Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children

Systematic review and meta-analysis of the accuracy of lung ultrasound and chest radiography in diagnosing community acquired pneumonia in children

Chest radiography (CXR) is commonly used for diagnosing childhood pneumonia, but concerns about radiation exposure have raised interest in using radiation-free lung ultrasound (LUS) as an alternative imaging modality. Therefore, we designed this meta-analysis to compare the accuracy of LUS and CXR for diagnosing childhood pneumonia. We searched 8 databases and 1 clinical trial registry for studies published from inception to March 2023. Studies assessing lung ultrasound and chest radiography for diagnosing childhood pneumonia were included. Two reviewers independently screened literature, extracted data, and assessed the risk of bias using the QUADAS-2 tool for each study. Meta-analysis was conducted using a random-effects model, and pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic (SROC) curve were assessed. Statistical analyses were performed using Meta-Disc 1.4, RevMan 5.4, and Stata 17.0 software. Heterogeneity was examined, and subgroup analysis was conducted to explore the accuracy of lung ultrasound in diagnosing childhood pneumonia. Out of the 4089 screened articles, 30 studies were included, encompassing a total of 4546 children. Of those, 3257 were diagnosed with pneumonia, 3190 through LUS, and 2925 via CXR. The meta-analysis showed that the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of LUS were 0.940 (95% CI 0.930-0.949), 0.855 (95% CI 0.835-0.873), 7.561 (95% CI 4.956-11.536), 0.08 (95% CI 0.056-0.113), and 110.77 (95% CI 62.156-197.40), respectively. The combined area under the SROC curve was 0.9712, Q index = 0.9218. For CXR, the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.893 (95% CI 0.881-0.905), 0.906 (95% CI 0.889-0.921), 18.742 (95% CI 7.551-46.520), 0.105 (95% CI 0.062-0.180), and 237.43 (95% CI 74.080-760.99), respectively. The combined area under the SROC curve was 0.9810, Q index = 0.9391. Subgroup analysis showed that the implementation location, interval between lung ultrasound and chest radiography, and operator experience had no impact on the accuracy of lung ultrasound in diagnosing childhood pneumonia. Existing evidence suggests that lung ultrasound has high accuracy for diagnosing childhood community-acquired pneumonia. Compared with chest radiography, lung ultrasound has higher sensitivity, similar specificity, and advantages such as radiation-free, lower cost, simplicity of operation, and ease of follow-up, making it an important imaging modality for diagnosing childhood pneumonia.

Comparison of lung ultrasound and chest radiography for detecting pneumonia in children: a systematic review and meta-analysis

BACKGROUND

Lung ultrasound (LUS) is recommended as a reliable diagnostic alternative to chest X-ray (CXR) for detecting pneumonia in children.

METHODS

PubMed, Embase, and Cochrane Library databases were used to identify eligible studies from their inception until April 2023. The investigated diagnostic parameters included sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curves (AUC).

RESULTS

Twenty-six studies involving 3,401 children were selected for meta-analysis. The sensitivity, specificity, PLR, NLR, DOR, and AUC of LUS for detecting pneumonia in children were 0.95, 0.92, 12.31, 0.05, 108.53, and 0.98, respectively, while the sensitivity, specificity, PLR, NLR, DOR, and AUC of CXR were 0.92, 0.93, 24.63, 0.08, 488.54, and 0.99, respectively. The sensitivity of LUS was higher than that of CXR for detecting pneumonia in children (ratio: 1.03; 95% CI: 1.01-1.06; P = 0.018), whereas the DOR of LUS was significantly lower than that of CXR (ratio: 0.22; 95% CI: 0.06-0.85; P = 0.028).

CONCLUSIONS

This study found that the diagnostic performance of LUS was comparable to that of CXR for detecting pneumonia, and the sensitivity of LUS was superior to that of CXR.

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 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.

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.

Childhood Pneumonia Diagnostics in Sub-Saharan Africa: A Systematic Review

BACKGROUND

The prompt and accurate aetiological diagnosis of childhood pneumonia remains a challenge, especially in sub-Saharan Africa (SSA) because of limited resources for disease management.

OBJECTIVE

To review existing diagnostics for childhood pneumonia and potential modalities available to differentiate between bacterial and viral aetiologies in SSA.

METHODS

Online databases were searched for relevant articles published between January 2010 and December 2020 regarding childhood pneumonia diagnosis, conducted in SSA in children less than 18 years of age. The 2020 PRISMA checklist was utilized in appraising the selected studies and the QUADAS-2 tool was employed to assess the risk of bias in each of the studies selected.

RESULTS

A total of 1542 study titles and abstracts were screened following which 45 studies (39 on childhood pneumonia diagnostics and 6 on discriminating between bacterial and viral childhood pneumonia) were selected for review. Microbiological investigations (79.7%) constituted the most utilized index tests with blood-related specimen (32.8%) being the most utilized specimen. The most performed index diagnostic modality was polymerase chain reaction (PCR) (53.1%). The commonest reference gold standard technique was based on clinical diagnosis of the disease (46.2%). Only six studies in SSA attempted at using serum biomarkers, either singly or in combination to distinguish between aetiologies with use of combined biomarkers showing promise.

