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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 1043-1050

Study of lung ultrasonography as a diagnostic tool in childhood pneumonia


1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Shibin El-Kom, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Egypt
3 Department of Pediatrics, Shibin El-Kom Teaching Hospital, Shibin El-Kom, Egypt

Date of Submission25-Nov-2017
Date of Acceptance20-Jan-2018
Date of Web Publication17-Oct-2019

Correspondence Address:
Mostafa M Shalaby
Department of Pediatrics, Shibin El-Kom Teaching Hospital, Shibin El-Kom, Menoufia 33511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_800_17

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  Abstract 

Objective
The aim of this study was to compare chest ultrasonography with chest radiography (CXR) in the diagnosis of children with pneumonia.
Background
In Egypt, pneumonia and other acute respiratory infections were the causes of death in ∼19% of children younger than 5 years. According to current guidelines, pneumonia is diagnosed by clinical history, respiratory rate, fever, respiratory signs, and symptoms.
Patients and methods
A cross-sectional study was conducted on 60 patients with fever and signs of respiratory distress, and they were divided in two groups: group I with pneumonia, which included 45 patients who were finally diagnosed as having clinically evident pneumonia, and group II without pneumonia, which included 15 patients who did not have pneumonia. Full history taken, clinical examination, laboratory investigations, CXR, and chest ultrasonography were done.
Results
There was no statistically significant difference between the two groups regarding age, birth order, weight, residence, parent's education, and employment. C-reactive protein level was higher in pneumonia group than nonpneumonia group (P < 0.001). Lung ultrasonography could detect consolidation in more than one lobe than CXR, which was statistically significant (P = 0.048).
Conclusion
Chest ultrasonography offers an important contribution to the diagnostic procedures of pleuropulmonary disorders in children, such as pneumonia and pleural effusion, with higher sensitivity, specificity, and positive predictive index compared with CXR.

Keywords: pleural effusion, pneumonia, radiographies, respiratory rate, ultrasonography


How to cite this article:
Elmashad GM, Bahbah WA, Mousa WA, Shalaby MM. Study of lung ultrasonography as a diagnostic tool in childhood pneumonia. Menoufia Med J 2019;32:1043-50

How to cite this URL:
Elmashad GM, Bahbah WA, Mousa WA, Shalaby MM. Study of lung ultrasonography as a diagnostic tool in childhood pneumonia. Menoufia Med J [serial online] 2019 [cited 2019 Nov 12];32:1043-50. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1043/268849




  Introduction Top


Respiratory infections have always been considered a worldwide health problem and a major cause of morbidity and mortality, with infants and young children especially susceptible [1]. Among these infections include pneumonia, which is a form of acute respiratory infection that affects the lungs. When a child has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake [2]. Children with community-acquired pneumonia (CAP) may present with fever, tachypnea, breathlessness or difficulty of breathing, cough, wheeze, or chest pain. They may also present with abdominal pain and/or vomiting and may have headache [3]. Children with upper respiratory tract infection and generalized wheeze with low-grade fever do not have pneumonia [4].

Pneumonia accounts for almost one million deaths every year, with 922 000 in 2015, which is 16% of total deaths among children younger than 5 years, 5% of which are neonates [5]. This makes it the single most common cause of child deaths worldwide [6]. Despite having made some progress, a 51% decrease in pneumonia from 2000 to 2015, it is nowhere near the greater than 86% decrease in malaria-related under-five mortalities in the same time frame [7]. There is still a significant road ahead to make a marked reduction in the preventable and treatable deaths owing to pneumonia [8]. However, in Egypt, it was estimated that 19% of children deaths below the age of 5 years are likely caused by pneumonia and other acute respiratory infections [9].

In 1986, Weinberg et al. [10] described a new method for evaluating CAP, using lung ultrasonography (LUS). For many years, transthoracic ultrasound was limited exclusively to the examination of pleural effusions [11]. However, over the past few years, ultrasonography of the pleural space and lung parenchyma is gaining a wide consensus in different conditions in clinical practice, particularly in emergency conditions [12],[13]. Chest ultrasound allows prompt management based upon reproducible data and generates fewer computed tomography examinations, thereby decreasing irradiation, delays, cost, and discomfort to the patient [14]. Point-of-care ultrasound imaging, performed at the patient's bedside, decreases the delays of chest radiography (CXR) in diagnosis of pulmonary diseases [15]. The aim of this work was to compare chest ultrasonography with CXR in the diagnosis of children with pneumonia.


