pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/claessens-tdm.pdf ·...
TRANSCRIPT
![Page 1: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/1.jpg)
Pneumonie aigue communautaire.
Place du scanner thoracique.
Yann-Erick Claessens
Service de Médecine d’Urgence
Centre Hospitalier Princesse Grace, Principauté de Monaco
![Page 2: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/2.jpg)
Conflicts of interest.
![Page 3: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/3.jpg)
Le bon diagnostic
Ray P et al. Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care Med. 2006;10:R82.Mandell LA et al. IDSA/ATS Guidelines for CAP in adults. Clin Infect Dis. 2007;44:S27-72.
« Almost all of the major decisions regarding management of CAP, including diagnostic and treatment issues,
revolve around the initial assessment »
Monocentrique. fev 2001 – sept 2002. EpidasaDyspnée < 2 semaines514 patients; 80 (9) ans
![Page 4: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/4.jpg)
Pneumonie Aiguë Communautaire
![Page 5: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/5.jpg)
;00,+$;&$%,+5/(*0,-$01$.3+)903/"$/3$20L+,$,+-./,"*0,#$*,"(*$/31+(*/03-6$M:$.,0-.+(*/N+$(0)74$(09.2/("*/03$(040,*$-*)5#&$O), !+-./, P&$$<=@I?Q=6@I==JMJ&
7+3+,"2$.,"(*/*/03+,-$6$Q8<<<
-)-.+(*+5$%':$6$<A8RAAM
@KL++S$(4+-*$TK!"#$6$I<=
5+1/3/*+$.,0U"U2+$%':$6$@@Q
:2/3/V)+$.+)$.+,10,9"3*+
Pneumonie Aiguë CommunautaireSignes et symptômes
![Page 6: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/6.jpg)
Pneumonie Aiguë CommunautaireRadiographie de thorax comme Gold standard
'3# ")*40, !"#$%&$'3#$*0./(&$'3#$W0),3"2&$'3#$#+",?$"3#$/--)+&
;"35+22 B'$+*$"2&$CDE'F'GE$H)/5+2/3+-$10,$:'%$/3$"5)2*-&$:2/3$C31+(*$D/-&$<==I?JJ6E<IKI<&
![Page 7: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/7.jpg)
Pneumonie Aiguë CommunautaireSignes et symptômes
Chandra A et al. A multicenter analysis of the ED diagnosis of pneumonia. Am J Emerg Med. 2010;28:862-5.
[Clinique + Radiographie standard] peu performante
3 services d’urgences de 3 hôpitaux universitaires (NY & NC, USA)
● diagnostic initial PAC : 800 patients
● diagnostic ICD-9 PAC : 219 (27.3%; 95% CI 24-31)
●
Ø 18% maladie respiratoire (asthma, BPCO, DDB, bronchite)
Ø 16% maladie rénale
Ø 9% (95% CI, 7-11) autre infection
Ø 3% maladie cardiovasculaire
Ø 28% autre maladie
(RGO, oesophagite, médiastinite, ostéomyélite, douleur thoracique NS)
![Page 8: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/8.jpg)
Pneumonie Aiguë CommunautaireRadiographie de thorax
![Page 9: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/9.jpg)
Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired pneumonia. Braz J Infect Dis. 2011;15:540-6.Le Blanche AF et al. Evaluation of hands-up ergonomics for chest radiography in geriatric patients. Invest radiol 2002;37:35-9.
Quality● 103 chest X-ray (median 86.5 yrs, 70-104)● Arms along the trunk 44 CAP [kappa 0.36]● « Hands-up » 59 CAP [kappa 0.84]
Pneumonie Aiguë CommunautaireDifficultés d’interprétation des radiographies (qualité et nouvel infiltrat)
![Page 10: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/10.jpg)
Young M et al. Interobserver variability in the interpretation of chest roentgenograms of patients with possible pneumonia. Arch Intern Med 1994;154:2729-32.
