CONCISE CLINICAL REVIEW

A Systematic Review of Tools to Measure Respiratory Rate in Order to

Identify Childhood Pneumonia
Amy Sarah Ginsburg1, Jennifer L. Lenahan1, Rasa Izadnegahdar2,3, and J. Mark Ansermino4
1
Department of Global Health, Save the Children Federation, Inc., Fairfield, Connecticut; 2Department of Pediatrics, University of
Washington, Seattle, Washington; 3Seattle Children’s Hospital, Seattle, Washington; and 4Department of Anesthesiology,
Pharmacology, and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada

Abstract describing manual devices took place in low-resource settings,

Pneumonia is the leading infectious cause of death in children
worldwide, with most deaths occurring in developing countries.
Measuring respiratory rate is critical to the World Health
Organization’s guidelines for diagnosing childhood pneumonia in
low-resource settings, yet it is difficult to accurately measure. We
conducted a systematic review to landscape existing respiratory
rate measurement technologies. We searched PubMed, Embase,
and Compendex for studies published through September 2017
assessing the accuracy of respiratory rate measurement technologies
in children. We identified 16 studies: 2 describing manual devices
and 14 describing automated devices. Although both studies
all studies describing automated devices were conducted in
well-resourced settings. Direct comparison between studies
was complicated by small sample size, absence of a consistent
reference standard, and variations in comparison methodology.
There is an urgent need for affordable and appropriate innovations
that can reliably measure a child’s respiratory rate in low-resource
settings. Accelerating development or scale-up of these technologies
could have the potential to advance childhood pneumonia diagnosis
worldwide.
Keywords: respiratory rate; childhood pneumonia; automated;
technology; low-resource settings

Pneumonia remains the leading infectious
cause of death among children younger
than 5 years of age. In 2015, pneumonia
accounted for 16% of child deaths globally
(1). Although childhood pneumonia deaths
can be prevented with simple interventions
and appropriate treatment, pneumonia
often goes undiagnosed and untreated in
the community until the child is severely
ill (2, 3). In low-resource settings,
pneumonia is diagnosed using the
World Health Organization Integrated
Management of Childhood Illness and
Integrated Community Case Management
(iCCM) guidelines, which rely on the
appreciation of subjective clinical signs
and symptoms. An important component
of the Integrated Management of
Childhood Illness and iCCM criteria is the
accurate classification of fast breathing,
defined as 60 or more breaths per minute in
infants younger than 2 months, 50 or more
breaths per minute in infants aged 2 to 11
months, and 40 or more breaths per minute
in children aged 12 to 59 months (4).
In low-resource settings, counting the
number of breaths typically is performed
manually with the aid of watches, timers,
and counting beads (5, 6). However, even
with these counting aids, measuring a
child’s respiratory rate (RR) through
visual observation requires focused
concentration and can be challenging in
a child who may be moving, crying, or
breathing rapidly. Inaccurate or imprecise
measurements can stem from factors including
poor visibility of the start or end of a breath,
an irritable or moving child, or difficulty
counting or remembering the count (7).
Accurate assessment of RR is critical in
low-resource settings where other diagnostic
tools, such as pulse oximetry or chest
radiography, are typically not available and
pneumonia is diagnosed based on the child’s
clinical signs alone. Given the high burden
and mortality of childhood pneumonia,
there is growing demand for better ways
to measure RR accurately and reliably.
Although there are numerous existing and
potential approaches for measuring RR
(Table 1), it is important to assess whether

( Received in original form November 12, 2017; accepted in final form February 23, 2018 )
Author Contributions: A.S.G.: study design, search term development, device category development, literature search, article review and analysis, table and
figure design, and manuscript writing and editing; J.L.L.: literature search, article review and analysis, table and figure design, and manuscript writing and
editing; R.I.: manuscript review and editing; and J.M.A.: manuscript writing, review, and editing.
Correspondence and requests for reprints should be addressed to Jennifer L. Lenahan, M.P.H., 501 Kings Highway East, Suite 400, Fairfield, CT 06825. E-mail:
jlenahan@savechildren.org.
CME will be available for this article at www.atsjournals.org.
Am J Respir Crit Care Med Vol 197, Iss 9, pp 1116–1127, May 1, 2018
Copyright © 2018 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201711-2233CI on February 23, 2018
Internet address: www.atsjournals.org

