Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis

Chest Physiotherapy for Mechanically Ventilated Children: A Systematic Review

The aim of this study was to appraise and summarize the effects of chest physiotherapy in mechanically ventilated children. A systematic review was completed by searching Medline, Embase, Cinahl Plus, PEDro, and Web of Science from inception to February 9, 2021. Studies investigating chest physiotherapy for mechanically ventilated children (0-18 years), in a pediatric intensive care unit were included. Chest physiotherapy was defined as any intervention performed by a qualified physiotherapist. Measurements of effectiveness and safety were included. Exclusion criteria included preterm infants, children requiring noninvasive ventilation, and those in a nonacute setting. Thirteen studies met the inclusion criteria: two randomized controlled trials, three randomized crossover trials, and eight observational studies. The Cochrane risk of bias and the Critical Appraisal Skills Program tools were used for quality assessment. Oxygen saturations decreased after physiotherapy involving manual hyperinflations (MHI) and chest wall vibrations (CWV). Although statistically significant, these results were not of clinical importance. In contrast, oxygen saturations improved after the expiratory flow increase technique; however, this was not clinically significant. An increase in expiratory tidal volume was demonstrated 30 minutes after MHI and CWV. There was no sustained change in tidal volume following a physiotherapy-led recruitment maneuver. Respiratory compliance and dead-space increased immediately after MHI and CWV. Atelectasis scores improved following intrapulmonary percussive ventilation, and MHI and CWV. Evidence to support chest physiotherapy in ventilated children remains inconclusive. There are few high-quality studies, with heterogeneity in interventions and populations. Future studies are required to investigate multiple physiotherapy interventions and the impact on long-term outcomes.

Curated and Annotated Dataset of Lung US Images in Zambian Children with Clinical Pneumonia

See also the commentary by Sitek in this issue. Supplemental material is available for this article.

Liquefied Petroleum Gas or Biomass Cooking and Severe Infant Pneumonia

BACKGROUND

Exposure to household air pollution is a risk factor for severe pneumonia. The effect of replacing biomass cookstoves with liquefied petroleum gas (LPG) cookstoves on the incidence of severe infant pneumonia is uncertain.

METHODS

We conducted a randomized, controlled trial involving pregnant women 18 to 34 years of age and between 9 to less than 20 weeks' gestation in India, Guatemala, Peru, and Rwanda from May 2018 through September 2021. The women were assigned to cook with unvented LPG stoves and fuel (intervention group) or to continue cooking with biomass fuel (control group). In each trial group, we monitored adherence to the use of the assigned cookstove and measured 24-hour personal exposure to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm [PM2.5]) in the women and their offspring. The trial had four primary outcomes; the primary outcome for which data are presented in the current report was severe pneumonia in the first year of life, as identified through facility surveillance or on verbal autopsy.

RESULTS

Among 3200 pregnant women who had undergone randomization, 3195 remained eligible and gave birth to 3061 infants (1536 in the intervention group and 1525 in the control group). High uptake of the intervention led to a reduction in personal exposure to PM2.5 among the children, with a median exposure of 24.2 μg per cubic meter (interquartile range, 17.8 to 36.4) in the intervention group and 66.0 μg per cubic meter (interquartile range, 35.2 to 132.0) in the control group. A total of 175 episodes of severe pneumonia were identified during the first year of life, with an incidence of 5.67 cases per 100 child-years (95% confidence interval [CI], 4.55 to 7.07) in the intervention group and 6.06 cases per 100 child-years (95% CI, 4.81 to 7.62) in the control group (incidence rate ratio, 0.96; 98.75% CI, 0.64 to 1.44; P = 0.81). No severe adverse events were reported to be associated with the intervention, as determined by the trial investigators.

CONCLUSIONS

The incidence of severe pneumonia among infants did not differ significantly between those whose mothers were assigned to cook with LPG stoves and fuel and those whose mothers were assigned to continue cooking with biomass stoves. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Accuracy of Thoracic Ultrasonography for the Diagnosis of Pediatric Pneumonia: A Systematic Review and Meta-Analysis

As an emerging imaging technique, thoracic ultrasonography (TUS) is increasingly utilized in the diagnosis of lung diseases in children and newborns, especially in emergency and critical settings. This systematic review aimed to estimate the diagnostic accuracy of TUS in childhood pneumonia. We searched Embase, PubMed, and Web of Science for studies until July 2023 using both TUS and chest radiography (CR) for the diagnosis of pediatric pneumonia. Two researchers independently screened the literature based on the inclusion and exclusion criteria, collected the results, and assessed the risk of bias using the Diagnostic Accuracy Study Quality Assessment (QUADAS) tool. A total of 26 articles met our inclusion criteria and were included in the final analysis, including 22 prospective studies and four retrospective studies. The StataMP 14.0 software was used for the analysis of the study. The overall pooled sensitivity was 0.95 [95% confidence intervals (CI), 0.92-0.97] and the specificity was 0.94 [95% CI, 0.88-0.97], depicting a good diagnostic accuracy. Our results indicated that TUS was an effective imaging modality for detecting pediatric pneumonia. It is a potential alternative to CXR and a follow-up for pediatric pneumonia due to its simplicity, versatility, low cost, and lack of radiation hazards.

The potential clinical value of pairing procalcitonin and lung ultrasonography to guide antibiotic therapy in patients with community-acquired pneumonia: a narrative review

INTRODUCTION

Lower respiratory tract infections (LRTIs) are among the most frequent infections and are prone to inappropriate antibiotic treatments. This results from a limited accuracy of diagnostic tools in identifying bacterial pneumonia. Lung ultrasound (LUS) has excellent sensitivity and specificity in diagnosing pneumonia. Additionally, elevated procalcitonin (PCT) levels correlate with an increased likelihood of bacterial infection. LUS and PCT appear to be complementary in identifying patients with bacterial pneumonia who are likely to benefit from antibiotics.

AREAS COVERED

This narrative review aims to summarize the current evidence for LUS to diagnose pneumonia, for PCT to guide antibiotic therapy and the clinical value of pairing both tools.

