The Use of Lung Ultrasound to Monitor the Antibiotic Response of Community-Acquired Pneumonia in Children: A Preliminary Hypothesis

Quantitative evaluation of bronchoalveolar lavage for the treatment of severe Mycoplasma pneumoniae pneumonia in children-A new complementary index: Bronchial Insufflation Sign Score

OBJECTIVE

The aim of this study was to investigate the value of Broncoplasma Insufflation Sign in lung ultrasound signs in assessing the efficacy of bronchoalveolar lavage in severe Mycoplasma pneumoniae pneumonia in children.

METHODS

Forty-seven children with severe Mycoplasma pneumoniae pneumonia were treated with medication and bronchial lavage. Laboratory and imaging results were collected, and lung ultrasonography was performed before bronchoalveolar lavage and 1, 3, and 7 days after lavage to record changes in Bronchial Insufflation Sign and changes in the extent of solid lung lesions. Factors affecting the effectiveness of bronchoalveolar lavage were analyzed using logistic regression and other factors.

RESULTS

Bronchial Insufflation Sign Score and the extent of lung solid lesions were the factors affecting the effectiveness of bronchoalveolar lavage treatment. The smaller the area of lung solid lesions and the higher the Bronchial Insufflation Sign Score, the more effective the results of bronchoalveolar lavage treatment were, and the difference was statistically significant, with a difference of p < 0.05. The Bronchial Insufflation Sign Score had the highest sensitivity and specificity for the prediction of the efficacy of bronchoalveolar lavage treatment in the first 7 days after the treatment.

CONCLUSION

Bronchial Insufflation Sign Score combined with the extent of solid lung lesions can assess the efficacy of bronchoalveolar lavage in the treatment of severe Mycoplasma pneumoniae pneumonia in children; lung ultrasound is a timely and effective means of assessing the efficacy of bronchoalveolar lavage.

Lung ultrasound: A potential tool in the diagnosis of ventilator-associated pneumonia in pediatric intensive care units

PURPOSE

Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in pediatric intensive care unit (PICU), increasing mortality, antibiotics use and duration of ventilation and hospitalization. VAP diagnosis is based on clinical and chest X-ray (CXR) signs defined by the 2018 Center for Disease Control (gold standard). However, CXR induces repetitive patients' irradiation and technical limitations. This study aimed to investigate if lung ultrasound (LUS) can substitute CXR in the VAP diagnosis.

METHODS

A monocentric and prospective study was conducted in a French tertiary care hospital. Patients under 18-year-old admitted to PICU between November 2018 and July 2020 with invasive mechanical ventilation for more than 48 h were included. The studied LUS signs were consolidations, dynamic air bronchogram, subpleural consolidations (SPC), B-lines, and pleural effusion. The diagnostic values of each sign associated with clinical signs (cCDC) were compared to the gold standard approach. LUS, chest X-ray, and clinical score were performed daily.

RESULTS

Fifty-seven patients were included. The median age was 8 [3-34] months. Nineteen (33%) children developed a VAP. In patients with VAP, B-Lines, and consolidations were highly frequent (100 and 68.8%) and, associated with cCDC, were highly sensitive (100 [79-100] % and 88 [62-98] %, respectively) and specific (95.5 [92-98] % and 98 [95-99] %, respectively). Other studied signs, including SPC, showed high specificity (>97%) but low sensibility (<50%).

CONCLUSION

LUS seems to be a powerful tool for VAP diagnosis in children with a clinical suspicion, efficiently substituting CXR, and limiting children's exposure to ionizing radiations.

Differentiating Viral from Bacterial Pneumonia in Children: The Diagnostic Role of Lung Ultrasound-A Prospective Observational Study

This prospective observational study aimed to investigate the utility of lung ultrasound (LUS) in diagnosing and managing pediatric respiratory infections, specifically focusing on viral, bacterial, and SARS-CoV-2 infections. Conducted over a period of 1 year and 8 months, this research involved 85 pediatric patients (showcasing a median age of 14 months) recruited based on specific criteria, including age, confirmed infection through multiplex PCR tests, and willingness to undergo LUS imaging. This study employed a 12-area scoring system for LUS examinations, utilizing the lung ultrasound score (LUSS) to evaluate lung abnormalities. The PCR examination results reveal diverse respiratory pathogens, with SARS-CoV-2, influenza, and bacterial co-infections being prominent among the cases. As an observational study, this study was not registered in the registry. Distinct LUS patterns associated with different pathogens were identified, showcasing the discriminatory potential of LUS in differentiating between viral and bacterial etiologies. Bacterial infections demonstrated more severe lung involvement, evident in significantly higher LUSS values compared with viral cases (p < 0.0001). The specific abnormalities found in bacterial superinfection can be integrated into diagnostic and management protocols for pediatric respiratory infections. Overall, this research contributes valuable insights into optimizing LUS as a diagnostic tool in pediatric pneumonia, facilitating more informed and tailored healthcare decisions.