  Patients and Methods Top


Study population

A cross-sectional study was conducted on 60 patients with fever and signs of respiratory distress aged from 12 to 60 months. They were enrolled from patients attending the Pediatric Department, Shibin El-Kom Teaching hospital, Menoufia Governorate, Egypt, during the period between October 2016 and March 2017. All study patients were divided in two groups:

  1. Group I was the pneumonia group, which included 45 patients who were finally diagnosed as have clinically evident pneumonia
  2. Group II was the nonpneumonia group, which included 15 age-matched and sex-matched patients who were clinically categorized as the nonpneumonia group (11 patients were diagnosed as having bronchiolitis and four patients were diagnosed as having acute bronchitis).


Ethical consideration

The study was approved by the Ethical Committee of Menoufia Faculty of Medicine, and oral consent was taken from at least one parent or caregiver of children included in the study. The participants included in this study were selected according to inclusion and exclusion criteria.

Inclusion criteria

The inclusion criteria were presence of fever together with increased respiratory rate more than expected for age and other signs of dyspnea: dyspnea grade I (tachypnea), dyspnea grade II (subcostal and intercostals retraction and working accessory muscles of respiration), dyspnea grade III (grunting), and dyspnea grade IV (cyanosis) [3].

Exclusion criteria

Patient with co-existing chronic lung disease or predisposing congenital abnormalities were excluded from the study.

All included patients were subjected to the following:

Full history taking, for example, demographic data included age, sex, residence, smoking habits in the families, and history of respiratory illness. Symptoms of respiratory tract infection before hospitalization were recorded upon admission, including the onset and duration of cough, fever, dyspnea, tachypnea, and rhinorrhea. Feeding, hydration status, and urine output were considered.

Complete physical examination including the following:

General examination included vital signs, which comprised assessment of temperature, heart rate, blood pressure, respiratory rate, and capillary refilling time [16].

Systemic examination included examination of chest, heart, and abdomen.

Standardized clinical assessment was done laying stress on chest examination, which included inspection of both sides of the chest (decreased chest movement on affected side) and chest percussion (dullness over affected part), and chest auscultation, which included air entry (diminished on affected area), breath sound (bronchial breathing on consolidating part), and adventitious sounds (wheeze/crepitations).

Laboratory investigations

On admission, a blood sample was taken for assessment of total white blood cell count with manually verified differential count, hemoglobin, platelet count (Sysmex N1000; Kobe, Hyogo Prefecture, Japan), and quantitative assessment of serum C-reactive protein (CRP) (Copas 6000 analyzer; Roche Diagnostics, Indianapolis, Indiana, USA).

Chest radiography (posteroanterior view)

Posteroanterior CXR were done to patients in supine position and recorded by commercially available radiography machines. In accordance with the British Thoracic Society Guidelines, in children, lateral radiographs were not obtained.

Chest ultrasound

Lung ultrasound immediately was done after plain radiography by a certified pediatric radiologist who was blinded to the CXR. Chest ultrasound is performed using a Toshiba XARio with 3–5 MHz convex transducer, which can visualize deeper lung structures (Toshiba, Minato-ku, Tokyo, Japan). A high-frequency 5–12 MHz linear-array probe is most effective in visualizing the chest wall, pleura, and the lung peripheral parenchyma.

Technique

Small infants are easily examined with high frequency (linear transducers), whereas older children require lower frequency transducers (convex transducers). Smaller footprint sector or vector transducers are needed to insonate between ribs, below the diaphragm, or from the suprasternal notch. Linear transducers are valuable for examining chest wall lesions [17].

Useful acoustic windows are depicted in the relatively unossified thorax of the infant, along with the presence of a relatively large thymus, which allows imaging of the anterior chest and thymus and sternal and costochondral cartilages. Suprasternal or supraclavicular approaches may also be useful in examining the anterior mediastinum and thoracic vessels.

Statistical analysis

Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS v. 22 (IBM Corp., Chicago, Illinois, USA). Statistical analysis was done using descriptive measures, for example percentage, mean, and SD for quantitative parametric measures in addition to both number and percentage for categorized data, and analytical measures, for example independent t-test and χ2-test. A value of P less than 0.05 was considered statistically significant.