EXPERT OPINION

LUS has excellent diagnostic accuracy for pneumonia in different settings, regardless of the examiner's experience. PCT guidance safely reduces antibiotic prescription in LRTIs. The combination of both tools has demonstrated an enhanced accuracy in the diagnosis of pneumonia, including CAP in the ED and VAP in the ICU, but randomized controlled studies need to validate the clinical impact of a combined approach.

Updates in pediatric ultrasound

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) has various diagnostic and therapeutic applications in the pediatric acute care setting that have an impact on clinical outcomes.

RECENT FINDINGS

POCUS can improve diagnostic efficiency and expedite management in pediatric patients who present to the emergency department with common complaints such as respiratory distress, abdominal pain, shock, and pain.

SUMMARY

Rapid advancements in POCUS have allowed it to become a powerful tool in pediatric care. As the clinical applications of ultrasound diversify, research is needed to evaluate impacts on healthcare outcomes, delivery, and costs.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

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.

B-mode ultrasound and contrast-enhanced ultrasound for evaluation of pneumonia: A pictorial essay

Due to their often peripheral pleural-based location, pneumonias can be visualised by B-mode ultrasound. Therefore, sonography can be used as an alternative imaging modality to chest X-ray in suspected cases of pneumonia. Depending on the clinical background of the patient, and various underlying pathological mechanisms, a heterogeneous pattern of pneumonia is seen in both B-mode lung ultrasound and contrast-enhanced ultrasound. Here, we describe the spectrum of sonographic manifestations of pneumonic/inflammatory consolidation on B-mode lung ultrasound and contrast-enhanced ultrasound.

Lung Ultrasound Protocol and Quality Control of Image Interpretation Using an Adjudication Panel in the Household Air Pollution Intervention Network (HAPIN) Trial

OBJECTIVE

Lung ultrasound (LUS) is an alternative to chest radiography to confirm a diagnosis of pneumonia. For research and disease surveillance, methods to use LUS to diagnose pneumonia are needed.

METHODS

In the Household Air Pollution Intervention Network (HAPIN) trial, LUS was used to confirm a clinical diagnosis of severe pneumonia in infants. We developed a standardized definition of pneumonia, protocols for recruitment and training of sonographers, along with LUS image acquisition and interpretation. We use a blinded panel approach to interpretation with LUS cine-loops randomized to non-scanning sonographers with expert review.

DISCUSSION

We obtained 357 lung ultrasound scans: 159, 8 and 190 scans were collected in Guatemala, Peru and Rwanda, respectively. The diagnosis of primary endpoint pneumonia (PEP) required an expert tie breaker in 181 scans (39%). PEP was diagnosed in 141 scans (40%), not diagnosed in 213 (60%), with 3 scans (<1%) deemed uninterpretable. Agreement among the two blinded sonographers and the expert reader in Guatemala, Peru and Rwanda was 65%, 62% and 67%, with a prevalence-and-bias-corrected kappa of 0.30, 0.24 and 0.33, respectively.

CONCLUSION

Use of standardized imaging protocols, training and an adjudication panel resulted in high confidence for the diagnosis of pneumonia using LUS.

Role of Lung Ultrasonography (LUS) as a Tool for Evaluating Children with Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS)

BACKGROUND

Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a novel entity. The inflammatory process involves the circulatory, digestive, respiratory, and central nervous systems, as well as the skin. Making a diagnosis requires extensive differential diagnoses, including lung imaging. The aim of our study was to retrospectively assess the pathologies found in lung ultrasound (LUS) in children diagnosed with PIMS-TS and to evaluate the usefulness of the examination in diagnostics and monitoring.

METHODS

The study group consisted of 43 children diagnosed with PIMS-TS, in whom LUS was performed at least three times, including on admission to hospital, on discharge, and 3 months after disease onset.

RESULTS

Pneumonia (mild to severe) was diagnosed in 91% of the patients based on the ultrasound image; the same number had at least one pathology, including consolidations, atelectasis, pleural effusion, and interstitial or interstitial-alveolar syndrome. By the time of discharge, the inflammatory changes had completely regressed in 19% of the children and partially in 81%. After 3 months, no pathologies were detected in the entire study group.

CONCLUSION

LUS is a useful tool for diagnosing and monitoring children with PIMS-TS. Inflammatory lesions of the lungs resolve completely when the generalized inflammatory process subsides.

Acute care diagnostics in children for general radiologists - not alone in the hospital at night

BACKGROUND

Radiologic care for children and adolescents during night and weekend shifts is challenging. This is especially true when a dedicated pediatric radiology front or background service is not available.

METHODS

The purpose of this review is to present the approach, the most relevant diagnoses, and their differential diagnoses based on four common example cases - abdominal pain, respiratory/chest pain, headache, and refusal to walk. Essentials such as clinical classification (e. g., disease dynamics) and practical instructions (e. g., necessity of acute cross-sectional imaging) are presented.

RESULTS AND CONCLUSION

For the abdomen, appendicitis ranks first among acute diseases. Other important diseases are intussusception and volvulus. Far more frequently, however, gastroenteritis is the cause of abdominal pain. Usually no imaging is required in this case. In unclear clinical situations, ultrasound may be indicated. In suspected pulmonary infections, chest imaging is limited to inconclusive cases and suspicion of complications such as pleural empyema. Major emergencies include (spontaneous) pneumothorax and aspiration. Headache is a common symptom. Immediate imaging is only necessary in cases of suspected acute inflammatory (meningitis/encephalitis) or vascular disease (e. g., hemorrhage due to vascular malformations). MRI is the primary imaging modality in these cases. Restricted walking/refusal to walk is a classic nonspecific sign, particularly of acute musculoskeletal disease, especially in younger children. Clinical examination is essential to narrow down the field of investigation. Besides the frequent and symptomatic coxitis fugax, the rare but serious (septic) arthritis/osteomyelitis must not be overlooked.

KEY POINTS

· Radiological care of children and adolescents is challenging, especially during night and weekend shifts.. · However, in close cooperation with the referring colleagues/clinics, the appropriate approach can be effectively determined even if the symptoms are not clear.. · The selection of the optimal imaging method is based on guidance and guidelines, but also on the condition of the child/adolescent.. · A silent or whimpering child is cause for alarm..

