Investigation of Chest X-Ray Use in the Emergency Department in
Pediatric Patients with Sickle Cell Disease
Abstract
Determining which patients are at highest risk of acute chest syndrome
(ACS) is challenging for pediatric emergency department (PED) providers,
resulting in more chest x-rays (CXR), increased radiation exposure, and
higher healthcare costs. The objective of this study was to identify
significant clinical predictors of ACS to better guide care. In this
retrospective review, we included patients diagnosed with sickle cell
disease (SCD), aged 2-12 years, who presented to the PED between
2016-2018. We compared patients who were febrile vs. afebrile on
presentation, and those diagnosed with ACS vs. those who were not. A
total of 424 patients met inclusion criteria, 25% presenting with
fever. For febrile patients, 69% received a CXR on presentation vs.
42% of afebrile subjects (p=<0.0001). Overall, 10% of
patients were diagnosed with ACS: 13% of febrile presentations vs. 9%
of afebrile presentations. Patients diagnosed with ACS were
significantly more likely to present with chest pain (p=0.003),
tachypnea (p=0.001), hypoxia (p<0.0001), and a history of
asthma (p=0.0085). Upon multivariable modeling the only significant
predictors were chest pain (OR 3.3, CI 1.5-7.4) and hypoxia (OR 8.4, CI
4-17.9). Current guidelines recommend empiric treatment and a CXR for
SCD patients presenting with fever, hypoxia, tachypnea, tachycardia or
abnormal respiratory exam. Our data demonstrate that hypoxia and chest
pain are significant predictors of ACS. Additionally, data indicated
that CXRs were likely performed in excess in febrile patients. Further
research is needed, but chest pain and hypoxia may focus the use of CXR
on the appropriate patients.