CONCLUSION

Microbiological investigations are the most employed diagnostic methods for childhood pneumonia in SSA. More studies are required to evaluate the potential use of serum biomarkers; either singly or in combination with the goal of discriminating bacterial and viral childhood pneumonia.

The Inter-Rater Reliability of Pediatric Point-of-Care Lung Ultrasound Interpretation in Children With Acute Respiratory Failure

OBJECTIVES

Use of point-of-care lung ultrasound (POC-LUS) has increased significantly in pediatrics yet it remains under-studied in the pediatric intensive care unit (PICU). No studies explicitly evaluate the reliability of POC-LUS artifact interpretation among critically ill children with acute respiratory failure (ARF) in the PICU. We thus designed this study to determine the inter-rater reliability of POC-LUS interpretation in pediatric ARF among pediatric intensivists trained in POC-LUS and an expert intensivist.

METHODS

We compared the interpretation of lung sliding, pleural line characteristics, ultrasound artifacts, and POC-LUS diagnoses among pediatric intensivists and an expert intensivist in a cohort of children admitted to the PICU for ARF. Kappa statistics (k) adjusted for maximum attainable agreement (k/k_max ) were used to quantify chance-correct agreement between the pediatric intensivist and expert physician.

RESULTS

We enrolled 88 patients, evaluating 3 zones per hemithorax (anterior, lateral, and posterior) for lung sliding, pleural line characteristics, ultrasound artifacts, and diagnosis. There was moderate agreement between the PICU intensivist and expert-derived diagnoses with 56% observed agreement (k/k_max  = 0.46, 95% confidence interval [CI] 0.31-0.65). Agreement in identification of lung sliding (k = 0.19, 95% CI -0.17 to 0.56) and pleural line characteristics (k = 0.24, 95% CI 0.08-0.40) was slight and fair, respectively, while agreement in the interpretation of ultrasound artifacts ranged from moderate to substantial.

CONCLUSIONS

Evidence supporting the evaluation of neonatal and adult patients with POC-LUS should not be extrapolated to critically ill pediatric patients. This study adds to the evidence supporting use of POC-LUS in the PICU by demonstrating moderate agreement between PICU intensivist and expert-derived POC-LUS diagnoses.

Lung Ultrasound Artifact Findings in Pediatric Patients Admitted to the Intensive Care Unit for Acute Respiratory Failure

PURPOSE

To describe point-of-care lung ultrasound (POC-LUS) artifact findings in children admitted to the pediatric intensive care unit (PICU) for acute respiratory failure (ARF).

METHODS

This is a secondary analysis of a prospective observational study completed in a 21-bed PICU. Children > 37 weeks gestational age and ≤ 18 years were enrolled from December 2018 to February 2020. POC-LUS was completed and interpreted by separate physicians blinded to all clinical information. POC-LUS was evaluated for the presence of lung sliding, pleural line characteristics, ultrasound artifacts, and the ultrasound diagnosis.

RESULTS

Eighty-seven subjects were included. A-lines were the most frequent artifact, occurring in 58% of lung zones (163/281) in those with bronchiolitis, 39% of lung zones (64/164) in those with pneumonia, and 81% of lung zones (48/59) in those with status asthmaticus. Sub-pleural consolidation was second most common, occurring in 28% (80/281), 30% (50/164), and 12% (7/59) of those with bronchiolitis, pneumonia, and status asthmaticus, respectively. The pattern a priori defined as bronchiolitis, pneumonia, and status asthmaticus was demonstrated in 31% (15/48), 10% (3/29), and 40% (4/10) of subjects with bronchiolitis, pneumonia, and status asthmaticus, respectively.

CONCLUSION

We found significant heterogeneity and overlap of POC-LUS artifacts across the most common etiologies of ARF in children admitted to the PICU. We have described the POC-LUS artifact findings in pediatric ARF to support clinicians using POC-LUS and to guide future pediatric POC-LUS studies. Determining the optimal role of POC-LUS as an adjunct in the care of pediatric patients requires further study.

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.

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.

Lung Ultrasound in Children with Cystic Fibrosis in Comparison with Chest Computed Tomography: A Feasibility Study

Background: Cystic fibrosis (CF) lung disease determines the outcome of this condition. For lung evaluation processes, computed tomography (CT) is the gold standard, but also causes irradiation. Lately, lung ultrasound (LUS) has proven to be reliable for the diagnosis of consolidations, atelectasis, and/or bronchiectasis. The aim of our study was to evaluate the value of a newly conceived LUS score by comparing it to the modified Bhalla CT score. A further aim was to evaluate the correlation between the score and the lung clearance index (LCI). Methods: Patients with CF were screened by LUS, followed by a CT scan. Spearman’s test was used for correlations. Results: A total of 98 patients with CF were screened, and 57 were included in the study; their mean age was 11.8 ± 5.5 (mean ± SD) years. The mean LUS score was 5.88 ± 5.4 SD. The LUS CF score had a very strong correlation with the CT score of rs = 0.87 (p = 0.000). LUS showed a good sensibility for detecting atelectasis (Se = 83.7%) and consolidations (Se = 94.4%). A lower Se (77.7%) and Sp (9%) were found for cylindrical bronchiectasis. Conclusion: Our study shows that LUS and the lung CF score are parameters that can be used with a complementary role in the diagnosis and monitoring of CF lung disease in children.