  Results Top


Of the total 60 patients who were admitted to the department with suspected pneumonia, 45 patients (29 male and 16 female) were finally diagnosed clinically with pneumonia, with mean age of 24.11 ± 9.42 months (range: 12–60 months), mean weight of 12.66 ± 2.13 kg (range: 9–20 kg), and mean length of 82.04 ± 8.02 cm (range: 53–106 cm). There was no statistically significant difference (P > 0.05) between the pneumonia and nonpneumonia groups regarding age, sex, order of birth, weight, length/height, residence, mother's education, mother's employment, father's education, father's employment, and passive smoking [Table 1].
Table 1: Demographic and clinical characteristics of all studied patients

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There was no statistically significant difference (P > 0.05) between the pneumonia and nonpneumonia groups regarding hemoglobin, platelets, total leukocyte count, and lymphocyte (%). However, neutrophil count (P = 0.041) and CRP level (P < 0.001) were significantly higher in pneumonia group than nonpneumonia group [Table 2].
Table 2: Hemoglobin, platelets, total and differential leukocytic counts, and C-reactive protein distribution among the studied cases

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CXR showed that consolidation was diagnosed in 88.9% and effusion in 15.6% of pneumonia cases. However, patients without pneumonia had consolidation in 13.3%, and no pleural effusion was detected. LUS was diagnostic in 95.6% of pneumonia cases, which was statistically highly significant (P < 0.001). Moreover, LUS could detect more obvious findings in pneumonia cases compared with nonpneumonia cases, as seen in 43/45 (95.6%) patients with consolidation [Figure 1] and 39/45 (86.7%) patients with air bronchogram [Figure 2], whereas multiple b-lines in 22/45 (48.9%) patients. In addition, fluid bronchogram finding was positive in 14/45 (31.1%) patients, pleural effusion in 11/45 (24.4%) patients, but pleural line abnormalities in only 8/45 (17.8%) patients. In contrast, LUS detected one case each with subpleural hepatization and pleural line irregularity in nonpneumonia cases [Table 3].
Figure 1: Lung ultrasound showing lung consolidation.

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Figure 2: Lung ultrasound showing air bronchogram.

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Table 3: Chest radiography and ultrasound findings in studied patients

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LUS could detect consolidation in more than one lobe than CXR, which was statistically significant (P < 0.05). Moreover, LUS was more specific and sensitive in detection of pneumonia in children than CXR [Table 4] and [Table 5].
Table 4: Lobar distribution of consolidation among pneumonia group patients

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Table 5: Diagnostic accuracy of chest radiography and lung ultrasonography in prediction of pneumonia cases

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  Discussion Top


In the present study, male to female ratio was 1.8 : 1 in patients with pneumonia. The slight predominance of males over females among children with pneumonia was supported by Siziya et al. [18] who represented 59.7% males among their studied cases. Moreover, Falagas et al. [19] reported a male predominance in lower respiratory tract infections. Anatomic differences of the respiratory tract may partially explain the different prevalence of infections between males and females. There is also evidence that the peripheral airways are disproportionately narrower during the early years of life in males, which may predispose for lower RTIs. This was in contrast to Montasser et al. [20] who reported comparable ratio, with slight predominance of females at 51%.

From the studied samples of children with pneumonia, 71.1% were urban inhabitants whereas 28.9% were rural inhabitants. This comes in agreement with the study done in Kenya and Gambia that reported that urban children had a higher rate of hospitalization for respiratory episodes than rural children, which is thought to be related to the distance to hospital facility, leading to more diagnoses in urban children [21]. This is in contrast to Awadalla et al. [22] who reported that nearly three-quarters (74.2%) of recorded cases with acute respiratory illness came from rural inhabitants. This could be explained by the fact that in rural areas of developing countries, there is increased burning biomass, principally wood and crop residues, which are an important source of exposure to a variety of toxins.

Additionally, this study showed that 62.2% of the studied children with pneumonia had been exposed to second-hand smoking. This comes in agreement with Azad et al. [23] who reported that among the children with ARTIs, 50.5% were exposed to second-hand smoking. Second-hand smoking is the most common and dangerous indoor environmental pollutant, to which children are exposed. The effect of tobacco smoke exposure was found to be more prominent in infants [24]. Passive smoking in children is associated with a higher rate of respiratory problems like asthma, bronchitis, pneumonia, bronchiolitis as well as otitis media and sudden infant death [25]. Passive smoking paralyzes cilia, allowing mucus accumulation, and promotes goblet cell growth, resulting in an increase in mucus [26].