CITATION FORMAT

· Beer M, Mentzel H, Steinborn M et al. Acute care diagnostics in children for general radiologists - not alone at night in the hospital. Fortschr Röntgenstr 2023; 195: 205 - 216.

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.

The utility of chest x-ray and lung ultrasound in the management of infants and children presenting with severe pneumonia in low-and middle-income countries: A pragmatic scoping review

Background

Chest x-ray (CXR) is commonly used (when available) to support clinical management decisions for child pneumonia and provide a reference standard for diagnosis in research studies. However, its diagnostic and technical limitations for both purposes are well recognised. Recent evidence suggests that lung ultrasound (LUS) may have diagnostic utility in pneumonia. This systematic scoping review of research on the utility of CXR and LUS in the management of severe childhood pneumonia aims to inform pragmatic guidelines for low- and middle-income countries (LMICs) and identify gaps in knowledge.

Methods

We included peer-reviewed studies published between 2000 and 2020 in infants and children aged from one month to nine years, presenting with severe pneumonia. CXR studies were limited to those from LMICs, while LUS studies included any geographic region. LUS and CXR articles were mapped into the following themes: indications, role in diagnosis, role in management, impact on outcomes, and practical considerations for LMIC settings.

Results

85 articles met all eligibility criteria, including 27 CXR studies and 58 LUS studies. CXR studies were primarily observational and examined associations between radiographic abnormalities and pneumonia aetiology or outcomes. The most consistent finding was an association between CXR consolidation and risk of mortality. Difficulty obtaining quality CXR images and inter-reader variability in interpretation were commonly reported challenges. Research evaluating indications for CXR, role in management, and impact on patient outcomes was very limited. LUS studies primarily focused on diagnostic accuracy. LUS had higher sensitivity for identification of consolidation than CXR. There are gaps in knowledge regarding diagnostic criteria, as well as the practical utility of LUS in the diagnosis and management of pneumonia. Most LUS studies were conducted in HIC settings with experienced operators; however, small feasibility studies indicate that good inter-operator reliability may be achieved by training of novice clinicians in LMIC settings.

Conclusions

The available evidence does not support the routine use of CXR or LUS as essential tools in the diagnosis and initial management of severe pneumonia. Further evaluation is required to determine the clinical utility and feasibility of both imaging modalities in low-resource settings.

Artificial Intelligence-Augmented Pediatric Lung POCUS: A Pilot Study of Novice Learners

OBJECTIVE

Respiratory symptoms are among the most common chief complaints of pediatric patients in the emergency department (ED). Point-of-care ultrasound (POCUS) outperforms conventional chest X-ray and is user-dependent, which can be challenging to novice ultrasound (US) users. We introduce a novel concept using artificial intelligence (AI)-enhanced pleural sweep to generate complete panoramic views of the lungs, and then assess its accuracy among novice learners (NLs) to identify pneumonia.

METHODS

Previously healthy 0- to 17-year-old patients presenting to a pediatric ED with cardiopulmonary chief complaint were recruited. NLs received a 1-hour training on traditional lung POCUS and the AI-assisted software. Two POCUS-trained experts interpreted the images, which served as the criterion standard. Both expert and learner groups were blinded to each other's interpretation, patient data, and outcomes. Kappa was used to determine agreement between POCUS expert interpretations.

RESULTS

Seven NLs, with limited to no prior POCUS experience, completed examinations on 32 patients. The average patient age was 5.53 years (±1.07). The median scan time of 7 minutes (minimum-maximum 3-43; interquartile 8). Three (8.8%) patients were diagnosed with pneumonia by criterion standard. Sensitivity, specificity, and accuracy for NLs AI-augmented interpretation were 66.7% (confidence interval [CI] 9.4-99.1%), 96.5% (CI 82.2-99.9%), and 93.7% (CI 79.1-99.2%). The average image quality rating was 2.94 (±0.16) out of 5 across all lung fields. Interrater reliability between expert sonographers was high with a kappa coefficient of 0.8.

CONCLUSION

This study shows that AI-augmented lung US for diagnosing pneumonia has the potential to increase accuracy and efficiency.

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.

LUNCH-Lung Ultrasound for early detection of silent and apparent aspiratioN in infants and young CHildren with cerebral palsy and other developmental disabilities: study protocol of a randomized controlled trial

Background

Children with neurological impairment may have dysphagia and/or gastro-esophageal reflux disease (GERD), which predispose to complications affecting the airways, increasing risk for aspiration-induced acute and chronic lung disease, or secondarily malnutrition, further neurodevelopmental disturbances, stressful interactions with their caregivers and chronic pain. Only multidisciplinary clinical feeding evaluation and empirical trials are applied to provide support to the management of feeding difficulties related to dysphagia or GERD, but no standardized feeding or behavioral measure exists at any age to assess aspiration risk and support the indication to perform a videofluoroscopic swallowing study (VFSS) or a fibre-optic endoscopic examination of swallowing (FEES), in particular in newborns and infants with neurological impairments. Lung ultrasound (LUS) has been proposed as a non-invasive, radiation-free tool for the diagnosis of pulmonary conditions in infants, with high sensitivity and specificity.

Methods

A RCT will be conducted in infants aged between 0 and 6 years having, or being at risk for, cerebral palsy, or other neurodevelopmental disease that determines abnormal muscular tone or motor developmental delay assessed by a quantitative scale for infants or if there is the suspicion of GERD or dysphagia based on clinical symptoms. Infants will be allocated in one of 2 groups: 1) LUS-monitored management (LUS-m); 2) Standard care management (SC-m) and after baseline assessment (T0), both groups will undergo an experimental 6-months follow-up. In the first 3 months, infants will be evaluated a minimum of 1 time per month, in-hospital, for a total of 3 LUS-monitored meal evaluations. Primary and secondary endpoint measures will be collected at 3 and 6 months.

Discussion

This paper describes the study protocol consisting of a RCT with two main objectives: (1) to evaluate the benefits of the use of LUS for monitoring silent and apparent aspiration in the management of dysphagia and its impact on pulmonary illness and growth and (2) to investigate the impact of the LUS management on blood sample and bone metabolism, pain and interaction with caregivers.

Trial registration

Trial registration date 02/05/2020; ClinicalTrials.gov Identifier: NCT04253951.

