Medicine of the Future in America

Rapid Clinical Diagnosis of Pulmonary Abnormalities in HIV-Seropositive Patients by Auscultatory Percussion: Results

The prevalence of radiologic lung abnormalities among the 126 lungs was 55.6 percent. Table 1 lists the prevalence of each radiographic abnormality. Table 2 gives patients demographic data, vital signs, and laboratory values prior to being examined.
Sixty-three hospitalized patients (126 lungs) were examined by 1 to 3 examiners yielding 308 single lung examinations (LEs) of a possible 378 LEs (ie, 63 patients X 2 lungs per patient X 3 examiners). Of these 308 LEs, results of 174 (56.5 percent) were abnormal by chest radiograph. Table 3 summarizes the abnormal results of radiographic examinations and the number of positive examination findings for each technique. Likelihood ratios for all examiners and techniques were greater than 1 which allowed us to pool likelihood ratios across examiners as described in the “Methods” section. Auscultatory percussion proved to be the most sensitive of all techniques for each examiner (range, 51.0 to 69.6 percent). The likelihood ratio was higher for two of the three examiners as well as the likelihood ratio pooled across examiners. Table 4 gives performance characteristics for each examiner as well as pooled likelihood ratios with 95 percent confidence intervals.
Diagnostic accuracy was fairly consistent among examiners as seen in the areas under the examiner operating characteristic curves (Table 5). Interobserver agreemerit, however, was only fair, but was better in ConA and AusP than ConP (Table 6).
Table 7 lists the performance characteristics of each combination of the three physical examination techniques. Conventional auscultation and AusP was the most sensitive combination of examinations. The addition of ConP to the combination of ConA and AusP did not add to the sensitivity, specificity, or likelihood ratio. The traditional physical examination of the lungs includes inspection, palpation, percussion, and auscultation. Although imperfect, the physical examination of the lungs complements the chest radiograph. Since chest radiographs cannot be obtained on every patient, an improvement in the physical examination of the chest could be worthwhile, especially if it does not require patient cooperation.

Table 1—Radiographic Finding by Type

Radiographic Abnormality N
Infiltrates 62
Pleural effusions 7
Nodules 7
Adenopathy 1
Atelectasis 2
Normal lungs 58

Table 2—Demographics of Subjects Enrolled and Vital Signs Prior to Examination (n=63)

Characteristic Mean ± SD (Range)
Age, yr 36.4 ±8 (19-58)
Sex
Male 92.4% (n=61)
Female 7.6% (n = 5)
Tobacco history
Current smoker 48.5% (n = 32)
Former smoker 24.2% (n=16)
Never smoked 27.3% (n = 18)
Positive PCP history 48.5% (n=32)
Positive ТВ history 13.6% (n=9)
Max temperature, °C 38.5 ±-16.6 (36.5-41)
Max respiratory rate, per min 23.9 ±6.0 (18-56)
Max pulse, per min 107.3 ±16.5 (70-152)
P(A-a)Oat (n = 42) 19.3 ±26.5 (0-158.2)
Serum LDH, U/L (n = 51) 387.0 ± 292.8 (109-1832)

Table 3—Abnormal Radiographic Remits by Abnormality Type

PtInfiltrates n* No. of Positive Exams Radiographic Description/Diagnosis^
AusP ConA ConP
1 3 1 2 1 R U&LL infil/K pneumoniae pneumonia
2 2 0 0 0 L patchy LL infil/no dx given
3 3 2 0 2 LLL infil/no dx given
4 1 1 1 0 LLL infil/// influenzae pneumonia
5 3 3 1 1 RUL infil/no dx given
6 3 1 0 0 RLL hazy infil/PCP
7 6 2 2 0 Bibasilar patchy densities/Cryptococcus
8 6 4 2 0 Bil diffuse LL infil/PCP (+ SS)
10 6 3 2 0 Bil diffuse infil/PCP (+ SS)
11 6 6 6 2 Bil diffuse infil/PCP (+SS)
12 3 1 2 0 Bil diffuse infil/No dx given
13 3 1 3 0 RML infil/pneumonia NOS
14 6 2 0 0 Bil diffuse LL infil/PCP (+ SS)
15 3 1 0 1 RML infil/no dx given
16 1 0 0 0 RML infil/pneumonia NOS
17 6 2 2 1 Bil diffuse infil/PCP (+ SS)
18 1 0 0 0 RLL infil/pneumococcal pneumonia
19 6 6 2 2 Bil diffuse interstitial pattern, > at bases/chronic bronchitis
20 4 3 3 0 Bil diffuse interstitial—miliary pattern/TB
21 4 3 4 1 RUL & LLL patchy infil/No dx given
22 2 0 0 0 LUL infil/TB
23 4 4 4 1 RUL, RLL, lingular patchy infil/aspergillosis
24 6 3 1 2 Bil infil R> L/Pneumonia NOS
25 6 3 1 1 Bil patchy infil/PCP (+SS)
26 6 4 2 0 RML, RUL & LLL infil/TB
27 6 6 5 3 Bil hazy infil/PCP (+ SS)
28 4 3 2 0 Bil ill-defined streaky infil/no dx given
29 4 4 4 0 Bil diffuse interstitial markings c/w opportunistic infection/Pneumonia NOS
30 1 1 0 0 LLL infil/no dx given
31 6 3 5 0 RLL, lingula, LLL infil/pneumonia NOS
32 4 2 2 0 Bil LL infil/no dx given
33 6 6 4 4 RLL, RML & LUL infil/Pseudomonas species
34 6 4 0 0 Bil diffuse infil/PCP (+ SS)
Nodules
35 3 0 0 0 L multiple small nodular opacities/no dx given
36 4 3 0 0 Faint nodular opacities in LLL, LUL & RU L/pneumonia NOS
37 6 4 4 2 Bil reticulonodular abnormality/no dx given
Atelectasis
38 3 0 0 0 L basilar subsegmental atelectasis
39 3 0 0 0 RML streaky opacities c/w atelectasis or scar/no dx given
Mixed abnormalities
40 6 6 6 5 Bil LL infil, bil pleural effusion R>L/PCP, H influenzae pneumonia
41 2 2 2 0 RML infil, bil pleural effusion/no dx given
42 4 3 1 0 Bil UL infil, AP window adenopathy/PCP
43 1 1 1 0 RML infil, R pleural effusion/pulmonary actinomycosis
44 4 4 4 4 Bil pleural effusion & bil infil c/w KS/KS, bil pleural effusion NOS