Lung Ultrasound and Pleural Artifacts: A Pictorial Review

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Effect of ultrasonographic lung consolidation on health and growth in dairy calves: A longitudinal study

Bovine respiratory disease (BRD) is a common and complex disease process in calves. Subclinical disease exists and early detection can be challenging due to inconsistent or nonexistent clinical signs. Thoracic ultrasonography (TUS) is often used and has the potential to improve the identification of respiratory diseases. Combining systematic TUS with clinical examination allows distinguishing BRD, including upper respiratory tract disease (clinical signs of respiratory disease, but no significant lung consolidation), clinical pneumonia (clinical signs of respiratory disease along with lung consolidations), and subclinical pneumonia (no clinical signs, but lung consolidations). Data on subclinical pneumonia are scarce, particularly outside of the North American or European contexts similar to Iran in west Asia with a dry and semi-arid climate and intensive breeding systems similar to North America which breeding calves begin in individual boxes, then moving to group pens, and finally to free stall or open shed housing systems. The first objective of this longitudinal study was to use weekly ultrasonography to monitor calves from birth until weaning in an Iranian dairy herd. The second objective was to look for any association between individual lung consolidation episode or cumulative consolidation episodes on preweaning growth. Thoracic ultrasonography was performed on calves (n = 221) weekly from birth to weaning (8 wk), and scanning occasions for each calf were equally distributed with 1-wk intervals (using consolidation threshold ≥3 cm as a specific lung consolidation definition, and ≥1 cm as a more sensitive threshold). Calf body weights were recorded using a weight tape. Other information recorded were transfer of passive immunity (TPI) using serum Brix (%) ≥8.4% as adequate TPI within the first week after birth and the treatment history of the calves. The main strategy for modeling was to determine how long-term lung consolidation affects average daily gain (ADG) during the preweaning period. A linear model was used to determine the effect of the number of weeks with consolidation on ADG. Using consolidation threshold of ≥3 cm, the mean (±SD) of total ADG for calves with no consolidation episode, 1 consolidation episode, and 2 or more consolidation episodes were 0.45 (±0.10), 0.39 (±0.10), and 0.38 (±0.11) kg/d, respectively. In the final multivariable regression analysis model and based on consolidation threshold of ≥3 cm, calves with 1 and 2 or more consolidation episodes had significantly lower ADG ± standard error (SE) of 0.04 ± 0.02 kg/d, and 0.06 ± 0.02 kg/d, respectively compared with animals with no consolidation episode. A total of 20% of calves (46/229 calves that entered the study) were treated for respiratory disease based on clinical signs (based on farmer examination). The final model also included specific confounders related to ADG and their interactions with lung consolidation (TPI and BRD treatment). An overall of 86% of adequate TPI was obtained. Bovine respiratory disease treatment based on farmer diagnosis had a larger negative effect on preweaning ADG than ultrasonography-diagnosed consolidation episodes (lower ADG ± SE of 0.10 ± 0.03 kg/d). When using a more sensitive consolidation threshold (≥1 cm as consolidation), the number of weeks with consolidation was also negatively associated with the ADG in the multivariable linear regression model with significant difference of 0.05 ± 0.02 kg/d for nonconsolidated calves versus calves consolidated for 2 or more weeks and insignificant difference of 0.01 ± 0.02 kg/d for nonconsolidated calves versus calves with 1 consolidation episode.

The Role of Ultrasound in the Diagnosis of Pulmonary Infection Caused by Intracellular, Fungal Pathogens and Mycobacteria: A Systematic Review

BACKGROUND

Lung ultrasound (LUS) is a widely available technique allowing rapid bedside detection of different respiratory disorders. Its reliability in the diagnosis of community-acquired lung infection has been confirmed. However, its usefulness in identifying infections caused by specific and less common pathogens (e.g., in immunocompromised patients) is still uncertain.

METHODS

This systematic review aimed to explore the most common LUS patterns in infections caused by intracellular, fungal pathogens or mycobacteria.

RESULTS

We included 17 studies, reporting a total of 274 patients with M. pneumoniae, 30 with fungal infection and 213 with pulmonary tuberculosis (TB). Most of the studies on M. pneumoniae in children found a specific LUS pattern, mainly consolidated areas associated with diffuse B lines. The typical LUS pattern in TB consisted of consolidation and small subpleural nodes. Only one study on fungal disease reported LUS specific patterns (e.g., indicating "halo sign" or "reverse halo sign").

CONCLUSIONS

Considering the preliminary data, LUS appears to be a promising point-of-care tool, showing patterns of atypical pneumonia and TB which seem different from patterns characterizing common bacterial infection. The role of LUS in the diagnosis of fungal disease is still at an early stage of exploration. Large trials to investigate sonography in these lung infections are granted.

Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review

BACKGROUND

Infectious diseases are common in pediatric patients. In these patients, ultrasound is a useful imaging modality that involves no irradiation or sedation and can be performed repeatedly at the patient's bedside. The purpose of this review was to show pediatric cases with infectious disease that used ultrasound to decide the methods of treatment.

DATA SOURCES

Literature review was performed using Pubmed as the medical database source. No year-of-publication restriction was placed. The mesh terms used were: "ultrasound", "sonography", "infectious disease", "treatment", "antibiotics", "surgical intervention", "pediatric", "children", "deep neck abscess", "pyothorax", "empyema", "pneumonia", "urinary tract infection", "intra-abdominal abscess", "soft tissue infection", "septic arthritis", "osteomyelitis", and "surgical site infection".

RESULTS

We presented pediatric case series with infectious diseases, including deep neck abscess, pyothorax and empyema, pneumonia, urinary tract infection, intra-abdominal abscess, soft tissue infection, septic arthritis and osteomyelitis, and surgical-site infection. Ultrasound was useful for evaluating the extent and location of inflammation and abscess and for decision-making concerning surgical intervention.

CONCLUSION

Knowledge of these sonographic findings is important for sonographers during examinations and for physicians when determining the treatment plan and period of antibiotic therapy for infected lesions.

Lung ultrasound to diagnose infectious pneumonia of newborns: A prospective multicenter study

INTRODUCTION

Whether lung ultrasound (LUS) can be used for pathogenic diagnosis remains controversial. This study was conducted to clarify whether ultrasound has diagnostic value for etiology.

METHODS

A total of 135 neonatal pneumonia patients with an identified pathogen were enrolled from the newborn intensive care units of 10 tertiary hospitals in China. The study ran from November 2020 to December 2021. The infants were divided into various groups according to pathogens, time of infection, gestational age, and disease severity. The distribution of pleural line abnormalities, B-line signs, and pulmonary consolidation, as well as the incidence of air bronchogram and pleural effusion based on LUS, were compared between these groups.

RESULTS

There were significant differences in pulmonary consolidation. The sensitivity and specificity of the diagnosis of severe pneumonia based on the extent of pulmonary consolidation were 83.3% and 85.2%, respectively. The area under the receiver operating characteristic curve for the identification of mild or severe pneumonia based on the distribution of pulmonary consolidation was 0.776.

CONCLUSION

LUS has good performance in diagnosing and differentiating the severity of neonatal pneumonia but cannot be used for pathogenic identification in the early stages of pneumonia.

Are Lung Ultrasound Features More Severe in Children Diagnosed with Bronchiolitis after the COVID-19 Lockdown Period?

The non-pharmacological measures implemented during the SARS-CoV-2 pandemic disrupted the usual bronchiolitis seasonality. Some authors have speculated that, after the lock down period, there would be an increase in the number and severity of respiratory infections due to the re-introduction of respiratory viruses. We collected clinical, microbiological and lung ultrasound data using the classification of the Italian Society of Thoracic Ultrasound (ADET) in children with bronchiolitis during the pandemic compared to the pre-pandemic period, with the aim of assessing whether the epidemic of bronchiolitis during the pandemic was characterized by a more severe lung involvement documented by lung ultrasound. We enrolled 108 children with bronchiolitis (52 pre-pandemic and 56 COVID-19 period), with a median age of 1.74 months (interquartile range, IQR 1-3.68) and 39.8% were females. Rhinovirus detection and high-flow nasal cannula usage were both increased during the COVID-19 period, although overall need of hospitalization and pediatric intensive care unit admissions did not change during the two periods. Lung ultrasound scores were similar in the two cohorts evaluated. Conclusions: our study suggests that, despite changes in microbiology and treatments performed, lung ultrasound severity scores were similar, suggesting that that bronchiolitis during the pandemic period was no more severe than pre-pandemic period, despite children diagnosed during the pandemic had a higher, but it was not statistically significant, probably, due to small sample size, probability of being admitted.

The Accuracy of Lung Ultrasonography Diagnosis of Community-Acquired Pneumonia, in an Adult Cohort

Objective:

Community-acquired pneumonia (CAP) is a common respiratory infection, and diagnosis is frequently performed using a chest radiography (CXR). Sonography is an available method with less radiation exposure, but has not been confirmed for diagnosis of CAP. The objective was to compare the diagnostic accuracy of sonography.

Materials and Methods:

In this cross-sectional study, 90 adult patients (aged >18 years) were admitted to the emergency department of two university-affiliated hospitals in Southwest Iran, from July to December 2019, with a confirmed diagnosis of CAP. The patient symptoms and CXR results were included as part of this study. Within 24 hours after obtaining a CXR, a lung ultrasonogram (LUS) was performed. The diagnostic accuracy of semiquantitative LUS (SQLUS) was compared with CXR results using the Pearson chi-square test and Fisher’s exact test.

