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Clinical Trial
. 2018 Dec 7;18(1):191.
doi: 10.1186/s12890-018-0750-1.

Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis

Carlotta Biagi  1 , Luca Pierantoni  1 , Michelangelo Baldazzi  2 , Laura Greco  2 , Ada Dormi  3 , Arianna Dondi  1 , Giacomo Faldella  4 , Marcello Lanari  5
Affiliations
Clinical Trial

Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis

Carlotta Biagi et al. BMC Pulm Med. .

Abstract

Background: Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients.

Methods: We enrolled children admitted to our hospital in 2016-2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient's clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines.

Results: Eighty seven children with bronchiolitis were investigated. A final diagnosis of concomitant pneumonia was made in 25 patients. Sensitivity and specificity of LUS for the diagnosis of pneumonia were 100% and 83.9% respectively, with an area under-the-curve of 0.92, while CXR showed a sensitivity of 96% and specificity of 87.1%. When only consolidation > 1 cm was considered consistent with pneumonia, the specificity of LUS increased to 98.4% and the sensitivity decreased to 80.0%, with an area under-the-curve of 0.89. Cohen's kappa between pediatrician and radiologist sonologists in the first 30 patients showed an almost perfect agreement in diagnosing pneumonia by LUS (K 0.93).

Conclusions: This study shows the good accuracy of LUS in diagnosing pneumonia in children with clinical bronchiolitis. When including only consolidation size > 1 cm, specificity of LUS was higher than CXR, avoiding the need to perform CXR in these patients. Added benefit of LUS included high inter-observer agreement.

Trial registration: Identifier: NCT03280732 . Registered 12 September 2017 (retrospectively registered).

Keywords: Bronchiolitis; Chest X-ray; Lung ultrasound; Pneumonia.

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Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the Institutional Ethics Committee of St. Orsola-Malpighi Hospital, University of Bologna (reference number: 13/2016/O/Sper). Parents of all the participants gave informed written consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Lung ultrasound images in a patient with bronchiolitis complicated by pneumonia. a Transversal intercostals approach showed multiple B lines, consistent with bronchiolitis. b Longitudinal thoracic scan, revealed irregular pleural surface and confluent B lines (arrow). c The left posterior lung field showed a small subpleural consolidation without sonographic air bronchograms (arrow) - a typical finding in infants with bronchiolitis – associated with focally confluent B lines arising from the margin of the consolidation. d The scan of the posterior region of the right lung revealed a consolidation with hyperechoic air bronchograms suggestive of pneumonia
Fig. 2
Fig. 2
Comparison of CXR and LUS in a patient with bronchiolitis complicated by pneumonia in the right lung. a CXR showed a right lung consolidation consistent with pneumonia, associated with hyperinflation and a mediastinal herniation of the left lung. b LUS revealed a large hypoechoic consolidated area with sonographic air bronchograms with branching pattern, compatible with pneumonia
Fig. 3
Fig. 3
Comparison of CXR and LUS in a patient with bronchiolitis complicated by pneumonia in the left lung. a CXR demonstrated a basal left consolidation suggestive of pneumonia and bilateral peri-bronchial thickening. b Ultrasound showed a consolidation with air bronchograms in the posterior region of the left lung
Fig. 4
Fig. 4
Receiver Operating Characteristic (ROC) curve for LUS for the diagnosis of bacterial pneumonia in children with bronchiolitis. a The ROC curve when all the consolidations associated with bronchogram were considered consistent with bacterial pneumonia. b The ROC curve when only ultrasound consolidations size > 1 cm were considered consistent with bacterial pneumonia
See this image and copyright information in PMC

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