Lung Ultrasound Patterns in Multisystem Inflammatory Syndrome in Children (MIS-C)-Characteristics and Prognostic Value

Objective and design: Following COVID-19 infection, children can develop an hyperinflammatory state termed Multisystem Inflammatory Syndrome in Children (MIS-C). Lung Ultrasound (LUS) features of COVID-19 in children have been described, but data describing the LUS findings of MIS-C are limited. The aim of this retrospective observational study conducted between 1 March and 31 December 2020, at a tertiary pediatric hospital in Milano, is to describe LUS patterns in patients with MIS-C and to verify correlation with illness severity. The secondary objective is to evaluate concordance of LUS with Chest X-ray (CXR). Methodology: Clinical and laboratory data were collected for all patients (age 0−18 years) admitted with MIS-C, as well as LUS and CXR patterns at admission. PICU admission, needed for respiratory support and inotrope administration, hospital, and PICU length of stay, were considered as outcomes and evaluated in the different LUS patterns. An agreement between LUS and CXR evaluation was assessed with Cohen’ k. Results: 24 children, who had a LUS examination upon admission, were enrolled. LUS pattern of subpleural consolidations < or > 1 cm with or without pleural effusion were associated with worse Left Ventricular Ejection Fraction at admission and need for inotropes. Subpleural consolidations < 1 cm were also associated with PICU length of stay. Agreement of CXR with LUS for consolidations and effusion was slight. Conclusion: LUS pattern of subpleural consolidations and consolidations with or without pleural effusion are predictors of disease severity; under this aspect, LUS can be used at admission to stratify risk of severe disease.

Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study

PURPOSE

We investigated whether lung ultrasound (US) performed in primary care is useful and feasible for diagnosing community-acquired pneumonia (CAP) compared with chest radiography, as most previous research has been conducted in hospital settings.

METHODS

We undertook a prospective observational cohort study of lung US performed in 12 primary care centers. Patients aged 5 years and older with symptoms suggesting CAP were examined with lung US (by 21 family physicians and 7 primary care pediatricians) and chest radiograph on the same day. We compared lung US findings with the radiologist's chest radiograph report as the reference standard, given that the latter is the most common imaging test performed for suspected CAP in primary care. The physicians had varied previous US experience, but all received a 5-hour lung US training program.

RESULTS

The study included 82 patients. Compared with chest radiography, positive lung US findings (consolidation measuring >1 cm or a focal/asymmetrical B-lines pattern) showed a sensitivity of 87.8%, a specificity of 58.5%, a positive likelihood-ratio of 2.12, and a negative likelihood-ratio of 0.21. Findings were similar regardless of the physicians' previous US training or experience. We propose a practical algorithm whereby patients having consolidation measuring greater than 1 cm or normal findings on lung US could skip chest radiography, whereas patients with a B-lines pattern without consolidation (given its low specificity) would need chest radiography to ensure appropriate management. Lung US was generally performed in 10 minutes or less.

CONCLUSION

Point-of-care lung US in primary care could be useful for investigating suspected CAP (avoiding chest radiography in most cases) and is likely feasible in daily practice, as short training programs appear sufficient and little time is needed to perform the scan.

Diagnostic accuracy of lung ultrasonography in childhood pneumonia: a meta-analysis

This meta-analysis aimed to assess the diagnostic accuracy of lung ultrasonography in pneumonia-affected pediatric patients. Literature search of published articles in Medline, Web of Science, Scopus, Embase and Journal of Web till September 2020 were reviewed for the predescribed accuracy assessors. In compliance with the inclusion and exclusion criteria, two researchers independently screened the literature, collected the results and assessed the risks of bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The pooled sensitivity and specificity, pooled positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were estimated for the meta-analysis. The overall efficiency of lung ultrasonography (LUS) was evaluated using a summary receiver operating characteristic curve. Q and I2 statistics were used to determine heterogeneity. Meta disc software was used for the analysis of the study. Out of 1182 studies, only 29 articles were chosen; 25 of them were prospective studies and 4 studies were retrospective. The overall pooled sensitivity was 0.83 [95% confidence intervals (CI), 0.81-0.84] and specificity was 0.84 (95% CI, 0.81-0.86), depicting good diagnostic performance. LUS is an efficient imaging technique for detecting childhood pneumonia with a high accuracy rate. It is an appealing alternative to chest X rays to detect and follow-up pneumonia in children because it is simple to do, widely available, comparatively cheap and free of radiation hazards.

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia

OBJECTIVES

To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.

STUDY DESIGN

We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.

RESULTS

A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period.

CONCLUSIONS

Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases.

Pleuro-pulmonary ultrasound in the diagnosis and follow-up of lung infections in children with cancer: a pilot study

PURPOSE

Febrile neutropenia and lung infections are common and potential fatal complications of pediatric cancer patients during chemotherapy. Lung ultrasound (LUS) has a good accuracy in the diagnosis of pneumonia in childhood, but there is no data concerning its use in the diagnosis and follow-up of pulmonary infection in children with cancer. The goal of this pilot study is to verify the feasibility of lung ultrasonography for the diagnosis and follow up of pneumonia in children and adolescents with cancer.

MATERIAL AND METHODS

This is a prospective observational case-control monocentric study conducted in the Pediatric Hematology and Oncology Department of University Hospital of Catania in patients aged < 18 years with cancer. Attending Physician used ultrasonography to detect pneumonia in cancer children with fever. As control group, cancer patients with no infection suspicion were also tested. LUS results were compared to chest X-ray (CXR) and/or chest CT scan, when these imaging techniques were performed, according to clinical indication.

RESULTS

Thirty-eight patients were studied. All underwent LUS, 16 underwent CXR, 3 chest CT. Statistical analysis showed LUS specificity of 93% (95% CI 84-100%), and sensitivity of 100%; CXR, instead, showed a specificity of 83% (95% CI 62-100%) and a sensitivity of 50% (95% CI 1-99%).

CONCLUSION

This study shows for the first time that LUS allows physicians to diagnose pneumonia in children and young adults with cancer, with high specificity and sensitivity.