Results:

The mean age of participants was 52.98 ± 16.77 years. 51 were men (56.7%). 28 patients (31.1%), who had abnormal SQLUS results, were not associated with CXR findings ( P = .296). SQLUS showed poor diagnostic accuracy for LUS (31.11%).

Conclusion:

This study results could not confirm LUS as an accurate method for diagnosing CAP in adult patients; although due to the convenient sample of adults and clinical-based diagnosis of CAP, any generalization of the results should be made with caution.

Image Human Thorax Using Ultrasound Traveltime Tomography with Supervised Descent Method

The change of acoustic velocity in the human thorax reflects the functional status of the respiratory system. Imaging the thorax’s acoustic velocity distribution can be used to monitor the respiratory system. In this paper, the feasibility of imaging the human thorax using ultrasound traveltime tomography with a supervised descent method (SDM) is studied. The forward modeling is computed using the shortest path ray tracing (SPR) method. The training model is composed of homogeneous acoustic velocity background and a high-velocity rectangular block moving in the domain of interest (DoI). The average descent direction is learned from the training set. Numerical experiments are conducted to verify the method’s feasibility. Normal thorax model experiment proves that SDM traveltime tomography can efficiently reconstruct thorax acoustic velocity distribution. Numerical experiments based on synthetic thorax model of pleural effusion and pneumothorax show that SDM traveltime tomography has good generalization ability and can detect the change of acoustic velocity in human thorax. This method might be helpful for the diagnosis and evaluation of respiratory diseases.

The Assessment of COVID-19 Pneumonia in Neonates: Observed by Lung Ultrasound Technique and Correlated with Biomarkers and Symptoms

Newborns infected with SARS-CoV2 infection develop different symptoms in comparison with adults, but one thing is clear: some of the most common manifestations include cough and other respiratory symptoms that need to be evaluated. In these cases, lung ultrasound is a useful imaging technique that can evaluate the newborns’ lung damage caused by COVID-19 pneumonia and can be used for the surveillance of the patients as well, being non-irradiating and easy to use. Nineteen neonates who were confirmed as having SARS-CoV2 infection were investigated using this imaging tool, and the results were compared and correlated with their symptoms and biomarkers. The mean of LUSS was 12.21 ± 3.56 (S.D), while the 95% CI for the arithmetic mean was 10.49–13.93. The difference of an independent t-test between the LUSS for the patient who presented cough and the LUSS for the patient without cough was −4.48 with an associated p-value of p = 0.02. The Pearson’s correlation coefficient r = 0.89 (p = 0.03, 95% CI 0.0642 to 0.993) between the LUSS and IL-6 level showed a positive strong correlation. This reliable correlation between lung ultrasound score and inflammatory markers suggests that LUS could be used for monitoring inflammatory lung diseases in the future.

Aspiration pneumonia in children with neurological disorders: a new indication for lung ultrasound? A case series

Aspiration pneumonia is a common cause of morbidity and mortality in both adults and children that, however, is difficult to accurately diagnose. In current literature, there are no reports or clinical research study focused on the possible use of lung ultrasound (LUS) in the diagnosis and follow-up of aspiration pneumonia in children. In this case series, we describe clinical, laboratory, radiological results as well as detailed lung ultrasound findings of three children with severe disability and diagnosed with aspiration pneumonia. In these three cases, albeit at different times, LUS played an important role in both the initial diagnostic process and follow-up.

Lung Ultrasonography Beyond the Diagnosis of Pediatrics Pneumonia

Pneumonia is a prevalent disease with considerable morbidity and mortality among the pediatric population. Early diagnosis and swift commencement of the correct treatment are vital for a favorable clinical outcome. Along with history-taking and clinical examination, imaging modalities commonly used, lung ultrasound provides a bedside, less invasive, radiation-free alternative to diagnose pneumonia when compared with other images such as chest x-ray (CXR) and computed tomography (CT) scan. It is therefore of the utmost magnitude to inspect the evidence of its accuracy and reliability in the diagnosis of this condition. The goal of this study is to look into the available data supporting the use of lung ultrasound in the diagnosis of juvenile pneumonia, its relevance in distinguishing between viral and bacterial diseases, and its superiority as compared to other diagnostic methods. As mentioned, early detection and differentiation of the type of pneumonia can reduce unnecessary antibiotic prescriptions and provide patients with a better prognosis, as well as the ability to predict the course of the disease and the need for advanced care or the development of complications. An extensive literature search of two popular online medical websites (PubMed and Embase) was conducted in this review, concentrating on studies that examined the role of lung ultrasound in the diagnosis of pediatric pneumonia published in the last five years. Only studies published in the English language were included in this review. With high sensitivity and specificity, lung ultrasound appeared to be a promising tool not only for pediatric pneumonia diagnosis, but also for treatment guidance and disease follow-up, especially when combined with clinical presentation and laboratory findings.