In the current study, there was significant difference between pneumonia group and nonpneumonia group in neutrophil percentage, as the mean neutrophil percentage in pneumonia group was higher at 61 ± 9.51. In addition, CRP was significantly high in pneumonia group (91.9% sensitivity) than nonpneumonia group (46.7% sensitivity). Similarly, Williams et al. [27] mentioned that increasing CRP was associated with increased fever duration and increased length of hospital stay for children with pneumonia. Ning et al. [28] demonstrated that the white blood cell count, neutrophil count, neutrophil percentage, and erythrocyte sedimentation rate in the CAP group were significantly higher than those of control group. There is some scientific evidence that a high CRP level indicates a severe respiratory tract infection such as pneumonia and that the general practitioner can use the CRP test if unsure of infection severity [29].

In our study, CXR showed that consolidation was diagnosed in 88.9% and effusion in 15.6% of pneumonia cases, whereas patients without pneumonia had consolidation in 13.3%, with no pleural effusion detected. LUS was diagnostic in 95.6% of pneumonia cases. Moreover, LUS could detect more obvious findings in pneumonia cases compared with nonpneumonia cases, with evidence of 95.6% of patients with consolidation, 86.7% with air bronchogram, but multiple b-lines in 48.9%, along with fluid bronchogram in 31.1%, pleural effusion in 24.4%, but pleural line abnormalities in 17.8%. This is similar to Copetti and Cattarossi [30] who reported that ultrasound was positive for the diagnosis of pneumonia in 100% of patients, whereas CXR was positive in 88.3%. In the seven patients with negative CXR and positive ultrasound findings, pneumonia was confirmed by chest computed tomography scans. Moreover, Ho et al. [31] reported that CXR could detect pneumonia in 93.3% of patients, whereas LUS detected pneumonia in 97.5%. In LUS, the following findings were observed: the positive rates of the multiple b-lines, air bronchograms, vascular pattern within the consolidation, and pleural effusion were 50.9, 93.7, 20.1, and 28.9%, respectively. Reali et al. [32] reported that 81 of 107 children were diagnosed with CAP. LUS and CXR were performed in all patients. Ultrasound had a sensitivity of 94% and specificity of 96%, whereas CXR showed a sensitivity of 82% and specificity of 94%. Cortellaro et al. [33] reported that the sensitivity of CXR for diagnosing pneumonia was 69%, whereas that of bedside ultrasonography was significantly higher at 96%.

In our study, LUS was superior to CXR in identifying parapneumonic effusion in one case with free chest x-ray. Moreover, LUS was superior to CXR in identifying consolidation pneumonia in five negative CXR cases. LUS could be used in the follow-up of patient through measurement the volume of the consolidating lesion and determining the presence of complication or resolving of the pathology, which did happen in two cases that showed decrease in the volume of the consolidating patch regarding clinical improvement, whereas the CXR showed no difference in the consolidating patch. Similarly, Sartori and Tombesi [34] reported more than one lung consolidation in their sonographic finding in 26/89 patients' versus CXR, which detected in 6/89 cases. Moreover, Caiulo et al. [35] demonstrated that follow-up through sonographic findings for more than 14 days in 76/83 patients with consolidations showed a decrease in size or disappearance of hypoechoic areas, which is always associated with clinical improvement.

In the current study, LUS is superior to CXR for identifying pleurapulmonary abnormalities in children with suspected pneumonia, with sensitivity of 95.6%, specificity of 93.3% and diagnostic accuracy of 94.4%, whereas CXR showed sensitivity of 88.9%, specificity of 86.6% and diagnostic accuracy of 86.7%. Similarly, Corradi et al. [36] showed that quantitative ultrasonography had higher sensitivity of 93%, specificity of 95%, and diagnostic accuracy of 94% than CXR, with sensitivity of 64%, specificity of 80%, and diagnostic accuracy of 69%.


  Conclusion Top


In view of our study, it can be concluded that chest ultrasonography offers an important contribution to the diagnostic procedures of pleuropulmonary disorders in children, such as pneumonia and pleural effusion, with higher sensitivity, specificity, and positive predictive index compared with CXR. LUS is a simple, safe, more sensitive, and more specific tool than CXR in diagnosis of childhood CAP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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