, Volume 193, Issue 4, pp 531–538 | Cite as

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

  • Miguel A. Chavez
  • Neha Naithani
  • Robert H. Gilman
  • James M. Tielsch
  • Subarna Khatry
  • Laura E. Ellington
  • J. Jaime Miranda
  • Ghanashyam Gurung
  • Shalim Rodriguez
  • William Checkley



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.


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.


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.


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.


Point-of-care ultrasound WHO algorithm Pneumonia Case management 



World Health Organization


Lung ultrasound


Chest X-ray


Acute lower respiratory infection

CT scan

Computerized tomography scan



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.


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Miguel A. Chavez
    • 1
    • 2
  • Neha Naithani
    • 1
    • 3
  • Robert H. Gilman
    • 3
  • James M. Tielsch
    • 4
  • Subarna Khatry
    • 5
  • Laura E. Ellington
    • 1
  • J. Jaime Miranda
    • 6
  • Ghanashyam Gurung
    • 7
  • Shalim Rodriguez
    • 8
  • William Checkley
    • 1
    • 3
    • 6
  1. 1.Division of Pulmonary and Critical Care, School of MedicineJohns Hopkins UniversityBaltimoreUSA
  2. 2.Biomedical Research UnitA.B. PRISMALimaPeru
  3. 3.Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA
  4. 4.Department of Global Health, School of Public Health and Health ServicesGeorge Washington UniversityWashingtonUSA
  5. 5.Nepal Nutrition Intervention Project SarlahiKathmanduNepal
  6. 6.CRONICAS Center of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
  7. 7.Department of Radiology and ImagingTribhuvan University Teaching HospitalKathmanduNepal
  8. 8.Unidad de Cuidados IntensivosHospital Nacional Eduardo Rebagliati MartinsLimaPeru

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