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.

Pediatric Lower Respiratory Tract Infections: Imaging Guidelines and Recommendations

Lower respiratory tract infection (LRTI) remains a major cause of morbidity and mortality in children. Various organisms cause LRTI, including viruses, bacteria, fungi, and parasites, among others. Infections caused by 2 or more organisms also occur, sometimes enhancing the severity of the infection. Medical imaging helps confirm a diagnosis but also plays a role in the evaluation of acute and chronic sequelae. Medical imaging tests help evaluate underlying pathology in pediatric patients with recurrent or long-standing symptoms as well as the immunocompromised.

Diagnostic Imaging in Newborns, Children and Adolescents Infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): Is There a Realistic Alternative to Lung High-Resolution Computed Tomography (HRCT) and Chest X-Rays? A Systematic Review of the Literature

Chest computed tomography has been frequently used to evaluate patients with potential coronavirus disease 2019 (COVID-19) infection. However, this may be particularly risky for pediatric patients owing to high doses of ionizing radiation. We sought to evaluate COVID-19 imaging options in pediatric patients based on the published literature. We performed an exhaustive literature review focusing on COVID-19 imaging in pediatric patients. We used the search terms "COVID-19," "SARS-CoV2," "coronavirus," "2019-nCoV," "Wuhan virus," "lung ultrasound (LUS)," "sonography," "lung HRCT," "children," "childhood" and "newborn" to query the online databases PubMed, Medical Subject Headings (MeSH), Embase, LitCovid, the World Health Organization COVID-19 database and Medline Bireme. Articles meeting the inclusion criteria were included in the analysis and review. We identified only seven studies using lung ultrasound (LUS) to diagnose severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in newborns and children. The studies evaluated small numbers of patients, and only 6% had severe or critical illness associated with COVID-19. LUS showed the presence of B-lines in 50% of patients, sub-pleural consolidation in 43.18%, pleural irregularities in 34.09%, coalescent B-lines and white lung in 25%, pleural effusion in 6.82% and thickening of the pleural line in 4.55%. We found 117 studies describing the use of chest X-ray or chest computed tomography in pediatric patients with COVID-19. The proportion of those who were severely or critically ill was similar to that in the LUS study population. Our review indicates that use of LUS should be encouraged in pediatric patients, who are at highest risk of complications from medical ionizing radiation. Increased use of LUS may be of particularly high impact in under-resourced areas, where access to chest computed tomography may be limited.

A new standard scoring for interstitial pneumonia based on quantitative analysis of ultrasonographic data: A study on COVID-19 patients

OBJECTIVE

To assess the effectiveness of 3 novel lung ultrasound (LUS)-based parameters: Pneumonia Score and Lung Staging for pneumonia staging and COVID Index, indicating the probability of SARS-CoV-2 infection.

METHODS

Adult patients admitted to the emergency department with symptoms potentially related to pneumonia, healthy volunteers and clinical cases from online accessible databases were evaluated. The patients underwent a clinical-epidemiological questionnaire and a LUS acquisition, following a 14-zone protocol. For each zone, a Pneumonia score from 0 to 4 was assigned by the algorithm and by an expert operator (kept blind with respect to the algorithm results) on the basis of the identified imaging signs and the patient Lung Staging was derived as the highest observed score. The output of the operator was considered as the ground truth. The algorithm calculated also the COVID Index by combining the automatically identified LUS markers with the questionnaire answers and compared with the nasopharyngeal swab results.

RESULTS

Overall, 556 patients were analysed. A high agreement between the algorithm assignments and the expert operator evaluations was observed, both for Pneumonia Score and Lung Staging, with the latter having sensitivity and specificity over 92% both in the discrimination between healthy/sick patients and between sick patients with mild/severe pneumonia. Regarding the COVID Index, an area under the curve of 0.826 was observed for the classification of patients with/without SARS-CoV-2.

CONCLUSION

The proposed methodology allowed the identification and staging of patients suffering from pneumonia with high accuracy. Moreover, it provided the probability of being infected by SARS-CoV-2.

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.

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 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.

Serial lung ultrasounds in pediatric pneumonia in Mozambique and Pakistan

Lung ultrasound (LUS) is a promising point-of-care imaging technology for diagnosing and managing pneumonia. We sought to explore serial LUS examinations in children with chest-indrawing pneumonia in resource-constrained settings and compare their clinical and LUS imaging courses longitudinally. We conducted a prospective, observational study among children aged 2 through 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 2 district hospitals in Mozambique and Pakistan. We assessed serial LUS at enrollment, 2, 6, and 14 days, and performed a secondary analysis of enrolled children’s longitudinal clinical and imaging courses. By Day 14, the majority of children with chest-indrawing pneumonia and consolidation on enrollment LUS showed improvement on follow-up LUS (100% in Mozambique, 85.4% in Pakistan) and were clinically cured (100% in Mozambique, 78.0% in Pakistan). In our cohort of children with chest-indrawing pneumonia, LUS imaging often reflected the clinical course; however, it is unclear how serial LUS would inform the routine management of non-severe chest-indrawing pneumonia.

