Diagnosing pediatric pneumonia under low-resource conditions: The predictive value and reporting reproducibility of chest x-rays

Background: To meet child mortality targets, it is necessary to improve diagnosis and management of pneumonia. Although CXRs are used as a reference gold standard, their predictive value and reporting reproducibility have never been studied under low-resource conditions. Methods: As part of a larger study of pneumonia in India, we enrolled 502 children below 5 yrs, who met WHO criteria for pneumonia. Patients underwent a detailed examination, saturation and CXR. We selected a sub-group of 133 who had digitized radiographs. ER physician and consultant interpreted films as: normal, minor or major patches, hyperinflation, lobar change, pleural effusion. All children were reviewed 4 days later by a pediatrician and given one of four clinical diagnoses: pneumonia, wheezy disease, mixed and non-respiratory. Films were later reviewed by 2 consultant radiologists. Results: The 10% of X rays showing pleural effusions had good reporter agreement and reliably predicted pneumonia and disease severity. For all other CXR findings (90%), there was no correlation between X ray category and clinical diagnosis, or with disease severity (defined by hospital admission). There was also poor agreement between X ray interpretations made by ER physician, pediatrician and radiologist (all kappa Conclusions: With the exception of pleural effusions, CXR findings, interpreted by a radiologist, had no power to predict clinical diagnosis, made by a pediatrician or disease severity. Clinical value of CXRs was further reduced by poor inter-observer agreement. When studying tachypneic children under low-resource conditions, CXRs have less clinical value than is commonly assumed.