1116 American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
CONCISE CLINICAL REVIEW
Table 1. Respiratory Rate Method Categories
Manual Methods Description
Manual count
Timers only Analog devices used to inform the observer when to
start and stop counting breaths.
Assisted count
Counters only Color-coded string of beads used in combination with
a timer to eliminate the need for an observer to
remember breath count and age-designated cutoff
rates.
Combined timer and Stand-alone digital devices or software-based mobile
counter applications with a built-in 1-min timer to eliminate
the need for an observer to remember breath count
by having the user press a button or tap the screen
to register each breath.
Automatic Methods Description
Exhaled breath
Humidity RR derived from oronasal moisture sensors measuring
fluctuations in humidity with respiration.
Temperature RR derived from oronasal temperature sensors
measuring fluctuations in temperature with
respiration.
Air pressure RR derived from oronasal sensors measuring
fluctuations in air pressure with respiration.
ETCO2 RR derived from oronasal capnography sensors
measuring fluctuations in carbon dioxide
concentrations with respiration.
ETO2 RR derived from oronasal oxygen sensors measuring
fluctuations in oxygen concentrations with respiration.
Thoracic effort
Thoracic RR derived from sensors measuring fluctuations in
circumference thoracic circumference with respiration.
Thoracic motion RR derived from sensors measuring fluctuations in
thoracic motion with respiration.
VT RR derived from electrodes measuring fluctuations in
lung volume with respiration.
Respiratory sounds
Oronasal RR derived from acoustic respiratory signals
measured near the oronasal area.
Thoracic RR derived from acoustic respiratory signals
measured near the chest, back, or armpit.
Tracheal RR derived from acoustic respiratory signals
measured near the throat or neck.
Concise Clinical Review
Examples*
ARI timer, wristwatch
Breath Abacus, International Rescue Committee
counting beads
Mobile software applications
Examples*
Interferometry sensors, relative humidity sensors,
absolute humidity (moisture) sensors,
hygrometers
Thermistors, infrared thermography, thermocouple
sensors, nasal prongs, face masks
Barometric pressure sensors, pressure transducers,
airflow velocity sensors, spirometers,
pneumotachometers
Capnometers, mid-infrared LED detectors
Differential paramagnetic sensors, fiber optic
fluorescence-based oxygen sensors, gas analysis
systems
Inductance plethysmography sensors, piezoelectric
sensors, rubber dilation sensors, stretch sensors,
chest straps, or belts
Accelerometers, gyroscopes, ballistocardiography
sensors, bioradiolocation sensors, noncontact
microwave and wireless networks, ferroelectric
sensors, mattress sensors, electromagnetic
generator, small movement motion amplification
programs
Bioimpedance electrode sensors varying in
presentation (disposable skin adhesive, portable
body-worn devices, wearable garments)
Noncontact microphones or wearable headsets
Electronic auscultation of signals collected from
modified digital stethoscopes
Sensor adhesives placed near the throat or neck
(Continued )
1117
 CONCISE CLINICAL REVIEW

Table 1. (Continued )

Automatic Methods Description Examples*

Indirect effects on
cardiovascular
physiology/blood
flow
ECG RR derived indirectly from the ECG measured by a Numerous portable ECG electrode systems
configuration of electrodes. integrating patented signal extraction techniques
PPG RR derived indirectly from the PPG measured by a pulse Numerous portable pulse oximetry systems
oximeter. integrating patented signal extraction techniques,
including finger clip sensors and wrist-worn
monitors, among others
PtcCO2 RR derived indirectly from the PtcCO2 measured by a wet CO2 measured potentiometrically by determining
Ag/AgCl electrode heated above fevered the pH of an electrolyte layer and used to
temperatures. calculate RR
PAT RR derived indirectly from the PAT waveform measured Fusion algorithms process PAT waveforms to
by an apparatus capable of sensing finger pulsatile identify respiratory events used to calculate RR
arterial volume changes.
ABP RR derived indirectly from the ABP measured by a Complete health monitoring systems displaying vital
sphygmomanometer. signs (e.g., ABP, pulse, and temperature) in
addition to RR

Definition of abbreviations: ABP = arterial blood pressure; ARI = acute respiratory infection; ETCO2 = end-tidal carbon dioxide concentration; ETO2 = end-
tidal oxygen concentration; LED = light-emitting diode; PAT = peripheral arterial tonometry; PPG = photoplethysmogram; RR = respriatory rate.
*Examples provided are for illustrative purposes and are not claimed to be complete.

these have been rigorously evaluated in
a way that facilitates comparisons of
accuracy and performance. This systematic
review provides an overview of the RR
measurement tools that have undergone a
clinical evaluation of accuracy against a
reference standard among spontaneously
breathing children younger than 5 years of
age. Some of the results of these studies
have been previously reported in the form
of an abstract (8).
Methods
Search Strategy and Selection
Criteria
PubMed, Embase, and Compendex/
Engineering Village were searched through
September 2017 for English-language
publications reporting on measuring or
monitoring RR in infants and children
younger than 5 years of age. The search
strategy used preferred indexing terms
from each database and was built around a
set of controlled vocabulary terms and
relevant text words in the title, abstract, or
subject fields (or a combination of those fields).
Articles were screened by two team
members for relevance to the analysis on the
basis of sequential review of study titles,
abstracts, and full text. The inclusion criteria
were specified as English publications
describing accuracy of assessment of breath
count or RR in spontaneously breathing
human infants and/or children younger
than 5 years of age compared with a
reference standard. The exclusion criteria
included mechanically ventilated subjects,
nonhuman animal subjects, failure to
report RR values, lack of a reference
standard, no assessment of accuracy, non-
English publication, subjects older than 5
years of age, inability to disaggregate data
on children younger than 5 years from data
on older children and/or adults, inability
to disaggregate data on mechanically
ventilated children from data on non–
mechanically ventilated children, review
article reporting secondary data, and
insufficiently detailed description of
methods. If not explicitly stated, study
authors were contacted for confirmation
that subjects were spontaneously breathing
and not mechanically ventilated. For this
review, accuracy is defined as the difference
between the values measured by the
experimental device and the “true value” as
quantified by the reference standard.
Data Extraction and Analysis
Included articles were critically appraised
for eligibility criteria and clearly described
methods following Preferred Reporting
Items for Systematic Reviews and Meta-
Analyses guidelines (9). The following data
were extracted into a database with
designated fields: author, title, publication
date, journal, country/countries of study,
population(s) studied, study setting (e.g.,
laboratory, hospital, field), sample size, time
period, study type, primary objective,
categorization of device as manual
or automated, reference standard,
measurement interval, who took the
measurement (e.g., research team, nurse),
outcome measure, and statistical method of
comparison. Included studies were divided
into two groups on the basis of how the
devices measured RR: manually by an
observer or automatically recording from a
physical measurement. Manual methods
were further categorized as manual count
(timers only) or assisted count (combined
timer and counter) (Table 1). Automated
technologies were categorized based on
the physiological parameter from which
the measurement was obtained: exhaled
breath (humidity, temperature, air pressure,
carbon dioxide, oxygen), thoracic effort
(circumference, motion, volume), respiratory
sounds (oronasal, thoracic, tracheal), and
indirect effects on cardiovascular physiology
(electrocardiogram, photoplethysmogram
[PPG], transcutaneous partial pressure of
carbon dioxide, peripheral arterial
tonometry, arterial blood pressure).
All data were analyzed qualitatively by
assessing the device category, method of