Air bronchogram integrated lung ultrasound score to monitor community-acquired pneumonia in a pilot pediatric population

Aims

Chest ultrasound is a non-invasive method for evaluating children with suspected community-acquired pneumonia (CAP). We evaluated the prognostic role of change of ultrasonographic (US) air bronchogram in management of CAP in terms of: rate of complicated CAP, change of empiric antibiotic therapy, relationship to defervescence time, and length of hospitalization.

Methods

Patients with CAP and radiographic evidence of lung consolidation were prospectively enrolled. Chest US examinations were performed within 12 h from admission and after 48 h. A new grading system (USINCHILD score) based on presence and features of air bronchogram was adopted.

Results

Thirty six patients were stratified into two groups according to the presence of an increase of at least 1 grade of US score (Δ US grade), expression of an improvement of lung consolidation. Δ US grade after 48 h ≥ 1 was associated with an increased risk of complicated CAP (p value 0.027) and a longer defervescence time (p value 0.036). Moreover, Δ US grade ≥ 1 was predictive of a short hospitalization (p value 0.008).

Conclusions

USINCHILD score could be an innovative biotechnology tool for the management of pediatric CAP.

Trial registration number and date of registration

NCT03556488, June 14, 2018.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s40477-020-00547-7) contains supplementary material, which is available to authorized users.

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.

Lung ultrasound vs chest radiography in the diagnosis of children pneumonia: Systematic evidence

BACKGROUND

The aim of this meta-analysis was to evaluate the diagnostic value of lung ultrasound (LUS) in comparison to chest radiography (CXR) in children with pneumonia.

METHODS

Computer-based retrieval was performed on PubMed and EMBASE. Quality was evaluated according to the quality assessment of diagnostic accuracy studies-2, and Meta-Disc was adopted to perform meta-analysis. Heterogeneity was assessed using Q and I statistics. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence intervals (CIs) as the primary outcomes were calculated for each index test.

RESULTS

Twenty two studies with a total of 2470 patients met the inclusion criteria. Our results showed that the pooled sensitivity, specificity, and DOR for children with pneumonia diagnosed by LUS were 0.95 (95% CI: 0.94 to 0.96), 0.90 (95% CI: 0.87 to 0.92), and 137.49 (95% CI: 60.21 to 313.98), respectively. The pooled sensitivity, specificity, and DOR for pediatric pneumonia diagnosed by CXR was 0.91 (95% CI: 0.90 to 0.93), 1.00 (95% CI: 0.99 to 1.00), and 369.66 (95% CI: 137.14 to 996.47), respectively. Four clinical signs, including pulmonary consolidation, positive air bronchogram, abnormal pleural line, and pleural effusion were most frequently observed using LUS in the screening of children with pneumonia.

CONCLUSIONS

The available evidence suggests that LUS is a reliable, valuable, and alternative method to CXR for the diagnosis of pediatric pneumonia.

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.

Lung ultrasound in children: What does it give us?

Lung ultrasound (LUS), a non-invasive non-ionizing radiation tool, has become essential at the bedside in both adults and children, particularly in the critically ill. This manuscript reviews normal LUS patterns and the most important pathologies that LUS allows to diagnose. Normal LUS is represented by the pleural line, the lung-sliding and the A-lines and B-lines. These two last findings are artifacts derived from the pleural line. Pleural effusion appears as an anechoic collection. Pneumothorax is suspected when only A-lines are present, without lung-sliding and B-lines. Alveolo-interstitial syndrome is characterized by different degrees of confluent B-lines and can be present in different pathologies such as pulmonary edema and acute respiratory distress syndrome. The distribution of B-lines helps to differentiate between them. LUS is useful to evaluate the response to lung recruitment in pathologies such as acute respiratory distress syndrome or acute chest syndrome. The distribution of B-lines also appears to be useful to monitor the response to antibiotics in pneumonia. However, further studies are needed to further ascertain this evidence. LUS is also useful to guide thoracocentesis.

Lung Ultrasound in Children with Respiratory Tract Infections: Viral, Bacterial or COVID-19? A Narrative Review

Respiratory tract infections (RTIs) are common complaints among patients presenting to the pediatric emergency department. In the diagnostic assessment of children with RTIs, many patients ultimately undergo imaging studies for further evaluation. Point-of-care lung ultrasound (LUS) can be used safely and with a high degree of accuracy in differentiating etiologies of RTIs in pediatric patients. Ultrasonographical features such as an irregular pleural line, subpleural consolidations, focal and lobar consolidation and signs of interstitial involvement can be used to distinguish between several pathologies. This work offers a comprehensive overview of pediatric LUS in cases of the most common pediatric RTIs including bacterial and viral pneumonia, bronchiolitis, and COVID-19.

