Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

McCollum, Eric D.; Ahmed, Salahuddin; Roy, Arunangshu D.; Islam, Asmd Ashraful; Schuh, Holly B.; King, Carina; Hooli, Shubhada; Quaiyum, Md. Abdul; Ginsburg, Amy Sarah; Checkley, William; Baqui, Abdullah H; Colbourn, Tim

doi:10.1016/s2213-2600(23)00098-x

Cited by 10 publications

(9 citation statements)

References 34 publications

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“…8,9 Additionally, recent data showed elevated mortality among children with a SpO2 90-92% than higher SpO2 levels. 7,[10][11][12] These findings challenge the currently recommended SpO2<90% threshold for hospitalization and oxygen treatment in LMICs.…”

Section: Introductionmentioning

confidence: 89%

“…5 However, when implemented without pulse oximeters, IMCI missed almost 70% of outpatient pneumonia cases with a SpO2<90% in Malawi and nearly 90% in Bangladesh. 6,7 As most children first access health systems at outpatient clinics, improving outpatient hypoxemia identification may be key to reducing LMIC pneumonia mortality. 4 Prior research attempted to determine whether clinical signs accurately identify a SpO2<90% in hospitalized children.…”

Section: Introductionmentioning

confidence: 99%

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Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Schuh

Hooli

Ahmed

et al. 2023

Preprint

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BackgroundPulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia.MethodsThis was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2<93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO. Results: 12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2<93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2<93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2<93% cases. Both LASSO models had similar performance for a SpO2<90%.ConclusionsIn the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.

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Section: Introductionmentioning

confidence: 89%

Section: Introductionmentioning

confidence: 99%

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Schuh

Hooli

Ahmed

et al. 2023

Preprint

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“…We explored associations between clinical variables and SpO 2 ranges to evaluate <93% as the primary outcome. We selected variables a priori : sex, age, weight-for-age z -score (WAZ), chest indrawing, wheezing, severe respiratory distress (grunting, head nodding, nasal flaring, and/or severe fast breathing), cyanosis, fever (temperature ≥38 °C), and WHO-defined general danger signs (stridor, inability to feed/drink, convulsions, and/or lethargy) ( 8 , 18 ). Severe fast breathing was defined as follows: respiratory rate ≥60 breaths/min for 3–11 month olds, ≥50 breaths/min for 12–59 month olds ( 20 ).…”

Section: Methodsmentioning

confidence: 99%

“…Evidence suggests that gaps remain with the IMCI case management strategy, especially regarding use of the algorithm without pulse oximetry. Specifically, research reported IMCI missed ∼70% of outpatient child pneumonia cases with a SpO 2 < 90% in Malawi and ∼90% in Bangladesh ( 8 , 9 ). However, a stronger emphasis on the integration of pulse oximetry into IMCI guidance—while an important next step—is unlikely to immediately solve this issue as healthcare providers in most high pneumonia burden LMICs lack access to pulse oximeter devices in outpatient settings where children usually present to care first.…”

Section: Introductionmentioning

confidence: 99%

“…Similar studies in outpatient contexts are lacking, and may reveal new evidence than research from hospitals relying on study populations of more severely ill children not representative of outpatient settings. In settings where pulse oximeters are available, recent data also showed elevated mortality among children with a SpO 2 90%–92% or 93%, as compared to higher SpO 2 levels ( 8 , 12 – 14 ). These findings further challenge the current guidelines, which recommend SpO 2 < 90% threshold for hospitalization and oxygen treatment in LMICs.…”

Section: Introductionmentioning

confidence: 99%

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Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Schuh,

Hooli,

Ahmed

et al. 2023

Front. Pediatr.

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BackgroundPulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia.MethodsThis was a retrospective pooled analysis of two outpatient datasets of 3–35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO.Results12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%.ConclusionsIn the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.

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Pneumonia

Howie,

Hamer,

Langridge

et al. 2025

International Encyclopedia of Public Health

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Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

Cited by 10 publications

References 34 publications

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Pneumonia

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