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TH E IN TERR ELATIO N S O F RAD IO LO G ICFIN D IN G S AN D

M ECH AN ICAL VEN TILATIO N IN CO M M U N ITY

ACQ U IRED PN EUM O N IA PATIEN TS

AD M ITTED TO TH E IN TEN SIVE CA RE U N IT:A

M U LTICEN TRE RETRO SPECTIVE STU DY

Pembimbing : dr Aziza Icksan Sp. RadPenyaji : dr Nina Aspasia Harli Siregar

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Background

We should consider I! admission : acu"e respira"ory #ailure$ se%ere sepsis or sep"ic shock and radiographic e&"ension o# in'l"ra"es$ se%erely decompensa"ed co(morbidi"ies$

urren" guidelines o# I! admission algori"hm$ mechanical %en"ila"ion ) sep"ic shock is major cri"eria

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Background

A large mul"icen"er s"udy *as held "o e%alua"e"he mor"ali"y indica"ors on "he clinical grounds#or "he AP pa"ien"s *ho *ere admi""ed "o

"he I!s

We sugges" "ha" AP *hich ends *i"h an I!

admission ) mechanical %en"ila"ion may ha%edi+eren" pa""erns in radiographic 'ndings

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Background

 ,he aim : "oe%alua"e "hose pa"ien"s regarding

ini"ial radiographic 'ndings "oe&plore "he correla"ions images *i"h

"he need #or mechanical %en"ila"ion

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M ethods

-a"abase o# "he s"udy a /(cen"ers re"rospec"i%e s"udy on

"he AP pa"ien"s admi""ed "o "heI!s

 ,he da"abase *as used "o e%alua"e"he radiological 'ndings de"ec"ed*i"h 0R and ,

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M ethods

Pa"ien"s Pa"ien"s admi""ed "o I!s *i"h "he

AP "horough 1c"ober 2334 "o 5anuary 23 6"uberculosis *eree&cluded7

 ,he enrolled pa"ien"s aged 89 years$ e%idence o# AP as primary

diagnosis$ con'rmed by 0R

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M ethods

Inclusion ri"eria admi""ed "o "he I! ei"her because "hey

re;uired mechanical %en"ila"ion or judged

"o be in an uns"able condi"ion re;uiringin"ensi%e care.

 ,he pa"ien"s *ere e%alua"ed #or "heir

radiological 'ndings and "he eligible ones

only "hose *i"h NI< or only I=< *erecompared

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M ethods

>&clusion cri"eria *hoe%er *i"h inconclusi%e or

inde"ermina"e 'ndings on 0R *ase&cluded

"hose *ho needed NI< *i"h subse;uen"

I=< or %ice %ersa *ere e&cluded

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Design and variables

, and 0R %ariables  "he de'ni"ion o# "he 'ndings:

consolida"ion$ in"ers"i"ial?pa"chy in%ol%emen"$ abscess and ca%i"a"ions

"he localiza"ion: unila"eral mul"i(lobar 6more "han "*o lobes7 in%ol%emen" bila"eral in%ol%emen"

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Statistical analysis

Analyses @i%aria" hi(s;uare "es" or ishersB e&ac" "es" 1dds ra"io 61R7 and /CD 6Is7 *ere gi%en

#or each signi'can" radiological %ariable alcula"ion o# correla"ions

be"*een 0R and , 'ndings$ used

kappa s"a"is"ic =ul"i%aria" analyses$

 all radiological parame"ers *ereincluded due "o "heir clinical signi'cance

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Results rom EEC pa"ien"s CF pa"ien"s *ere e&cluded because

o# inconclusi%e or inde"ermina"e 'ndings  A "o"al o# G44 pa"ien"s *ere enrolled. 1# all$

29C 694D7 *ere males

2G 6G2D7 *ere #emales "he mean age *as 92 J ( 4.2 years 6min 9$ ma& /C7

onsolida"ion *as "he main 'nding 4/.2D 60R7$ F/.FD 6,7

=ul"i(lobar in%ol%emen"  EE.FD 60R7$ EE./D 6,7

@ila"eral in%ol%emen" *as  G/.GD 60R7$ EG.CD 6,7

Abscesses and ca%i"a"ions *ere rarely #ound

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Tabel 1

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Results

rom all G44 pa"ien"s$ 9/ pa"ien"s 64D7 didn" need any kind o#

%en"ila"or spor"  G/ pa"ien"s: 642D7 needed mechanical

%en"ila"ion:

rom all G44 pa"ien"s$ 9F 6EGD7 pa"ien"s re;uired I=< and 22 6CFD7 pa"ien"s needed NI<

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Results

 ,he G/ pa"ien"s *ho needed %en"ila"orsuppor" 9/needed subse;uen" uses o# bo"h I=<

and NI< 6e&cluded7  ,he remaining 2C3 pa"ien"s *ho jus"

needed I=< or NI< 6analysed7 /4 pa"ien" 6I=

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Results

In uni%aria"e analysis$ NI< re;uiremen"

*as more common in pa"ien"s *i"h mul"ilobar

in%ol%emen" on 0R "hough s"a"is"icallyinsigni'can" 6p K 3.7.

pa"ien"s *i"h consolida"ion on , 6p L 3.337.

