Paediatrica Indonesiana

VOLUME 52 July  NUMBER 4

Original Article

Chest x-ray findings and outcomes of children with

suspected ventilator-associated pneumonia
Neni Sumarni1, Muhammad Sholeh Kosim1, Mohamad Supriatna1, Eddy Sudijanto2

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Abstract HQWLODWRUDVVRFLDWHG SQHXPRQLD  9$3
Background 9HQWLODWRUDVVRFLDWHG SQHXPRQLD 9$3 LV D
nosocomial infection in patients who have received mechanical
ventilation (MV), either by endotracheal intubation or
WUDFKHRVWRP\IRUPRUHWKDQKRXUV9$3UHSUHVHQWVRI
DOO KRVSLWDODFTXLUHG SQHXPRQLDV 9$3 LQFLGHQFH YDULHV IURP
 7KH PRGLILHG FOLQLFDO SXOPRQDU\ LQIHFWLRQ VFRUH
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UDGLRJUDSKLF HYLGHQFH 9$3 LV DVVRFLDWHG ZLWK VLJQLILFDQW
morbidity and mortality.
Objective To determine the relationship between chest x-ray
ILQGLQJVDQGRXWFRPHVLQFKLOGUHQZLWKVXVSHFWHG9$3
Methods7KLVUHWURVSHFWLYHVWXG\ZDVKHOGLQ'U.DULDGL+RVSLWDO
IURP-DQXDU\'HFHPEHU'DWDZDVFROOHFWHGIURPPHGLFDO
is the second most common nosocomial
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6WDWHV9$3LVDQRVRFRPLDOSQHXPRQLD
in patients who have been mechanically ventilated for
!48 hours, who develop signs of new lower respiratory
tract infection. Despite advances in supportive care,
antimicrobial therapies, and mechanical ventilation,
9$3UHPDLQVDPDMRUWKUHDWWR,&8SDWLHQWV,QDGXOWV
WKH UHSRUWHG LQFLGHQFH RI 9$3 UDQJHV IURP  WR
28% worldwide.3,47KHLQFLGHQFHRI9$3LQSHGLDWULF
SDWLHQWV YDULHV IURP  The National
UHFRUGVRISHGLDWULF,&83,&8SDWLHQWVZLWKVXVSHFWHG9$3 1RVRFRPLDO ,QIHFWLRQV 6XUYHLOODQFH 11,6 V\VWHP
&KHVW[UD\ILQGLQJVDQGSDWLHQWRXWFRPHVZHUHUHFRUGHG;UD\ RI WKH &HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQ
ILQGLQJVZHUHDVVHVVHGE\WKHRQGXW\UDGLRORJLVW&KLVTXDUHWHVW
was used for statistical analysis.
Results6XEMHFWVZHUHFKLOGUHQFRQVLVWLQJRIPDOHVDQG
IHPDOHV3DWLHQWRXWFRPHVZHUHSDWLHQWVVXUYLYHGDQGSDWLHQWV
died. Chest x-ray findings were categorized into the following
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&'& UHSRUWHG D PHDQ 9$3 UDWH RI  SHU 
YHQWLODWRUGD\VIRUSDUWLFLSDWLQJ3,&8VLQWKH8QLWHG
6WDWHV 7KH (XURSHDQ 0XOWLFHQWHU 6WXG\ *URXS
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to be pneumonia, at 53% of all infections.8 Adult
25 3 &,WRORFDOL]HG
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to patient outcomes.
Conclusion There was no significant relationship between chest
[UD\ ILQGLQJV DQG RXWFRPHV LQ FKLOGUHQ ZLWK VXVSHFWHG 9$3
[Paediatr Indones. 2012;52:233-8].
Keywords: chest x-ray, outcome, ventilator-
associated pneumonia
)URPWKH'HSDUWPHQWRI&KLOG+HDOWK, and Department of Radiology2,
'LSRQHJRUR8QLYHUVLW\0HGLFDO6FKRRO'U.DULDGL+RVSLWDO6HPDUDQJ
Indonesia.
Reprint requests to: 1HQL 6XPDUQL 'HSDUWPHQW RI &KLOG +HDOWK
'LSRQHJRUR 8QLYHUVLW\ 0HGLFDO 6FKRRO 'U .DULDGL +RVSLWDO -O 'U
6RHWRPR QR  6HPDUDQJ  ,QGRQHVLD 7HO 
(PDLO neni_thea@yahoo.com
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5DGLRORJ\&RQJUHVV.XWD%DOL1RYHPEHU
Paediatr Indones, Vol. 52, No. 4, July 2012 233
 Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

