Multicentre pilot study evaluation of lung ultrasound for the management of paediatric pneumonia in low-resource settings: a study protocol

Assessing the acceptability of technological health innovations in sub-Saharan Africa: a scoping review and a best fit framework synthesis

Acceptability is a key concept used to analyze the introduction of a health innovation in a specific setting. However, there seems to be a lack of clarity in this notion, both conceptually and practically. In low and middle-income countries, programs to support the diffusion of new technological tools are multiplying. They face challenges and difficulties that need to be understood with an in-depth analysis of the acceptability of these innovations. We performed a scoping review to explore the theories, methods and conceptual frameworks that have been used to measure and understand the acceptability of technological health innovations in sub-Saharan Africa. The review confirmed the lack of common definitions, conceptualizations and practical tools addressing the acceptability of health innovations. To synthesize and combine evidence, both theoretically and empirically, we then used the "best fit framework synthesis" method. Based on five conceptual and theoretical frameworks from scientific literature and evidence from 33 empirical studies, we built a conceptual framework in order to understand the acceptability of technological health innovations. This framework comprises 6 determinants (compatibility, social influence, personal emotions, perceived disadvantages, perceived advantages and perceived complexity) and two moderating factors (intervention and context). This knowledge synthesis work has also enabled us to propose a chronology of the different stages of acceptability.

Radiology for Thoracic Conditions in Low- and Middle-Income Countries

With a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases (CRDs) in low and middle-income countries (LMICs), access to radiological services is of critical importance for screening, diagnosis, and treatment guidance.

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.

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.

Feasibility, usability and acceptability of paediatric lung ultrasound among healthcare providers and caregivers for the diagnosis of childhood pneumonia in resource-constrained settings: a qualitative study

OBJECTIVES

Paediatric pneumonia burden and mortality are highest in low-income and middle-income countries (LMIC). Paediatric lung ultrasound (LUS) has emerged as a promising diagnostic tool for pneumonia in LMIC. Despite a growing evidence base for LUS use in paediatric pneumonia diagnosis, little is known about its potential for successful implementation in LMIC. Our objectives were to evaluate the feasibility, usability and acceptability of LUS in the diagnosis of paediatric pneumonia.

DESIGN

Prospective qualitative study using semistructured interviews SETTING: Two referral hospitals in Mozambique and Pakistan PARTICIPANTS: A total of 21 healthcare providers (HCPs) and 20 caregivers were enrolled.

RESULTS

HCPs highlighted themes of limited resource availability for the feasibility of LUS implementation, including perceived high cost of equipment, maintenance demands, time constraints and limited trained staff. HCPs emphasised the importance of policymaker support and caregiver acceptance for long-term success. HCP perspectives of usability highlighted ease of use and integration into existing workflow. HCPs and caregivers had positive attitudes towards LUS with few exceptions. Both HCPs and caregivers emphasised the potential for rapid, improved diagnosis of paediatric respiratory conditions using LUS.

CONCLUSIONS

This was the first study to evaluate HCP and caregiver perspectives of paediatric LUS through qualitative analysis. Critical components impacting feasibility, usability and acceptability of LUS for paediatric pneumonia diagnosis in LMIC were identified for initial deployment. Future research should explore LUS sustainability, with a particular focus on quality control, device maintenance and functionality and adoption of the new technology within the health system. This study highlights the need to engage both users and recipients of new technology early in order to adapt future interventions to the local context for successful implementation.

TRIAL REGISTRATION NUMBER

NCT03187067.

Lung ultrasound patterns in paediatric pneumonia in Mozambique and Pakistan

Objective

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

Methods

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

Results

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

Discussion

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

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

Performance of lung ultrasound in the diagnosis of pediatric pneumonia in Mozambique and Pakistan

INTRODUCTION

Improved pneumonia diagnostics are needed in low-resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. The objective was to compare LUS versus chest radiograph (CXR), and among LUS interpreters, to compare expert versus limited training with respect to interrater reliability.

METHODS

We conducted a prospective, observational study among children with World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) chest-indrawing pneumonia at two district hospitals in Mozambique and Pakistan, and assessed LUS and CXR examinations. The primary endpoint was interrater reliability between LUS and CXR interpreters for pneumonia diagnosis among children with WHO IMCI chest-indrawing pneumonia.

RESULTS

Interrater reliability was excellent for expert LUS interpreters, but poor to moderate for expert CXR interpreters and onsite LUS interpreters with limited training.

CONCLUSIONS

Among children with WHO IMCI chest-indrawing pneumonia, expert interpreters may achieve substantially higher interrater reliability for LUS compared to CXR, and LUS showed potential as a preferred reference standard. For point-of-care LUS to be successfully implemented for the diagnosis and management of pneumonia in LRS, the clinical environment and amount of appropriate user training will need to be understood and addressed.

Response to Comment on Jaworska, J. et al. Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children. Diagnostics 2020, 10, 935

Thank you for the opportunity to respond to the issues raised by Nenna et al [...].

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.