1118 American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
CONCISE CLINICAL REVIEW
evaluation, and accuracy in comparison to a (10–23). Both papers on manual devices
reference standard. An objective of this reported data from low-resource settings,
review was to pool outcome measures across with one conducted in India and the
studies through meta-analytic methods. other consolidating evidence from studies
However, the dearth of studies reporting like in Ghana, South Sudan, and Uganda
outcomes precluded this type of quantitative (Table 2) (6, 24).
analysis.
Manual Devices
Results The two publications describing the
accuracy of fast breathing assessment using
Studies Included through Systematic manual devices included primarily low
Review literacy, community-based, frontline
From a total of 7,669 unique citations, providers in low-resource settings and used
89 publications were identified as a reference standard of clinician count over
sufficiently relevant for full text review, 1 minute (Table 2). In a study conducted in
and 16 were ultimately included India in the early 1990s, the accuracy of fast
(Figure 1). Fourteen of those papers breathing assessment by 10 traditional birth
reported on automated devices, and two attendants was higher when assisted by age-
reported on manual devices (Table 2). All specific color-coded counting beads in
included studies on automated devices comparison to no device (82 vs. 60%) (24).
reported data from well-resourced settings, In more recent years, studies assessing the
including the United Kingdom (n = 4), relative benefit of counting beads in
Sweden (n = 3), the Netherlands (n = 3), the conjunction with an acute respiratory
United States (n = 1), Israel (n = 1), infection timer have been conducted to
Switzerland (n = 1), and Australia (n = 1) inform iCCM guidelines on pneumonia
Records identified through database
searches
(n = 9,367)
Records after duplicates removed
(n = 7,669)
Records after abstracts screened
(n = 89)
Full-text articles excluded (n = 75)
-No measure of RR accuracy reported (n = 36)
-Subjects 5 years of age (n = 16)
-Unable to disaggregate data on children <5
from older age groups (n = 9)
-Subjects mechanically ventilated (n = 6)
-Insufficiently described methods (n = 5)
-Review article (n = 2)
-Not published in English (n = 1)
Studies included in review
(n = 16)
Figure 1. Systematic review flow diagram. RR = respiratory rate.
Concise Clinical Review
(6). Formative research in Ghana suggested
that color-coded beads could facilitate
classification accuracy by assisting
community health workers (CHWs) in
identifying fast breathing by age without
the need to remember age-specific cutoff
rates. Pooled data from studies among
primarily illiterate CHWs in South Sudan
and Uganda indicate a 41% absolute
increase in the accuracy of fast breathing
classification when assisted by counting
beads in conjunction with a timer
compared with an acute respiratory
infection timer alone (odds ratio [OR],
5.7; P , 0.005) (Table 2). In South Sudan,
the use of counting beads enabled 60% of
illiterate CHWs to accurately classify fast
breathing. In Uganda, findings differed
based on the literacy level of the CHWs.
Among illiterate CHWs, the ability to
classify fast breathing increased from 37%
using the timer alone to 73% using the
timer and counting beads combined (OR,
4.4; P , 0.005). However, literate CHWs
were 5.6 times as likely to report a breath
count within plus or minus two breaths of
the reference standard when assisted with
a timer alone compared with a timer in
conjunction with counting beads (OR, 5.6;
P , 0.001). A mobile phone application
was also assessed in this study, and no
significant difference in accuracy was
noted between the timer and the mobile
phone application (OR, 1.1; P = 0.08) (6).
Among literate CHWs using any method,
breath count was typically more accurate
at slower breathing rates rather than faster
rates, and CHWs tended to overestimate
RR in the slow-rate scenario and
underestimate RR in the fast-rate scenario.
Automated Devices
We identified 14 studies assessing the
accuracy of automated breath counters
(Table 2). One study assessed multiple
devices, for a total of 15 technologies
assessed. Automated breath counters
fell into four categories: indirect effects
on cardiovascular physiology/blood flow
(n = 8); thoracic effort, VT (n = 3); thoracic
effort, thoracic motion (n = 3); and
exhaled breath humidity (n = 1) (Table 2).
Indirect effects on cardiovascular
physiology/blood flow. Two studies describing
PPG took place in a neonatal ICU (NICU)
in Sweden, using transthoracic impedance
(TTI) plethysmography as the reference
standard (10, 11). In one study, a
PPG probe, designed to cover a small skin
1119
 Table 2. Respiratory Rate Measuring Methods Evaluated for Accuracy in Children Younger Than 5 Years of Age

1120
Location, Users, Reference
Author, Year Device Category Setting Subjects Standard Results

Manual
Bang and Bang, Breath Counter Assisted count, India, household Users: TBAs (n = 10); Physician count, 82% TBAs accurately
1992 (24) counting beads counter only subjects: children 1 min identified fast breathing
,5 yr (n = 5) using Breath Counter,
compared with 60%
accuracy without using
Breath Counter (P , 0.05).