have longer ICU and hospital stays than children.3
2IDGXOWSDWLHQWVZKRUHTXLUHPHFKDQLFDOYHQWLODWLRQ
IRUKRXUVDFTXLUH9$3ZLWKPRUWDOLW\
UDWHVRIWR8,9&KLOGUHQZLWK9$3KDYHQHHG
for prolonged mechanical ventilation, longer ICU
stays and higher mortality rates.
The modified clinical pulmonary infection
respiratory patients were eligible for enrollment if their
clinical status improved. This study was approved by
the institutional review board.
Data collected from medical records included
demographic data (age at time of intubation, gender,
and admission diagnosis), clinical signs (maximum
temperature, presence of endotracheal secretions
VFRUH &3,6 LV XVHG WR GLDJQRVH VXVSHFWHG 9$3 defined as non-purulent, purulent, or absent,
in children. 'HILQLWLYH 9$3 PD\ EH GLDJQRVHG
by bronchoscopic bronchoalveolar lavage (BAL)
culture.   &3,6 KDV D VHQVLWLYLW\ RI  DQG
VSHFLILFLW\ RI  Chest x-ray finding is one of
WKH&3,6YDULDEOHVGHILQHGDVGLIIXVHORFDOL]HGRU
no infiltrates. Localized infiltrates score higher points
),2DWWLPHRIWKHORZHVW3D2ODERUDWRU\GDWD
PD[LPXP ZKLWH FHOO FRXQW ORZHVW 3D2 IURP
arterial source), chest radiograph data (development
of new infiltrates, diffuse infiltrates, localized
infiltrates or no infiltrates) and culture data (results
of endotracheal tube, blood, urine, and other tissue
than that of diffuse infiltrates.
&KHVW [UD\ ILQGLQJV DV WKH\ UHODWH WR 9$3
outcomes are not as well documented in pediatric
SDWLHQWVDVWKH\DUHLQDGXOWV9$3LQDGXOWVKDVEHHQ
associated with prolonged duration of mechanical
ventilation, as well as increased length of ICU stay,
hospital stay, hospital cost, and absolute mortality.3
3,&8SDWLHQWVQRWRQO\HQFRPSDVVDZLGHUDQJHRIDJHV
different from adult ICU patients, but also differ in
their developmental physiology, underlying disorders,
DQGWUHDWPHQWQHHGV0RUHSHGLDWULF9$3VWXGLHVDUH
needed to elucidate these factors.
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chest x-ray findings and outcomes of children with
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Methods
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Indonesia. This tertiary-care hospital receives referrals
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radiograph data (diffuse, localized or no infiltrates),
and patient outcomes defined as survived or died.
Chest x-rays findings were determined as by the on-
duty radiologist.
:H XVHG WKH PRGLILHG &3,6 VFRUH WR GLDJQRVH
VXVSHFWHG9$3IRUZKLFKWKHVHQVLWLYLW\LVDQG
VSHFLILFLW\LV&3,6FRQVLVWVRIYDULDEOHVRQHRI
which is radiologic findings as shown in Table 1.
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EHWZHHQWKHFKHVW[UD\ILQGLQJV&3,6DQGRXWFRPHV
Logistic regression analysis was not used to assess a
correlation between chest x-ray findings and outcomes
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FRUUHODWLRQ6WDWLVWLFDODQDO\VHVZHUHSHUIRUPHGZLWK
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Results
Thirty-four patients met the inclusion criteria, but
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The outcomes of patients were survived (23 out of
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All pediatric and neonatal patients admitted to PDOHVDQGIHPDOHV7KHPHDQDJHRIWKHPDOHV
'U.DULDGL+RVSLWDOIURP-DQXDU\WR'HFHPEHU ZDV6'PRQWKVDQGRIWKHIHPDOHVZDV
ZHUH VFUHHQHG IRU VWXG\ HQUROOPHQW :H LQFOXGHG 6'PRQWKV
SDWLHQWV ZKR ZHUH PHFKDQLFDOO\ YHQWLODWHG IRU  :HGLYLGHG&3,6VFRUHVLQWRJURXSVWKRVHZLWK
48 hours and not diagnosed with pneumonia prior VFRUHVRISDWLHQWVIRUZKLFKWKHGHDWKUDWH
WR 3,&8 DGPLVVLRQ 3DWLHQWV ZHUH H[FOXGHG LI WKHLU ZDVDQGWKRVHZLWK&3,6VFRUHVSDWLHQWV
UHVSLUDWRU\VWDWXVZDVXQVWDEOHLHUHTXLUHGIUDFWLRQ IRUZKLFKWKHGHDWKUDWHZDV:HIRXQGVLJQLILFDQW
RILQVSLUHGR[\JHQ>),2@RUKLJKIUHTXHQF\ UHODWLRQVKLSVEHWZHHQ&3,6DQGRXWFRPHVLQWKHILUVW
oscillatory ventilation), support was withdrawn JURXS25 3 &,WR
or declaration of death was imminent. Unstable DQGWKHVHFRQGJURXS25 3 