Lung ultrasound to detect cardiopulmonary interactions in acutely ill children

OBJECTIVE AND DESIGN

Our prospective observational study is the first study that evaluates the lung ultrasound (LUS) findings of cardiopulmonary interactions in acutely ill children with elevated pro-brain natriuretic peptide (BNP) levels, with the aim of establishing the specific LUS pattern in this category of patients without primary lung diseases.

METHODOLOGY

We prospectively analyzed epidemiological, clinical, laboratory, instrumental, and lung ultrasound parameters in acutely ill children aged 1 month to 18 years admitted to the Department of Pediatrics between March 2020 to August 2020. Among the acutely ill patients evaluated, only patients with pro-BNP > 300 pg/ml and who underwent LUS before the start of any treatment were included. They were stratified into three subcategories based on the diagnosis (A) cardiac disease, (B) systemic inflammatory disease/sepsis without functional and/or organic alterations of the myocardium, and (C) systemic inflammatory disease/sepsis and cardiac disease, and were classified into two groups based on the level of pro-BNP. We also enrolled patients belonging to two other categories (patients with primary infectious lung disease and completely healthy patients) analyzing their epidemiological, clinical, laboratory, instrumental parameters, and lung ultrasound findings and comparing them with those of acutely ill children.

RESULTS AND CONCLUSION

We found that LUS findings in these acutely ill children are different from the ultrasound pattern of other categories of children and in particular (1) children with acute lower respiratory tract infections and (2) healthy infants. The finding in a child of a sonographic interstitial syndrome with multiple, bright, long, separate, and nonconfluent B-lines/long vertical artifacts deriving from a normal and regular pleural line, in the absence of subpleural consolidations, is strongly predictive of cardiogenic pulmonary edema or pulmonary congestion in the course of systemic inflammatory disease/sepsis.

ECHOPAEDIA: Echography in Paediatric Patients in the Age of Coronavirus Disease 2019: Utility of Lung Ultrasound and Chest X-Ray in Diagnosis of Community-Acquired Pneumonia and Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia

BACKGROUND

In recent years, lung ultrasound (LUS) has spread to emergency departments and clinical practise gaining great support, especially in time of pandemic, but only a few studies have been done on children. The aim of the present study is to compare the diagnostic accuracy of LUS (using Soldati LUS score) and that of chest X-ray (CXR) in CAP and COVID-19 pneumonia in paediatric patients. Secondary objective of the study is to examine the association between LUS score and disease severity. Finally, we describe the local epidemiology of paediatric CAP during the study period in the era of COVID-19 by comparing it with the previous 2 years.

METHODS

This is an observational retrospective single-centre study carried out on patients aged 18 or younger and over the month of age admitted to the Paediatric Unit of our Foundation for suspected community-acquired pneumonia or SARS-CoV-2 pneumonia during the third pandemic wave of COVID-19. Quantitative variables were elaborated with Shapiro-Wilks test or median and interquartile range (IQR). Student's t-test was used for independent data. Association between quantitative data was evaluated with Pearson correlation. ROC curve analysis was used to calculate best cut-off of LUS score in paediatric patients. Area under the ROC curve (AUC), sensibility, and specificity are also reported with 95% confidence interval (CI).

RESULTS

The diagnostic accuracy of the LUS score in pneumonia, the area underlying the ROC curve (AUC) was 0.67 (95% CI: 0.27-1) thus showing a discrete discriminatory power, with a sensitivity of 89.66% and specificity 50% setting a LUS score greater than or equal to 1 as the best cut-off. Nine patients required oxygen support and a significant statistical correlation (p = 0.0033) emerged between LUS score and oxygen therapy. The mean LUS score in patients requiring oxygen therapy was 12. RCP was positively correlated to the patient's LUS score (p = 0.0024).

CONCLUSIONS

Our study has shown that LUS is a valid alternative to CXR. Our results show how LUS score can be applied effectively for the diagnosis and stratification of paediatric pneumonia.

Lung Ultrasound to Detect Pneumothorax in Children Evaluated for Acute Chest Pain in the Emergency Department: An Observational Pilot Study

BACKGROUND

Spontaneous pneumothorax is a relatively uncommon and poorly studied condition in children. While several protocols have been developed to evaluate the use of lung ultrasound for dyspneic adult patients in the emergency department, no specific guidelines are present for pediatric emergency physicians.

OBJECTIVES

We prospectively analyzed children with acute chest pain and clinical suspicion of pneumothorax evaluated at the pediatric emergency department.

METHODS

We consecutively enrolled children aged 5-17 years presenting to the pediatric emergency department with clinically suspected pneumothorax based on sudden onset of acute chest pain. After clinical examination, all children underwent lung ultrasound followed by chest X-ray (reference standard). We enrolled 77 children, of which 13 (16.9%) received a final diagnosis of pneumothorax.

RESULTS

The lung point had a sensitivity of 92.3% (95% CI 77.8-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax. The "barcode sign" had a sensitivity of 100% (95% CI 75.3-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax.