Concordance between 2 radiologists for CAP diagnosis (282 patients)Question Answer Agreement Kappa
Infiltrate ? YesNo
79,4%6%
0,37 (0,22-0,52)
Distribution ? UnilobarMultilobar
41,50%33,90%
0,51 (0,28-0,62)
Effusion ? YesNo
10,70%73,20%
0,46 (0,33-0,50)
Caracteristics ? AlveolarInterstitial
93,60%100%
- 0.01 (-0,03 – 0,00)
Bronchogram ? YesNo
7,60%52,90%
0,01 (-0,13-0,15)
Interobserver variability (gold-standard : 3 board-certified radiologists)
• original radiologists 87%• medical students (1yr) 59% • medical students (4yr) 54%• medical residents 66%• attending staff 72%
Pneumonie Aiguë CommunautaireDifficultés d’interprétation des radiographies (cliniciens et radiologues)
![Page 11: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/11.jpg)
;"35+22 B'$+*$"2&$CDE'F'GE$H)/5+2/3+-$10,$:'%$/3$"5)2*-&$:2/3$C31+(*$D/-&$<==I?JJ6E<IKI<&
Pneumonie Aiguë Communautaire La radiographie standard peut être normale
![Page 12: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/12.jpg)
Imagerie thoracique et interprétationUne histoire de cônes et de bâtonnets
![Page 13: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/13.jpg)
Imagerie thoracique et interprétationUne histoire de cônes et de bâtonnets
![Page 14: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/14.jpg)
Future is now
![Page 15: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/15.jpg)
Rajpurkar P et al. CheXNet: Radiologist-Level Pneumonia Detection on Chest X-Rays with Deep Learning. arXiv:1711.05225v3
input chest X-ray imageoutput CAP 85%112,120 frontal X-ray; 30,805 patients
Pneumonie Aiguë CommunautaireImagerie et machine learning
![Page 16: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/16.jpg)
Massat MB. Artificial intelligence in radiology: Hype or hope? Applied Radiol. March 2018. 22-28.Rajpurkar P et al. CheXNet: Radiologist-Level Pneumonia Detection on Chest X-Rays with Deep Learning. arXiv:1711.05225v3
Pneumonie Aiguë CommunautaireImagerie et machine learning
![Page 17: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/17.jpg)
;"35+22 B'$+*$"2&$CDE'F'GE$H)/5+2/3+-$10,$:'%$/3$"5)2*-&$:2/3$C31+(*$D/-&$<==I?JJ6E<IKI<&
Pneumonie Aiguë CommunautaireDiagnostic incertain : penser au scanner thoracique
![Page 18: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/18.jpg)
Esayag Y et al. Diagnostic Value of Chest Radiographs in Bedridden Patients Suspected of Having Pneumonia. Am J Emerg Med 2010;123:88e1-e6
Pneumonie Aiguë CommunautaireScanner thoracique et incertitude diagnostique
RP positive / TDM négative RP positive / TDM négative
![Page 19: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/19.jpg)
Esayag Y et al. Diagnostic Value of Chest Radiographs in Bedridden Patients Suspected of Having Pneumonia. Am J Emerg Med 2010;123:88e1-e6
Pneumonie Aiguë CommunautaireScanner thoracique et incertitude diagnostique
Difficultés d’interprétation si lésion des bases
![Page 20: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/20.jpg)
Prendki V et al. Low-dose CT for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study. Eur Respir J. 2018; in press. doi.org/10.1183/13993003.02375-2017.
65+ years(dpt internal medicine)suspected pneumonia chest X-ray and CT-scan / 72hprobability pneumonia (Likert scale) before and after CT-scanGold standard adjudication committee
D 90 (45%) patients• 60 (30%) downgraded• 30 (15%) upgraded
Pneumonie Aiguë CommunautaireScanner thoracique modifie la certitude diagnostique
![Page 21: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/21.jpg)
Claessens YE et al. Early Chest Computed Tomography Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-acquired Pneumonia. AJRCCM 2015;192:174-82.