Pediatric pneumonia (PedPne) lung ultrasound score and inflammatory markers: A pilot study

INTRODUCTION

Pneumonia is the principal cause of death among children worldwide. Lung ultrasound (LUS) is a reliable tool for the diagnosis and assessment of community-acquired pneumonia in children. Furthermore, objective parameters, including the pneumonia LUS score, might be useful for pneumonia monitoring. Thus, our aim was to present a newly developed LUS score for pediatric pneumonia (PedPne) and evaluate its relationship with commonly assessed inflammatory markers.

METHODS

Children referred to the Pediatric Pneumology Clinic between September 2017 and February 2018 with suspected pneumonia were screened for eligibility for inclusion in the study and informed consent was obtained. In addition to clinical assessment, LUS was performed during consultation, and inflammatory biomarkers, including C-reactive protein level, erythrocyte sedimentation rate (ESR), and leukocyte count, were measured in all inpatients. An LUS score for pneumonia and pleurisy in children (pediatric pneumonia lung ultrasound score [PedPne LUS]) was subsequently developed. Chest radiography (CXR) was also performed according to local guidelines for pneumonia diagnosis. Spearman's correlation test was used to evaluate the correlation between the PedPne score and inflammatory markers.

RESULTS

A total of 217 patients were screened, of which 64 patients diagnosed with consolidated pneumonia were included in this study. The median PedPne LUS score of the included patients was 8.02, which was consistent with the consolidations detected on LUS and confirmed by CXR. A very strong positive correlation was found between the LUS PedPne score and C-reactive protein and ESR, and a good correlation was found with the leukocyte count.

CONCLUSION

The LUS pneumonia score is a reliable parameter for the evaluation of pneumonia, and shows a strong correlation with inflammatory biomarkers. The PedPne LUS score is a potential noninvasive surrogate parameter of inflammation in pediatric pneumonia.

Ten Years of Pediatric Lung Ultrasound: A Narrative Review

Lung diseases are the most common conditions in newborns, infants, and children and are also the primary cause of death in children younger than 5 years old. Traditionally, the lung was not thought to be a target for an ultrasound due to its inability to penetrate the gas-filled anatomical structures. With the deepening of knowledge on ultrasound in recent years, it is now known that the affected lung produces ultrasound artifacts resulting from the abnormal tissue/gas/tissue interface when ultrasound sound waves penetrate lung tissue. Over the years, the application of lung ultrasound (LUS) has changed and its main indications in the pediatric population have expanded. This review analyzed the studies on lung ultrasound in pediatrics, published from 2010 to 2020, with the aim of highlighting the usefulness of LUS in pediatrics. It also described the normal and abnormal appearances of the pediatric lung on ultrasound as well as the benefits, limitations, and possible future challenges of this modality.

Lung ultrasound in young children with neurological impairment: A proposed integrative clinical tool for deaeration-detection related to feeding

Infants and children with neurological impairment, such as cerebral palsy (CP), often experience abnormal ingestion functions, including oropharyngeal dysphagia and gastroesophageal reflux disease, which led to aspiration-related respiratory complications, morbidity, hospitalization, or death. There is a lack of evidence-based, repeatable, infant-friendly instrumental procedures to assess aspiration-risk in infants with CP or other neurological disorders, with also a lack of clinical assessment measures to support the use of more invasive diagnostic techniques. To this purpose, in the current study we explore the feasibility of lung ultrasound (LUS), to assess lung deaeration possibly related to aspiration during meal, in a cohort of 35 subjects affected by CP or other encephalopathies, and 10 controls in the same age-range. We coupled LUS procedure with meal caregiver administration for each child. Our results support the feasibility of this innovative approach in the clinical setting. Exploratory findings revealed a number of lung abnormalities likely related to abnormal ingestion function in subjects. Subgroup analyses revealed possible differences in LUS abnormalities between CP and other encephalopathies, possibly related to different mechanism of disease or dysfunction. Also, some evidences arose about the possible relationship between such LUS abnormalities and feeding and swallowing abilities in CP or other encephalopathies. LUS showed preliminarily feasibility and effectiveness in detecting meal-related LUS abnormalities in a dynamic manner in the clinical setting. This approach demonstrated usefulness as a potential tool for improving assessment and management in complex care of infants and young children with severe neurological disorders.

A training plan to implement lung ultrasound for diagnosing pneumonia in children

BACKGROUND

Lung ultrasound (LUS) for critical patients requires trained operators to perform them, though little information exists on the level of training required for independent practice. The aims were to implement a training plan for diagnosing pneumonia using LUS and to analyze the inter-observer agreement between senior radiologists (SRs) and pediatric intensive care physicians (PICPs).

METHODS

Prospective longitudinal and interventional study conducted in the Pediatric Intensive Care Unit of a tertiary hospital. Following a theoretical and practical training plan regarding diagnosing pneumonia using LUS, the concordance between SRs and the PICPs on their LUS reports was analyzed.

RESULTS

Nine PICPs were trained and tested on both theoretical and practical LUS knowledge. The mean exam mark was 13.5/15. To evaluate inter-observer agreement, a total of 483 LUS were performed. For interstitial syndrome, the global Kappa coefficient (K) was 0.51 (95% CI 0.43-0.58). Regarding the presence of consolidation, K was 0.67 (95% CI 0.53-0.78), and for the consolidation pattern, K was 0.82 (95% CI 0.79-0.85), showing almost perfect agreement.

CONCLUSIONS

Our training plan allowed PICPs to independently perform LUS and might improve pneumonia diagnosis. We found a high inter-observer agreement between PICPs and SRs in detecting the presence and type of consolidation on LUS.

IMPACT

Lung ultrasound (LUS) has been proposed as an alternative to diagnose pneumonia in children. However, the adoption of LUS in clinical practice has been slow, and it is not yet included in general clinical guidelines. The results of this study show that the implementation of a LUS training program may improve pneumonia diagnosis in critically ill patients. The training program's design, implementation, and evaluation are described. The high inter-observer agreement between LUS reports from the physicians trained and expert radiologists encourage the use of LUS not only for pneumonia diagnosis, but also for discerning bacterial and viral patterns.