CONCLUSION

Lung ultrasound is highly accurate in detecting or excluding pneumothorax in children with acute chest pain evaluated in the pediatric emergency department. If pneumothorax is suspected, but the lung point is not visible, the barcode sign should always be sought as it could be a form of massive pneumothorax.

Implementation of lung ultrasound in low- to middle-income countries: a new challenge global health?

Pneumonia remains the leading cause of death globally in children under the age of five. The poorest children are the ones most at risk of dying. In the recent years, lung ultrasound has been widely documented as a safe and easy tool for the diagnosis and monitoring of pneumonia and several other respiratory infections and diseases. During the pandemic, it played a primary role to achieve early suspicion and prediction of severe COVID-19, reducing the risk of exposure of healthcare workers to positive patients. However, innovations that can improve diagnosis and treatment allocation, saving hundreds of thousands of lives each year, are not reaching those who need them most. In this paper, we discuss advantages and limits of different tools for the diagnosis of pneumonia in low- to middle-income countries, highlighting potential benefits of a wider access to lung ultrasound in these settings and barriers to its implementation, calling international organizations to ensure the indiscriminate access, quality, and sustainability of the provision of ultrasound services in every setting. What is Known: • Pneumonia remains the leading cause of death globally in children under the age of five. The poorest children are the ones most at risk of dying. In the recent years, lung ultrasound has been widely documented as a safe and easy tool for the diagnosis and monitoring of pneumonia and several other respiratory infections and diseases. During the pandemic, it played a primary role to achieve early suspicion and prediction of severe COVID-19, reducing the risk of exposure of healthcare workers to positive patients. However, innovations that can improve diagnosis and treatment allocation, saving hundreds of thousands of lives each year, are not reaching those who need them most. What is New: • We discuss advantages and limits of different tools for the diagnosis of pneumonia in low- to middle-income countries, highlighting potential benefits of a wider access to lung ultrasound in these settings and barriers to its implementation, calling international organizations to ensure the indiscriminate access, quality, and sustainability of the provision of ultrasound services in every setting.

Usefulness of Lung Ultrasound in Paediatric Respiratory Diseases

Respiratory infection diseases are among the major causes of morbidity and mortality in children. Diagnosis is focused on clinical presentation, yet signs and symptoms are not specific and there is a need for new non-radiating diagnostic tools. Among these, lung ultrasound (LUS) has recently been included in point-of-care protocols showing interesting results. In comparison to other imaging techniques, such as chest X-ray and computed tomography, ultrasonography does not use ionizing radiations. Therefore, it is particularly suitable for clinical follow-up of paediatric patients. LUS requires only 5-10 min and allows physicians to make quick decisions about the patient's management. Nowadays, LUS has become an early diagnostic tool to detect pneumonia during the COVID-19 pandemic. In this narrative review, we show the most recent scientific literature about advantages and limits of LUS performance in children. Furthermore, we discuss the major paediatric indications separately, with a paragraph fully dedicated to COVID-19. Finally, we mention potential future perspectives about LUS application in paediatric respiratory diseases.

Classification of Lung Disease in Children by Using Lung Ultrasound Images and Deep Convolutional Neural Network

Bronchiolitis is the most common cause of hospitalization of children in the first year of life and pneumonia is the leading cause of infant mortality worldwide. Lung ultrasound technology (LUS) is a novel imaging diagnostic tool for the early detection of respiratory distress and offers several advantages due to its low-cost, relative safety, portability, and easy repeatability. More precise and efficient diagnostic and therapeutic strategies are needed. Deep-learning-based computer-aided diagnosis (CADx) systems, using chest X-ray images, have recently demonstrated their potential as a screening tool for pulmonary disease (such as COVID-19 pneumonia). We present the first computer-aided diagnostic scheme for LUS images of pulmonary diseases in children. In this study, we trained from scratch four state-of-the-art deep-learning models (VGG19, Xception, Inception-v3 and Inception-ResNet-v2) for detecting children with bronchiolitis and pneumonia. In our experiments we used a data set consisting of 5,907 images from 33 healthy infants, 3,286 images from 22 infants with bronchiolitis, and 4,769 images from 7 children suffering from bacterial pneumonia. Using four-fold cross-validation, we implemented one binary classification (healthy vs. bronchiolitis) and one three-class classification (healthy vs. bronchiolitis vs. bacterial pneumonia) out of three classes. Affine transformations were applied for data augmentation. Hyperparameters were optimized for the learning rate, dropout regularization, batch size, and epoch iteration. The Inception-ResNet-v2 model provides the highest classification performance, when compared with the other models used on test sets: for healthy vs. bronchiolitis, it provides 97.75% accuracy, 97.75% sensitivity, and 97% specificity whereas for healthy vs. bronchiolitis vs. bacterial pneumonia, the Inception-v3 model provides the best results with 91.5% accuracy, 91.5% sensitivity, and 95.86% specificity. We performed a gradient-weighted class activation mapping (Grad-CAM) visualization and the results were qualitatively evaluated by a pediatrician expert in LUS imaging: heatmaps highlight areas containing diagnostic-relevant LUS imaging-artifacts, e.g., A-, B-, pleural-lines, and consolidations. These complex patterns are automatically learnt from the data, thus avoiding hand-crafted features usage. By using LUS imaging, the proposed framework might aid in the development of an accessible and rapid decision support-method for diagnosing pulmonary diseases in children using LUS imaging.