ReclassificationD 187 (59%) patients• 128 (40%) downgraded 11 definite è excluded)• 59 (18%) upgraded (2 excluded è definite)
Pneumonie Aiguë CommunautaireScanner thoracique modifie la certitude diagnostique
![Page 22: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/22.jpg)
Claessens YE et al. Early Chest Computed Tomography Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-acquired Pneumonia. AJRCCM 2015;192:174-82.
Reclassification & Gold standardD 100 (59%) patients• 20 not adequate• 80 adequate (25.1% population, NRI=0.39)
è 70 downgraded, 10 upgraded
Pneumonie Aiguë CommunautaireScanner thoracique modifie la certitude diagnostique
![Page 23: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/23.jpg)
1280 ED patients 245 ED physicians387 chest pain / dyspnea+/ - D level of certainty
(+) (-)
Pandharipande PV et al. CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making. Radiology 2016;78:812-21.
Pneumonie Aiguë CommunautairePlus le diagnostic est incertain, plus le scanner est utile
![Page 24: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/24.jpg)
1280 patients des urgences245 médecins387 douleur thoracique / dyspnée+ D / - certitude
(+) (-)
… change d’autant plus le diagnostic qu’il est incertain
Pre-CT scan Level of Diagnosis Certainty
Patie
nts (
%) w
ithdi
agno
sisc
hang
es a
fter
CT sc
an
Pandharipande PV et al. CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making. Radiology 2016;78:812-21.
Nb of patients
Pneumonie Aiguë CommunautairePlus le diagnostic est incertain, plus le scanner est utile
Plus grande est l’incertitude,
Plus utile est le scanner
![Page 25: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/25.jpg)
Before CT-scan After CT-scan
Antibiotics Initiation n=207 (65%) StopInitiationChange
n=29n= 51n=70
(9%)(16%)(22%)
Other treatments Anti-coagulation (PE)Diuretics (HF)
n=3n=11
Site of care Admission n=250 (78%) AdmissionChanges- ambulatory è admission- admission è ambulatory
n=249
n=45n=22 n=23
(78%)(14%)
Claessens YE et al. Early Chest Computed Tomography Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-acquired Pneumonia. AJRCCM 2015;192:174-82.
Pneumonie Aiguë CommunautaireLe scanner thoracique modifie les décisions médicales
![Page 26: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/26.jpg)
Tubiana S et al. Antibiotic guidelines adherence in clinical practice in patients visiting emergency units for community acquired pneumonia: Role of diagnosis level of certainty. submitted
Avant scanner Après scanner
Adherent to guidelines Yes (n=108) No (n=208) Final model (multivariate analysis)
Age ≥ 65 years 71 (65.7) 105 (50.5) 1.38 (1.01; 1.87)
Previous antibiotic treatment 23 (21.3) 86 (41.4) 0.50 (0.35; 0.72)
Pleural effusion 38 (35.2) 46 (22.2) 1.37 (1.03; 1.82)
High levels of certainty (definite or excluded CAP) 75 (69.4) 71 (34.1) 2.61 (1.88; 3.62)
Pneumonie Aiguë CommunautaireLe scanner thoracique améliore les décisions médicales
![Page 27: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/27.jpg)
Upchurch CP et al. Community-Acquired Pneumonia Visualized on CT Scans but Not Chest Radiographs: Pathogens, Severity, and Clinical Outcomes. Chest. 2018;153:601-10.
2,251 patients avec PAC• 2,185 (97%) è Radiographie thoracique POS• 66 (3%) è Radiographie thoracique NEG / CT-scan POS
Patients comparables pour• Caractéristiques cliniques• Comorbidités• Signes vitaux• DMS• Pathogènes (virus 30% vs. 26%; bacteries 12% vs. 14%)• Admission soins critiques (23% vs. 21%)• Ventilation mécanique (6% vs. 5%)• Choc septique (5% vs. 4%)• Mortalité hostpitalière (0 vs. 2%)
Des patients similaires devraient avoir une prise en charge identiqueAvantages du bon diagnostic ? Scanner pour tout le monde
Pneumonie Aiguë CommunautairePAC certaines ou PAC occultes : la même maladie
![Page 28: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/28.jpg)
Garin N et al. Rational Use of CT-Scan for the Diagnosis of Pneumonia: Comparative Accuracy of Different Strategies. J Clin Med. 2019 Apr 15;8(4). pii: E514. doi: 10.3390/jcm8040514.
