Skip to main content

Ultrasound detection of pneumonia in febrile children with respiratory distress: a prospective study

Abstract

To analyse the usefulness of bedside lung ultrasound (LUS) in detecting lung consolidation in a paediatric emergency room (ER) setting, febrile children seen at our ER from 2008 to 2012 with a moderate to severe respiratory distress underwent LUS, chest X-ray (CXR) and laboratory investigations. At first ER assessment, LUS identified a lung consolidation in 207 patients of 222 children enrolled, with a liver-like appearance in 75 (36.2 %) and an associated pleural effusion in 36.7 % of cases. CXR proved positive in 197 cases, showing a parenchymal consolidation (68.5 %) or a focal ground-glass opacity (31.4 %). LUS liver-like consolidation was significantly associated with longer duration of fever (p = 0.002), higher neutrophil counts and C-reactive protein (CRP) values (p = 0.015 and p < 0.0001, respectively), and with the discovery of a homogeneous and dense parenchymal consolidation on CXR (p < 0.0001).

Conclusion: LUS can be adopted by the clinician as a non-invasive bedside tool to expand the physical evaluation of febrile children with respiratory distress. In our study, LUS results appeared not only as reliable as CXR in detecting lung consolidations but also consistent with clinical and laboratory data.

What is known:
The diagnosis of pneumonia is mainly based on physical examination plus radiologic and laboratory evaluation when needed.
Although lung ultrasound (LUS) has shown high sensitivity in detecting several pleuropulmonary diseases in adults, its role in the work-up of pneumonia in children is not yet widely recognized.
What is new:
• LUS is confirmed to be a reliable imaging technique for the diagnostic work-up of febrile children with respiratory distress, consistent not only with CXR results as previously reported by others but also with clinical and laboratory data.
• In the hands of trained clinicians, it may represent a valuable supplemental bedside tool for a rapid evaluation in such circumstances.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Abbreviations

CAP:

community-acquired pneumonia

CRP:

C-reactive protein

CXR:

chest X-ray

ER:

emergency room

LUS:

lung ultrasound

PPE:

parapneumonic pleural effusion

WBC:

white blood cell

References

  1. Beckh S, Bolcskei PL, Lessnau K (2002) Real-time chest ultrasonography. Chest 122:1759–1773

    Article  PubMed  Google Scholar 

  2. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT (2011) Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 53:617–630

    PubMed Central  Article  PubMed  Google Scholar 

  3. Brenner D, Elliston C, Hall E, Berdon W (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR 176:289–296

    Article  CAS  PubMed  Google Scholar 

  4. Brenner D, Hall E (2007) Computed tomography—an increasing source of radiation exposure. NEJM 357:2277–2284

    Article  CAS  PubMed  Google Scholar 

  5. British Thoracic Society of Standards of Care Committee (2002) BTS guidelines for the management of community acquired pneumonia in childhood. Thorax 57:1–24

    Article  Google Scholar 

  6. Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E, Mele G (2012) Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol. doi:10.1002/ppul.22585

    PubMed  Google Scholar 

  7. Chotas HG, Ravin CE (1994) Chest radiography: estimated lung volume and projected area obscured by the heart, mediastinum, and diaphragm. Radiology 193:403–404

    Article  CAS  PubMed  Google Scholar 

  8. Cicchetti DV, Feinstein AR (1990) High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 43:551–558

    Article  CAS  PubMed  Google Scholar 

  9. Copetti R, Cattarossi L (2008) Ultrasound diagnosis of pneumonia in children. Radiol Med 113:190–198

    Article  CAS  PubMed  Google Scholar 

  10. Cortellaro F, Colombo S, Coen D, Duca PG (2012) Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Emerg Med J 29:19–23

    Article  PubMed  Google Scholar 

  11. Davies H, Wang E (1996) Reliability of the chest radiograph in the diagnosis of lower respiratory infections in young children. Pediatr Infect Dis J 15:600–604