The Role of Lung Ultrasonography in Etiologic Diagnosis of Acute Dyspnea in a Resource Limited Setting

The aim of the current study was to describe lung ultrasonography (LUS) characteristics and to evaluate the agreement between LUS and chest radiography (CXR) in diagnosis of four conditions causing most acute dyspnea in children, namely, pneumonia, pleural effusion, pneumothorax and acute pulmonary edema in children at a teaching hospital in Vietnam. We reviewed the records of the chidren between January and June 2018, who presented to emergency department (ED) or pediatric intensive care unit (PICU) at children hospital 1 (CH1) with acute dyspnea and had final diagnosis of one of four etiologies including pneumonia, pleural effusion, pneumothorax and acute pulmonary edema. All patients underwent CXR and LUS at the time of admission. Eighty-one children with acute dyspnea including pneumonia (n=65, 80%), pleural effusion (n=9, 11%), pneumothorax (n=3, 4%) and acute pulmonary edema (n=4, 5%) were enrolled. LUS was identified among 100% of cases with pleural effusion and pneumothorax (CXR only showed 73.3% and 50%, respectively); 92.3% of cases with pneumonia (CXR showed 93.8%) and only 75% of cases with acute pulmonary edema (CXR showed 50%). When comparing LUS with CXR, we noticed a good agreeement between the 2 methods in the diagnosis of pneumonia (kappa=0.64, p<0.001). LUS was shown to be a feasible and non-invasive technique which can help clinicians to comfirm the etiology of acute pulmonary dyspnea.

Lung ultrasound-a new diagnostic modality in persistent tachypnea of infancy

Lung ultrasound (LUS) has been increasingly used in diagnosing and monitoring of various pulmonary diseases in children. The aim of the current study was to evaluate its usefulness in children with persistent tachypnea of infancy (PTI). This was a controlled, prospective, cross-sectional study that included children with PTI and healthy subjects. In patients with PTI, LUS was performed at baseline and then after 6 and 12 months of follow-up. Baseline results of LUS were compared to (a) baseline high-resolution computed tomography (HRCT) images, (b) LUS examinations in control group, and (c) follow-up LUS examinations. Twenty children with PTI were enrolled. B-lines were found in all children with PTI and in 11 (55%) control subjects (P < .001). The total number of B-lines, the maximal number of B lines in any intercostal space, the distance between B-lines, and pleural thickness were significantly increased in children with PTI compared to controls. An irregularity of the pleural line was found in all patients with PTI and in none of the healthy children. There were no significant changes in LUS findings in patients with PTI during the study period. The comparison of HRCT indices and LUS findings revealed significant correlations between the mean lung attenuation, skewness, kurtosis and fraction of interstitial pulmonary involvement, and the number of B-lines as well as the pleural line thickness. LUS seems to be a promising diagnostic tool in children with PTI. Its inclusion in the diagnostic work-up may enable to reduce the number of costly, hazardous, and ionizing radiation-based imaging procedures.

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

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality among children worldwide. Over the last 10 years, lung ultrasound (US) has been widely studied as an alternative diagnostic tool for adult and pediatric CAP with excellent results. In this case series, we describe clinical and laboratory results as well as detailed lung US findings in 6 children with CAP, showing the potential use of lung US in monitoring the response to antibiotic therapy.

Pediatric lung ultrasound - pros and potentials

Lung ultrasound (US) cannot be considered a new diagnostic imaging technique anymore, with some articles dating back 50 years. The question that hovers over it recently is why it is still not widely accepted, like chest radiography. So, have we wasted a lot of time without using lung US, or are we wasting our time using lung US? The main goals of this article are to underline all the advantages, potentials and reasons to use lung US in everyday clinical practice, but also to address the main concerns linked to this imaging tool. From the standpoint of an experienced pediatric radiologist from a tertiary health care children's hospital who has been performing this examination for more than 10 years on a daily basis, this article also addresses the most common applications of lung US, such as detection of pneumonia and neonatal lung diseases.

Lung ultrasound in pediatric radiology - cons

In the 1990s, intensivists suggested a new type of sonography: lung ultrasound, based on artefacts that receive information even from physical acoustic phenomena not directly convertible into images of the human body. They compared the artefacts from the lung zones with no acoustic window with various computed tomography (CT) patterns. They used and still use US as a tool to evaluate patients bedside, i.e. monitoring of lung recruitment. They included Lung ultrasound in what was termed POCUS (Point-of-Care Ultrasound). Lung ultrasound has been progressively extended to paediatrics in general. The most appealing novelty has been the diagnosis of pneumothorax. Lung ultrasound was developed as a support tool for critical patients. Extrapolation with mass diffusion, in the absence of appropriate training, has led to misunderstandings and dangerous therapeutic diagnostic drifts.

Lung Ultrasonography in the Diagnosis of Pneumonia in Children-A Metaanalysis and a Review of Pediatric Lung Imaging

BACKGROUND

Pneumonia is one of the most frequent widespread and severe infectious diseases in pediatric patients worldwide. Pneumonia is characterized by high incidence and possibility of complications in the course of the disease in pediatric patients. For this reason, there is a need to have a rapid and safe diagnostic method to recognize it. Imaging diagnostic tools, such as x-ray examinations, necessitate caution while using these methods. To date, there have been lots of studies with the aim to determine the role of lung ultrasonography (LUS) in the diagnosis of inflammatory lesions in children. Our aim was to assess the accuracy of the LUS as diagnostic method of pneumonia in children by making a systematic research of literature.

OBJECTIVES

This work is a review of available literature and studies on LUS in pneumonia in children and summary of necessary information about the usefulness of LUS and sonographic findings to diagnose pneumonia in the pediatric population.

