Clinician assessment for acute chest syndrome in febrile patients with sickle cell disease: Is it accurate enough?

Study objective: To determine whether the use of empiric chest radiography (CXR) is of significant value in detecting clinically unsuspected acute che st syndrome (ACS) in febrile patients with sickle cell disease (SCD), Methods: Patients with SCD presenting to the emergency department and hemat ology clinic with temperature greater than or equal to 38 degrees C were pr ospectively evaluated using a physician-completed questionnaire. The questi onnaire included inquiries into the patient's physical signs and symptoms a nd the physician's clinical impression for the presence of ACS. The questio nnaire was completed before obtaining CXR results in all patients. Results: Seventy-three patients with SCD with 96 febrile events were evalua ted over a 1-year period. Twenty-four percent (23/96) of the patients had C XR evidence of ACS. On the basis of the questionnaire data, 61% (14/23) of ACS cases were not clinically suspected by the evaluating physician before obtaining CXR. Comparing the patients with and without ACS revealed that, w ith the exception of splinting (4/23 [17%] versus 0/73 [0%]), no symptom or physical examination finding helped to identify which patients had ACS. Fi fty-seven percent of patients with ACS had completely normal findings on ph ysical examination. The presentation of patients with clinically detected v ersus clinically unsuspected ACS also did not differ significantly. Length of hospitalization, oxygen use, and need for transfusion were the same in b oth the unsuspected and detected ACS groups. Overall physician sensitivity for predicting BCS was only 39%, and diagnostic accuracy did not improve si gnificantly with increasing levels of pediatric training, Conclusion: ACS is common in patients with SCD who present with fever and w as grossly underestimated by evaluating physicians. History and physical ex amination appear to be of little value in defining which febrile patients r equire CXR. In view of the mortality and morbidity associated with ACS, emp iric CXR should be considered when evaluating a febrile patient with SCD.