234Paediatr Indones, Vol. 52, No. 4, July 2012

 Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

Table 16JGOQFKGFENKPKECNRWNOQPCT[KPHGEVKQPUEQTG12
CPIS parameters 0 1 2
6TCEJGCNUGETGVKQPU Rare Abundant CDWPFCPV RWTWNGPV
%JGUVZTC[KPNVTCVGU 0QKPNVTCVGU &KHHWUG Localized
6GORGTCVWTG 36.5 and 38.4 38.5. and 38.9 39 or 36
Leukocyte count, per mm3 4,000 and 11,000 <4,000 or >11,000 QT  DCPFHQTOU
500
PAO2/FIO2, mmHg >240 or ARDS CPFPQGXKFGPEGQH#4&5
Microbiology Negative Positive

Table 2. 6JGTGNCVKQPUJKRDGVYGGP%2+5CPFQWVEQOGU
Cases Survived Died
CPIS score OR 95% CI P
n n n
6-7 22 20 2 0.06 0.008 to 0.461 0.007
 8 3 5 16.67 2.167 to 128.17 0.007

Table 32CVJQIGPUEWNVWTGFHTQOGPFQVTCEJGCNVWDGU Diffuse infiltrates was found in all region of the

Pathogens n
lung for most patients and this contributed one point
Acinetobacter baumanni 4
RI &3,6 SDUDPHWHU Figure 1). Most of them were
Enterobacter aerogenes 4 survived.
Pseudomonas aeruginosa 15 Localized infiltrates was found in certain region of
Staphylococcus aureus 2 the lung and the most common location was in the right
Klebsiella pneumoniae 3 upper region of the lung (Figure 2). These chest x-ray
No pathogen growth 2
findings were found in less number of patients than

Table 4.6JGTGNCVKQPUJKRDGVYGGPEJGUVZTC[PFKPIUCPFQWVEQOGU
Case Survived Died
%JGUVZTC[ OR 95% CI P
% % %
&KHHWUGKPNVTCVGU 76.7 60 16.6 0.694 0.102 to 4.717 0.532
.QECNK\GFKPNVTCVGU 13.3 6.7 6.7 4.200 0.470 to 37.499 0.225
0QKPNVTCVGU 10 10 0 1.222 0.222 to 6.730 0.581