The Application of Pulmonary Ultrasound in Neonatal Ventilator-Associated Pneumonia

This study explored the application value of lung ultrasound (LUS) in neonatal ventilator-associated pneumonia (NVAP). In this study, 122 newborns suspected of NVAP were treated in the NICU of Liaocheng People's Hospital between July 1, 2020, and July 1, 2021. Of these, 115 were clinically diagnosed with NVAP. The diagnostic value of LUS for NVAP was determined by comparing the different signs of LUS and chest X-ray (CXR). The confirmed cases were divided into the failure and success groups according to the first ventilator weaning test results. The consistency between the results of LUS and CXR and the actual test results was compared between the two groups. Before treatment, the LUS findings of the confirmed cases showed a lung consolidation with air bronchogram sign (111/115), alveolar-interstitial syndrome (113/115), pleural effusion (12/115), pleural line abnormalities (114/115), and lung pulse (15/115). CXR showed 109 cases of pneumonia. Taking the clinical diagnosis of VAP as the gold standard, the lung consolidation with air bronchogram sign on LUS had a higher sensitivity, specificity, and accuracy for the diagnosis of NVAP than those of other LUS and CXR findings and showed better consistency with the clinical diagnosis (AUC = 0.983, kappa value = 0.761, p < 0.05). After treatment, the 115 cases were divided into two groups according to the results of the first weaning from ventilation: the failed group (19 cases) and the successful group (96 cases). The lung consolidation with air bronchogram sign was used as the positive diagnostic standard of ultrasound. The sensitivity and specificity of LUS (94.7 and 89.6%, respectively) in evaluating the outcome of weaning from the ventilator of pneumonia were higher than those of CXR (73.7 and 84.4%, respectively). Additionally, the consistency of the LUS findings with the weaning results was higher than that of CXR (AUC = 0.922, kappa value = 0.709, p < 0.05). Therefore, compared with CXR, LUS has a higher value in diagnosing NVAP and can better predict the results of the ventilator off-line test. LUS can replace CXR as the first imaging examination for NVAP.

ATS Core Curriculum 2021. Pediatric Pulmonary Medicine: Pulmonary Infections

The following is a concise review of the Pediatric Pulmonary Medicine Core reviewing pediatric pulmonary infections, diagnostic assays, and imaging techniques presented at the 2021 American Thoracic Society Core Curriculum. Molecular methods have revolutionized microbiology. We highlight the need to collect appropriate samples for detection of specific pathogens or for panels and understand the limitations of the assays. Considerable progress has been made in imaging modalities for detecting pediatric pulmonary infections. Specifically, lung ultrasound and lung magnetic resonance imaging are promising radiation-free diagnostic tools, with results comparable with their radiation-exposing counterparts, for the evaluation and management of pulmonary infections. Clinicians caring for children with pulmonary disease should ensure that patients at risk for nontuberculous mycobacteria disease are identified and receive appropriate nontuberculous mycobacteria screening, monitoring, and treatment. Children with coronavirus disease (COVID-19) typically present with mild symptoms, but some may develop severe disease. Treatment is mainly supportive care, and most patients make a full recovery. Anticipatory guidance and appropriate counseling from pediatricians on social distancing and diagnostic testing remain vital to curbing the pandemic. The pediatric immunocompromised patient is at risk for invasive and opportunistic pulmonary infections. Prompt recognition of predisposing risk factors, combined with knowledge of clinical characteristics of microbial pathogens, can assist in the diagnosis and treatment of specific bacterial, viral, or fungal diseases.

The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.

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.

Lung Ultrasound Fundamentals, "Wet Versus Dry" Lung, Signs of Consolidation in Dogs and Cats

Vet BLUE, a standardized and validated rapid lung ultrasound examination, includes 9 acoustic windows: 4 transthoracic bilaterally applied named Caudodorsal, Perihilar, Middle, and Cranial Lung Regions plus the Diaphragmatico-Hepatic view of AFAST/TFAST. Moreover, Vet BLUE has a B-line scoring system (weak positives-1, 2, and 3 and strong positives->3 and infinite) that semiquantitate degree of alveolar-interstitial syndrome and a visual lung language for signs of consolidation (Shred Sign [air bronchogram], Tissue Sign [hepatization], Nodule Sign, and Wedge Sign [pulmonary infarction]). Using its regional, pattern-based approach, a respiratory working diagnosis may be rapidly developed point-of-care and followed serially.

Lung Ultrasound in Pediatrics and Neonatology: An Update

The potential role of ultrasound for the diagnosis of pulmonary diseases is a recent field of research, because, traditionally, lungs have been considered unsuitable for ultrasonography for the high presence of air and thoracic cage that prevent a clear evaluation of the organ. The peculiar anatomy of the pediatric chest favors the use of lung ultrasound (LUS) for the diagnosis of respiratory conditions through the interpretation of artefacts generated at the pleural surface, correlating them to disease-specific patterns. Recent studies demonstrate that LUS can be a valid alternative to chest X-rays for the diagnosis of pulmonary diseases, especially in children to avoid excessive exposure to ionizing radiations. This review focuses on the description of normal and abnormal findings during LUS of the most common pediatric pathologies. Current literature demonstrates usefulness of LUS that may become a fundamental tool for the whole spectrum of lung pathologies to guide both diagnostic and therapeutic decisions.

Lung Ultrasound Is More Sensitive for Hospitalized Consolidated Pneumonia Diagnosis Compared to CXR in Children

BACKGROUND

Pneumonia is the leading cause of death among children; thus, a correct early diagnosis would be ideal. The imagistic diagnosis still uses chest X-ray (CXR), but lung ultrasound (LUS) proves to be reliable for pneumonia diagnosis. The aim of our study was to evaluate the sensitivity and specificity of LUS compared to CXR in consolidated pneumonia.

METHODS

Children with clinical suspicion of bacterial pneumonia were screened by LUS for pneumonia, followed by CXR. The agreement relation between LUS and CXR regarding the detection of consolidation was evaluated by Cohen's kappa test.

RESULTS

A total of 128 patients with clinical suspicion of pneumonia were evaluated; 74 of them were confirmed by imagery and biological inflammatory markers. The highest frequency of pneumonia was in the 0-3 years age group (37.83%). Statistical estimation of the agreement between LUS and CXR in detection of the consolidation found an almost perfect agreement, with a Cohen's kappa coefficient of K = 0.89 ± 0.04 SD, p = 0.000. Sensitivity of LUS was superior to CXR in detection of consolidations.

