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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 119-123

Chest sonography in diagnosis of childhood pneumonia: A single-center experience


Department of Pediatrics, Veer Surendra Sai Institute of Medical Sciences and Research, Sambalpur, Odisha, India

Date of Submission31-Jan-2020
Date of Decision24-Mar-2020
Date of Acceptance28-Mar-2020
Date of Web Publication25-May-2020

Correspondence Address:
Dr. Nihar Ranjan Mishra
Department of Pediatrics, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Sambalpur, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_21_20

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  Abstract 

Objective: The objective of this study was to determine the diagnostic accuracy of chest sonography (CS) in diagnosis of pneumonia among children.
Materials and Methods: This present cross-sectional analytical diagnostic study was conducted in the department of pediatrics of Western Odisha over a period of 2 years after institutional ethics committee approval. Totally 1475 children with clinical diagnosis of pneumonia were enrolled by a simple convenient sampling technique after getting written informed consent from their parents and/or guardian. The children with congenital anomalies, immunocompromised conditions, critically ill, and CS done after 24 h of chest radiography (CR) were excluded from the study. CS and CR were performed on 1475 children, and CR was taken as the gold standard for diagnosis of pneumonia in this study. All the relevant statistics were done by appropriate statistical software.
Results: Out of 1475 children, 911 (68.8%) were male and 563 (38.2%) were female. The mean age of the study population was 3.94 ± 3.42 years. The sensitivity of CS was 99.6% (98.8%, 99.9%), specificity: 89.3 (86.8%–91.4%), positive predictive value: 90.5% (88.3%–92.4%), negative predictive value: 99.5% (98.7%–99.9%), and diagnostic accuracy of 83.62%.
Conclusion: CS can be used as a good screening tool for early detection of pneumonia among children.

Keywords: Chest radiography, chest sonography, diagnostic accuracy, pneumonia


How to cite this article:
Majhi SC, Mishra NR, Pradhan S, Nayak BK. Chest sonography in diagnosis of childhood pneumonia: A single-center experience. J Pediatr Crit Care 2020;7:119-23

How to cite this URL:
Majhi SC, Mishra NR, Pradhan S, Nayak BK. Chest sonography in diagnosis of childhood pneumonia: A single-center experience. J Pediatr Crit Care [serial online] 2020 [cited 2020 Sep 22];7:119-23. Available from: http://www.jpcc.org.in/text.asp?2020/7/3/119/284930




  Introduction Top


According to the World Health Organization, pneumonia is the most common infectious cause of death among children worldwide among children. Approximately 920,000 children under 5 years died from pneumonia in 2015.[1] Childhood pneumonia still remains a diagnostic challenge in resource-limited settings.[2] Signs and symptoms of pneumonia vary depending on a child's age and the etiology of infection. Moreover, presenting signs and symptoms have poor diagnostic specificity (Sp), which may further complicate the diagnosis.[3],[4],[5]

In the present clinical practice, chest radiography (CR) is frequently advised by a physician for differential diagnosis, complications, and diagnosis of pneumonia.[6] CRs are performed at present approximately in 90% cases of children with clinically suspected pneumonia.[7] There should be cautious use of CR due to its deleterious effects of ionizing radiation,[8],[9],[10] its false-negative report among neonates,[11] and false-positive report among young infants.[12] Chest sonography (CS) is an emerging diagnostic tool for pneumonia in both adults[13] and children.[14] It has many advantages for pediatric respiratory diseases in resource-poor settings such as us, portability, user-friendly, rapid and repeat testing, no ionizing radiation, and ease of use.[15],[16]

Many studies done in the past[17],[18],[19],[20],[21],[22],[23] using CS as a diagnostic tool in childhood pneumonia found a sensitivity (Sn) in the range of 90%–96% and Sp in the range of 85%–100%. A study done in Italy in the year 2015 shows that CS has a positive likelihood ratio (LR) of 22.2 and a negative LR of 0.04 in diagnosing pneumonia.[21] There are no studies so far till date in our (Odisha/India) province. The purpose of this study was to ascertain the diagnostic accuracy of CS among children with suspected pneumonia and to demonstrate its benefit in diagnosing pneumonia in comparison with CR.


