Pneumonie aigue communautaire.

Place du scanner thoracique.

Yann-Erick Claessens

Service de Médecine d’Urgence

Centre Hospitalier Princesse Grace, Principauté de Monaco

Conflicts of interest.

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

Pneumonie Aiguë Communautaire

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Pneumonie Aiguë CommunautaireSignes et symptômes

Pneumonie Aiguë CommunautaireRadiographie de thorax comme Gold standard

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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)

Pneumonie Aiguë CommunautaireRadiographie de thorax

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)

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)

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Pneumonie Aiguë Communautaire La radiographie standard peut être normale

Imagerie thoracique et interprétationUne histoire de cônes et de bâtonnets

Imagerie thoracique et interprétationUne histoire de cônes et de bâtonnets

Future is now

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

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

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Pneumonie Aiguë CommunautaireDiagnostic incertain : penser au scanner thoracique

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

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

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

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

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

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

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

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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

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

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

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

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

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Pneumonie Aiguë CommunautaireLe scanner thoracique : pas pour tout le monde

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.

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

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

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

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