CONCLUSION

Lung ultrasound is a reliable method for the detection of pneumonia consolidation in hospitalized children, with sensitivity and specificity superior to CXR. LUS should be used for rapid and safe evaluation of child pneumonia.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Half of all hospitalised children treated with antibiotics for pneumonia did not fulfil radiological, microbiological or laboratory criteria

AIM

Evaluating the management of paediatric pneumonia is important. We aimed to estimate the proportion of children receiving antibiotics for suspected community-acquired pneumonia (CAP) that were likely to have a bacterial infection. Furthermore, we described antibiotic use in relation to guidelines.

METHODS

We conducted a prospective observational study from a paediatric department in Norway. During 2017, all admitted children aged 0-17 years receiving antibiotics for CAP were enrolled in the study. We collected relevant data and defined likely CAP as one or more of the following: radiologically confirmed pneumonia, c-reactive protein of at least 100 mg/L, positive bacterial culture from blood or pleura, detection of bacteria from the nasopharynx associated with atypical pneumonia.

RESULTS

In total, 70 episodes of suspected CAP were included. Median age was 41.5 months, and 36 (51%) were girls. Of all treatments, 38 (54%) fulfilled our criteria for likely CAP. Median duration of treatment was 10 days. Of empirical treatments, 36 (57%) only involved penicillin. None of the children had neutropenia or complications, and only two needed intensive care.

CONCLUSION

Only half of children receiving antibiotics for suspected CAP were likely to have bacterial infection. Despite no obvious reason, antibiotic treatment was longer than currently recommended.

Point of care diaphragm ultrasound: An objective tool to predict the severity of pneumonia and outcomes in children

BACKGROUND

Pneumonia is one of the most common serious infections in children. Scoring systems have been adopted to quantify the severity of the disease, but they were based on clinical findings that can vary according to the subjective assessment of the clinician. We hypothesized that diaphragm ultrasound (DUS) parameters may be a new useful tool to objectively score the severity of the disease and predict outcomes in children with pneumonia.

METHODS

Children diagnosed with pneumonia, aged between 1 month and 18 years, were prospectively evaluated in the pediatric emergency department. The Pediatric Respiratory Severity Score was used to indicate the severity of the disease and DUS was performed. Diaphragm thickness at the end of inspiration and expiration, thickening fraction (TF), diaphragm excursion, inspiratory slope (IS), expiratory slope (ES), and total duration time of the respiratory cycle were calculated.

RESULTS

There were 96 patients enrolled in the study. Inspiratory slope and ES measurements had positive correlations with respiratory rate and length of stay in the hospital and negative correlations with oxygen saturation levels. Furthermore, TF values were negatively correlated with respiratory rate and length of stay in the emergency department. Patients with higher clinical scores had increased IS and ES and decreased TF values.

CONCLUSION

DUS can be a promising and useful tool to assess diaphragmatic dysfunction in patients diagnosed with pneumonia. Diaphragm parameters, especially TF, IS, and ES, may provide objective and reliable information to predict the severity of the illness, the need for respiratory support, and outcomes.

Point-of-care lung ultrasound in COVID-19 patients: inter- and intra-observer agreement in a prospective observational study

With an urgent need for bedside imaging of coronavirus disease 2019 (COVID-19), this study’s main goal was to assess inter- and intraobserver agreement in lung ultrasound (LUS) of COVID-19 patients. In this single-center study we prospectively acquired and evaluated 100 recorded ten-second cine-loops in confirmed COVID-19 intensive care unit (ICU) patients. All loops were rated by ten observers with different subspeciality backgrounds for four times by each observer (400 loops overall) in a random sequence using a web-based rating tool. We analyzed inter- and intraobserver variability for specific pathologies and a semiquantitative LUS score. Interobserver agreement for both, identification of specific pathologies and assignment of LUS scores was fair to moderate (e.g., LUS score 1 Fleiss’ κ = 0.27; subpleural consolidations Fleiss’ κ = 0.59). Intraobserver agreement was mostly moderate to substantial with generally higher agreement for more distinct findings (e.g., lowest LUS score 0 vs. highest LUS score 3 (median Fleiss’ κ = 0.71 vs. 0.79) or air bronchograms (median Fleiss’ κ = 0.72)). Intraobserver consistency was relatively low for intermediate LUS scores (e.g. LUS Score 1 median Fleiss’ κ = 0.52). We therefore conclude that more distinct LUS findings (e.g., air bronchograms, subpleural consolidations) may be more suitable for disease monitoring, especially with more than one investigator and that training material used for LUS in point-of-care ultrasound (POCUS) should pay refined attention to areas such as B-line quantification and differentiation of intermediate LUS scores.

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 compared to chest X-ray for the diagnosis of CAP in children

BACKGROUND

Community-acquired pneumonia (CAP) represents one of the most common infectious diseases among children. Diagnosis of CAP is mainly clinical. Chest X-ray (CXR) remains the gold standard for the diagnosis in severe or controversial conditions. Recently, some authors have focused on the application of ultrasound in lung diseases but the role of lung ultrasound (LUS) in the diagnosis of CAP is still debated. We aimed to study the concordance between LUS and CXR in evaluating specific signs of CAP. As a secondary aim, we sought to determine the sensitivity and specificity of LUS in CAP diagnosis compared with CXR. Finally, we evaluated the role of LUS during the follow up.

METHODS

We enrolled 68 children (<16 years old) hospitalized from October 2018 to September 2019 with a clinical and radiological diagnosis of CAP (cases: N = 41), or with no respiratory diseases (controls: N = 27), in whom a CXR was performed for clinical indications. All the children underwent LUS during hospitalization. The average time needed to perform LUS was 5-10 min for each child, and 19/41 cases were re-evaluated by LUS and CXR 30 days after discharge.

RESULTS

Lung ultrasound confirmed CAP diagnosis in 40/41 patients. Concordance between the two techniques was K = 0.88 for the right lung and K = 0.70 for the left lung. Lung ultrasound showed a sensitivity of 97% and a specificity of 96% compared with CXR. At the follow up, sensitivity increased to 100% while specificity was 94%.