Risk Ratio [95%CI] Weight
Cough (acute) 3.77 [1.51-9.4] 1
Male 2.23 [1.12-4.44] 1
Urea 0.92 [0.86-0.98] 1
C reactive protein 1.01 [1.0-1.01] 1
54% de scanner
AUC .55 (95% CI [.46–.64]) • Se .95 • Sp .48 • PPV 1.8 • NPV .1
Pneumonie Aiguë CommunautaireLe scanner thoracique : pas pour tout le monde
![Page 29: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/29.jpg)
B0)U+* %$+*$"2&$:099)3/*#$"(V)/,+5$.3+)903/"$5/"730-/-$/3$*4+$+9+,7+3(#$5+.",*9+3*6$5+N+20.9+3*$"35$+]*+,3"2$N"2/5"*/03$01$*4+$OE:'%OD "270,/*49$*0$1"(/2/*"*+$5/"730-/-$"35$7)/5+$(4+-*$:GK-("3$/35/("*/03&$:2/3 ;/(,0U/02 C31+(*&$<=@e$P)2$Q&$.//6$E@@eAKIJMT^@ecM=MIIKQ&$50/6$@=&@=@>FW&(9/&<=@e&=>&=<>&
D(3T,D7&(",iB=WQ^j k%(HN&
Q"*HN 1+>,i1+0P1+Bj 1
QN%3&,47(# 1+X,i1+1P1+Lj 1
e%.%',Af,X@mQC 1+X,i1+0P1+Lj 1
E"3(&(.%,EQD,A%Z$%4&,'N(#".('*3C 1+>,i1+1P1+Rj 1
Q,'%7$&(.%,4'"&%(#,f,0+=0,<HFS 1+R,i1+XP/+/j /
E7'%#$N9<7I,(#-(I&'7&% 1+R,i1+XP/+Xj /
0
10
/0
X0
>0
=0
L0
R0
@0
B0
100
0 1 / X > = L R @
E'"K
7K(I(&9,"-,4
'"K7KI%F6%-(#
(&%,QaE
U'%9,n"#%,iXP=j,o,1RRFX1B,A==WC,
alQ,+@1,AB=W,Q^,i+RR2+@=jC,q b%,,,,+RX,AB=W,Q^,i+LL2+@0jCq b4 +@B,AB=W,Q^,i+@XP+B>jCq EEh,+@@,AB=W,Q^,i+@1P+BXjC,q ]Eh,+RL,AB=W,Q^,i+LBP+@/jC
Pneumonie Aiguë CommunautaireLe scanner thoracique : pas pour tout le monde
![Page 30: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/30.jpg)
Risk Ratio [95%CI] Weight
Cough 1.3 [1.0-1.8] 1
Chest pain 1.3 [1.1-1.5] 1
Fever (≥ 38°C) 1.4 [1.1-1.7] 1
C reactive protein ≥ 0.50 mg/L 1.3 [1.1-1.6] 2
Parenchymal infiltrate 1.9 [1.5-2.6] 3
Grey zone [3-6] : 219/319 (69%)
AUC .81 (95% CI [.77–.86]) • Se .72 (95% CI [.64–.79])• Sp .91 (95% CI [.85-.95]) • PPV .89 (95% CI [.82-.94]) • NPV .76 (95% CI [.70-.82])
Pneumonie Aiguë CommunautaireLe scanner thoracique : pas pour tout le monde
Loubet P et al. Community acquired pneumonia diagnosis in the emergency department: development and external validation of the ESCAPED algorithm to facilitate diagnosis and guide chest CT-scan indication. Clin Microbiol Infect. 2019 Jul 5. pii: S1198-743X(19)30377-5. doi: 10.1016/j.cmi.2019.06.026.
![Page 31: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/31.jpg)
Scanner thoracique et Pneumonie aiguë Communautaire.Take Home Message.