I=< re;uiremen" common in "hose *i"h ca%i"y on 0R 6p K3.3G7

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Tabel 2

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Results

In mul"i%aria"e analyzes$ Among all 0R 'ndings$

only mul"ilobar in%ol%emen" on 0R *as #ound "o be

a risk #ac"or #or NI< 61R: 2.G9$ /CD Is: .2F(E.G4$ pK 3.3397 No rela"ion *as #ound be"*een 0R 'ndings and

I=

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Results

Regarding , 'ndings$ consolida"ion *as a risk #ac"or #or NI<

 61R: EF.E/$D/CIs:G.FF(C/F.C9$ p K 3.3G7 mul"ilobar in%ol%emen" *as a risk #ac"or

#or I=< 61R: F.FF /CD Is:.29(EF./E$ p K 3.32F7.

in"ers"i"ial in%ol%emen"  could be a risk#ac"or #or NI< as *ell 61R: 9.GG$ /CD Is:3.99(9.2G p K 3.7. 6i# *e *ould "ake"he p %alue as 3.7

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CT vs CXR

1# all$ "here *ere 9/ pa"ien"s *ho had bo"h ,and 0R e&amina"ions a%ailable

 ,he highes" correla"ion be"*een , and 0R'ndings *as obser%ed #or in"ers"i"ialin%ol%emen" 6M K 3.C3$ p L 3.337

orrela"ion o# consolida"ion be"*een "*oimaging modali"y *as also signi#ican" 6M K3.G2$ p K 3.33G7.

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CT vs CXR

1nly one o# '%e pa"ien"s *ho had abscesses on 0Rhad also , e&amina"ion

None o# "he pa"ien"s *ho *ere repor"ed "o ha%eca%i"a"ions in 0R had ,

correla"ion analysis could no" be per#ormed #or abscessand ca%i"a"ions.

  Al"hough s"a"is"ically signi'can"$ correla"ions be"*een

0R and , *ere *eak #or bila"eral and mul"ilobarin%ol%emen" 6M K3.22$ p K 3.3C and M K3.GC$ p K3.33G7.

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Discussion

 ,he radiographic 'nding "he in"errerrela"ions*i"h mechanical %en"ila"ion #or AP pa"ien"sadmi""ed "o "he I!s *ere e%alua"ed in "his

s"udy

 Al"hough 0R has only around G3Dspeci'ci"y$ s"ill 0R is "he key "ool *i"h i"s

e&cellen" cos"(bene'" ra"io in "he diagnosis$especially i# i" demons"ra"es a charac"eris"icarea o# al%eolar consolida"ion

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Discussion

 ,he sensi"i%i"y and speci'ci"y o#clinical 'ndings on physicale&amina"ion *ere repor"ed "o beC4D and 9FD$ respec"i%ely

When "he radiography is nega"i%e$"he signi'cance o# "he clinical'ndings is unclear

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Discussion

 ,he ini"ial images o# 0R may no" disclose radiological'ndings in one('#"h o# AP pa"ien"s.

Ho*e%er$ in more "han hal# o# "hese pa"ien"s *i"hou" ini"ial

radiological con'rma"ion$ in'l"ra"es had been obser%ed onsubse;uen" 0R

,is also needed in some cases "o clear ou" "he diagnosis$par"icularly in case o# complica"ions.

Since "he inclusion cri"eria o# our group *as mainlydependen" on radiographic 'ndings$ a" leas" on 0R$ "hecomparison be"*een "he radiology nega"i%e and posi"i%egroups *ere una%ailable in our s"udy.

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Discussion

 ,he main radiographic 'nding: consolida"ion 64/D in 0R and 43D in ,7 in"ers"i"ial in%ol%emen" *as #ound in one(

#our"h o# "he cases in 0R and inappro&ima"ely hal# o# , e&amina"ions.

Abscesses and ca%i"a"ions *ere rare'ndings.

