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
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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.
KeywordsPoint-of-care ultrasound WHO algorithm Pneumonia Case management
World Health Organization
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.
- 2.UNICEF/WHO. Global action plan for prevention and control of pneumonia (GAPP) 2009Google Scholar
- 6.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,1985Google Scholar
- 16.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):293–300PubMedCrossRefGoogle Scholar