544 - Imaging Practices of Pediatric Inpatients with Complicated Pneumonia Requiring Chest Tube

Publication Number: 544.5531

Melissa Cameron, UC San Diego-Rady Children's Hospital, San Diego, CA, United States; Michelle Polich, UC San Diego/Rady Children's Hospital San Diego, San Diego, CA, United States; Christiane Lenzen, UCSD, San Diego, CA, United States; Kyung Rhee, UC San Diego School of Medicine, La Jolla, CA, United States; Elizabeth Mannino Avila, UCSD/Rady Children's Hospital San Diego, San Diego, CA, United States

Background: Patients with pneumonia complicated by empyema or effusion often require chest tube (CT) placement. Although chest x-ray (CXR) is used to monitor these patients with a CT, there are no guidelines for imaging pediatric patients with pneumonia with a CT. Routine CXRs for monitoring patients raise concerns due to questionable clinical value and radiation exposure.

Objective: We aim to assess typical imaging practices for pediatric patients with CTs for complicated pneumonia.

Design/Methods: We created a survey in REDCap focused on typical practices related to imaging hospitalized pediatric patients with CT placed for complicated pneumonia. We emailed surveys to Pediatric Hospital Medicine division directors of the 49 Pediatric Health Information System (PHIS) hospitals up to 5 times weekly before a second hospitalist was contacted for a response. We asked recipients to forward the survey to the physician who could best answer questions about the typical practice at their hospital. Surveys were identified by hospital to ensure only 1 survey per site.

Results: 30 (61%) surveys were completed. Hospitalists completed 29 (97%) surveys, 15 (50%) of whom were division or section chiefs. Most were from free-standing children’s hospitals (n=23, 77%) in urban areas (n=26, 87%). They reported that these patients were typically on the hospital medicine service, though surgery and pulmonary services were also reported by 3 (10%) hospitals each. Eighteen (60%) reported daily CXRs were typical at their institution with 9 only obtaining CXRs as needed for clinical indications. 15 hospitals have a clinical pathway for complicated pneumonia with 6/15 recommending daily CXR while CT in place. Surgeons led decisions related to chest tube management at 17 institutions (57%). All hospitals reported use of tissue plasminogen activator (TPA) via CT, with 16 (53%) reporting TPA use “almost always.” Most (n=25, 83%) said that TPA use didn’t affect the decision to obtain imaging. Fourteen (47%) reported that routine chest x-rays were not helpful in management. While ultrasound (US) use was common prior to CT placement (n=24, 80%), only 1 site reported using US to monitor the patient with a CT.

Conclusion(s): Daily CXRs are commonly obtained in children hospitalized with complicated pneumonia with CT despite nearly half of those surveyed reporting that it was not helpful in management. Future studies should focus on the utility of this practice and identify clinical characteristics in which CXR would optimize diagnostic value in pediatric patients.