Ad%anced 'ndings like mul"ilobar andbila"eral in%ol%emen"s *ere also common'ndings seen in up "o hal# in our s"udygroup

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Discussion

In "he rou"ine $ 0R is e%alua"edby "he physician *hile "he ,assessed by "he radiologis"

Physicians ) radiologis"s are#re;uen"ly kno*n "o disagree

 In one s"udy$ nearly C3D pa"ien"*i"h pneumonia 6physician7 *ere

normal by "he radiologis"

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Discussion

 ,he correla"ion be"*een , and 0R 'ndings in ours"udy *as highes" #or in"ers"i"ial in%ol%emen" 6C3D7  #ollo*ed by mul"ilobar in%ol%emen"

 consolida"ion in GGD @ila"eral in%ol%emen" in 23D

Al"hough correla"ions seem "o e&is" be"*een 0R and,$ , *i"h be""er resolu"ion should be considered in "he

diagnosis o# pulmonary disorders unde"ec"ed by 0R.

 ,hus$ , should be "aken in"o considera"ion *hen ini"ialpor"able ches" roen"genogram and clinical course o# "heI! pa"ien" *i"h AP do no" correla"e.

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Discussion

1nly 4D o# our s"udy group had ,e%alua"ion due "o "he dicul"ies inper#orming ches" , #or "hose uns"able

or #or pa"ien"s *i"h se%ere respira"ory#ailure hospi"alized in "he I!

 ,here#ore$ comparison o# all 'ndings on0R and , *ere unlikely

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Discussion

When should consider higher c" #orolder age 6mean age 927 and se%eri"yo# cases bu" only one o# si& cases

under*en" , e%alua"ion

Hence$ *e may also sugges" "ha"

al"hough a%ailable in all cen"ers , isno" rou"inely used$ e%en in se%ere cases

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Discussion

NI< re;uiremen" *as seen "o be more common in "hose*i"h mul"ilobar in%ol%emen" on 0R as 2.E(#old onsolida"ion on , as EF(#old

1n "he o"her hand$ I=< need increased 4(#old in pa"ien"s*i"h mul"ilobar in%ol%emen" on ,

No associa"ion *as #ound be"*een 0R 'ndings and I=<

 ,here#ore$ pa"ien"s *i"h consolida"ion and mul"ilobarin%ol%emen" re;uire a %ery close #ollo* up #or "hesubse;uen" need #or mechanical %en"ila"ion.

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Discussion

In general medical prac"ice$ "he usualAP is so called lobar pneumonia and i"is usually limi"ed "o one lobe or segmen"

>%en "hough "he mul"ilobar in'l"ra"esare o# minor cri"eria and ca%i"a"ion is

no" included in "he lis" #or admission o#"he AP pa"ien"s "o "he I! $ "hey seem"o deser%e major a""en"ion according "oour 'ndings

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Discussion

 ,he de"ec"ion o# mul"ilobar in%ol%emen" and"he presence o# consolida"ion *ould #re;uen"lyre;uire mechanical %en"ila"ion in AP pa"ien"s

in "he I!s. 1n "he o"her hand$ our s"udy could no" in%ol%e

"he subse;uen" images o# our pa"ien"s.  Radiologic progression o# pulmonary

in'l"ra"es *i"hin "he 'rs" E4 hours in pa"ien"s*i"h se%ere AP is an independen" predic"or o#ad%erse ou"come *i"h a "hree#old increase in"he risk o# dea"h

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Discussion

Ho*e%er$ some o"her s"udies do no"suppor" "he se;uen"ial 0R since i" isbelie%ed no" "o ha%e a signi'can"impac" on clinical managemen" o#"he disease

 ,hus our da"a should be in"erpre"ed

as "he ecacy o# ini"ial imagingduring I! admission in predic"ing"he need o# mechanical %en"ila"ion

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Conclusion

AP pa"ien"s *ho are admi""ed "o "he I! are se%ere casesre;uiring %en"ila"or suppor".

0R and , 'ndings correla"e up "o a limi" in "erms o#

in"ers"i"ial in%ol%emen" and consolida"ion as *ell as bila"eraland mul"ilobar in%ol%emen". 0R is used *idely and , e%alua"ion is no" a%ailable #or all

pa"ien"s.  Al"hough "he correla"ions *ere no" %ery high be"*een "*o

modali"ies$ bo"h can be used in daily prac"ice. We #ound a cer"ain rela"ion be"*een mechanical %en"ila"ion

need and radiological 'ndings$ bu" "he assumed ongoing realprac"ice is impor"an" and "he %alue o# radiologic e%alua"ionbeyond clinical 'ndings "o predic" "he mechanical %en"ila"ionneed is subjec" #or #ur"her e%alua"ion *i"h large pa"ien" series.

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 ,hank Oou