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Chairperson: Dr. Azizul Hoque ( MBBS, D.Ped, FCPS)

Associate ProfessorDepartment of Pediatrics(U-II), MMCH.

Speaker: Dr. Tapash Chandra Gope

Assistant Registrar Ped. U-II



Relationship of Respiratory Symptoms andSigns with Hypoxemia in Infants Under 2

months of Age



Dr. Keshav AgrawalDr. Chandeshwor MahasethDr. Ajit Raymajhi

Source: Nepal Pediatric Society JournalV 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 Patientsdepartment (OPD) or Emergency departmentwith any acute illness were included .



Exclusion criteria:

Infants ≤24 hours of age With major congenital malformationsReferred cases after previous hospitalization,Severely ill requiring intensive care andclinically suspectedCyanotic Congenital Heart Disease or foundlater on Echocardiography.



This study included a total of 164 infants out ofwhich 4 were excluded because they werediagnosed to have Congenital Heart Disease by

Echocardiography.

Out of remaining 160 infants, 95 (59.4%) weremales and 65 (40.6%) were females.

Of the total population,56(35%) were hypoxicwhere as 104(65%) were not hypoxic.



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

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

Fever and decrease sucking were the two mostcommon complaintsCough is the second common complaint.

In the age group of 29 – 60 days :Fever and cough were the main complaint categorydifficulty in breathing as the next common complaint.

History of convulsion was found to be the leastcommon in all age categories.



Age Groups

>>

1-7 days

(n=22)

8-28 days

(n=60)

29 – 60 days

(n=78)

Total (160)

n (%)Symptoms Present n (%) Present n (%) Present n (%)

Fever 18 (82%) 54 (90%) 68 (87.2%) 140 (87.5%)

Cough 12 (54.5%) 43 (71.6%) 58 (74.4%) 113 (70.6%)

DifficultBreathing

6 (27.2%) 39 (65%) 55 (70.5%) 100 (62.5%)

Irritable Cry 9 (40.9%) 15 (25%) 11 (14.1%) 35 (21.8%)

PoorSucking

19 (86.4%) 49 (81.6%) 45 (57.7%) 113 (70.6%)

Convulsion 1 (4.5%) 0 (0%) 5 (6.4%) 6 (3.75%)

≥ 3Symptoms

16 (72.7%) 51 (85%) 61 (78.2%) 128 (80%)



Clinical

Features

SpO2<9

0% n(%)

SpO2>90

% n(%)

P

Value

Sensitiv

ity (%)

Specifi

city (%)

PPV

(%)

NPV

(%)Fever (n=140) 51 (36.4) 89 (63.6) 0.316 91 14.4 36.4 75

Cough (n=113) 47 (41.6) 66 (58.4) 0.007 83.9 36.5 41.6 80.8

D. Breathing

(n=100)

46

(46)

54

(54)

0.001 82.1 48 46 83.3

Irritable/Inconsolablecry (n=35)

11(31.4)

24(68.6)

0.616 19.6 76.9 31.4 64

Poor Sucking(n=113) 44(38.9) 69(61.1) 0.105 78.5 33.6 38.9 74.4

Convulsion(n=6)

3(50 )

3(50)

0.423 5.3 33.6 50 65.5

≥ 3 symptoms

(n=128)

52

(40.6)

76

(59.4)

0.003 92.8 26.9 40.6 87.5



Symptoms were grouped into two categories as≥3 symptoms and<3 symptomsand was then analyzed.

Taking the whole study population together,symptoms like fever, cough, difficult breathing,

poor feeding, irritability and convulsion and signslike tachypnea, conscious level, nasal aring, chestindrawing, grunting, head nodding and central cyanosiswere individually correlated with hypoxia althoughcombination of these signs and symptoms were present

in each patient.



Individually it was seen that patientswho presented with more than 3 symptoms, weretachypneiclethargic, Orhad 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 agood screening tool to detect hypoxia.



Hypoxia is a serious condition and prolonged hypoxiacan 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 notavailable in most centers in this country.



The aim of this study was to nd out therelationship between respiratory symptoms and signs

with percentage of hemoglobin in arterial blood thatis saturated with oxygen (SpO2) and was consideredhypoxia 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 arespiratory rate of ≥60/min predicted hypoxia with 80% sensitivity and 68% specicity.

These values were quite similar to this study where arespiratory rate ≥ 60/min predicted hypoxia with 75% sensitivity and 65.3% specicity.



Another study conducted by Lodha R et al to seewhether 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 RespiratoryRate ≥70/min could predict hypoxia with 44.6%sensitivity and 96% specicity.This difference could be due to the inclusion of only <2months of age in this study.



Small sample size.Only 2 hospital based study



Hypoxia can be best determined by the use of a pulseoxymeter but in many centers this may not be available.

This study has helped in identifying certain symptomsand signs that can predict hypoxia and hence providenecessary treatment.



Infants presenting with ≥3 symptoms, lethargy,respiratory rate of ≥70/minute or chest indrawing can

be used for screening purpose to detect hypoxia

andInfants showing signs like grunting, head nodding,

nasal aring or central cyanosis should be considered hypoxic and treated with supplemental oxygen.

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