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Three Part Question

In patients who [have nearly drowned] is [chest X-ray] provide [useful diagnostic information]?

Clinical Scenario

A 15-year-old male presents to the Emergency Department after falling into a canal. He was resuscitated at the scene and is currently asymptomatic. You wonder if performing a chest X-ray will help to provide diagnostic information.

Search Strategy

Medline 1946 to June week 2 2015 and Embase 1980 to 2015 week 25 using the OVID interface.
Medline: [exp Near Drowning/ OR exp Drowning/ OR drowning.mp. OR drown$.mp. OR exp Immersion/ OR immersion.mp. OR immer$.mp.] AND [exp X-Rays/ OR Xray.mp OR Chest X Ray.mp. OR exp Radiography, Thoracic/ OR CXR.mp.] LIMIT to human AND English Language.

Embase: [exp Near Drowning/ OR exp Drowning/ OR drowning.mp. OR drown$.mp. OR exp Immersion/ OR immersion.mp. OR immer$.mp.] AND [exp X-Rays/ OR Xray.mp OR Chest X Ray.mp. OR exp Radiography, Thoracic/ OR CXR.mp.] LIMIT to human AND English Language.

The Cochrane Library Issue 6 of 12 date of searching 03/07/2015 : MeSH descriptor: [Drowning] explode all trees.

Search Outcome

Altogether 37 papers were identified by the Medline search strategy and 173 by the Embase search strategy. Of these 3 papers were considered relevant to the three-part question. No relevant reviews were found in the Cochrane library.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hunter TB et al 1974 USA	16 cases of near drowning in children aged 21months-23 years in a University Hospital and a County hospital.	Retrospective review of records	Chest X-Ray findings	perihilar pulmonary oedema 8 (50%) generalized pulmonary oedema 5 (31%) normal CXR 3 (19%)	Retrospective. Small number of patients.
Gregorakos L et al 2009 Greece	43 cases of near drowning in adults aged 18-88 years old over 8 years in a general hospital close to the coast.	Retrospective review of records	Chest X-Ray Findings	Bilateral diffuse infiltrates 34 (79%) Localised alveolar infiltrates 5 (12%) Normal CXR despite low PaO2/FiO2 4 (9%)	Retrospective. Single centre. Only adults studied. 79% of patients studied were >60 – drowning more commonly affects children.
Wunderlich P et al 1985 Germany	10 cases of near drowning in children aged 1-4years admitted to a childrens hospital in Dresden between 1972-1983.	Retrospective review of records.	Chest X-Ray findings	Evidence of aspiration 3 (30%) Evidence of pulmonary oedema 5 (50%) Normal CXR 2 (20%)	Retrospective. Very small number of patients. Single centre.

Comment(s)

Although there were few relevant papers and all were retrospective and included small patient numbers, it is clear from each of them that pulmonary infiltrates suggesting pulmonary oedema are a common finding on the chest X-ray of near drowning patients. As the study by Gregorakos et al examines exclusively adults, and the other two studies exclusively children, it is suggested the same radiographic findings are likely to be present irrespective of age. An aspiration pneumonia, as found in 3 patients in the study by Wunderlich P et al, is an important diagnosis to make.

Editor Comment

BF

Clinical Bottom Line

All patients who have had a drowning episode should have a chest X-ray.

References

1. Hunter TB, Whitehouse WM. Fresh-water near-drowning: radiological aspects. Radiology 1974; 112: 51-56
2. Gregorakos L, Markou N, Psalida V et al. Near-drowning: clinical course of lung injury in adults. Lung 2009; 187: 93-97
3. Wunderlich P, Rupprecht E, Trefftz F et al Chest radiographs of near-drowned children. Pediatr Radiol 1985; 15: 297-299