Noordam et al., Study 1: ARI timer vs. Assisted count, Study 1: South Study 1: Users: CHWs Physician count, Study 1: Illiterate CHWs 5.7
2015 (6) ARI timer and combined timer and Sudan and (n = 65); subjects: 1 min (accuracy times as likely to accurately
counting beads counter Uganda, children 2–59 mo window 63 breaths classify fast breathing when
household (n = 65) for Study 1 and using ARI timer and
Study 2, 62 breaths counting beads together
for Study 3) compared with using ARI
timer alone (OR, 5.7;
P , 0.005).
Study 2: Counting Study 2: South Study 2: Users: CHWs Study 2: Among illiterate
beads Sudan, hospital (n = 27); subjects: CHWs, 60% accurately
children 2–59 mo classified fast breathing
(n = 69) using counting beads.
Study 3: ARI timer vs. Study 3: Uganda, Study 3: Users: CHWs Study 3: Literate CHWs 5.6
ARI timer and virtual (video) (n = 94); subjects: times as likely to accurately
counting beads; ARI video case series classify fast breathing when
timer vs. mobile (each CHW shown using ARI timer alone,
phone application in two children with compared with using ARI
which button fast breathing and timer and counting beads
pressed for every one without) together (OR, 5.6; P ,
breath observed, 0.001). No significant
and which beeped difference in accuracy
after 1 min between ARI timer and
mobile phone application
(OR, 1.1; P = 0.08).

Automatic
Johansson et al., PPG Indirect effects on Sweden, NICU Users: research team; TTI, 30 s PPG signal 2.7% (SD, 61.1%)
1999 (10) cardiovascular subjects: neonates false-negative breaths and
physiology/blood (n = 6) 1.5% (SD, 60.4%)
flow false-positive breaths
(Continued )
CONCISE CLINICAL REVIEW

American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
 Table 2. (Continued )

Location, Users, Reference

Author, Year Device Category Setting Subjects Standard Results

Olsson et al., PPG at three Indirect effects on Sweden, NICU and Users: research team; TTI, 30 s Strong association between
2000 (11) monitoring sites cardiovascular neonatal subjects: infants RR recorded by PPG and
(leg, buttock, and physiology/blood intermediate (n = 10) RR recorded by TTI at all
IR) flow care unit three sites, with correlation
coefficients as follows:

Concise Clinical Review

Leg: 0.995 (95% CI,
0.980–0.999)
IR: 0.997 (95% CI,
0.988–0.999)
Buttock: 0.995 (95% CI,
0.980–0.999)

Neuman et al., CHIME device, Indirect effects on United States, Users: research team; Human observer Sensitivity: 96%
CONCISE CLINICAL REVIEW

2001 (12) which measures cardiovascular home (data subjects: infants using Specificity: 65%
RR using physiology/blood collection) and (n = 20) simultaneously
Respitrace Plus flow CHIME base recorded CO2 and
RIP station oronasal air
(interpretation) temperature
(thermistor probe)
to identify breaths,
5 min

Roback et al., FORE FORE: exhaled Sweden, NICU Users: research team; Manual count (1 min, FORE: Mean bias, 23.4%;
2005 (13) breath, humidity subjects: neonates repeated every 6 deviation from reference of
(n = 17) min until at least more than 20% in 22.7%
8 recordings were observations
obtained)
TTI TTI: thoracic effort, VT TTI: Mean bias, 21.6%;
deviation from reference of
more than 20% in 23.8%
observations

Wertheim et al., Pleth trace Indirect effects on United Kingdom, Users: research team; Respiratory airflow Median difference (pleth
2009 (14) cardiovascular postnatal subjects: infants measured using 2 flow), 20.01 breaths/min
physiology/blood hospital ward (n = 14) low–dead space (range, 25.84 to 0.76;
flow ultrasonic flowmeter P = 0.802). Mean difference
connected to face (pleth 2 flow) using Bland-
mask, 2 min Altman analysis, 20.82
breaths/min. Using 1 Hz
LPF to generate a
respiratory-like trace,
median difference, 20.89
breaths/min (range, 28.41
to 0.38; P = 0.038).
(Continued )

1121
 Table 2. (Continued )

1122
Location, Users, Reference
Author, Year Device Category Setting Subjects Standard Results

Wertheim et al., Pleth recordings Indirect effects on United Kingdom, Users: research team; Manual count by Analysis of pleth within 10
2013 (15) cardiovascular inpatient subjects: acutely direct observation breaths/min of manual
physiology/blood hospital unit wheezy children of chest wall count in 15 of 18 children
flow aged 1–4 yr (n = 18) movement, 30 s during acute wheezing
and 15 of 16 children at
follow-up. Using paired t
test, no significant
difference between pleth
and manual count during
acute wheezing or
follow-up.

