding 17 patients. The remaining 165 children were examined for fever and/or chest indrawing, and if they had a history of previous respiratory distress, challenge with a BD. The association of persistent tachypnea after BD and presence of pulmonary infiltrates was recorded.
  
  
  RESULTS
  The median age was 22 months (mean 25.1 +- 14.5 mo) and 75.8% were aged greater than 1 year. There were 58.8% males. Previous respiratory distress occurred in 65.0% and 79.2% of children aged less than 1 year and 1 year, respectively. Pneumonia was radiologically diagnosed in 26/165 (15.8%). 2/40 (5 %) of children without a history of previous respiratory distress had pneumonia diagnosed. Of 125 children with history of previous respiratory distress, pneumonia was identified in 24 (19.2 %). Persistence of tachypnea after BD was associated with pulmonary infiltrate in 14/24 (58.3%), whereas, tachypnea persisted in 32/101 (31.7%) children without pulmonary infiltrates (P = 0.02). The negative predictive value of resolution of tachypnea was 87.3% (95% CI 77.5 93.4). BD non-response was most useful in children without fever and/or with chest indrawing to indicate pneumonia as the cause of the tachypnea.
  
  
  CONCLUSIONS
  This study indicates that by adding the simple procedures of a history of previous respiratory distress, recording of fever and chest indrawing, and observing the response to bronchodilators, pneumonia can be reliably identified in children presenting with tachypnea and cough. It is probable that this approach to management of children with cough and tachypnea could reduce unnecessary use of antibiotics.
authors.affiliation: Departments of Pediatrics and Radiodiagnosis, Federal University of Bahia and the Emergency Department, Jorge Valente Hospital, Salvador, Bahia, Brazil.
authors.forename: A V
authors.initials: AV
authors.lastname: Castro
authors.forename: C M
authors.initials: CM
authors.lastname: Nascimento-Carvalho
authors.forename: F
authors.initials: F
authors.lastname: Ney-Oliveria
authors.forename: C A
authors.initials: CA
authors.lastname: Araújo-Neto
authors.forename: S C S
authors.initials: SC
authors.lastname: Andrade
authors.forename: L L S
authors.initials: LL
authors.lastname: Loureiro
authors.forename: P O
authors.initials: PO
authors.lastname: Luz
mesh_terms: D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001249:Asthma; D001938:Brazil; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D002675:Child, Preschool; D003371:Cough; D005260:Female; D005334:Fever; D006801:Humans; D007223:Infant; D008297:Male; D011014:Pneumonia / Q000175:diagnosis* / Q000188:drug therapy; D011446:Prospective Studies; D012119:Respiration; D014944:World Health Organization
chemical_list: D000900:Anti-Bacterial Agents; D001993:Bronchodilator Agents