Scolaris Content Display Scolaris Content Display

Flow diagram of study selection and inclusion.
Figuras y tablas -
Figure 1

Flow diagram of study selection and inclusion.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Chest radiograph versus management without chest radiograph (children only), outcome: 1.2 Hospitalisation rates.
Figuras y tablas -
Figure 4

Forest plot of comparison: 1 Chest radiograph versus management without chest radiograph (children only), outcome: 1.2 Hospitalisation rates.

Comparison 1 Chest radiograph versus management without chest radiograph (children only), Outcome 1 Time to resolution of clinical signs and symptoms.
Figuras y tablas -
Analysis 1.1

Comparison 1 Chest radiograph versus management without chest radiograph (children only), Outcome 1 Time to resolution of clinical signs and symptoms.

Comparison 1 Chest radiograph versus management without chest radiograph (children only), Outcome 2 Hospitalisation rates.
Figuras y tablas -
Analysis 1.2

Comparison 1 Chest radiograph versus management without chest radiograph (children only), Outcome 2 Hospitalisation rates.

The effectiveness of chest radiographs in addition to clinical judgement compared with clinical judgement alone for acute lower respiratory tract infections

Patient or population: adults and children with clinical signs and symptoms of acute lower respiratory tract infection

Settings: South Africa and USA

Intervention: chest radiographs and clinical judgement

Comparison: clinical judgement alone, without the use of chest radiographs

Outcomes

Illustrative comparative risks* (95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Without chest radiograph (control)

With chest radiograph

Mortality

Adults

Not assessed

Children

0

0

518 (1)

⊕⊕⊕⊝
moderate

Not included as an outcome, however it was reported that "no deaths were recorded" during the trial

Time to resolution of clinical signs and symptoms

[days]

Adults

17.0

16.9

1502 (1)

⊕⊕⊝⊝
low

Average duration of illness in the radiograph group was 16.9 days and 17.0 days in the no radiograph group (P > 0.05)

Relative risks not provided in original RCT

Inadequate data provided in original RCT ‐ further analysis of these data could not be conducted as a specific P value was not stated (only whether the P value was greater or less than 0.05)

Follow‐up continued to either end of illness or for at least 1 month after presentation

Downgraded to low quality due to risk of bias and the lack of evidence that the estimate excludes clinically meaningful differences in either direction

Children

7 (95% CI 6 to 9)

7 (95% CI 6 to 8)

518 (1)

⊕⊕⊝⊝
low

Median time to recovery in control group was 7 days (95% CI 6 to 9 days) and in the chest radiograph group was 7 days (95% CI 6 to 8 days)

P = 0.50, log‐rank test

Hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34)

Follow‐up until recovery or censored at 28 days

Downgraded to low quality due to risk of bias and the lack of evidence that the estimate excludes meaningful differences in either direction

Hospitalisation rates

Adults

Not reported. Data only provided in subgroup of patients that was not randomised

Children

2.3% (6 of 261 children)

4.7% (12 of 257 children)

518 (1)

⊕⊕⊝⊝
low

The estimated risk ratio for this study was 2.03 (0.77 to 5.03). Not statistically significant (P = 0.154)

Downgraded to low quality due to risk of bias and imprecision of data

Complications of infection

Adults

Not assessed

Children

Not assessed

Adverse effects from chest radiographs

Adults

Not assessed

Children

Not assessed

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; P: P value; NNT: number needed to treat; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Bushyhead 1983: limitations in the design and implementation of available studies suggesting high risk for detection bias and low or unclear risk for selection, attrition and reporting bias (Risk of bias in included studies).

Swingler 1998: limitations in the design and implementation of the study suggesting high risk for selection and attrition bias and low risk for detection and reporting bias (Risk of bias in included studies).

No serious risk of unexplained heterogeneity or publication bias in either of the trials. Both outcomes for time to resolution of symptoms and hospitalisation rates in both trials were downgraded to 'low quality' due to imprecision of results.

A column for relative effects was not included as part of the 'Summary of findings' table as data needed to calculate relative risks were not presented in either of the included trials.

Although mortality in children did not occur, we have included this in our summary of findings Table for the main comparison as it may reflect the severity of illness and the use of appropriate management.

Figuras y tablas -
Table 1. Time to resolution of clinical signs and symptoms (children only)

Study

Chest radiograph

Without chest radiograph

Median (days)

SD

Total

Median (days)

SD

Total

Swingler 1998

7

8.2

257

7

12.4

261

Chest radiograph versus management without chest radiograph (children only), outcome: 1.1 Time to resolution of clinical signs and symptoms.

Figuras y tablas -
Table 1. Time to resolution of clinical signs and symptoms (children only)
Comparison 1. Chest radiograph versus management without chest radiograph (children only)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Time to resolution of clinical signs and symptoms Show forest plot

1

518

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐1.81, 1.81]

2 Hospitalisation rates Show forest plot

1

518

Risk Ratio (M‐H, Fixed, 95% CI)

2.03 [0.77, 5.33]

Figuras y tablas -
Comparison 1. Chest radiograph versus management without chest radiograph (children only)