METHODS

We searched the following databases: PubMed, Scopus, MEDLINE, and Ovid. The following key words were used: pediatrics, pneumonia, ultrasound, chest x-ray, and LUS.

RESULTS

The total search results amounted to 1987. From 1987 potentially eligible studies, 19 were included, and 3 were meta-analysis. We studied and performed the statistical analysis of the results publication.

CONCLUSIONS

As a result of the analysis, a significant advantage of the ultrasound examination in comparison with the x-ray study was demonstrated. Lung ultrasound could be a safe diagnostic method for this reason.

The Usefulness of Lung Ultrasound for the Aetiological Diagnosis of Community-Acquired Pneumonia in Children

The aetiology of community-acquired pneumonia (CAP) is not easy to establish. As lung ultrasound (LUS) has already proved to be an excellent diagnostic tool for CAP, we analysed its usefulness for discriminating between the aetiologically different types of CAP in children. We included 147 children hospitalized because of CAP. LUS was performed in all patients at admission, and follow-up LUS was performed in most patients. LUS-detected consolidations in viral CAP were significantly smaller, with a median diameter of 15 mm, compared to 20 mm in atypical bacterial CAP (p = 0.05) and 30 mm in bacterial CAP (p < 0.001). Multiple consolidations were detected in 65.4% of patients with viral CAP and in 17.3% of patients with bacterial CAP (p < 0.001). Bilateral consolidations were also more common in viral CAP than in bacterial CAP (51.9% vs. 8.0%, p < 0.001). At follow-up, a regression of consolidations was observed in 96.6% of patients with bacterial CAP and in 33.3% of patients with viral CAP (p < 0.001). We found LUS to be especially suitable for differentiating bacterial CAP from CAP due to other aetiologies. However, LUS must be interpreted in light of clinical and laboratory findings.

Lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: A prospective study

OBJECTIVE

The purpose of this study was to describe lung ultrasound (LUS) findings at baseline and 48 hours after the beginning of treatment and evaluate how they correlate with outcome DESIGN: We prospectively analyzed patients from 1 month to 17 years of age with community acquired pneumonia (CAP) evaluated at a tertiary level pediatric hospital. At baseline and 48 hours after the beginning of treatment, history, clinical examination, laboratory testing, chest X-ray, and LUS were performed.

RESULTS

One hundred one children were enrolled in the study (13 with complicated CAP). At baseline those who developed complications presented a larger size of the subpleural pulmonary parenchymal lesions (P = .001) often associated with a complex pleural effusion (63.6%, P = .013). Those with an uncomplicated CAP presented an air, arboriform, superficial and dynamic bronchogram, as opposed to complicated CAP which had an air and liquid bronchogram, deep, fixed (P = .001). At the 48-hour control in the noncomplicated CAP group, bronchogram was more frequently superficial and dynamic (P = .050). Pleural effusion disappeared in half cases (P = .050). In all patients, neutrophilic leucocytosis with increased C-reactive protein was detected and decreased at control (P = .001). The linear regression analyses showed the switch from a deep to a superficial bronchogram as the only explanatory variable (r = 0.97, R²  = 0.94, P = .001, t = 10.73).

CONCLUSIONS

Our study describe early LUS features of CAP that might be able to predict the development of complicated CAP.

Diagnostic Accuracy of Lung Ultrasound Performed by Novice Versus Advanced Sonographers for Pneumonia in Children: A Systematic Review and Meta-analysis

BACKGROUND

Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x-ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta-analysis.

METHODS

We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. We used QUADAS-2 to appraise the included studies' methodologic quality. We employed a random-effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta-regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers.

RESULTS

Twenty-five studies (n = 3,353) were included in the meta-analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta-regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p < 0.01).

CONCLUSION

LUS can accurately diagnose pneumonia in children. However, this test demonstrates operator-dependent variability, with more experienced sonographers having higher diagnostic accuracy. Further work on evidence-based educational methods to train novice sonographers in LUS is required.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

Lung Ultrasound Volume Sweep Imaging for Pneumonia Detection in Rural Areas: Piloting Training in Rural Peru

Objective:

Pneumonia is the leading cause of pediatric mortality worldwide among children 0–5 years old. Lung ultrasound can be used to diagnose pneumonia in rural areas as it is a portable and relatively economic imaging modality with ~95% sensitivity and specificity for pneumonia in children. Lack of trained sonographers is the current limiting factor to its deployment in rural areas. In this study, we piloted training of a volume sweep imaging (VSI) ultrasound protocol for pneumonia detection in Peru with rural health workers. VSI may be taught to individuals with limited medical/ultrasound experience as it requires minimal anatomical knowledge and technical skill. In VSI, the target organ is imaged with a series of sweeps and arcs of the ultrasound probe in relation to external body landmarks.

Methods:

Rural health workers in Peru were trained on a VSI ultrasound protocol for pneumonia detection. Subjects were given a brief didactic session followed by hands-on practice with the protocol. Each attempt was timed and mistakes were recorded. Participants performed the protocol until they demonstrated two mistake-free attempts.

Results:

It took participants a median number of three attempts (range 1–6) to perform the VSI protocol correctly. Time to mastery took 51.4 ± 17.7 min. There were no significant differences among doctors, nurses, and technicians in total training time (P = 0.43) or number of attempts to success (P = 0.72). Trainee age was not found to be significantly correlated with training time (P = 0.50) or number of attempts to success (P = 0.40).