Role of lung ultrasound for the etiological diagnosis of acute lower respiratory tract infection (ALRTI) in children: a prospective study

Objective and design

Our prospective study assesses the role of detailed lung ultrasound (LUS) features to discriminate the etiological diagnosis of acute lower respiratory tract infection (ALRTI) in children.

Methodology

We analyzed patients aged from 1 month to 17 years admitted between March 2018 and April 2020 who were hospitalized for ALRTI. For all patients, history, clinical parameters, microbiological data, and lung ultrasound data were collected. Patients were stratified into three main groups (“bacterial”, “viral”, “atypical”) according to the presumed microbial etiology and LUS findings evaluated according to the etiological group. Nasopharyngeal swabs were obtained from all patients. A qualitative diagnostic test developed by Nurex S.r.l. was used for identification of bacterial and fungal DNA in respiratory samples. The Seegene Allplex™ Respiratory assays were used for the molecular diagnosis of viral respiratory pathogens. In addition, bacterial culture of blood and respiratory samples were performed, when indicated.

Results

A total of 186 children with suspected ALRTI (44% female) with an average age of 6 were enrolled in the study. We found that some ultrasound findings as size, number and distribution of consolidations, the position and motion of air bronchograms, pleural effusions and distribution of vertical artifacts significantly differ (p < 0.05) in children with bacterial, viral and atypical ALRTI.

Conclusion

Our study provides a detailed analysis of LUS features able to predict the ALRTI ethology in children. These findings may help the physicians to better manage a child with ALRTI and to offer personalized approach, from diagnosis to treatment and follow-up.

Lung ultrasound in the diagnosis and monitoring of 30 children with coronavirus disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) has caused a new global pandemic and is responsible for millions of infections and thousands of deaths in the world. The lung ultrasound (LUS) is a noninvasive and easily repeatable tool and can be carried out by the pediatrician at the bedside of children with a consequent reduction in the risk of transmission of the virus.

OBJECTIVE

We hypothesized that ultrasound findings in these patients would (1) be associated with their disease severity and (2) change over time in alignment with clinical outcome.

METHODS

The study was made in the emergency department (ED) in a tertiary level pediatric hospital. All patients with swab-confirmed COVID-19 infection were subjected to a LUS within 6 h from admission and after 96 h.

RESULTS

Among a total of 30 children, 18 (60%) were males, 4 reported exertional dyspnea, and only 1 chest pain. The mean oxygen saturation was 98.8 ± 1.0% in ambient air in the ED and no patient needed oxygen therapy during hospitalization. Children with moderate disease presented more B line (p = .03). After 96 h, we had observed ultrasound abnormality only in 20% of the children. We found a statistically significant reduction in pleural irregularities (30% vs. 16.7; p = .001) and in B lines (50% vs. 20%; p = .008).

CONCLUSIONS

The LUS is a useful, feasible, and safe tool for the clinician to complement the clinical evaluation and to monitor the evolution of lung disease in children with COVID-19.

Lung Ultrasound: Its Findings and New Applications in Neonatology and Pediatric Diseases

Lung ultrasound has become increasingly used in both adult and pediatric populations, allowing the rapid evaluation of many lung and pleura diseases. This popularity is due to several advantages of the method such as the low cost, rapidity, lack of ionizing radiation, availability of bedside and repeatability of the method. These features are even more important after the outbreak of the SARS-CoV-2 pandemic, given the possibility of recognizing through ultrasound the signs of interstitial lung syndrome typical of pneumonia caused by the virus. The purpose of this paper is to review the available evidence of lung ultrasound (LUS) in children and its main applications in pediatric diseases.

Lung Ultrasound: The Essentials

Although US of the lungs is increasingly used clinically, diagnostic radiologists are not routinely trained in its use and interpretation. Lung US is a highly sensitive and specific modality that aids in the evaluation of the lungs for many different abnormalities, including pneumonia, pleural effusion, pulmonary edema, and pneumothorax. This review provides an overview of lung US to equip the diagnostic radiologist with knowledge needed to interpret this increasingly used modality. Supplemental material is available for this article. © RSNA, 2021.

Lung Ultrasound Pattern in Healthy Infants During the First 6 Months of Life

OBJECTIVES

Lung ultrasound (LUS) has gained a primary role in the diagnosis and management of pleuropulmonary disorders in pediatric practice. However, normal and pathologic patterns are translated from adult studies and have never been specifically studied in children, particularly in infants. This was a prospective observational pilot study aiming to define the normal LUS pattern in healthy infants during the first 6 months of life.

