Abstract
Purpose
The World Health Organization (WHO) case management algorithm for acute lower respiratory infections has moderate sensitivity and poor specificity for the diagnosis of pneumonia. We sought to determine the feasibility of using point-of-care ultrasound in resource-limited settings to identify pneumonia by general health practitioners and to determine agreement between the WHO algorithm and lung consolidations identified by point-of-care ultrasound.
Methods
An expert radiologist taught two general practitioners how to perform point-of-care ultrasound over a seven-day period. We then conducted a prospective study of children aged 2 months to 3 years in Peru and Nepal with and without respiratory symptoms, which were evaluated by point-of-care ultrasound to identify lung consolidation.
Results
We enrolled 378 children: 127 were controls without respiratory symptoms, 82 had respiratory symptoms without clinical pneumonia, and 169 had clinical pneumonia by WHO criteria. Point-of-care ultrasound was performed in the community (n = 180), in outpatient offices (n = 95), in hospital wards (n = 19), and in Emergency Departments (n = 84). Average time to perform point-of-care ultrasound was 6.4 ± 2.2 min. Inter-observer agreement for point-of-care ultrasound interpretation between general practitioners was high (κ = 0.79, 95 % CI 0.73–0.81). The diagnosis of pneumonia using the WHO algorithm yielded a sensitivity of 69.6 % (95 % CI 55.7–80.8 %), specificity of 59.6 % (95 % CI 54.0–65.0 %), and positive and negative likelihood ratios of 1.73 (95 % CI 1.39–2.15) and 0.51 (95 % CI 0.30–0.76) when lung consolidation on point-of-care ultrasound was used as the reference.
Conclusions
The WHO algorithm disagreed with point-of-care ultrasound findings in more than one-third of children and had an overall low performance when compared with point-of-care ultrasound to identify lung consolidation. A paired approach with point-of-care ultrasound may improve case management in resource-limited settings.
Similar content being viewed by others
Abbreviations
- WHO:
-
World Health Organization
- LUS:
-
Lung ultrasound
- CXR:
-
Chest X-ray
- ALRI:
-
Acute lower respiratory infection
- CT scan:
-
Computerized tomography scan
References
Graham SM, English M, Hazir T et al (2008) Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings. Bull WHO 86(5):349–355
UNICEF/WHO. Global action plan for prevention and control of pneumonia (GAPP) 2009
Williams BG, Gouws E, Boschi-Pinto C et al (2002) Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis 2(1):25–32
Mulholland K (2007) Childhood pneumonia mortality–a permanent global emergency. Lancet 370(9583):285–289
Sazawal S, Black RE (2003) Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet Infect Dis 3(9):547–556
World Health Organization. Case management of acute respiratory infections in children in developing countries. Report of a Working Group Meeting, Geneva, 3–6 April, 1984 WHO/RSD/8515. Geneva: WHO,1985
Cherian T, Steinhoff MC, Simoes EA et al (1997) Clinical signs of acute lower respiratory tract infections in malnourished infants and children. Pediatr Infect Dis J 16(5):490–494
Falade AG, Tschappeler H, Greenwood BM et al (1995) Use of simple clinical signs to predict pneumonia in young Gambian children: the influence of malnutrition. Bull WHO 73(3):299–304
Ayieko P, English M (2007) Case management of childhood pneumonia in developing countries. Pediat Infect Dis J 26(5):432–440
Lozano JM, Steinhoff M, Ruiz JG et al (1994) Clinical predictors of acute radiological pneumonia and hypoxaemia at high altitude. Arch Dis Child 71(4):323–327
Cardoso MR, Nascimento-Carvalho CM, Ferrero F et al (2011) Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children. Arch Dis Child 96(1):58–61
Puumalainen T, Quiambao B, Abucejo-Ladesma E et al (2008) Clinical case review: a method to improve identification of true clinical and radiographic pneumonia in children meeting the World Health Organization definition for pneumonia. BMC Infect Dis 8:95
Hazir T, Nisar YB, Qazi SA et al (2006) Chest radiography in children aged 2–59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan. BMJ 333(7569):629
Palafox M, Guiscafre H, Reyes H et al (2000) Diagnostic value of tachypnoea in pneumonia defined radiologically. Arch Dis Child 82(1):41–45
March Mde F, Sant’Anna CC (2005) Signs and symptoms indicative of community-acquired pneumonia in infants under 6 months. Braz J Infect Dis 9(2):150–155
Hazir T, Nisar YB, Abbasi S et al (2011) Comparison of oral amoxicillin with placebo for the treatment of world health organization-defined nonsevere pneumonia in children aged 2–59 months: a multicenter, double-blind, randomized, placebo-controlled trial in pakistan. Clin Infect Dis 52(3):293–300
Davies HD, Wang EE, Manson D et al (1996) Reliability of the chest radiograph in the diagnosis of lower respiratory infections in young children. Pediatr Infect Dis J 15(7):600–604