  Materials and Methods Top


This is an observational cross-sectional analytical diagnostic study (diagnostic study Phase I) conducted in the department of pediatrics of a tertiary care teaching hospital of Western Odisha from November 2017 to October 2019 after approval from the institutional ethics committee. All the clinically diagnosed cases of pneumonia[17] below the age 15 years of either gender attending our both outpatient and inpatient departments were included in the study. Children with congenital lung anomalies, sickle cell anemia with acute chest syndrome, immunosuppressive conditions (long-term steroid therapy, HIV, taking antimetabolite, diabetes mellitus, nephrotic syndrome, and diagnosed case of pulmonary and/or extrapulmonary tuberculosis with or without antitubercular therapy), critically ill children, and children with time duration between chest X-ray and chest ultrasound more than 24 h were excluded from the study. Sample size calculation was done by nMaster 2.0 (BRTC, Vellore) by applying diagnostic test comparing the Sn of a new test method. From the previous published literature[24] based on Sn of CS, the minimum sample size was calculated to be 1470 after adjusting for correction factor and attrition. With our estimated sample size of 1470, power was calculated to be 99.9% by STATA I/C 16.0 for Windows (Statacorp LLC, 4905 Lakeway Drive College Station, TX 77845, USA) using Wald Z-test. Out of 6163 clinically diagnosed cases of pneumonia during the study period, 5164 cases were included as per the predefined inclusion and exclusion criteria. From this study pool, 1640 cases were selected by systematic random sampling with sampling interval of 3. Out of these, 165 cases did not give consent and finally 1475 cases were enrolled in the study [Figure 1].
Figure 1: Study flowchart

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All clinically diagnosed childhood pneumonia cases underwent chest radiograph by Konica Minolta Inc. (AeroDR S33, Japan) digital X-ray machine. Chest sonography (CS) (GE LOGIQ E9 XDclear 2.0 ultrasound machine, India) was performed within 24 h after the CR. Criteria to define pneumonia based on CR and CS findings were predefined.[17]

All the relevant data were recorded in a predesigned case report format. Data validation was done manually by two separate persons not involved in the study. Continuous data were expressed in mean ± standard deviation; categorical data were expressed in proportions. Data normalcy testing of continuous data was done by Shapiro–Wilk test, and no transformation was required. All the descriptive statistics were done by SPSS version 25 (IBM, New York, NY, USA), and all the diagnostic accuracy tests were done by Dxt version 1.0 (BRTC, Vellore). Youden index J > 0.5 was considered acceptable for diagnostic accuracy tests.


  Results Top


Out of 1475 children, 911 (61.8%) were male and 564 (38.2%) were female. The mean age of our study participants was 3.94 (3.42), and the male:female ratio was 1.6:1. [Table 1] shows the baseline characteristics of the study participants. On clinical examination, the mean respiratory rate (/min) of clinically diagnosed pneumonia cases was 55 (11) and the mean oxygen saturation (%) at room air was 93 (3). Out of 1475 clinically diagnosed pneumonia patients, 823 and 748 cases were positive for CS and on CR findings for pneumonia, respectively [Table 2]. The most common finding among children with pneumonia on CS was subpleural consolidation with air bronchogram (50%). Diagnostic accuracy (DA) of chest sonography for detection of childhood pneumonia was calculated to be 94.5%. Various other diagnostic parameters of CS are summarized in [Table 3].
Table 1: Baseline characteristics of study population (n=1475)

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Table 2: Comparison of radiographic and sonographic findings of study participants (n=1475)

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Table 3: Diagnostic parameter values of lung sonography in detecting childhood pneumonia

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  Discussion Top


The present study was conducted in a tertiary care teaching hospital of Western Odisha where the prevalence of childhood pneumonia is very high (approximately 51% in our study). The average age was found to be 4 years with more number of pneumonia cases among male children of lower socioeconomic status background. In our study, CS detected 99.6% of children clinically presented as pneumonia under 15 years of age and approximately 89.3% of children without features of pneumonia as compared to CR. The probability of detecting pneumonia in children <15 years of age with positive CS features was 90.5%, whereas the probability of not detecting pneumonia with no features of pneumonia in CS was 99.5%. If we use CS as a diagnostic tool for detection of pneumonia in children, approximately in 85% times we will get above results. Using CS as a diagnostic tool, the probability of detecting pneumonia among children under 15 years of age increases by 9-fold, whereas if we do not use this tool, the probability of detection almost remains the same as compared to CR. Odds of detecting findings suggestive of pneumonia among clinically diagnosed pneumonia cases are 2066 times higher if we are using CS as a diagnostic tool.