Conclusion:

Rural health workers learned a VSI protocol for pneumonia detection with relative ease in a short amount of time. Future studies should investigate the clinical efficacy of this VSI protocol for pneumonia detection.

Key Message:

A volume sweep imaging (VSI) protocol for pneumonia detection can be taught with minimal difficulty to rural health workers without prior ultrasound experience. No difference was found in training performance related to education level or age. VSI involves no significant knowledge of anatomy or technical skill.

Utilize lung ultrasound B-lines and KL-6 to monitor anti-MDA-5 antibody-positive clinically amyopathic dermatomyositis-associated interstitial lung disease: a case report and literature review

In the past decade, lung ultrasound (LUS) B-lines and serum Krebs von den Lungen-6 (KL-6) antigen have been recognized as biomarkers of the connective tissue disease-associated interstitial lung diseases (CTD-ILDs). Robust data have demonstrated that B-lines total numbers and KL-6 levels are correlated with high-resolution computed tomography findings, pulmonary function test, and some clinical parameters in CTD-ILDs. However, limited data are available regarding the use of these two biomarkers to follow CTD-ILDs. Herein, we report a case with anti-melanoma differentiation-associated gene 5 antibody-positive clinically amyopathic dermatomyositis-associated ILD, successfully treated with high-dose methylprednisolone, cyclophosphamide, intravenous immunoglobulin, pirfenidone, and followed using lung ultrasound and KL-6.

Chest ultrasound for the diagnosis of paediatric pulmonary diseases: a systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Chest ultrasound is an emerging imaging modality, for several paediatric pulmonary diseases.

SOURCES OF DATA

MEDLINE and EMBASE (1946-47 to 10 March 2017) were searched to collect evidence on the diagnostic accuracy of chest ultrasound, compared to other imaging modalities, for the diagnosis of paediatric pulmonary diseases.

AREAS OF AGREEMENT

Eighteen pneumonia studies, comprising 2031 children, were included for meta-analysis; the summary estimate sensitivity was 95.0% (95%CI: 90.7-97.3%) and specificity was 96.1% (95%CI: 89.1-98.7%).

AREAS OF CONTROVERSY

Other pulmonary diseases also yielded high sensitivity and specificity, but a meta-analysis could not be conducted due to a limited number of studies includable, and their heterogeneity.

GROWING POINTS

Chest ultrasound should be considered as a first-line imaging modality for children with suspected pneumonia.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research should focus on the diagnostic accuracy of chest ultrasound for the diagnosis of paediatric pulmonary diseases, other than pneumonia, comparing against a valid gold standard.

Emergency Department Resource Use in Pediatric Pneumonia: Point-of-Care Lung Ultrasonography versus Chest Radiography

OBJECTIVES

Point-of-care lung ultrasonography (US) is an alternative to chest radiography for imaging of suspected community-acquired pneumonia (CAP) in children. We compared pediatric emergency department (ED) time metrics between children who received point-of-care lung US versus chest radiography. Secondary objectives were comparisons of health system costs and other resources in these imaging groups.

METHODS

This work was a retrospective matched cohort study of children aged 0 to 18 years in an academic urban pediatric ED who were imaged for suspected CAP with either point-of-care lung US or chest radiography.

RESULTS

A total of 202 patients (101 in each group) were included in the study. The point-of-care lung US group spent a mean of 75.9 (SE, 14.3) minutes less from physician assessment to discharge (P < .0001) and 60.9 (SE, 18.1) minutes less in the overall ED length of stay (P = .0008). Physician billings and facility fees were both significantly lower (P < .0001) in the point-of-care lung US group, for a mean health systems savings of CAN$187.1 (SE, CAN$21.9).

CONCLUSIONS

In children undergoing imaging for suspected CAP in our pediatric ED, point-of-care lung US by pediatric emergency medicine physicians was associated with decreased time and cost compared with chest radiography.

Radiologic Diagnosis and Hospitalization among Children with Severe Community Acquired Pneumonia: A Prospective Cohort Study

Objectives

This study was designed to assess the role of chest radiography for the diagnosis of pneumonia and assess the association of clinical characteristics with radiologic findings and predictors of hospitalization among children with severe community acquired pneumonia.

Methods

A prospective study was conducted on 122 children between ages of 3 month and 14 years admitted to pediatric emergency unit with diagnosis of severe pneumonia from September 1^st to November 30^th, 2017. Eligible children were subjected to chest radiography which was read by two senior radiologists independently (R1 and R2). Disagreements between R1 and R2 were resolved by a third senior radiologist (R3). Level of agreement between radiologists was assessed using Cohen's kappa coefficient. Clinical and laboratory parameters which could explain the variability in the duration of hospital stay were assessed using a linear regression mode. Independent predictors were assessed using multiple linear regression.