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(2):119–125
Copetti R, Cattarossi L (2008) Ultrasound diagnosis of pneumonia in children. Radio Med 113(2):190–198
Caiulo VA, Gargani L, Caiulo S et al (2013) Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 48(3):280–287
Iuri D, De Candia A, Bazzocchi M (2009) Evaluation of the lung in children with suspected pneumonia: usefulness of ultrasonography. Radiol Med 114(2):321–330
Parlamento S, Copetti R, Di Bartolomeo S (2009) Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emer Med 27(4):379–384
Gehmacher O, Mathis G, Kopf A et al (1995) Ultrasound imaging of pneumonia. Ultrasound Med Biol 21(9):1119–1122
Lichtenstein DA, Lascols N, Meziere G et al (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30(2):276–281
Lichtenstein D, Goldstein I, Mourgeon E et al (2004) Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 100(1):9–15
Shephard MD, Mazzachi BC, Watkinson L et al (2009) Evaluation of a training program for device operators in the Australian Government’s Point of Care Testing in General Practice Trial: issues and implications for rural and remote practices. Rural Remote Health 9(3):1189
Bahner DP, Royall NA (2013) Advanced ultrasound training for fourth-year medical students: a novel training program at the Ohio State University College of Medicine. Acad Med 88(2):206–213
Wong I, Jayatilleke T, Kendall R et al (2011) Feasibility of a focused ultrasound training programme for medical undergraduate students. Clin Teach 8(1):3–7
Ellington LE, Gilman RH, Tielsch JM et al (2012) Computerised lung sound analysis to improve the specificity of paediatric pneumonia diagnosis in resource-poor settings: protocol and methods for an observational study. BMJ Open 2(1):e000506
Volpicelli G, Elbarbary M, Blaivas M et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38(4):577–591
Volpicelli G, Silva F, Radeos M (2010) Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emer Med 17(2):63–72
Reissig A, Copetti R, Mathis G et al (2012) Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest 142(4):965–972
Sperandeo M, Carnevale V, Muscarella S et al (2011) Clinical application of transthoracic ultrasonography in inpatients with pneumonia. Eur J Clin Invest 41(1):1–7
Barillari A, De Franco F, Colonna F (2011) Chest ultrasound helps to diagnose pulmonary consolidations in pediatric patients. J Med Ultrasound 19(1):27–31
Reissig A, Kroegel C (2003) Transthoracic sonography of diffuse parenchymal lung disease: the role of comet tail artifacts. J Ultrasound Med 22(2):173–180
Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O (1997) The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Critical Care Med 156(5):1640–1646
Lichtenstein D, Meziere G, Seitz J (2009) The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 135(6):1421–1425
Lichtenstein DA, Lascols N, Prin S, Meziere G (2003) The, “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 29(12):2187–2192
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174
Chavez MA, Shams N, Ellington LE et al (2014) Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 15(1):50
Pereda MA, Chavez MA, Hooper-Miele CC et al (2015) Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics 135:714–722
Darge K, Chen A (2013) Ultrasonography of the lungs and pleurae for the diagnosis of pneumonia in children: prime time for routine use. JAMA Pediatr 167(2):187–188
Acknowledgments
This article was prepared by Miguel A. Chavez in fulfillment of the requirements for a Master degree in Epidemiological Research offered jointly by the Universidad Peruana Cayetano Heredia (UPCH) and the US Naval Medical Research Unit No. 6 (NAMRU-6), Peru. The Master program is part of the grant 2D43 TW007393, sponsored by the Fogarty International Center of the United States National Institutes of Health. The authors are thankful for the contributions, support, and guidance received from the faculty and fellow students of the program. This work was supported in part by federal funds of the National Heart, Lung And Blood Institute, United States National Institutes of Health, Department of Health and Human Services under contract number HHSN268200900033C. Miguel A. Chavez was further supported by Fogarty International Center Grant (#5R25TW009340) from the National Health Institute and the National Heart, Lung And Blood Institute and the University North Carolina Center for AIDS Research.
Conflicts of interest
The authors have no conflicts of interest to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chavez, M.A., Naithani, N., Gilman, R.H. et al. Agreement Between the World Health Organization Algorithm and Lung Consolidation Identified Using Point-of-Care Ultrasound for the Diagnosis of Childhood Pneumonia by General Practitioners. Lung 193, 531–538 (2015). https://doi.org/10.1007/s00408-015-9730-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00408-015-9730-x