In a study done in the year 2017 at Turkey, CS had a Sn of 94% and Sp of 96%, whereas CR showed a Sn of 82% and a Sp of 94%, considering gold standard for diagnosis of pneumonia by two clinicians based on the recommendation of the British Thoracic Society.[17] Our study had more Sn and less Sp compared to this study. This may be due to the fact of difference in the age group which was under 18 years and the type of gold standard they have used. Another study done in the USA[18] shows a Sn and Sp of CS as 88.5% and 100%, respectively, which is different from our study. The positive predictive value (100%) and negative predictive value (91.3%) were also different from our study. This may be explained on the basis of age group selection (<5 years of age) and case inclusion criteria (taken all cases with any respiratory symptoms). A meta-analysis done in the year 2015 in Baltimore showed a 96% Sn and 93% Sp taking combined clinical and radiological diagnosis as the gold standard for the age group under 18 years.[19] Their study also has different LR+ (15.3) and LR− (0.06) from our study, which may be explained due to the degree of heterogeneity among those eight studies they have included. A study done in the Department of Pediatrics of San Giovanni di Dio Hospital, Italy, reviewing medical records of all cases admitted with respiratory signs and symptoms found a 96.5% Sn and 95.6% Sp, LR + of 22, and LR − of 0.04 taking discharge diagnosis made out of clinical and radiological finding as the gold standard.[20] In an another study done at Italy taking clinical diagnosis as the gold standard, chest ultrasound was found to be 94% sensitive and 96% specific, whereas chest X-ray was 82% sensitive and 94% specific.[21] Our study has a high Sn and low Sp as compared to these studies,[20],[21] which may be due to different reference test in those studies. A study done exclusively on neonates[22] found mean age 9.5 (6) days, whereas other studies[17],[18],[19],[20],[21] used mean age almost similar to our study. Another study including patients from birth to 21 years found lung ultrasound to be 86% sensitive and 89% specific in diagnosing pneumonia with LR+ (7.8) and LR− (0.2).[23] Our results are similar to this study except the Sn, which may be explained on the basis of inclusion criteria of cases.

This study has provided important information regarding the utility of CS as a new diagnostic tool in diagnosing childhood pneumonia at the same time decreasing the chances of ionizing radiation exposure due to CR. The present study has some limitations like it is a cross-sectional study, so biases and confounders could not be avoided fully. It is a single-center and hospital-based study, so results cannot be generalized. We could not do computerized tomography scan on all children due to ethical issues. Hence, in the future, a large multicenter study using computerized tomography as the gold standard is ideal to get a better level of evidence.


  Conclusion Top


CS is found to be highly sensitive and specific in the detection of childhood pneumonia in this study. CS can be used in both neonates and pediatric age group as an alternative to CR. CS has reproducible results for ruling out underlying pneumonic process as well as helps in early detection of pneumonia. We found that CS is a quick, easy, noninvasive, nonionizing, and very sensitive tool in detection of pneumonia and parapneumonic effusion in children under 15 years of age; however, larger studies with higher level of evidence are needed to confirm the robustness of CS in diagnosing childhood pneumonia.

