Retrospective study on the usefulness of pulse oximetry for the identification of young children with severe illnesses and severe pneumonia in a rural outpatient clinic of Papua New Guinea.

Julien Blanc,Noémie Boillat-Blanco,Mario Gehri,Blaise Genton,Patricia Rarau,Nicolas Senn,Isabella Locatelli,Ivo Mueller

doi:10.1371/journal.pone.0213937

Abstract

ObjectiveThis secondary analysis of data of a randomized controlled trial (RCT) retrospectively investigated the performance of pulse oximetry in identifying children with severe illnesses, with and without respiratory signs/symptoms, in a cohort of children followed for morbid episodes in an intervention trial assessing the efficacy of Intermittent Preventive Treatment for malaria in infants (IPTi) in Papua New Guinea (PNG) from June 2006 to May 2010.SettingThe IPTi study was conducted in a paediatric population visiting two health centres on the north coast of PNG in the Mugil area of the Sumkar District.ParticipantsA total of 669 children visited the clinic and a total of 1921 illness episodes were recorded. Inclusion criteria were: age between 3 and 27 months, full clinical record (signs/symptoms) and pulse oximetry used systematically to assess sick children at all visits. Children were excluded if they visited the clinic in the previous 14 days.OutcomesThe outcome measures were severe illness, severe pneumonia, pneumonia, defined by the Integrated Management of Childhood Illness (IMCI) definitions, and hospitalization.ResultsOut of 1921 illness episodes, 1663 fulfilled the inclusion criteria. A total of 139 severe illnesses were identified, of which 93 were severe pneumonia. The ROC curves of pulse oximetry (continuous variable) showed an AUC of 0.63, 0.68 and 0.65 for prediction of severe illness, severe pneumonia and hospitalization, respectively. Pulse oximetry allowed better discrimination between severe and non-severe illness, severe and non-severe pneumonia, admitted and non-admitted patients, in children ≤12-months of age relative to older patients. For the threshold of peripheral arterial oxygen saturation ≤ 94% measured by pulse oximetry (SpO2), unadjusted odds ratios for severe illness, severe pneumonia and hospitalization were 6.1 (95% Confidence Interval (CI) 3.9–9.8), 8.5 (4.9–14.6) and 5.9 (3.4–10.3), respectively.ConclusionPulse oximetry was helpful in identifying children with severe illness in outpatient facilities in PNG. A SpO2 of 94% seems the most discriminative threshold. Considering its affordability and ease of use, pulse oximetry could be a valuable additional tool assisting the decision to admit for treatment.

Highlights

Pneumonia is the leading infectious cause of mortality in children under five years, responsible for 704 000 deaths in 2015 [1]
Pulse oximetry was helpful in identifying children with severe illness in outpatient facilities in Papua New Guinea (PNG)
Considering its affordability and ease of use, pulse oximetry could be a valuable additional tool assisting the decision to admit for treatment

Summary

Introduction

Pneumonia is the leading infectious cause of mortality in children under five years, responsible for 704 000 deaths in 2015 [1]. Hypoxemia is usually identified using pulse oximetry, whereas in resource-poor settings indirect clinical signs such as cyanosis, or others signs reflecting respiratory distress (high respiratory rate, lower chest wall indrawing, head nodding, nasal flaring, grunting, drowsiness, and/or inability to drink/breastfeed) are usually used. The latter signs are correlated with a higher risk of mortality than with hypoxemia. In a Papua New Guinean prospective observational study, cyanosis was highly specific but poorly sensitive to identify children with hypoxemia, it is a late sign and shows considerable inter-observer variability, failing to detect hypoxemia in 30–40% of the cases [12]

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Conclusion