Table 4—Performance Characteristics by Examiner and Technique With Pooled Estimates

Auscultation
Examiner 1 Examiner 2 Examiner 3 Pooled
PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl
Sensitivity 49.3% 37.5-61.1 42.9% 29.9-55.8 46.9% 33.0-60.9
Specificity 76.4% 65.1-87.6 82.6% 71.7-93.6 69.0% 52.1-85.8
LR* 2.08 1.22-3.55 2.46 1.23-4.96 1.51 0.81-2.18 1.51 1.24-1.83
Percussion
Examiner 1 Examiner 2 Examiner 3 Pooled
PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl
Sensitivity 8.7% 2.1-15.3 25.0% 13.7-36.3 26.5% 14.2-38.9
Specificity 94.6% 88.5-100.0 95.7% 89.8-100.0 93.1% 83.9-100.0
LR 1.59 0.42-6.09 5.75 1.38-24.01 3.85 0.93-15.85 1.54 1.20-1.1.98
Auscultatory Percussion
Examiner 1 Examiner 2 Examiner 3 Pooled
PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl PointEstimate 95% Cl
Sensitivity 69.6% 58.7-80.4 60.7% 47.9-73.5 51.0% 37.0-65.0
Specificity 74.6% 63.0-86.1 93.5% 86.3-100.0 75.9% 60.3-91.4
LR 2.73 1.69-4.41 9.31 3.06-28.37 2.11 1.05-4.26 2.13 1.75-2.60

Table 5—Алее Under Examiner Receiver Operating Characteristic Curves

Examiner Status NormalsExamined AbnormalsExamined Area SE Area*
1 Student 55 69 0.72 0.05
2 Attending 46 56 0.76 0.05
3 Intern 29 49 0.65 0.06

Table 6—Interexaminer Agreement by Examination Technique

Po к Ppoe Pnec
Auscultation
Elf vs E2 .64 .21 .47 .72
El vs E3 .59 .16 .66 .50
E2vsE3 .74 .44 .80 .63
Percussion
El vs E2 .82 .17 .90 .24
El vs E3 .81 .05 .89 .13
E2vsE3 .80 .28 .88 .40
Auscultatory percussion
El vs E2 .70 .39 .76 .62
El vsE3 .59 .18 .64 .53
E2vsE3 .70 .36 .77 .59

Table 7—Performance Characteristics of Combined Technique Examinations

Examiner 1 Examiner 2 Examiner 3
ConA or ConP ConP or AusP ConA or AusP ConA, ConP, or AusP ConA or ConP ConP or AusP ConA or AusP ConA, ConP, or AusP ConA or ConP ConP or AusP ConA or AusP ConA, ConP, or AusP
Nt 35 48 53 53 27 34 38 38 26 25 31 31
Sensitivity, % 50.7 69.6 76.8 76.8 48.2 60.7 67.9 67.9 53.1 51.0 63.3 63.3
Specificity, % 70.9 74.6 63.6 63.6 80.4 93.5 80.4 80.4 65.5 72.4 58.6 55.2
Likelihood ratio 1.74 2.73 2.11 2.11 2.46 9.31 3.47 3.47 1.54 1.85 1.53 1.41
This entry was posted in HIV-Seropositive Patients and tagged lung disease, pleural effusion, Pneumonia, pulmonary abnormalities.
Copyright © 2012 Medicine of the Future in America www.perfexis.org