Acknowledgment

We are thankful to our head of the department, colleagues who have continuously encouraged us, and at last but not least, the patients without whom this study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Pneumonia. Fact Sheet No. 331. World Health Organization. Available from: www.who.int/mediacenter/factsheets/fs331/en/. [Last accessed on 2017 Nov 01].  Back to cited text no. 1
    
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Schlaudecker EP, Frenck RW Jr. Adolescent pneumonia. Adolesc Med State Art Rev 2010;21:202-19, vii-viii.  Back to cited text no. 4
    
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Ebell MH. Clinical diagnosis of pneumonia in children. Am Fam Physician 2010;82:192-3.  Back to cited text no. 5
    
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Ho MC, Ker CR, Hsu JH, Wu JR, Dai ZK, Chen IC. Usefulness of lung ultrasound in the diagnosis of community-acquired pneumonia in children. Pediatr Neonatol 2015;56:40-5.  Back to cited text no. 6
    
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Bowen SJ, Thomson AH. British thoracic society paediatric pneumonia audit: A review of 3 years of data. Thorax 2013;68:682-3.  Back to cited text no. 7
    
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Mazrani W, McHugh K, Marsden PJ. The radiation burden of radiological investigations. Arch Dis Child 2007;92:1127-31.  Back to cited text no. 8
    
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Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: What pediatric health care providers should know. Pediatrics 2003;112:951-7.  Back to cited text no. 9
    
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Hall EJ. Lessons we have learned from our children: Cancer risks from diagnostic radiology. Pediatr Radiol 2002;32:700-6.  Back to cited text no. 10
    
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Mathur NB, Garg K, Kumar S. Respiratory distress in neonates with special reference to pneumonia. Indian Pediatr 2002;39:529-37.  Back to cited text no. 11
    
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Kim OH, Kim WS, Kim MJ, Jung JY, Suh JH. US in the diagnosis of pediatric chest diseases. Radiographics 2000;20:653-71.  Back to cited text no. 12
    
13.
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious diseases society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adult. Clin infect Dis 2007;44 Suppl 2:S27-72.  Back to cited text no. 13
    
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Pereda MA, Chavez MA, Hooper-Miele CC, Gilman RH, Steinhoff MC, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in children: A meta-analysis. Pediatrics 2015;135:714-e22.  Back to cited text no. 14
    
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Shah S, Noble VE, Umulisa I, Dushimiyimana JM, Bukhman G, Mukherjee J, et al. Development of an ultrasound training curriculum in a limited resource international setting: Successes and challenges of ultrasound training in rural Rwanda. Int J Emerg Med 2008;1:193-6.  Back to cited text no. 15
    
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Shah SP, Epino H, Bukhman G, Umulisa I, Dushimiyimana JM, Reichman A, et al. Impact of the introduction of ultrasound services in a limited resource setting: Rural Rwanda 2008. BMC Int Health Hum Rights 2009;9:4.  Back to cited text no. 16
    
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Yilmaz HL, Özkaya AK, Sarı Gökay S, Tolu Kendir Ö, Şenol H. Point-of-care lung ultrasound in children with community acquired pneumonia. Am J Emerg Med 2017;35:964-9.  Back to cited text no. 17
    
18.
Ellington LE, Gilman RH, Chavez MA, Pervaiz F, Marin-Concha J, Compen-Chang P, et al. Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med 2017;128:57-64.  Back to cited text no. 18
    
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Pereda MA, Chavez MA, Hooper-Miele CC, Gilman RH, Steinhoff MC, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in children: A meta-analysis. Pediatrics 2015;135:714-22.  Back to cited text no. 19
    
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Iorio G, Capasso M, de Luca G, Prisco S, Mancusi C, Laganà B, et al. Lung ultrasound in the diagnosis of pneumonia in children: Proposal for a new diagnostic algorithm. PeerJ 2015;3:e1374.  Back to cited text no. 20
    
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Reali F, Sferrazza Papa GF, Carlucci P, Fracasso P, di Marco F, Mandelli M, et al. Can lung ultrasound replace chest radiography for the diagnosis of pneumonia in hospitalized children? Respiration 2014;88:112-5.  Back to cited text no. 21
    
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Dien HM, Eilatif DA. The value of bedside lung ultrasonography in diagnosis of neonatal pneumonia. Egypt J Radiol Nucl Med 2013;44:339-47.  Back to cited text no. 22
    
23.
Shah VP, Tunic MG, Tsung JW. Prospective evaluation of point of care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 2012;167:119-25.  Back to cited text no. 23
    
24.
Ellington LE, Gilman RH, Chavez MA, Pervaiz F, Marin-Concha J, Compen-Chang P, et al. Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med 2017;128:57-64.  Back to cited text no. 24
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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