Petrus et al., Tidal breathing Thoracic effort, VT Switzerland, Users: research team; Ultrasonic flowmeter Mean difference (vest 2 mask),
2015 (16) flow–volume loop hospital subjects: healthy with face mask 0.71 breaths/min (95% CI,
measurements infants (n = 19); (Spiroson) 0.24–1.17; P = 0.031).
using vest-based infants with lung
inductive disease (n = 18)
plethysmograph
system (FloRight)

Kohn et al., 1. Transthoracic Thoracic effort, VT Israel, NICU Users: research team; Manual count using Tight correlation between
2016 (17) impedance subjects: premature video recording of motion sensor modality and
continuously infants (n = 9; 11 chest and abdomen visual count (r2 = 0.83), with
monitored via sessions) (1-min span slope of 0.96, very close to
standard pediatric counted every 5 min) line of equality.
chest electrodes Impedance-based RR
determinations had lower
2. Continuous correlation with manual count
monitoring of (r2 = 0.65) and larger deviation
respiratory from expected line of equality.
dynamics and
measurement
of local tidal
displacement using
three motion
sensors attached
to both sides of
chest wall and
upper abdomen

Shah et al., PPG using modified Indirect effects on United Kingdom, Users: research team; Manual count by Mean absolute error
2015 (18) autoregressive cardiovascular hospital subjects: children nurse (15 or 30 s) in breaths per minute
modeling; RR physiology/blood emergency aged 0–5 yr (n = between intervention and
measured over 60-s flow department 126) reference, 7.6.
sliding window with Median absolute error, 6.0.
50-s overlap
(Continued )
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American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
 Table 2. (Continued )

Location, Users, Reference

Author, Year Device Category Setting Subjects Standard Results

Kraaijenga et al., dEMG; 1-h recording Thoracic effort, Netherlands, NICU Users: research team; Chest impedance, RR measured by dEMG
2015 (19) taken on Days 1, 3, thoracic motion subjects: preterm measured at same significantly correlated to
and 7; calculated infants (n = 31) time points as chest impedance (r = 0.85;
mean RR from dEMG P , 0.001). Bland-Altman
1-min time intervals plot between techniques

Concise Clinical Review

at six fixed time with mean difference of
points (5, 15, 25, 35, 22.3 breaths/min.
45, and 55 min)
van Gastel et al., Noncontact camera Indirect effects on Netherlands, NICU Users: research team; Overall performance CHROM strongest performer
2016 (20) detecting cardiovascular subjects: neonates compared with of four algorithms, with
respiratory-induced physiology/blood (n = 2; 20 videos ECG-derived correlation coefficient (r) of
color differences of flow analyzed) respiratory signal. 0.87 and mean absolute
CONCISE CLINICAL REVIEW

the skin; two remote CHROM and error of 4.67 breaths,

PPG algorithms PBV algorithms compared with
used: CHROM and compared with ECG-derived respiratory
PBV two benchmark signal.
PPG-based
algorithms

Seddon et al., Pleth trace Indirect effects on United Kingdom, Users: parents; RIP bands Median difference (RIP 2 pleth),
2016 (21) cardiovascular home subjects: healthy 0 (range, 21.75 to 6.5
physiology/blood preterm infants with breaths/min). Bland-Altman
flow no respiratory plot indicated no difference
disease (n = 12); in accuracy at higher rates.
preterm infants who
subsequently
developed chronic
lung disease of
prematurity (n = 9)

Janssen et al., VRM system Thoracic effort, Netherlands, NICU Users: research team; Contact-based Average accuracy of VRM in
2016 (22) thoracic motion subjects: neonates thoracic impedance close-view and wide-view
(n = 2; 20 videos) plethysmography videos among neonates,
(ECG) 88.7 and 92.6%,
respectively.

Al-Naji and Thermal camera Thoracic effort, Australia, setting Users: research team; Visual count using Correlation analysis between
Chahl, 2016 using a motion thoracic motion not stated subject: 8-mo-old input video experimental device and
(23) magnification infant (n = 1) reference carried out using
technique to PCC and SRC (PCC, 0.966;
magnify breathing SRC, 0.9566).
movement (15-s Reproducibility coefficient,
video clips) 0.67 breaths/min (2.8%) and
mean difference (bias) 0.21,
with limits of agreement
10.88 and 20.46.

Definition of abbreviations: ARI = acute respiratory infection; CI = confidence interval; CHIME = Collaborative Home Infant Monitor Evaluation; CHROM = chrominance-based; CHW =
community health worker; dEMG = transcutaneous electromyography; FORE = fiberoptic respirometry; IR = interscapular region; LPF = low-pass filtering; NICU = neonatal ICU; OR = odds
ratio; PBV = pulse blood volume; PCC = Pearson correlation coefficient; pleth = pulse oximeter plethysmogram; PPG = photoplethysmogram; RIP = respiratory inductance plethysmograph;
RR = respiratory rate; SRC = Spearman Rho coefficient; TBA = traditional birth attendant; TTI = transthoracic impedance; VRM = video respiration monitoring.

