Can Chest Computed Tomography Be Replaced by Lung Ultrasonography With or Without Plain Chest Radiography in Pediatric Pneumonia?

Radiological Imaging in Chest Diseases: Moving Away from Conventional Modes

A chest radiograph is the most common and the initial radiological investigation for evaluating a child presenting with respiratory complaints. However, performing and interpreting chest radiography optimally requires training and skill. With the relatively easy availability of computed tomography (CT) scanning and more recently multidetector computed tomography (MDCT), these investigations are often performed. Although these can be the cross-sectional imaging modalities of choice in certain situations where detailed and exact anatomical and etiological information is required, both these investigations are associated with increased radiation exposure which has more detrimental effects on children, especially when repeated follow-up imaging is necessary to assess the disease status. Ultrasonography (USG) and magnetic resonance imaging (MRI) have evolved as radiation-free radiological investigations for evaluating the pediatric chest pathologies over the last few years. In the present review article, the utility and the current status, as well as the limitations of USG and MRI for evaluation of pediatric chest pathologies, are discussed. Radiology has grown beyond having just the diagnostic capabilities in managing children with chest disorders in the last two decades. Image-guided therapeutic procedures (percutaneous and endovascular) are routinely performed in children with pathologies in the mediastinum and lungs. The commonly performed image-guided pediatric chest interventions, including biopsies, fine needle aspiration, drainage procedures and therapeutic endovascular procedures, are also discussed in the current review.

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.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

Recent Findings

Summary

Supplementary Information

Chest radiography in children aged 2-59 months enrolled in the Innovative Treatments in Pneumonia (ITIP) project in Lilongwe Malawi: a secondary analysis

BACKGROUND

Pneumonia is the leading infectious cause of death in children aged under 5 years in low- and middle-income countries (LMICs). World Health Organization (WHO) pneumonia diagnosis guidelines rely on non-specific clinical features. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes.

METHODS

When clinically indicated, CXRs were obtained from ITIP-enrolled children aged 2 to 59 months with community-acquired pneumonia hospitalized with treatment failure or relapse. ITIP1 (fast-breathing pneumonia) and ITIP2 (chest-indrawing pneumonia) trials enrolled children with non-severe pneumonia while ITIP3 enrolled children excluded from ITIP1 and ITIP2 with severe pneumonia and/or selected comorbidities. A panel of trained pediatricians classified the CXRs using the standardized WHO CXR research methodology. We analyzed the relationship between CXR classifications, enrollee characteristics, and outcomes.

RESULTS

Between March 2016 and June 2018, of 114 CXRs obtained, 83 met analysis criteria with 62.7% (52/83) classified as having significant pathology per WHO standardized interpretation. ITIP3 (92.3%; 12/13) children had a higher proportion of CXRs with significant pathology compared to ITIP1 (57.1%, 12/21) and ITIP2 (57.1%, 28/49) (p-value = 0.008). The predominant pathological CXR reading was "other infiltrates only" in ITIP1 (83.3%, 10/12) and ITIP2 (71.4%, 20/28), while in ITIP3 it was "primary endpoint pneumonia"(66.7%, 8/12,; p-value = 0.008). The percent of CXRs with significant pathology among children clinically cured (60.6%, 40/66) vs those not clinically cured (70.6%, 12/17) at Day 14 was not significantly different (p-value = 0.58).

CONCLUSIONS

In this secondary analysis we observed that ITIP3 children with severe pneumonia and/or selected comorbidities had a higher frequency of CXRs with significant pathology, although these radiographic findings had limited relationship to Day 14 outcomes. The proportion of CXRs with "primary endpoint pneumonia" was low. These findings add to existing data that additional diagnostics and prognostics are important for improving the care of children with pneumonia in LMICs.

TRIAL REGISTRATION

ITIP1, ITIP2, and ITIP3 were registered with ClinicalTrials.gov ( NCT02760420 , NCT02678195 , and NCT02960919 , respectively).

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.

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 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.

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.

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.

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.

