title: Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? A prospective observational study in four Indian hospitals.
abstract: BACKGROUND
  Acute respiratory infections are the commonest cause of mortality and morbidity in children worldwide. A quarter of all deaths occur in India alone. In order to reduce this disease burden, there is a need for better diagnostic criteria, particularly ones allowing early detection of high-risk children.
  
  
  METHODS
  We enrolled 516 under 5 year olds, in four Indian hospitals, who met WHO age-dependent tachypnoea criteria for pneumonia at presentation. Patients underwent a protocolised examination assessing 29 items, including history, examination, O2 saturation, plus scores for chest X-ray, auscultation and conscious level. Treatment was determined by the emergency room (ER) physician. All children were reviewed at day 4 by a paediatrician and placed into four diagnostic categories: pneumonia, wheezy disease, mixed and non-respiratory.
  
  
  RESULTS
  The majority had wheezy diseases (42.8%). The remainder had pneumonia (35.9%), mixed disease (18.6%) and non-respiratory (2.7%). Best diagnostic predictors for wheezy disease were (auscultation/previous similar episodes) and for pneumonia (auscultation/CXR score). Mortality was 1.6%. Best disease severity predictors were conscious level, weight/age z score and respiratory/pulse rates.
  
  
  CONCLUSIONS
  Current tachypnoea-based algorithms significantly overdiagnose pneumonia in children and underdiagnose wheezy diseases. Diagnostic accuracy can be improved by various combinations of clinical variables, but the best single diagnostic predictor is auscultation. Simple criteria can also be defined that reliably detect which tachypnoeic children are at high risk of death or deterioration. Management plans based on these protocols could reduce unnecessary antibiotic use, improve the management of wheezy diseases and reduce mortality by earlier identification of high-risk children.
authors.affiliation: Divisions of Respiratory Medicine, BC's Children's Hospital, Vancouver, Canada.
authors.forename: Vishwanath
authors.initials: V
authors.lastname: Gowraiah
authors.affiliation: Department of Paediatrics, King George Medical University, Lucknow, India.
authors.forename: Shally
authors.initials: S
authors.lastname: Awasthi
authors.affiliation: Department of Pediatrics, Regency Hospital, Kanpur, India.
authors.forename: Rashmi
authors.initials: R
authors.lastname: Kapoor
authors.affiliation: Department of Paediatrics, Vanivilas Hospital, Bangalore Medical College & Research Centre, Bangalore, India.
authors.forename: Devdas
authors.initials: D
authors.lastname: Sahana
authors.affiliation: Department of Paediatrics, Bowring and Lady Curzon Hospital, Bangalore Medical College & Research Centre, Bangalore, India.
authors.forename: Pushpalatha
authors.initials: P
authors.lastname: Venkatesh
authors.affiliation: Department of Paediatrics, Vanivilas Hospital, Bangalore Medical College & Research Centre, Bangalore, India.
authors.forename: Belvadi
authors.initials: B
authors.lastname: Gangadhar
authors.affiliation: Department of Pediatrics, Regency Hospital, Kanpur, India.
authors.forename: Aradhana
authors.initials: A
authors.lastname: Awasthi
authors.affiliation: Department of Paediatrics, King George Medical University, Lucknow, India.
authors.forename: Anilkumar
authors.initials: A
authors.lastname: Verma
authors.affiliation: Department of Paediatrics, Vanivilas Hospital, Bangalore Medical College & Research Centre, Bangalore, India.
authors.forename: Nanditha
authors.initials: N
authors.lastname: Pai
authors.affiliation: Divisions of Respiratory Medicine, BC's Children's Hospital, Vancouver, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Seear
mesh_terms: D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D006295:Health Resources; D006801:Humans; D007194:India; D007223:Infant; D008297:Male; D011014:Pneumonia / Q000175:diagnosis* / Q000401:mortality; D011203:Poverty; D011446:Prospective Studies; D012135:Respiratory Sounds / Q000175:diagnosis* / Q000209:etiology; D012141:Respiratory Tract Infections / Q000175:diagnosis* / Q000401:mortality; D059246:Tachypnea / Q000175:diagnosis* / Q000209:etiology
keywords: children; developing countries; pneumonia; wheezy diseases