METHODS

We recruited healthy neonates at 7 to 10 days of life, and these were followed until the sixth month of life (times: 7-10 days, 1 month, 3 months, and 6 months). We excluded neonates with a gestational age before 33 weeks and neonates with cardiac or lung abnormalities or diseases, immune deficiencies, metabolic or genetic conditions, and acute or chronic respiratory diseases. A LUS evaluation was performed by a single certified pediatrician. The chest wall was examined in 18 areas, addressing A-lines, short and long B-lines, pleural abnormalities, and subpleural consolidations.

RESULTS

Thirty-seven neonates were enrolled and followed until the sixth month of life, 27 (73%) of whom were born at term (≥37 weeks) and 10 (27%) of whom were born preterm (33-36 weeks). Most of the patients at 7 to 10 days showed multiple B-lines (long and short) with a progressive normalization toward a normal A pattern at 6 months (P < .00001; 95% confidence interval, 13.75-23.24). No infants showed subpleural consolidations or pleural abnormalities.

CONCLUSIONS

This study has implications for the interpretation of LUS during the first 6 months of life. Most healthy infants show a diffuse pattern of vertical artifacts (B-lines), and the LUS pattern tends to be similar to the physiologic pattern (A-lines) after the sixth month of life. The only pathologic LUS findings were pleural irregularities and effusion and subpleural consolidations, which have never been described in healthy infants.

Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children

This evidence-based consensus aims to establish the role of point-of-care lung ultrasound in the management of pneumonia and bronchiolitis in paediatric patients. A panel of thirteen experts form five Polish tertiary pediatric centres was involved in the development of this document. The literature search was done in PubMed database. Statements were established based on a review of full-text articles published in English up to December 2019. The development of this consensus was conducted according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluations)-adopted and Delphi method. Initially, 22 proposed statements were debated over 3 rounds of on-line discussion and anonymous voting sessions. A total of 17 statements were agreed upon, including four statements referring to general issues, nine referring to pneumonia and four to bronchiolitis. For five statements experts did not achieve an agreement. The evidence supporting each statement was evaluated to assess the strength of each statement. Overall, eight statements were rated strong, five statements moderate, and four statements weak. For each statement, experts provided their comments based on the literature review and their own experience. This consensus is the first to establish the role of lung ultrasound in the diagnosis and management of pneumonia and bronchiolitis in children as an evidence-based method of imaging.

Could It Be Pneumonia? Lung Ultrasound in Children With Low Clinical Suspicion for Pneumonia

Supplemental Digital Content is available in the text.

Background:

Community-acquired pneumonia (CAP) is a significant cause of pediatric morbidity and mortality worldwide. Emergency department point of care ultrasound (POCUS) is a first-line modality for diagnosis of CAP. The current coronavirus disease 2019 pandemic creates a unique opportunity to incorporate lung POCUS into the evaluation of a broader range of children. It has increased the utility of lung POCUS in both evaluation and follow-up of pediatric coronavirus cases. An increased use of lung POCUS creates an opportunity for earlier diagnosis while allowing the opportunity for overdiagnosis of small infiltrates and atelectasis. We collated a case series to demonstrate the benefit of lung POCUS in a very broad range of children.

Methods:

We collected a case series of 5 patients between December 2018 and December 2019 who presented nonclassically and were diagnosed with CAP on POCUS by a pediatric emergency physician.

Conclusion:

Routine lung POCUS in ill children will allow treating physicians to identify and follow a pulmonary infiltrate consistent with CAP quickly. We anticipate that early and more frequent use of POCUS and earlier diagnosis of CAP may improve outcomes by decreasing healthcare encounters within the same illness and by reducing the incidence of late sequelae of pneumonia such as empyema and effusions. However, we acknowledge that this may come at the expense of the overtreatment of viral infiltrates and atelectasis. Further study is required to improve the specificity of lung POCUS in the evaluation of CAP.

Lung Ultrasound in Children with COVID-19: Preliminary Findings

Recent evidence indicates the usefulness of lung ultrasound (LUS) in detecting coronavirus disease 19 (COVID-19) pneumonia. However, no data are available on the use of LUS in children with COVID-19 pneumonia. In this report, we describe LUS features of 10 consecutively admitted children with COVID-19 in two tertiary-level pediatric hospitals in Rome. LUS revealed signs of lung involvement during COVID-19 infection. In particular, vertical artifacts (70%), pleural irregularities (60%), areas of white lung (10%) and subpleural consolidations (10%) were the main findings in patients with COVID-19. No cases of pleural effusions were found. According to our experience, the routine use of LUS in the evaluation of children with suspected or confirmed COVID-19, when performed by clinicians with documented experience in LUS, was useful in diagnosing and monitoring pediatric COVID-19 pneumonia, reducing unnecessary radiation/sedation in children and exposure of health care workers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).