Lung ultrasound vs. chest X-ray in children with suspected pneumonia confirmed by chest computed tomography: A retrospective cohort study

The chest X-ray is routinely requested by pediatricians for children with suspected pneumonia, but has been demonstrated to be an insensitive method with relatively low accuracy. Computed tomography (CT) allows for the characterization of the consolidation in pneumonia but has a high risk of radiation exposure in children. Lung ultrasonography can identify subpleural lung consolidation in adults, but it is not accepted in routine clinical practice and is also not used for the diagnosis of children with pneumonia. The objective of the present study was to compare diagnostic parameters of lung ultrasound with chest X-ray in children with suspected pneumonia, using CT as a reference standard. Medical records of 949 children, aged ≤16 years, with suspected pneumonia were reviewed. Data regarding the chest radiograph, lung ultrasound and chest CT were collected and analyzed. Beneficial score analysis for each diagnostic modality was evaluated according to the pneumonia severity index. The chest radiograph successfully detected subpleural lung consolidation and dense lung opacity. The lung ultrasound successfully detected pleural effusion and perilesional inflammatory edema. The chest CT successfully detected a liquefied area, enhancement and necrosis of the lungs. Compared with the chest CT, the lung ultrasound displayed 0.906 sensitivity and 0.661 accuracy, while the chest radiograph displayed 0.793 sensitivity and 0.559 accuracy. For a pneumonia severity index of <3, the chest CT displayed a good beneficial score, followed by the lung ultrasound and chest radiograph. In conclusion, lung ultrasound is a non-invasive and simple method that could be used for the diagnosis of suspected pneumonia in children.

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.

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.

Review of bedside surgeon-performed ultrasound in pediatric patients

PURPOSE

Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS.

METHODS

PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation.

RESULTS

There are no standards for the practice of PSPBUS.

CONCLUSIONS

As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management.

TYPE OF STUDY

Review Article.

LEVEL OF EVIDENCE

Level III.

Is lung ultrasonography a useful method to diagnose children with community-acquired pneumonia in emergency settings?

Background:

Lung ultrasonography is a new method for diagnosing community-acquired pneumonia. Lung ultrasonography has some advantages over chest X-ray, such as lack of ionizing radiation risk, bedside performance, and cost-effectiveness.

Objectives:

In this study, we aimed to determine the feasibility of lung ultrasonography in emergency settings in children with community-acquired pneumonia.

Methods:

The study included patients younger than 18 years of age with suspicion of community-acquired pneumonia. On the first evaluation, patients with positive clinical and/or chest X-ray findings were defined to have community-acquired pneumonia, and this was accepted as the gold standard. The chest X-rays were evaluated by the chief of the pediatric emergency department, who was blinded to the patients and the lung ultrasonography results. Lung ultrasonography was performed by another pediatric emergency physician who was also blinded to the chest X-ray results and clinical findings such as fever, respiratory distress, rales, and wheezing.

Results:

Of the 91 patients enrolled, 71 (78.0%) were diagnosed with community-acquired pneumonia based on clinical and chest X-ray findings. The median (interquartile range) duration of the lung ultrasonography procedure was 4.0 (3.5–6.0) min. Shred sign, air bronchogram, and hepatization were significantly more frequent in the patients with community-acquired pneumonia ( p < 0.01, p < 0.01, and p = 0.01, respectively). Sensitivity and specificity of lung ultrasonography were 78.5% (67.1–87.4) and 95.2% (76.1–99.8), respectively.

Conclusion:

Lung ultrasonography is a useful diagnostic method for children with suspicion of community-acquired pneumonia.

New directions in point-of-care ultrasound at the crossroads of paediatric emergency and critical care

PURPOSE OF REVIEW

The diagnostic capability, efficiency and versatility of point-of-care ultrasound (POCUS) have enabled its use in paediatric emergency medicine (PEM) and paediatric critical care (PICU). This review highlights the current applications of POCUS for the critically ill child across PEM and PICU to identify areas of progress and standardized practice and to elucidate areas for future research.

RECENT FINDINGS

POCUS technology continues to evolve and advance bedside clinical care for critically ill children, with ongoing research extending its use for an array of clinical scenarios, including respiratory distress, trauma and dehydration. Rapidly evolving and upcoming applications include diagnosis of pneumonia and acute chest syndrome, identification of intra-abdominal injury via contrast-enhancement, guidance of resuscitation, monitoring of increased intracranial pressure and procedural guidance.

SUMMARY

POCUS is an effective and burgeoning method for both rapid diagnostics and guidance for interventions and procedures. It has clinical application for a variety of conditions that span PEM and PICU settings. Formal POCUS training is needed to standardize and expand use of this valuable technology by PICU and PEM providers alike.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.