Results

The median age of the cohort was 10.0 months (interquartile range (IQR): 6.75-24.0); 76 (62.3%) were male. Nearly half, 63 (51.6%) did not have radiologic evidence of pneumonia. There was low level of agreement between R1 and R2 in reporting consolidation (kappa=0.435, p-value≤0.001), haziness (kappa=0.375, p-value≤0.001), and infiltration (kappa=0.267, p-value=0.008). Children with higher recorded temperature were more likely to have radiologic abnormalities suggesting pneumonia (p-value=0.033). The median duration of hospitalization was 3 days (IQR: 1-4 days); 118 (96.7%) were discharged with improvement. Height-for-age z-score (Coef.=0.203, R²=0.041, p-value=0.027); and hemoglobin level (Coef.=-0.249, R²=0.062, p-value=0.006) explained 4.1% and 6.2% of the variability in the duration of hospital stay, respectively.

Conclusion

Radiologic evidence of pneumonia was absent in half of the children with severe pneumonia. There was low agreement between senior radiologists in reporting chest radiographic findings, potentially necessitating harmonization activities to uniformly implement the WHO guidelines in reading chest radiographs.

Prospective observational study of point-of-care ultrasound for diagnosing pneumonia

OBJECTIVES

The clinical diagnosis of pneumonia lacks specificity and may lead to antibiotic overuse, whereas radiological diagnoses can lack sensitivity. Point-of-care lung ultrasound is an emerging diagnostic tool. There are limited prospective data, however, on the accuracy of sonologists in the paediatric emergency department setting. We aimed to test the diagnostic accuracy of lung ultrasound for pneumonia using chest radiograph (CR) as the reference standard.

METHODS

This prospective observational cohort study in a paediatric emergency department enrolled children aged 1 month to <18 years, who had a CR ordered for possible pneumonia. Lung ultrasounds were performed by two blinded sonologists with focused training. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Radiograph and ultrasound results both required agreement between two readers, with final results determined by an arbiter in cases of disagreement. Patient management was decided by treating clinicians who were blinded to lung ultrasound results. Follow-up was performed by phone and medical record review to obtain final diagnosis and antibiotic use.

RESULTS

Of 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics.

CONCLUSION

Lung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm.

TRIAL REGISTRATION NUMBER

ACTRN12616000361404, http://www.ANZCTR.org.au/ACTRN12616000361404.aspx.

Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis

BACKGROUND

Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients.

METHODS

We enrolled children admitted to our hospital in 2016-2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient's clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines.

RESULTS

Eighty seven children with bronchiolitis were investigated. A final diagnosis of concomitant pneumonia was made in 25 patients. Sensitivity and specificity of LUS for the diagnosis of pneumonia were 100% and 83.9% respectively, with an area under-the-curve of 0.92, while CXR showed a sensitivity of 96% and specificity of 87.1%. When only consolidation > 1 cm was considered consistent with pneumonia, the specificity of LUS increased to 98.4% and the sensitivity decreased to 80.0%, with an area under-the-curve of 0.89. Cohen's kappa between pediatrician and radiologist sonologists in the first 30 patients showed an almost perfect agreement in diagnosing pneumonia by LUS (K 0.93).

CONCLUSIONS

This study shows the good accuracy of LUS in diagnosing pneumonia in children with clinical bronchiolitis. When including only consolidation size > 1 cm, specificity of LUS was higher than CXR, avoiding the need to perform CXR in these patients. Added benefit of LUS included high inter-observer agreement.

TRIAL REGISTRATION

Identifier: NCT03280732 . Registered 12 September 2017 (retrospectively registered).

Diagnostic value of signs, symptoms and diagnostic tests for diagnosing pneumonia in ambulant children in developed countries: a systematic review

Identifying a child with pneumonia in the large group of children with acute respiratory tract infections can be challenging for primary care physicians. Knowledge on the diagnostic value of specific signs and symptoms may guide future decision rules and guidelines for clinicians. We aimed to identify and systematically review available evidence for the diagnostic value of signs, symptoms, and additional tests to diagnose pneumonia in children in an ambulatory setting in developed countries. We conducted a systematic review, searching in the electronic databases of PubMed and Embase. Quality assessment of studies was done using the QUADAS-2 criteria. After data extraction from selected studies, we calculated and summarized test characteristics (sensitivity, specificity, negative and positive predictive values) of all available signs, symptoms, additional laboratory tests, and chest ultrasonography. The original search yielded 4665 records, of which 17 articles were eligible for analysis: 12 studies on signs and symptoms, 4 on additional laboratory tests, and 6 on ultrasonography. All included studies were performed in a secondary care setting. Risk of bias was present in the majority of studies in the domain of patient selection. Prevalence of pneumonia varied from 3.4% to 71.7%. The diagnostic value of the available 27 individual signs and symptoms to identify pneumonia was low. In a low prevalence setting, (4 studies, pneumonia prevalence <10%) clinically ill appearance of the child and oxygen saturation <94% can aid a physician. In a high prevalence setting (10 studies, pneumonia >10%), additional diagnostic tests such as oxygen saturation, C-reactive protein, and white blood cell count are more promising. Chest ultrasonography showed high diagnostic value in settings with higher prevalence of pneumonia. Single signs and symptoms from medical history and physical examination or individual additional diagnostic tests are insufficient to diagnose pneumonia in ambulant children. Very few diagnostic studies are conducted in settings with low prevalence of pneumonia. Future research in low prevalence settings should focus on the diagnostic value of the combination of clinical features and additional testing possibly using meta-analysis of individual data.