1123

surface area while still having a sufficiently
large detector area, was attached to
neonates’ skin on the lateral left thigh, and
RR was extracted using a band-pass filter.
When compared with the reference, the
PPG signal included 2.7% (61.1%) false-
negative breaths and 1.5% (60.4%) false-
positive breaths (mean 6 SD) (10). In
another study, PPG was used to assess RR
at three monitoring sites (i.e., leg, buttock,
and interscapular region). A strong
association between RR recorded by PPG
and RR recorded by TTI was noted at all
three sites, with the highest correlation in
the interscapular region (correlation
coefficient, 0.997; 95% confidence interval,
0.988–0.999) (11).
A device developed for the
Collaborative Home Infant Monitor
Evaluation (CHIME) project in the United
States involving multiple components
including a pulse oximeter, a thoracic
impedance monitor, and a Respitrace Plus
respiratory inductance plethysmography (RIP)
device collected data from infants at their
homes, and data was analyzed at the CHIME
base station. Compared with a human
observer using simultaneously recorded CO2
and oronasal air temperature to identify
breaths, the CHIME monitor was found to
have 96% sensitivity and 65% specificity (12).
Three additional studies assessed the
accuracy of RR detection using a pulse
oximeter plethysmographic (pleth) trace
(14, 15, 21). In a study analyzing pleth
traces among infants in a postnatal hospital
ward in the United Kingdom and
comparing to the reference standard of
respiratory airflow measured using an
ultrasonic flowmeter connected to a face
mask, the median difference was 20.01
breaths/min and the mean difference (using
Bland-Altman analysis) was 20.82
breaths/min (14). In a study analyzing pleth
traces among acutely wheezy children in an
inpatient hospital unit in the United
Kingdom, analysis of pleth was within 10
breaths/min of the manual count by direct
observation reference standard in 15 of 18
children during acute wheezing and in 15 of
16 children at follow-up. Using a paired t
test, there was no significant difference
between pleth and manual count during
acute wheezing or follow-up (15). In
another study from the United Kingdom
assessing the accuracy of pleth traces using
home recordings of both healthy preterm
infants and preterm infants with chronic
lung disease of prematurity and using RIP
1124 American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
bands as the reference standard, the Bland-
Altman plot indicated no difference in
accuracy at higher rates, and the median
difference was 0 (21).
In a study evaluating PPG recordings
using modified autoregressive modeling
among children aged 0 to 5 years of age
presenting at a hospital emergency
department in the United Kingdom, and
using manual count as the reference
standard, the mean absolute error was 7.6
breaths/min and the median absolute error
was 6.0 breaths/min (18). Finally, a study
using a noncontact camera to detect
respiratory-induced color differences of the
skin among a sample of neonates in a
NICU in the Netherlands, and using an
ECG-derived respiratory signal as the
reference standard, the camera method
demonstrated a mean absolute error of 4.67
breaths/min and a correlation coefficient of
0.87 (20).
Thoracic effort, VT. To measure VT to
assess RR, TTI was used among a sample of
neonates hospitalized in a NICU in Sweden,
using manual count as the reference
standard. TTI demonstrated a mean bias of
21.6%, and a deviation from the reference
of more than 20% was found in 23.8% of
observations. The accuracy of TTI was
subject dependent, with decreased accuracy
during body movement, and TTI tended to
overestimate because of motion artifacts
(13). In another study among a sample of
premature infants in a NICU in Israel, two
methods to assess RR were used 1) TTI
continuously monitored via standard
pediatric chest electrodes, and 2)
continuous monitoring of respiratory
dynamics and measurement of local tidal
displacement using motion sensors
attached to the chest wall and upper
abdomen. Using manual count via video
recording as the reference standard, a tight
correlation was obtained between the
motion sensor modality and the visual
count (r2 = 0.83), with a slope of 0.96. The
impedance-based measurements had a
lower correlation with the manual count
(r2 = 0.65) and a larger deviation from the
expected line of equality (17). In a study
among both healthy infants and infants
with lung disease in a hospital setting in
Switzerland, a FloRight vest–based
inductive plethysmograph system was used
to collect tidal breathing flow–volume loop
measurements to assess RR. Using an
ultrasonic flowmeter with a face mask as
the reference standard, the mean difference
CONCISE CLINICAL REVIEW
was 0.71 breaths/min (95% confidence
interval, 0.24–1.17; P = 0.031) (16).
Thoracic effort, thoracic motion.
Thoracic motion was captured using
transcutaneous electromyography to
calculate RR among preterm infants in a
NICU in the Netherlands. Using chest
impedance as the reference standard,
RR measured by transcutaneous
electromyography was significantly
correlated to chest impedance (r = 0.85; P ,
0.001). The Bland-Altman plot between
techniques showed a mean difference of
22.3 breaths/min (19). In another NICU-
based study in the Netherlands, a video
respiration monitoring system was used to
assess RR among neonates. With contact-
based thoracic impedance plethysmography
as a reference, the average accuracy of the
video system in close-view and wide-view
among neonates was, respectively, 88.7 and
92.6% (22). In a study from Australia,
a thermal camera using a motion
magnification technique was used to
identify respirations in 15-second video
clips taken from a single 8-month-old
infant. Using visual count from the same
input video as the reference standard,
correlation analysis between the
experimental device and the reference was
performed using Pearson correlation
coefficient and Spearman Rho coefficient
(Pearson correlation coefficient, 0.966;
Spearman Rho coefficient, 0.9566). The
reproducibility coefficient was 0.67
breaths/min (2.8%) and the mean
difference was 0.21 (23).
Exhaled breath, humidity. To assess the
humidity of exhaled breath to measure RR
among neonates in a NICU in Sweden and
using manual count as the reference, fiber
optic respirometry found a mean bias of
23.4% and a deviation from the reference of
more than 20% in 22.7% of observations.
The accuracy of fiber optic respirometry
was found to be subject dependent, with
decreased accuracy during body movement,
and tended to underestimate RR because of
probe displacement (13).
Discussion
Given the immense burden of childhood
pneumonia and the fact that RR is the
primary method for diagnosing pneumonia
in low-resource settings, it is critical
to understand the landscape of RR
measurement technologies. This systematic
CONCISE CLINICAL REVIEW
review identified 3 manual and 15
automated RR counting devices evaluated
for accuracy among spontaneously
