Top

Published in:

01-09-2019 | Ultrasound | Original Article

Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions

Authors: Tiago Henrique de Souza, José Antonio Hersan Nadal, Andressa Oliveira Peixoto, Ricardo Mendes Pereira, Marina Pavan Giatti, Ana Carolina Siqueira Soub, Marcelo Barciela Brandão

Published in: European Journal of Pediatrics | Issue 9/2019

Abstract

The objective of this study was to evaluate the interoperator agreement of lung ultrasonography (LUS) on specific thoracic regions in children diagnosed with pneumonia and to compare the findings of the LUS with the chest X-ray. Participants admitted to the ward or PICU underwent LUS examinations performed by an expert and a novice operator. A total of 261 thoracic regions in 23 patients were evaluated. Median age and weight of participants were 30 months and 11.6 kg, respectively. A substantial overall agreement between operators was found for normal lung tissue (κ = 0.615, 95% confidence interval (95% CI) = 0.516–0.715) and for consolidations (κ = 0.635, 95% CI = 0.532–0.738). For B-lines, a moderate agreement was observed (κ = 0.573, 95% CI = 0.475–0.671). An almost perfect agreement was found for pleural effusion (κ = 0.868, 95% CI = 0.754–0.982). The diagnosis of consolidations by LUS showed a high sensitivity (93% for both operators) but a low specificity (14% for expert and 25% for novice operator). While intubated patients presented significantly more consolidations, nonintubated patients presented more normal ultrasound patterns.

Conclusion: Even when performed by operators with very distinct degrees of experience, LUS had a good interoperator reliability for detecting sonographic patterns on specific thoracic regions.

What is Known:

• Lung ultrasound is feasible, safe, and highly accurate for the diagnosis of pneumonia in children; however, it does not allow global visualization of the thorax in a single moment as in chest X-rays, and, similar to the stethoscope, partial thorax assessments must be performed sequentially.

What is New:

• This is the first study evaluating the agreement of LUS on specific thoracic regions between operators with distinct degrees of experience performing the sonograms.

• There is a good agreement between an expert operator and a novice operator who underwent a brief theoretical-practical training program on LUS.

Available only for authorised users

Ben Shimol S, Dagan R, Givon-Lavi N, Tal A, Aviram M, Bar-Ziv J, Zodicov V, Greenberg D (2012) Evaluation of the World Health Organization criteria for chest radiographs for pneumonia diagnosis in children. Eur J Pediatr 171:369–374. https://doi.org/10.1007/s00431-011-1543-1 CrossRefPubMed

Biagi C, Pierantoni L, Baldazzi M, Greco L, Dormi A, Dondi A, Faldella G, Lanari M (2018) Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis. BMC Pulm Med 18:191. https://doi.org/10.1186/s12890-018-0750-1 CrossRefPubMedPubMedCentral

Boursiani C, Tsolia M, Koumanidou C, Malagari A, Vakaki M, Karapostolakis G, Mazioti A, Alexopoulou E (2017) Lung ultrasound as first-line examination for the diagnosis of community-acquired pneumonia in children. Pediatr Emerg Care 33:62–66. https://doi.org/10.1097/PEC.0000000000000969 CrossRefPubMed

Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America (2011) Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 53:617–630. https://doi.org/10.1093/cid/cir625 CrossRefPubMedPubMedCentral

Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E (2011) Lung ultrasound in bronchiolitis: comparison with chest X-ray. Eur J Pediatr 170:1427–1433. https://doi.org/10.1007/s00431-011-1461-2 CrossRefPubMed

Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E, Mele G (2013) Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 48:280–287. https://doi.org/10.1002/ppul.22585 CrossRefPubMed

Cardenas-Garcia J, Mayo PH (2015) Bedside ultrasonography for the intensivist. Crit Care Clin 31:43–66. https://doi.org/10.1016/j.ccc.2014.08.003 CrossRefPubMed

Copetti R, Cattarossi L (2008) Ultrasound diagnosis of pneumonia in children. Radiol Med 113:190–198. https://doi.org/10.1007/s11547-008-0247-8 CrossRefPubMed

Elemraid MA, Muller M, Spencer DA, Rushton SP, Gorton R, Thomas MF, Eastham KM, Hampton F, Gennery AR, Clark JE, on behalf of the North East of England Paediatric Respiratory Infection Study Group (2014) Accuracy of the interpretation of chest radiographs for the diagnosis of paediatric pneumonia. PLoS One 9:–e106051. https://doi.org/10.1371/journal.pone.0106051

10.

