The Lancet. Respiratory medicine · 2026
PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study.
СтатьяМногоцентровое исследованиеНаблюдательное исследованиеНазвание и аннотация: Перевод в очереди
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Ellison Angela M, Kuppermann Nathan, Shihabuddin Bashar S, Hickingbotham Hilary, Cator Allison, Lubell Tamar R, Hoehn Erin, O'Connell Karen J, Spencer Sandra, Chumpitazi Corrie E, Hennelly Kara, Kaplan Ron, Eisenberg Matthew A, Powell Elizabeth C, Mercurio Laura, Riney Lauren C, Johnson Tiffani J, Johnson Michael D, Bogie Amanda, Schultz Megan, Mendelson Jenny, DeLaroche Amy M, Race Jonathan, Casper T Charles, Kline Jeffrey A
Аннотация
BACKGROUND: In emergency care, clinicians currently have scarce evidence-based guidance on whether to order diagnostic tests for suspected pulmonary embolism in children. We aimed to test whether the Pulmonary Embolism Rule-Out Criteria in Children (PERC-Peds) can safely rule out pulmonary embolism in children.
METHODS: This multicentre, prospective, observational, diagnostic accuracy study was done in 21 paediatric emergency departments across the USA. We enrolled children aged 4-17 years who presented with symptoms prompting the emergency physician to order, or strongly consider ordering, a diagnostic test for pulmonary embolism. Participants formed a consecutive series. At the point of care, clinicians completed a case report form to record the components of the PERC-Peds rule. Diagnostic testing, including D-dimer testing, was done at clinician discretion. Trained research personnel collected patient-reported demographic data, symptoms, medications, and past medical histories prospectively and cross-checked patient-reported past medical histories and medications against data in the electronic health record. Follow-up was done 45 days after enrolment with a standardised, automated SMS message to caregivers. The criterion standard for pulmonary embolism was the outcome of any venous thromboembolism (VTE; including image-proven pulmonary embolism or proximal deep vein thrombosis [DVT; above knee or elbow, but not including isolated saphenous, brachial, or calf vein clots]) within 45 days, as adjudicated by an independent committee of three board-certified paediatric emergency physicians. Adjudicators viewed all imaging reports, information from the 45-day follow-up, and outside medical records. The primary endpoint was safe exclusion by use of PERC-Peds in all participants who were adjudicated, defined as the upper limit of the 95% CI for the false-negative rate not crossing 1·5%.
FINDINGS: Between July 29, 2020, and Sept 29, 2024, 4039 children were enrolled, with 4011 participants adjudicated for pulmonary embolism or proximal DVT. Date of last follow-up was Sept 18, 2025. The median age of the adjudicated population was 15 years (IQR 13-16); 2567 (64·0%) were female and 1444 (36·0%) were male. 3988 participants had complete data, and 253 (6·3%, 95% CI 5·6-7·2) were diagnosed with pulmonary embolism or proximal DVT within 45 days. The sensitivity of the PERC-Peds rule was 99·6% (95% CI 97·8-100·0), specificity was 19·6% (18·4-20·9), and false-negative rate was 0·1% (0·0-0·8). D-dimer test was ordered in 3161 (78·8%) of 4011 participants. Sequential use of PERC-Peds followed by D-dimer test ruled out pulmonary embolism or proximal DVT in 2167 (54·3%) with a false-negative rate of 0·9% (0·6-1·4).
INTERPRETATION: In this multicentre, prospective, observational, diagnostic accuracy study of children with suspected pulmonary embolism in the emergency department, we found a 6·3% prevalence of pulmonary embolism or proximal DVT; in this population, the PERC-Peds negative rule can safely rule out pulmonary embolism. Use of PERC-Peds might reduce low-value diagnostic testing for pulmonary embolism in children and adolescents.
FUNDING: US National Institutes of Health.
METHODS: This multicentre, prospective, observational, diagnostic accuracy study was done in 21 paediatric emergency departments across the USA. We enrolled children aged 4-17 years who presented with symptoms prompting the emergency physician to order, or strongly consider ordering, a diagnostic test for pulmonary embolism. Participants formed a consecutive series. At the point of care, clinicians completed a case report form to record the components of the PERC-Peds rule. Diagnostic testing, including D-dimer testing, was done at clinician discretion. Trained research personnel collected patient-reported demographic data, symptoms, medications, and past medical histories prospectively and cross-checked patient-reported past medical histories and medications against data in the electronic health record. Follow-up was done 45 days after enrolment with a standardised, automated SMS message to caregivers. The criterion standard for pulmonary embolism was the outcome of any venous thromboembolism (VTE; including image-proven pulmonary embolism or proximal deep vein thrombosis [DVT; above knee or elbow, but not including isolated saphenous, brachial, or calf vein clots]) within 45 days, as adjudicated by an independent committee of three board-certified paediatric emergency physicians. Adjudicators viewed all imaging reports, information from the 45-day follow-up, and outside medical records. The primary endpoint was safe exclusion by use of PERC-Peds in all participants who were adjudicated, defined as the upper limit of the 95% CI for the false-negative rate not crossing 1·5%.
FINDINGS: Between July 29, 2020, and Sept 29, 2024, 4039 children were enrolled, with 4011 participants adjudicated for pulmonary embolism or proximal DVT. Date of last follow-up was Sept 18, 2025. The median age of the adjudicated population was 15 years (IQR 13-16); 2567 (64·0%) were female and 1444 (36·0%) were male. 3988 participants had complete data, and 253 (6·3%, 95% CI 5·6-7·2) were diagnosed with pulmonary embolism or proximal DVT within 45 days. The sensitivity of the PERC-Peds rule was 99·6% (95% CI 97·8-100·0), specificity was 19·6% (18·4-20·9), and false-negative rate was 0·1% (0·0-0·8). D-dimer test was ordered in 3161 (78·8%) of 4011 participants. Sequential use of PERC-Peds followed by D-dimer test ruled out pulmonary embolism or proximal DVT in 2167 (54·3%) with a false-negative rate of 0·9% (0·6-1·4).
INTERPRETATION: In this multicentre, prospective, observational, diagnostic accuracy study of children with suspected pulmonary embolism in the emergency department, we found a 6·3% prevalence of pulmonary embolism or proximal DVT; in this population, the PERC-Peds negative rule can safely rule out pulmonary embolism. Use of PERC-Peds might reduce low-value diagnostic testing for pulmonary embolism in children and adolescents.
FUNDING: US National Institutes of Health.