&,WRDVVKRZQLQTable 2.
2QHSDUDPHWHURIWKH&3,6VFRUHLVPLFURELRORJ\
meaning pathogens found in endotracheal cultures.
In our study, Pseudomonas aeruginosa was the most
common isolated pathogenic microorganism, found
LQHQGRWUDFKHDOFXOWXUHV2WKHUSDWKRJHQVZHUH
Acinetobacter baumanni in 4 samples, Enterobacter
aerogenes in 4 samples, Staphylococcus aureus in 2
samples and Klebsiella pneumoniae in 3 samples. No
pathogens were found in 3 endotracheal cultures
(Table 3).
The chest x-ray findings in our study of diffuse
those with diffuse infiltrates, but contributed to more
SRLQWRI&3,6SDUDPHWHU/RFDOL]HGLQILOWUDWHILQGLQJV
was significantly more common in patients with positive
BAL (bronchoalveolar lavage) culture.
Discussion
9$3 LV SQHXPRQLD WKDW GHYHORSV DIWHU !48 hours
of mechanical ventilation provided by way of an
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the invasion of the lower respiratory tract and lung
LQILOWUDWHV25 3 &,WR parenchyma by microorganisms. In our study,
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WRDQGQRLQILOWUDWHV25 3  within the mortality rate range from an adult study
&,WRKDGQRVLJQLILFDQWUHODWLRQVKLSVZLWK WKDW UHSRUWHG WKH FUXGH PRUWDOLW\ UDWH IRU 9$3
patient outcomes as shown in Table 4. WR EH 2XWFRPHV RI 9$3 KDYH QRW EHHQ

Paediatr Indones, Vol. 52, No. 4, July 2012 235

 Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia

Figure 1%JGUVZTC[PFKPIUQHFKHHWUGKPNVTCVGU

Figure 2.%JGUVZTC[PFKPIU
QHNQECNK\GFKPNVTCVGU

236Paediatr Indones, Vol. 52, No. 4, July 2012

 Neni Sumarni et al: Chest x-ray findings and outcomes of ventilator-associated pneumonia
documented as well in pediatric patients as in adults.
1HYHUWKHOHVV6ULQLYDVDQet al. found that children
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References
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infections in pediatric intensive care units in the United
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WLODWRUDVVRFLDWHGSQHXPRQLD&KHVW
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WRDQGLQWKHVHFRQGJURXSZLWKVFRUHV 5HVSLU&ULW&DUH0HG
25 3 &,WR  5HOOR-2OOHQGRUI'$2VWHU*9HUD/ORQFK0%HOOP/
:HDOVRIRXQGWKDWWKHPRVWFRPPRQSDWKRJHQ Redman R, et al. Epidemiology and outcomes of ventilator-
cultured was Pseudomonas aeruginosa6LPLODUO\ DVVRFLDWHG SQHXPRQLD LQ D ODUJH 86 GDWDEDVH &KHVW
WKH 11,6 LQ WKH 8QLWHG 6WDWHV DQG WKH (XURSHDQ 
0XOWLFHQWHU6WXG\*URXSIRXQGSQHXPRQLDLQWKHLU  6KDUPD+6LQJK'3RRQL30RKDQ8$VWXG\SURILOHRI
pediatric populations to be most often associated YHQWLODWRUDVVRFLDWHG SQHXPRQLD LQ FKLOGUHQ LQ 3XQMDE -
with Pseudomonas aeruginosa  DQG S. aureus 7URS3HGLDWU
 In contrast, Tripathi et al. reported that  $VHPEHUJLHQH-*XUNLV9.HYDODV59DOLQWHOLHQH51RVRFR-
the most common bacteria isolated from endotracheal mial infection in pediatric intensive care units in Lithuania.
DVSLUDWHV RI 9$3 1,&8 SDWLHQWV ZDV Klebsiella spp
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encountering resistant Enterobacter, Pseudomonas
and Acinetobacter VSHFLHV LQ ODWH RQVHW 9$3 DIWHU
5 days of hospitalization), while the etiologic agent
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by age which the most common bacterial cause of
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older was Streptococcus pneumonia. 
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finding, defined as diffuse, localized or no infiltrates.
Localized infiltrates score higher points than diffuse
infiltrates. In our study, we did not find a significant
relationship between chest x-ray findings and patient
RXWFRPHV6LPLODUO\6DFKGHYet al. reported that of
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DQG3D22)L22 ratio were significant for assessing the
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A limitation of our study was that we were
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agreement between radiologists, since this was a
retrospective study. Also, our small sample size may
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A large, multicenter study should be done to better
assess a relationship between chest x-ray findings
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conclusion, we found no significant relationship
between chest x-ray findings and outcomes of children
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teriologic analysis of bronchoscopic and nonbronchoscopic
blind bronchoalveolar lavage fluid. Am Respir Crit Med.

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Paediatr Indones, Vol. 52, No. 4, July 2012 237
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associated pneumonia in critically ill patients. Ann Intern
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