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

Amy Sarah Ginsburg,Marta Valente,Pio Vitorino,Naila Nadeem,Rubao Bila,Fyezah Jehan,Lola Madrid,Alessandro Lamorte,Susanne May,Reyes Balcells,Jun Hwang,Neel Kanth,Quique Bassat,Benazir Baloch,Jennifer L Lenahan,Rosauro Varo,Muhammad Imran Nisar,Giovanni Volpicelli

doi:10.1002/ppul.25176

Abstract

IntroductionImproved 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.MethodsWe 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.ResultsInterrater reliability was excellent for expert LUS interpreters, but poor to moderate for expert CXR interpreters and onsite LUS interpreters with limited training.ConclusionsAmong 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.

Highlights

Improved pneumonia diagnostics are needed in low‐resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia
Among children with World Health Organization (WHO) Integrated Management of Childhood Illness (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

Summary

Introduction

Improved pneumonia diagnostics are needed in low‐resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. Chest radiographs (CXR) can be expensive, difficult to obtain, time‐ consuming, and expose the child to ionizing radiation.[5,6,7] Microbiology (e.g., blood, lung/pleural aspiration, and/or bronchoalveolar lavage culture) is invasive, slow, and detects a limited proportion of cases.[5] Biomarkers such as C‐reactive protein can correlate with bacterial infection but do not have a set threshold nor indicate a specific etiology.[5] Given these limitations and that diagnostic tests used for pediatric pneumonia have not been sufficiently validated despite their routine use, there is no satisfying safe and effective reference standard for the accurate and reliable diagnosis of pediatric pneumonia.[8] Lung ultrasound (LUS) is a promising technology that can dynamically visualize the lungs with potentially high diagnostic accuracy for pneumonia.[6] Advantages of LUS, relative to CXR, include its lower cost, portability, ease of use, and absence of ionizing radiation.[6,7,9] We conducted a pilot study in Mozambique and Pakistan to investigate the use of point‐of‐care LUS as a tool for the diagnosis of pediatric pneumonia in LRS among children with WHO IMCI chest‐indrawing pneumonia

Results

Discussion

Conclusion