Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? A prospective observational study in four Indian hospitals

Abstract

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.

Pneumonia and bronchiolitis in developing countries

“…The current study in India did not report the proportion of participants who were treated with antibiotics or whether wheeze was used by the treating clinicians as the indication to withhold antibiotics 1. Therefore, no conclusion can be drawn about the safety of using wheeze heard by auscultation to make antibiotic decisions.…”

“…These guidelines include the differential diagnosis of cough and difficult breathing, and separate guidelines for the management of pneumonia, bronchiolitis and asthma. This recognises the core issue behind the study in this edition of Archives by Dr Vishwanath Gowraiah and colleagues from four hospitals in India; that many children who fulfil WHO's traditional criteria for pneumonia (cough and difficult breathing with or without chest in-drawing) have wheezy viral infections 1. The WHO guideline, contained in the second edition of the Pocket Book of Hospital Care for Children ,2 lists the clinical features in favour of pneumonia, bronchiolitis, asthma and other common and less common causes of cough and respiratory distress.…”

“…The study by Gowraiah et al concluded that using a stethoscope to detect wheeze on auscultation was the most reliable way to distinguish pneumonia from wheezy viral infection 1. This might be true, but it is arguable.…”

“…Although radiologists have good agreement on the presence of consolidation in non-severe pneumonia,13 14 chest radiographs do not help the diagnosis of bronchiolitis, nor do they help limit antibiotic therapy 11. Fever has not been shown to distinguish viral from bacterial infection in infants with clinical bronchiolitis, but it does predict severe disease and radiographic consolidation,15 and the Indian study found significantly higher rates of fever in children classified as pneumonia than ‘wheezy disease’ 1…”

Antibiotics for community‐acquired pneumonia: Only sometimes!

“…That re‐evaluation determined that the diagnosis of pneumonia was not supported in 40% of the patients, and antibiotics were judged to be unnecessarily given in 85%. An observational study at four hospitals in India of 516 children under 6 years of age diagnosed as pneumonia based on WHO criteria found that 43% had what was called “wheezy disease,” more consistent with asthma or bronchiolitis than pneumonia …”