First-line diagnosis of paediatric pneumonia in emergency: lung ultrasound (LUS) in addition to chest-X-ray (CXR) and its role in follow-up

Abstract

Objective: The role of lung ultrasound (LUS) integrated with chest X-ray (CXR) for the first-line diagnosis of paediatric pneumonia; to define its role during the follow-up to exclude complications.

Methods: We performed a retrospective review of a cohort including 84 consecutive children (age range: 3-16 years; mean age: 6 years; 44 males, 40 females) with clinical signs of cough and fever. All the patients underwent CXR at admission integrated with LUS. Those positive at LUS were followed up with LUS until the complete resolution of the disease.

Results: CXR showed 47/84 pneumonic findings. LUS showed 60/84 pneumonic findings; 34/60 pneumonic findings had a typical pattern of lung consolidation; 26/60 pneumonic findings showed association of multiple B-lines, findings consistent with interstitial involvement, and small and hidden consolidations not achievable by CXR. One case was negative at LUS because of retroscapular location. 60 patients were followed up with LUS; 28/60 patients showed a complete regression of the disease; 23/60 patients had a significant decrease in size of consolidation; 9/60 patients showed disease stability or insignificant decrease in size, thus requiring adjunctive LUS examinations.

Conclusion: LUS, integrated with CXR, revealed to be an accurate first-line technique to identify small pneumonic consolidations, especially for "CXR-occult" findings, and for early diagnosis of pleural effusion; furthermore, LUS follow-up allows complications to be verified and additional radiation exposures to be avoided.

Advances in knowledge: The effective role of LUS in the diagnosis and follow-up of lung consolidations and pleural effusions in paediatric patients in an emergency setting.

Figure 1.

A 6-year-old boy with cough and fever. (a) Chest X-ray (CXR) performed at admission in anterior–posterior projection shows an extensive medial lobe consolidation; (b) lung ultrasound (LUS) performed simultaneously with CXR shows a typical pneumonic consolidation with “arborescent bronchogram”; (c) in association, there was a wider consolidation with “parallel” bronchogram suggesting a prevalent atelectasis component, measures were taken to follow up it up; (d) follow-up at 7 days. LUS shows a significative reduction in size of lung consolidation, with persistent “parallel” bronchogram suggesting residual minimal atelectasis component; (e) follow-up at 14 days. LUS shows complete resolution of lung consolidation, with residual pleural line thickening.

Figure 2.

An 8-year-old patient presenting with persistent cough and fever after therapy. (a) Chest X-ray shows a left parahilar consolidation; (b) lung ultrasound (LUS) performed simultaneously depicts well a well-defined wide pneumonic consolidation; (c) best detail of the well-defined wide pneumonic consolidation. (d) Colour-Doppler ultrasound shows its typical hypervascularity; (e) LUS follow-up (7 days after): wide reduction of pneumonic consolidation, but still present; (f) LUS follow-up (14 days after): pneumonic consolidation disappearance; regular “A-lines”.

Figure 3.

A 15-year-old boy presenting at emergency department with dyspnoea and fever. (a, b) Chest X-ray shows rise of the right diaphragm, and the latero-lateral projection enhances the presence of posterior pleural effusion; (c) lung ultrasound (LUS) performed at the same time demonstrates a large amount of pleural effusion; (d) LUS, performed after tube insertion and drainage of partially corpusculated pleural effusion, shows a quite complete resolution of empyema; (e) follow-up at 7 days: LUS shows a complete resolution of empyema.

Figure 4.

A 10-year-old patient presenting with dyspnoea, cough and fever after 5 days of pneumonia therapy. (a) Anterior–posterior Chest X-ray shows an inhomogeneous right basal opacification. (b, c) Lung ultrasound (LUS) performed simultaneously well depicts a multiloculated and corpusculated pleural effusion with a large posterobasal consolidation; (d) LUS at 7 days after pleural drainage shows a wide reduction in size of the multiloculated pleural effusion; (e) the follow-up at 14 days after pleural drainage demonstrates a complete re-absorption of the septated pleural effusion with some residual “B-lines”, expression of interstitial involvement.

Figure 5.

A 14-month-old boy presenting with cough and fever. (a) Chest X-ray does not show any consolidation or evident interstitial disease; (b) lung ultrasound performed simultaneously depicts well a well-defined left posterobasal small consolidation.

Figure 6.

A 11-year-old boy presenting with mild dyspnoea, cough and fever. (a, b) Chest X-ray does not show any consolidation or interstitial disease. (c, d) Lung ultrasound performed simultaneously on lung bases depicts well multiple “B-lines”, ring-down, vertical artefacts, expression of interstitial involvement, so much different from the normal pattern of “A-lines”. (e) Artefacts parallel to pleural lines, which are present at upper lobes.