breathing children younger than 5 years of
age. Although automated technologies were
divided a priori into 4 categories and 16
subcategories (Table 1), only 4 of the
subcategories were identified in this review:
PPG (n = 8), VT (n = 3), thoracic motion
(n = 3), and exhaled breath humidity (n = 1)
(Table 2). Although devices in other
categories may be in the development or
evaluation stage, these four categories
represent devices whose accuracy has been
assessed against a reference standard. No
devices in the respiratory sounds category
were identified in this review. Acoustically
derived respiratory devices may be subject
to signal artifact, leading to difficulties in
obtaining an accurate count. On the basis
of the devices identified in this review,
promising RR technologies include
noncontact devices, those that can detect
changes in motion or color among children
of a range of ages and skin tones, and those
that may be integrated into an existing
device like a pulse oximeter or a multiuse
device such as a tablet or smart phone.
A rigorous evaluation of accuracy
is necessary to validate any technology
before widespread use as a diagnostic tool.
Although all studies in this review included
an assessment of accuracy, there was wide
variation in reference standard selection and
statistical methods of comparison. This
variation precluded the ability to compare
devices head-to-head and complicated
attempts to develop standard criteria or a
cutoff for determining accuracy. Among the
studies evaluating automated technologies,
reference standards included manual count
(n = 5), TTI (n = 2), ECG (n = 2), ultrasonic
flowmeter connected to face mask (n = 2),
RIP bands (n = 1), chest impedance (n = 1),
and human observer using simultaneously
recorded CO2 and oronasal air temperature
to identify breaths (n = 1). This variation in
reference standards made interpreting the
accuracy of the experimental devices
challenging, because the accuracy of the
reference standards themselves was not
clear. Consensus regarding an appropriate
reference standard would improve the
generalizability of future RR device
evaluations.
Although manual breath count was the
most common reference standard in this
review, it is known to have issues with
accuracy and reliability (13, 18). Challenges
Concise Clinical Review
to manual count include distraction, an
agitated or crying child, and mistaking
nonrespiratory movements and sounds as
breaths (13, 18, 25). Furthermore, if the
premise of evaluating RR measurement
technologies is to develop a device that
improves on the accuracy of manual count,
one would need a reference standard
accepted as more accurate than manual
count. In the absence of a gold standard for
RR measurement, we would recommend
that future RR accuracy assessments
include a clear indication of the start of the
breath count and that the repeatability of
the reference standard, whether it be
manual count, auscultation, video
recordings, and/or capnography, be
evaluated with simultaneous observations
and methods. This methodology will allow
for the estimation of the measurement error
relative to the device accuracy.
The appropriate methods and the
challenges involved in measuring
agreement between a clinical standard and
a new device have previously been
described in detail (26, 27). With regard to
statistical methods, we would suggest that
the accuracy of RR measurement be
reported as the root-mean-square
deviation between measured values and
reference values over a range of RRs (as is
done with devices such as pulse
oximeters). It should be clearly stated
whether observations were independent
(more than one observation per subject).
Although there is no currently accepted
reference standard for RR, an indication of
test–retest reliability of the standard (the
variation in measurements taken by a
single person or instrument on the same
subject) would give an indication of
precision.
Another factor to consider is the
definition of an accurate RR count. The
current UNICEF target product profile for
acute respiratory infection diagnostic aids
requires that the “accuracy of obtained RR
should be at least 62 breaths per minute
when compared with the number of
respiratory cycles measured over a period
of 60 seconds” (28). If a child is breathing at
20 breaths/min, a single missed breath at
the start or end of counting (due to the
variation in the count’s start/end time) would
account for this 2% error. This was confirmed
in a study that measured RR twice over a
10-minute period with the same observer and
found a mean difference of 1.8 breaths/min
(29). Although a root-mean-square deviation
of less than 2.5 breaths/min at 20
breaths/min appears technically achievable,
the current cutoff of 62 breaths/min may
be too strict, given the aforementioned
challenges in starting and stopping
times (30).
In well-resourced settings, measuring
RR and other vital signs can be achieved
in multiple ways, sometimes involving
sophisticated and expensive sensors and
signal processing. However, the greatest
need for accurate RR technologies is in low-
resource settings, where such high-cost
technologies may not be appropriate or
feasible. Although all of the manual devices
assessed were evaluated in low-resource
settings, all of the automated devices were
tested in well-resourced settings, often in
tightly controlled environments. In the
absence of validation in low-resource
settings, it is difficult to assess the strengths
and weaknesses of the devices included in
this review. However, low-cost devices with
multiple uses (including the CHIME
monitor and those that assess RR using a
pulse oximeter) may have an advantage
over single-purpose devices, because they
would allow providers to assess multiple
vital signs with a single device, potentially
reducing the complexity and training
involved in incorporating a new technology
into clinical care.
It is critical that RR devices are
developed with the needs of low-resource
settings in mind and should be validated in
the settings where they will ultimately be
used. In-country stakeholders and CHWs
should be consulted during the planning
and development phases, as they may
provide different perspectives (31).
Characteristics of an RR counter most
promising for advancement include
portability, durability, and low cost
(Table 3). The RR device should be simple
to use and should provide the result in a
way that a CHW or the child’s caregiver
can understand (31, 32).
The manual count assessments
identified in this review targeted lower-level
providers like CHWs and traditional birth
attendants as the users of the device. In
contrast, in all but one of the automated
device evaluations, research team members
were the users; the exception was a study
of pulse oximeter pleth trace, in which
parents were the users. As RR technologies
move further along in development and
validation, it will be important to determine
the level of training required for accurate use
1125

