Chairperson: Dr. Azizul Hoque (MBBS, D.Ped, FCPS) Associate Professor Department of Pediatrics(U-II), MMCH.

Speaker:
Dr. Tapash Chandra Gope Assistant Registrar Ped. U-II

Relationship of Respiratory Symptoms and Signs with Hypoxemia in Infants Under 2 months of Age

Dr. Keshav Agrawal Dr. Chandeshwor Mahaseth Dr. Ajit Raymajhi

Source: Nepal Pediatric Society Journal V 31/Issue 3/2011 P:202-208

 Study site: Kanti Children Hospital,

Maharajgunj and Kathmandu, Nepal.

Study period: August 2007 to July 2008. Study type: Hospital based

prospective cross sectional study

 Age group:

1. 24 hours to 7 days of life (Early Neonate) 2. 8 days to 28 days of life (Late Neonate) 3. 29 days to 60 days of life.(Early Infant)
Sample Size:

160 infant < 2 months

 Inclusion criteria:

Infant < 2 months, presenting to Out Patients department (OPD) or Emergency department with any acute illness were included.

 Exclusion criteria:
Infants

24 hours of age With major congenital malformations Referred cases after previous hospitalization, Severely ill requiring intensive care and clinically suspected Cyanotic Congenital Heart Disease or found later on Echocardiography.

 This study included a total of 164 infants out of

which 4 were excluded because they were diagnosed to have Congenital Heart Disease by Echocardiography.
Out of remaining 160 infants, 95 (59.4%) were

males and 65 (40.6%) were females.

Of the total population,56(35%) were hypoxic

where as 104(65%) were not hypoxic.

Based on different symptoms (chief complaints), it was found that :

In the age group of 1-7 days and 8-28 days:

Fever and decrease sucking were the two most common complaints Cough is the second common complaint.

In the age group of 2960 days :

Fever and cough were the main complaint category difficulty in breathing as the next common complaint. common in all age categories.

History of convulsion was found to be the least

Age Groups >>

1-7 days (n=22) 18 (82%)

8-28 days (n=60) 54 (90%)

29 60 days Total (160) (n=78) n (%) 68 (87.2%) 140 (87.5%)

Symptoms
Fever

Present n(%) Present n(%) Present n(%) 12 (54.5%)

6 (27.2%) 9 (40.9%) 19 (86.4%) 1 (4.5%) 16 (72.7%)

Cough
Difficult Breathing Irritable Cry Poor Sucking Convulsion 3 Symptoms

43 (71.6%)
39 (65%) 15 (25%) 49 (81.6%) 0 (0%) 51 (85%)

58 (74.4%)

113 (70.6%)

55 (70.5%) 100 (62.5%) 11 (14.1%) 45 (57.7%) 5 (6.4%) 61 (78.2%) 35 (21.8%) 113 (70.6%) 6 (3.75%) 128 (80%)

Clinical Features

SpO2<9 SpO2>90 0% n(%) % n(%)

P Value

Sensitiv Specifi ity (%) city (%)

PPV (%)

NPV (%)

Fever (n=140) 51 (36.4) 89 (63.6)

Cough (n=113) 47 (41.6) 66 (58.4) D. Breathing (n=100) Irritable/ Inconsolable cry (n=35) Poor Sucking (n=113) Convulsion (n=6) 3 symptoms (n=128) 46 (46) 11 (31.4) 44 (38.9) 3 (50 ) 52 (40.6) 54 (54) 24 (68.6) 69 (61.1) 3 (50) 76 (59.4)

0.316
0.007 0.001 0.616

91
83.9 82.1 19.6

14.4
36.5 48 76.9

36.4
41.6 46 31.4

75
80.8 83.3 64

0.105 0.423 0.003

78.5 5.3 92.8

33.6 33.6 26.9

38.9 50 40.6

74.4 65.5 87.5

 Symptoms were grouped into two categories as

3 symptoms and <3 symptoms and was then analyzed. Taking the whole study population together, symptoms like fever, cough, difficult breathing, poor feeding, irritability and convulsion and signs like tachypnea, conscious level, nasal aring, chest indrawing, grunting, head nodding and central cyanosis were individually correlated with hypoxia although combination of these signs and symptoms were present in each patient.

 Individually it was seen that patients

who presented with more than 3 symptoms, were tachypneic lethargic, Or had chest indrawing had higher sensitivity (92.8%, 75%, 75% and 89.3 % respectively) and therefore had higher Negative Predictive Value (87.5%, 81.8%, 82.9%, and 91.3% respectively). So combination of these markers can be used as a good screening tool to detect hypoxia.

 Patients who had

nasal aring, grunting, head nodding and central cyanosis

should be considered hypoxic as they had high specicity (91.3%, 87.5%, 98% and 100% respectively).

 Hypoxia is a serious condition and prolonged hypoxia

can lead to death of number of cells leading to dysfunction of various systems.

Prompt identication of hypoxia is possible with the

help of a pulse -oxymeter but unfortunately this is not available in most centers in this country.

The aim of this study was to nd out the relationship between respiratory symptoms and signs with percentage of hemoglobin in arterial blood that is saturated with oxygen (SpO2) and was considered hypoxia if it was less than 90 %.

 In a study conducted by Rajesh VT et al, where

they evaluated the respiratory rate as an indicator of hypoxia in infants <2 months of age found out that a respiratory rate of 60/min predicted hypoxia with 80 % sensitivity and 68% specicity. These values were quite similar to this study where a respiratory rate 60/min predicted hypoxia with 75% sensitivity and 65.3% specicity.

 Another study conducted by Lodha R et al to see

whether clinical signs and symptoms could accurately predict hypoxia in children with Acute Lower Respiratory Tract Infections found that a respiratory rate 70/min in infants 3 months of age had a sensitivity of 89.2% and specicity of 51.8% for detecting hypoxia which was found to be in contrast with this study where Respiratory Rate 70/min could predict hypoxia with 44.6% sensitivity and 96% specicity. This difference could be due to the inclusion of only <2 months of age in this study.

 Small sample size. Only 2 hospital based study

 Hypoxia can be best determined by the use of a pulse

oxymeter but in many centers this may not be available.

This study has helped in identifying certain symptoms

and signs that can predict hypoxia and hence provide necessary treatment.

 Infants presenting with 3 symptoms, lethargy,

respiratory rate of 70/minute or chest indrawing can be used for screening purpose to detect hypoxia and Infants showing signs like grunting, head nodding, nasal aring or central cyanosis should be considered hypoxic and treated with supplemental oxygen.