Ellington LE, Gilman RH, Chavez MA, Pervaiz F, Marin-Concha J, Compen-Chang P, Riedel S, Rodriguez SJ, Gaydos C, Hardick J, Tielsch JM, Steinhoff M, Benson J, May EA, Figueroa-Quintanilla D, Checkley W, Lung Ultrasound for Pneumonia Assessment (LUPA) Study Investigators (2017) Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med 128:57–64. https://doi.org/10.1016/j.rmed.2017.05.007 CrossRefPubMedPubMedCentral

11.

Esayag Y, Nikitin I, Bar-Ziv J et al (2010) Diagnostic value of chest radiographs in bedridden patients suspected of having pneumonia. Am J Med 123:88.e1–88.e5. https://doi.org/10.1016/j.amjmed.2009.09.012 CrossRef

12.

Esposito S, Papa SS, Borzani I, Pinzani R, Giannitto C, Consonni D, Principi N (2014) Performance of lung ultrasonography in children with community-acquired pneumonia. Ital J Pediatr 40:1–6. https://doi.org/10.1186/1824-7288-40-37 CrossRef

13.

Gereige RS, Laufer PM (2013) Pneumonia. Pediatr Rev 34:438–456. https://doi.org/10.1542/pir.34-10-438 CrossRefPubMed

14.

Gravel CA, Monuteaux MC, Levy JA, Miller AF, Vieira RL, Bachur RG (2019) Interrater reliability of pediatric point-of-care lung ultrasound findings. Am J Emerg Med. https://doi.org/10.1016/j.ajem.2019.01.047

15.

Hall EJ (2002) Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 32:700–706. https://doi.org/10.1007/s00247-002-0774-8 CrossRefPubMed

16.

Harel-Sterling M, Diallo M, Santhirakumaran S, Maxim T, Tessaro M (2019) Emergency department resource use in pediatric pneumonia: point-of-care lung ultrasonography versus chest radiography. J Ultrasound Med 38:407–414. https://doi.org/10.1002/jum.14703 CrossRefPubMed

17.

Harris M, Clark J, Coote N et al (2011) British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66:ii1–ii23. https://doi.org/10.1136/thoraxjnl-2011-200598 CrossRefPubMed

18.

Jones BP, Tay ET, Elikashvili I, Sanders JE, Paul AZ, Nelson BP, Spina LA, Tsung JW (2016) Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest 150:131–138. https://doi.org/10.1016/j.chest.2016.02.643 CrossRefPubMed

19.

Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRef

20.

Lichtenstein DA, Lascols N, Mezière G, Gepner A (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30:276–281. https://doi.org/10.1007/s00134-003-2075-6 CrossRefPubMed

21.

Lissaman C, Kanjanauptom P, Ong C, Tessaro M, Long E, O’Brien A (2018) Prospective observational study of point-of-care ultrasound for diagnosing pneumonia. Arch Dis Child 0:1–7. https://doi.org/10.1136/archdischild-2017-314496 CrossRef

22.

Llor C, Bjerrum L (2014) Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv drug Saf 5:229–241. https://doi.org/10.1177/2042098614554919 CrossRefPubMedPubMedCentral

23.

Mazrani W, McHugh K, Marsden PJ (2007) The radiation burden of radiological investigations. Arch Dis Child 92:1127–1131. https://doi.org/10.1136/adc.2006.101782 CrossRefPubMedPubMedCentral

24.

Moncada DC, Rueda ZV, Marcías A et al (2011) Reading and interpretation of chest X-ray in adults with community-acquired pneumonia. Braz J Infect Dis 15:540–546. https://doi.org/10.1590/S1413-86702011000600007 CrossRefPubMed

25.

Pereda MA, Chavez MA, Hooper-Miele CC, Gilman RH, Steinhoff MC, Ellington LE, Gross M, Price C, Tielsch JM, Checkley W (2015) Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics 135:714–722. https://doi.org/10.1542/peds.2014-2833 CrossRefPubMed

26.

Pietersen PI, Madsen KR, Graumann O, Konge L, Nielsen BU, Laursen CB (2018) Lung ultrasound training: a systematic review of published literature in clinical lung ultrasound training. Crit Ultrasound J 10:23. https://doi.org/10.1186/s13089-018-0103-6 CrossRefPubMedPubMedCentral

27.

Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, Aliberti S, Neumann R, Kroegel C, Hoyer H (2013) Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. Chest 142:965–972. https://doi.org/10.1378/chest.12-0364 CrossRef

28.

Shah VP, Tunik MG, Tsung JW (2013) Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 167:119–125. https://doi.org/10.1001/2013.jamapediatrics.107 CrossRefPubMed

29.

Sim J, Wright CC (2005) The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 85:257–268PubMed

30.

Svigals PZ, Chopra A, Ravenel JG, Nietert PJ, Huggins JT (2017) The accuracy of pleural ultrasonography in diagnosing complicated parapneumonic pleural effusions. Thorax 72:94–95. https://doi.org/10.1136/thoraxjnl-2016-208904 CrossRefPubMed

31.

Swingler GH, Zwarenstein M (2008) Chest radiograph in acute respiratory infections. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD001268.pub3

32.

Tripathi S, Ganatra H, Martinez E, Mannaa M, Peters J (2018) Accuracy and reliability of bedside thoracic ultrasound in detecting pulmonary pathology in a heterogeneous pediatric intensive care unit population. J Clin Ultrasound 47:1–8. https://doi.org/10.1002/jcu.22657 CrossRef

33.

Tsung JW, Kessler DO, Shah VP (2012) Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic : distinguishing viral from bacterial pneumonia. Crit Ultrasound J 4:1–9. https://doi.org/10.1186/2036-7902-4-16 CrossRef

34.

Volpicelli G, Elbarbary M, Blaivas M et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591. https://doi.org/10.1007/s00134-012-2513-4 CrossRefPubMed

35.

Wardlaw TM, Johansson EW, Hodge M, World Health Organization & UNICEF. (2006) Pneumonia: the forgotten killer of children. Geneva

36.

Williams GJ, Macaskill P, Kerr M, Fitzgerald DA, Isaacs D, Codarini M, McCaskill M, Prelog K, Craig JC (2013) Variability and accuracy in interpretation of consolidation on chest radiography for diagnosing pneumonia in children under 5 years of age. Pediatr Pulmonol 48:1195–1200. https://doi.org/10.1002/ppul.22806 CrossRefPubMed

37.

World Health Organization (2001) Model chapter for textbooks : IMCI Integrated Management of Childhood Illness. World Health Organization, Geneva

38.

World Health Organization Pneumonia Vaccine Trial Investigator’ group (2001) Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. In: WHO/V&B/01.35. http://www.who.int/iris/handle/10665/66956. Accessed 2 Dec 2018

39.

Yousefifard M, Baikpour M, Ghelichkhani P et al (2016) Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion; a meta-analysis. Emerg (Tehran, Iran) 4:1–10

40.

Zimmerman DR, Kovalski N, Fields S, Lumelsky D, Miron D (2012) Diagnosis of childhood pneumonia: clinical assessment without radiological confirmation may lead to overtreatment. Pediatr Emerg Care 28:646–649. https://doi.org/10.1097/PEC.0b013e31825cfd53 CrossRefPubMed

Title: Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions
Authors: Tiago Henrique de Souza
José Antonio Hersan Nadal
Andressa Oliveira Peixoto
Ricardo Mendes Pereira
Marina Pavan Giatti
Ana Carolina Siqueira Soub
Marcelo Barciela Brandão
Publication date: 01-09-2019
Publisher: Springer Berlin Heidelberg
Keywords: Ultrasound
Pleural Effusion
Pneumonia
Ultrasound
Lung Ultrasound
Published in: European Journal of Pediatrics / Issue 9/2019
Print ISSN: 0340-6199
Electronic ISSN: 1432-1076
DOI: https://doi.org/10.1007/s00431-019-03428-2

At a glance: The STEP trials

Springer Medicine

Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions

Abstract

At a glance: The STEP trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 9/2019

Correction to: Oral vitamin A supplementation in very low birth weight neonates: a randomized controlled trial

Emergency or urgent splenectomy in children for non-traumatic reasons

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning

Isolated antenatal hydronephrosis with renal pelvis antero-posterior diameter ≤ 20 mm

Hyponatremia in children under 100 days old: incidence and etiologies

Topical application of coconut oil to the skin of preterm infants: a systematic review