● Chest X-ray as a Gold standardü imperfect but helpful
ü sparcely used for ambulatory patients
● CT-scan for uncertain diagnosisü 2/3 should have CT-scan
ü additional information (mPCR) to limit the use
● Computer to help interpretation
● Chest ultrasoundsü interesting PPV
ü operator – dependent
ü ongoing studies to precise strategy
● Balanced recommendation for real life practices
![Page 32: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/32.jpg)
Diagnosing CAP. CAP diagnosis on examination and chest X-ray is difficult
Flateau C et al. Discrepancies in Community-Acquired Pneumoniae Definition in Randomized Clinical Trial: Possible Impact on Trial Validity. submitted
Inclusion criteria for CAP Corresponding Escaped patients (n=319)
Sensitivity (%) Specificity (%) VPP (%) VPN (%)
Infiltrate on chest X-ray 61 31.3 93.6 83.6 55.6and ≥ 1 respiratory symptom and fever and biological inflammatory syndrome
Infiltrate on chest X-ray and ≥ 1 respiratory symptom and fever
103 47.2 83.3 74.8 60.2
Infiltrate on chest X-ray 187 73.0 56.4 63.6 66.7and ≥ 1 respiratory symptomInfiltrate on chest X-ray and ≥ 2 respiratory symptoms
170 67.5 61.5 64.7 64.4
Infiltrate on chest X-ray 178 71.2 60.3 65.2 66.7and > 1 or ≥ 2 criteria among
Dyspnoea or polypnoeaChest painCoughSputumAbnormal pulmonary auscultation
Biological inflammatory syndrome
![Page 33: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/33.jpg)
Inclusion criteria for CAP Corresponding Escaped patients (n=319)
Se (%) Sp (%) Positive PV(%)
Negative PV (%)
Infiltrate on chest X-ray 61 31.3 93.6 83.6 55.6and ≥ 1 respiratory symptom and fever and biological inflammatory syndrome
Infiltrate on chest X-ray and ≥ 1 respiratory symptom and fever
103 47.2 83.3 74.8 60.2
Infiltrate on chest X-ray 187 73.0 56.4 63.6 66.7and ≥ 1 respiratory symptomInfiltrate on chest X-ray and ≥ 2 respiratory symptoms
170 67.5 61.5 64.7 64.4
Infiltrate on chest X-ray 178 71.2 60.3 65.2 66.7and > 1 or ≥ 2 criteria among
Dyspnoea or polypnoeaChest painCoughSputumAbnormal pulmonary auscultation
Biological inflammatory syndrome
Fever and dyspnoea / polypnoeaand new cough and purulent sputum Abnormal pulmonary auscultation
20 9.8 97.4 80.0 50.8
Fever 50 23.3 92.3 76.0 53.5and new sputum and ≥ 2 criteria among
DyspnoeaPolypnoeaChest pain
Flateau C et al. Discrepancies in Community-Acquired Pneumoniae Definition in Randomized Clinical Trial: Possible Impact on Trial Validity. submitted
Diagnosing CAP. Good medicine without X-ray
![Page 34: Pneumonie aigue communautaire.emc2-congres.com/files/105/2019/coms/jeudi/Claessens-TDM.pdf · Moncada DC et al. Reading and interpretation of chest X-ray in adults with community-acquired](https://reader034.vdocuments.site/reader034/viewer/2022052008/601c8b8f443e4204d35f4b88/html5/thumbnails/34.jpg)
Moore M et al. Predictors of pneumonia in lower respiratory tract infections: 3C prospective cough complication cohort study. Eur Respir J 2017;50:1700434.van Vugt SF et al. Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography. Eur Respir J 2013;42:1076–82.
Few LRTI have chest-Xrays5,222 practices; 2009–2013• 28,883 acute cough• 1782 (6%) chest X-ray d0-d30• 720 (3%) chest X-ray d0-d7
LRTI might be CAP294 general practitioners• 2810 acute cough• chest X-ray d0-d7• 2670 evaluable
Pneumonie Aiguë Communautaire - ApparteLa radiographie standard dans la vraie vie