Table 3. Performance Needs for Respiratory Rate Counter Technologies
Reliability Automatically and accurately measures respiratory rate
Noninvasiveness Easily placed on and tolerated by an infant or child for the
shortest time possible
Affordability Low cost
Simplicity Simple and intuitive to use
Cultural appropriateness Result can be understood by caregiver
Portability Compact, lightweight, and portable
Durability Robust, dust- and water-resistant
Sustainability Independent and long-lasting power source
Customization Credible and culturally acceptable
Minimalism Least essential hardware and appropriate for low-skilled
community health workers
Validation Prototype refined and demonstrates significant progress
throughout product development cycle
Integration Leverages a multipurpose-built platform to provide an integrated
diagnostic toolkit
Based on information in Reference 32.
as well as the appropriate amount of distress the child, which could impact the
information to present. Whether the RR child’s breathing pattern (13, 22, 34).
device should present only the breath count Movement-based RR counter technologies
or whether it should identify tachypnea can be vulnerable to motion artifacts.
depends on the training of the end user and The challenge is to separate respiratory
the needs of the setting. If the device does from nonrespiratory signals, including
identify tachypnea, the device should be agile discriminating a moving child from a
enough to have settings that may be adapted breath movement or a cry from a breath
if guidelines change globally or regionally. sound (13, 19, 20). Technologies that
In performing a landscape analysis calculate RR on the basis of a subset of
of available RR technologies, it is also breaths may be biased by respiratory pauses
important to address the value of RR as a or brief periods of tachypnea in healthy
diagnostic tool for pneumonia. Many factors newborns (35). In younger children, periods
can influence RR, including temperature, of respiratory distress and fast breathing can
agitation, and whether the child is awake. be irregular and intermittent. With this in
A 2017 systematic review assessing the mind, RR measurement tools should allow
accuracy of clinical symptoms in identifying for an assessment over a period of time
children with radiographic pneumonia rather than at a single time point. The
found that among children with cough, challenge in this is finding a middle ground
fever, or both, tachypnea did not increase between a rapid device appropriate for
the likelihood of radiographic pneumonia health workers with limited time and a tool
(33). Although tachypnea may be a tool with a long enough window to capture
in the diagnosis of pneumonia, tachypnea variation and identify the peak RR.
should be assessed in tandem with other There were also limitations to our
clinical signs and symptoms (such as work landscape analysis and literature review,
of breathing) and should not act as a stand- most significantly that our review may not
alone diagnostic criterion. include all RR counters in development.
There are clear limitations of current Work on RR counting and monitoring
RR devices. Manual counter technologies technologies spans many disciplines that use
do not eliminate reliance on the observer disparate methods and have different aims.
or susceptibility to observer error and Studies that did not include an assessment of
distractions. Automated RR technologies accuracy against a reference standard and
can be expensive and may not be feasible those that did not provide results among
for low-resource settings. Contact-based spontaneously breathing children younger
monitors may not be suitable for neonates than 5 years of age were excluded from this
because of the fragility of their skin and may analysis. We also did not review the non-English
1126 American Journal of Respiratory and Critical Care Medicine Volume 197 Number 9 | May 1 2018
CONCISE CLINICAL REVIEW
literature, and we were not able to verify
whether the RR counters highlighted
here have moved beyond the concept or
development phase. Although some of the
included RR counters did list costs, cost
estimates were not always available and were
excluded from this analysis. Because this
review focuses on accuracy, it does not
address reliability, feasibility, usability, and
acceptability. However, these factors are
important to evaluate and consider when
introducing a new technology.
Finally, although this systematic review
was not prospectively registered, several
steps were taken to minimize selection bias.
The inclusion and exclusion criteria were
developed a priori, and an effort was
made to minimize ambiguity within these
criteria. Two individuals screened the
citations for inclusion in this review to
reduce the risk of biased study decisions.
All decisions regarding inclusion or
exclusion of each citation were thoroughly
documented (36).
Conclusions
Assessment of RR is integral to the
pneumonia diagnostic pathway in low-
resource settings. Accelerating the
development of innovations and spurring
the adaptation of current devices could
significantly improve the process of
pneumonia diagnosis. New devices not only
must be evaluated for their effectiveness in
measuring RR in young children and infants
but also should be designed specifically for
use in low-resource settings. This should
involve prioritizing the needs of healthcare
providers and understanding the constraints
of using this technology in low-resource
settings. Furthermore, the lack of a gold
standard or even a common reference
standard may impede the process of
developing and evaluating future RR
devices. By identifying existing RR counters
and highlighting the gaps in current
evaluation protocols, we hope to encourage
researchers, developers, manufacturers, and
innovators to address the need for better
ways to diagnose pneumonia and reduce
childhood mortality in low-resource
settings. A single accurate measurement
of RR alone is unlikely to provide a clear
diagnosis of pneumonia, but, rather,
measurement will need to be repeated over
time and combined with other clinical signs
and symptoms interpreted by a trained
frontline health worker. n
CONCISE CLINICAL REVIEW
Author disclosures are available with the text Acknowledgment: The authors thank Jaclyn
of this article at www.atsjournals.org. Delarosa for her assistance in developing the
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