Of the 129 children admitted to the hospital in status asthmaticus during the study period, 128 had chest roentgenograms. Eighty-four (65.6 percent) of the patients had been admitted previously for asthma, while 32 ( 24.8 percent) had previously been treated only as outpatients. The remaining patients had never wheezed before the episode which precipitated admission. Three patients were admitted to the intensive care unit; the remainder were admitted to a regular pediatric floor.
The episodes of asthma not responding to conventional emergency room bronchodilator therapy were attributed to a respiratory infection in 96 cases (74.4 percent), exposure to a known allergen in 13 cases (10.2 percent) and non-compliance or an error in medication in five cases (3.8 percent). In 15 cases (11.6 percent) no precipitating factors were identified.
The subjects were divided into five groups based on roentgenographic findings. Group 1 consisted of 46 patients (35.7 percent) with normal x-ray film findings. The three patients who were admitted to the intensive care unit were in this group. Group 2 consisted of 46 patients (35.7 percent) in whom the roentgenograms were read as “hyperaerated only.” Group 3 consisted of 24 patients with sub-segmental atelectasis (18.6 percent), while the five patients (3.9 percent) in group 4 exhibited segmental atelectasis. The seven patients (5.5 percent) in group 5 had roentgenograms that were consistent with pneumonia, possible pneumonia or pneumomediastinum (Table 1). Fifty-five of the 128 patients (43.0 percent) exhibited peribronchial thickening. There was no significant difference between the groups in the frequency or severity of this finding (chi-square, p > .05).
The age, vital signs following treatment in the emergency room, and duration of wheezing prior to presentation are shown in Table 2. There was no significant difference between the five groups in age, admission temperature, pulse or respiratory rate, or duration of prior wheezing (one-way ANOVA, p > .05 for all parameters).
There was no difference between the five groups in the factors precipitating the acute asthmatic attack or in the respiratory score on admission. When the portion of the respiratory score detailing P02 was examined more closely, no difference in oxygenation between the groups was found (chi-square, p > .05 for all parameters).
The admitting physician suspected significant roentgenographic abnormalities in a total of 17 patients. There were 15 patients in whom pneumonia was clinically suspected. Rales or rhonchi were cited in 12 of these cases, in addition to or combined with fever (n = 7), decreased breath sounds (n = 2), and petechiae (n = l). Three of these 15 patients had possible pneumonia demonstrated roentgenographically. The other films showed normal findings (three), hyperaeration (two), sub-segmental atelectasis (three) or segmental atelectasis (four). Pneumothorax was suspected in one patient who had unequal breath sounds, and one patient was suspected of having pneumomediastinum based on what was felt to be subcutaneous emphysema. Neither of these suspicions was confirmed roentgenographically. Radiologically-con-firmed pneumomediastinum in one patient was not clinically suspected. In retrospect, however, the patient’s complaint of substemal chest pain might have suggested this finding.
The treatment plan as outlined before obtaining the roentgenogram was altered in only three cases. Blood was drawn for culture in three of the six patients with roentgenographic evidence of pneumonia, and ampicillin was started in one of these. No bacteria were isolated from any of the specimens, although respiratory syncytial virus (RSV) was isolated from the nasopharynx of the one child in whom it was looked for.
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Table 1—Patients wnih Significant Roentgenographic Abnormalities
|Roentgenographic Patient Findings||Basis For Suspicion||Age||Wood Score||Temperature (°C)||PulseRate/MinV||Symptom duration Resp before Rate/Min Admission||Precipi tating Event||Treatment|
|1||hyperinflated, subsegmental atelectasis, pneumonia||not suspected||26 mo||2||38.0||142||50||1 day||URI||Blood culture (no growth); ampicillin; no follow-up roentgenogram|
|2||hyperinflated, pneumonia||not suspected||10 mo||3||38.3||162||48||1 day||URI||None; follow-up roentgenogram in 3 weeks: hyperinflated|
|3||hyperinflated, segmental atelectasis or pneumonia||not suspected||18 yr||3||37.0||104||24||2 days||URI||None; no follow-up roentgenogram|
|4||hyperinflated, segmental atelectasis or pneumonia||not suspected||13 mo||2||39.2||140||48||3 days||URI||Blood culture (no growth), no follow-up roentgenogram (RSV isolated)|
|5||hyperinflated, segmental atelectasis or pneumonia||decreased breath sounds, rales||28 mo||4||37.8||120||64||1 day||URI||Blood culture (no growth); no follow-up roentgenogram|
|6||pneumonia||fever, rales||15 mo||1||37.8||120||32||1 day||URI||None;no follow-up roentgenogram|
|7||pneumo mediastinum||not suspected||16 у 8 mo||8||37.0||95||20||4 days||URI||Observed; resolved in 2 days|
Table 2 — Admission Findings
|No. Roentgenographic Age Group Patients Findings (Years)* Temp (°C)*1 46 Normal 6.7 ±5.8 37.8 ±1.0||Pulse/min* 129.0 ±22.6||Respiratory E Rate/min* (Di 41.8 ±15.6||duration of Symptoms Etye Prior to Admission) 1.8±2.6|
|2 46 Hyperinflated 6.6 ±4.9 37.6 ±0.7||123.5 ±33.7||38.7 ±16.0||1.4 ±1.3|
|3 24 Subsegmental 3.4 ±2.7 37.7 ±0.7 atelectasis||131.9 ±16.6||40.9 ±13.4||1.3 ±1.2|
|4 5 Segmental atelectasis 2.9 ±2.5 38.2 ±0.6||134.8 ±10.6||38.4 ±11.2||1.6 ± 1.1|
|5 7 Possible pneumonia or 6.0 ±7.7 37.9 ±0.7 pneumomediastinum||125.9 ±22.8||40.9 ±15.9||1.9 ±1.2|