Lung ultrasound patterns in paediatric pneumonia in Mozambique and Pakistan

Point-of-care lung ultrasound in detecting pneumonia: A systematic review

Purpose

Limited evidence exists to assess the sensitivity, specificity, and accuracy of point-of-care lung ultrasound (LUS) across all age groups. This review aimed to investigate the benefits of point-of-care LUS for the early diagnosis of pneumonia compared to traditional chest X-rays (CXR) in a subgroup analysis including pediatric, adult, and geriatric populations.

Material and Methods

This systematic review examined systematic reviews, meta-analyses, and original research from 2017 to 2021, comparing point-of-care LUS and CXR in diagnosing pneumonia among adults, pediatrics and geriatrics. Studies lacking direct comparison or exploring diseases other than pneumonia, case reports, and those examining pneumonia secondary to COVID-19 variants were excluded. The search utilized PubMed, Google Scholar, and Cochrane databases with specific search strings. The study selection, conducted by two independent investigators, demonstrated an agreement by the Kappa index, ensuring reliable article selection. The QUADAS-2 tool assessed the selected studies for quality, highlighting risk of bias and applicability concerns across key domains. Statistical analysis using Stata Version 16 determined pooled sensitivity and specificity via a bivariate model, emphasizing LUS and CXR diagnostic capabilities. Additionally, RevMan 5.4.1 facilitated the calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), offering insights into diagnostic accuracy.

Results

The search, conducted across PubMed, Google Scholar, and Cochrane Library databases by two independent investigators, initially identified 1045 articles. Following screening processes, 12 studies comprised a sample size of 2897. LUS demonstrated a likelihood ratio of 5.09, a specificity of 81.91%, and a sensitivity of 92.13% in detecting pneumonia in pediatric, adult, and geriatric patients, with a p-value of 0.0002 and a 95% confidence interval, indicating diagnostic accuracy ranging from 84.07% to 96.29% when compared directly to CXR.

Conclusion

Our review supports that LUS can play a valuable role in detecting pneumonia early with high sensitivity, specificity, and diagnostic accuracy across diverse patient demographics, including pediatric, adult, and geriatric populations. Since it overcomes most of the limitations of CXR and other diagnostic modalities, it can be utilized as a diagnostic tool for pneumonia for all age groups as it is a safe, readily available, and cost-effective modality that can be utilized in an emergency department, intensive care units, wards, and clinics by trained respiratory care professionals.

Lung ultrasound: are we diagnosing too much?

The clinical use of lung ultrasound (LUS) has made more efficient many diagnostic processes at bedside. The great power of LUS is a superior diagnostic sensitivity in many applications, when compared to chest radiography (CXR). The implementation of LUS in emergency is contributing to reveal a growing number of radio-occult pulmonary conditions. In some diseases, the superior sensitivity of LUS is a great advantage, like for pneumothorax and pulmonary edema. Diagnosing at bedside pneumothoraxes, pulmonary congestions, and COVID-19 pneumonia that are visible by LUS but undetected by CXR may be decisive for appropriate management, and even for saving lives. However, in other conditions, like bacterial pneumonia and small peripheral infarctions due to subsegmental pulmonary embolism, the high sensitivity of LUS does not always lead to advantages. Indeed, we doubt that it is always necessary to treat by antibiotics patients suspected of lower respiratory tract infection, who show radio-occult pulmonary consolidations, and to treat by anticoagulation patients with small subsegmental pulmonary embolism. The possibility that we are overtreating radio-occult conditions should be investigated with dedicated clinical trials.

Training for Pediatric Cardiac and Pulmonary Point of Care Ultrasound in Eastern Uganda

Caring for children with acute illness is a challenge in limited-resource settings, especially when diagnostic imaging is limited or unavailable. We developed a training program in cardiac and lung point-of-care ultrasound (POCUS) for pediatric patients in eastern Uganda. Fourteen trainees including physicians, resident physicians and midlevels received training in cardiac and lung POCUS. Training included formal lectures, hands-on skills practice and individualized teaching sessions. Assessment included written knowledge assessment, direct observation and longitudinal image review. Blinded review of 237 consecutive ultrasound studies revealed satisfactory image quality (94.2% for lung and 93% for cardiac) and accurate image interpretation. Sensitivity and specificity of image interpretation were 0.93 (0.75-0.99) and 0.94 (0.78-0.99) for lung and 0.86 (0.71-0.95) and 0.94 (0.84-0.99) for cardiac compared with expert review. All trainees passed written knowledge assessments. After training, 100% of trainees reported that they would use POCUS in clinical activity and thought it would improve patient outcomes. Our training program indicated that trainees were able to perform high-quality cardiac and lung POCUS for pediatric patients with accurate interpretation. This builds a foundation for future studies addressing how POCUS can change outcomes for children in limited-resource settings.