CONCLUSIONS

Our study showed a potential benefit of LUS compared with CXR in the diagnosis and the follow up of CAP.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Lung ultrasound patterns in paediatric pneumonia in Mozambique and Pakistan

Objective

Improved pneumonia diagnostics are needed, particularly in resource-constrained settings. Lung ultrasound (LUS) is a promising point-of-care imaging technology for diagnosing pneumonia. The objective was to explore LUS patterns associated with paediatric pneumonia.

Methods

We conducted a prospective, observational study among children aged 2 to 23 months with World Health Organization Integrated Management of Childhood Illness chest-indrawing pneumonia and among children without fast breathing, chest indrawing or fever (no pneumonia cohort) at two district hospitals in Mozambique and Pakistan. We assessed LUS and chest radiograph (CXR) examinations, and viral and bacterial nasopharyngeal carriage, and performed a secondary analysis of LUS patterns.

Results

LUS demonstrated a range of distinctive patterns that differed between children with and without pneumonia and between children in Mozambique versus Pakistan. The presence of LUS consolidation or interstitial patterns was more common in children with chest-indrawing pneumonia than in those without pneumonia. Consolidations were also more common among those with only bacterial but no viral carriage detected (50.0%) than among those with both (13.0%) and those with only virus detected (8.3%; p=0.03). LUS showed high interrater reliability among expert LUS interpreters for overall determination of pneumonia (κ=0.915), consolidation (κ=0.915) and interstitial patterns (κ=0.901), but interrater reliability between LUS and CXR for detecting consolidations was poor (κ=0.159, Pakistan) to fair (κ=0.453, Mozambique).

Discussion

Pattern recognition was discordant between LUS and CXR imaging modalities. Further research is needed to define and standardise LUS patterns associated with paediatric pneumonia and to evaluate the potential value of LUS as a reference standard.

This study explored distinctive lung ultrasound patterns associated with paediatric community-acquired pneumonia in Mozambique and Pakistan, and found reliable pattern recognition critical to identifying pneumoniahttps://bit.ly/3eWWvXr

Point-of-care ultrasound by the pediatrician in the diagnosis and follow-up of community-acquired pneumonia

OBJECTIVES

To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines.

SOURCE OF DATA

A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected.

SYNTHESIS OF DATA

CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance.

CONCLUSIONS

Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

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.

The role of point of care ultrasound in radiology department: update and prospective. A statement of Italian college ultrasound

Ultrasound, in its new point-of-care conception, has been called the stethoscope of the future. Goal-directed bedside ultrasound examination, performed by a healthcare provider to answer a specific diagnostic question or guide an invasive procedure, is currently revolutionizing medical practice. It is used by various specialties in multiple clinical contexts for procedural, diagnostic, and screening applications. Point-of-care ultrasound is also a strategic technique in clinical radiology; it brings the radiologist closer to the patient (in interaction and understanding) like interventional and angiography procedures and, as an integrative imaging modality, is a vital radiological tool for decision-making in many situations. In this commentary, we present our observations on the use of ultrasound, in a sincere appeal to refrain from omitting ultrasound as a diagnostic technique in this era of deep professional change, in which radiologists must return to being a true clinical semiologist.

Lung Point-of-Care Ultrasound in Pediatric COVID-19: A Case Series

Lung point-of-care ultrasound (POCUS) has been shown to be useful for identifying pulmonary pathology in adult patients with coronavirus disease 2019 (COVID-19). However, pediatric literature for POCUS in COVID-19 is limited. The objective of this case series was to describe lung POCUS findings in pediatric patients with COVID-19. Three patients with COVID-19 who had lung POCUS performed in a pediatric emergency department were included. Point-of-care ultrasound revealed bilateral abnormalities in all patients, including pleural line irregularities, scattered and coalescing B-lines, consolidations, and pleural effusions. Additional pediatric studies are necessary to gain a broader understanding of COVID-19's sonographic appearance in this age group and to determine whether POCUS may be helpful to facilitate diagnosis and expedite management decisions.

Procalcitonin and lung ultrasound algorithm to diagnose severe pneumonia in critical paediatric patients (PROLUSP study). A randomised clinical trial

Background

Lung ultrasound (LUS) in combination with a biomarker has not yet been studied. We propose a clinical trial where the primary aims are: 1. To assess whether an algorithm with LUS and procalcitonin (PCT) may be useful for diagnosing bacterial pneumonia; 2. To analyse the sensitivity and specificity of LUS vs chest X-ray (CXR).

Methods/design

A 3-year clinical trial. Inclusion criteria: children younger than 18 years old with suspected pneumonia in a Paediatric Intensive Care Unit. Patients will be randomised into two groups: Experimental Group: LUS will be performed as first lung image. Control Group: CXR will be performed as first pulmonary image. Patients will be classified according to the image and the PCT: a) PCT < 1 ng/mL and LUS/CXR are not suggestive of bacterial pneumonia (BN), no antibiotic will be prescribed; b) LUS/CXR are suggestive of BN, regardless of the PCT, antibiotic therapy is recommended; c) LUS/CXR is not suggestive of BN and PCT > 1 ng/mL, antibiotic therapy is recommended.

Conclusion

This algorithm will help us to diagnose bacterial pneumonia and to prescribe the correct antibiotic treatment. A reduction of antibiotics per patient, of the treatment length, and of the exposure to ionizing radiation and in costs is expected.

Trial registration

NCT04217980.

COVID-19 Control by Computer Vision Approaches: A Survey

The COVID-19 pandemic has triggered an urgent call to contribute to the fight against an immense threat to the human population. Computer Vision, as a subfield of artificial intelligence, has enjoyed recent success in solving various complex problems in health care and has the potential to contribute to the fight of controlling COVID-19. In response to this call, computer vision researchers are putting their knowledge base at test to devise effective ways to counter COVID-19 challenge and serve the global community. New contributions are being shared with every passing day. It motivated us to review the recent work, collect information about available research resources, and an indication of future research directions. We want to make it possible for computer vision researchers to find existing and future research directions. This survey article presents a preliminary review of the literature on research community efforts against COVID-19 pandemic.

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.