    Article  CAS  PubMed  Google Scholar 

  12. Eibenberger KL, Dock WI, Ammann ME, Dorffner R, Hormann MF, Grabenwoger F (1994) Quantification of pleural effusions: sonography versus radiography. Radiology 191:681–684

    Article  CAS  PubMed  Google Scholar 

  13. Flood RG, Badik J, Aronoff SC (2008) The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children. Pediatr Infec Dis J 27:95–99

    Article  Google Scholar 

  14. Gehmacher O, Mathis G, Kopf A, Scheier M (1995) Ultrasound imaging of pneumonia. Ultrasound Med Biol 21:1119–1122

    Article  CAS  PubMed  Google Scholar 

  15. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722

    Article  PubMed  Google Scholar 

  16. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, Thomson A et al (2011) British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66:1–23

    Article  Google Scholar 

  17. Hayden GE, Wrenn KW (2009) Chest radiograph vs. computed tomography scan in the evaluation for pneumonia. Emerg Med J 36:266–270

    Article  Google Scholar 

  18. Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M (1997) Chest radiography in the ICU. Clin Imaging 21:90–103

    Article  CAS  PubMed  Google Scholar 

  19. Iuri D, De Candia A, Bazzocchi M (2009) Evaluation of the lung in children with suspected pneumonia: usefulness of ultrasonography. Radiol Med 114:321–330

    Article  CAS  PubMed  Google Scholar 

  20. Kim OH, Kim WS, Kim MJ, Jung JY, Suh JH (2000) US in the diagnosis of pediatric chest diseases. Radiographics 20:653–671

    Article  CAS  PubMed  Google Scholar 

  21. Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S (2009) Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. AJR 193:1648–1654

    Article  PubMed  Google Scholar 

  22. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ (2004) Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute distress syndrome. Anesthesiology 100:9–15

    Article  PubMed  Google Scholar 

  23. Lichtenstein D, Lascols N, Meziere G, Gepner A (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30:276–281

    Article  PubMed  Google Scholar 

  24. Lichtenstein D, Lascols N, Prin S, Mezière G (2003) The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 29:2187–2192

    Article  PubMed  Google Scholar 

  25. Lichtenstein D, Mezière G, Biderman P, Gepner A, Barré O (1997) The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 156:1640–1646

    Article  CAS  PubMed  Google Scholar 

  26. Lichtenstein D, Mezière G, Seitz J (2009) The dynamic air bronchogram: a lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 135:1421–1425

    Article  PubMed  Google Scholar 

  27. McNemar-Test: sample size (paired comparison at one sample). http://www.acomed-statistik.de

  28. Parlamento S, Copetti R, Di Bartolomeo S (2009) Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 27:379–384

    Article  PubMed  Google Scholar 

  29. Pinotti KF, Ribeiro SM, Cataneo AJ (2006) Thorax ultrasound in the management of pediatric pneumonias complicated with empyema. Pediatr Surg Int 22:775–778

    Article  PubMed  Google Scholar 

  30. Raoof S, Feigin D, Sung A, Raoof S, Irugulpati L, Rosenow EC 3rd (2012) Interpretation of plain chest roentgenogram. Chest 141:545–558

    Article  PubMed  Google Scholar 

  31. Reissig A, Kroegel C (2007) Sonographic diagnosis and follow-up of pneumonia: a prospective study. Respiration 74:537–547

    Article  PubMed  Google Scholar 

  32. Reiβig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, Aliberti S, Neumann R, Kroegel C, Hoyer H (2012) Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. A prospective multicentre diagnostic accuracy study. Chest 142:965–972

    Article  Google Scholar 

  33. Riccabona M (2008) Ultrasound of the chest in children (mediastinum excluded). Eur Radiol 18:390–399

    Article  PubMed  Google Scholar 

  34. Ruuskanen O, Lahti E, Jennings LC, Murdoch D (2011) Viral pneumonia. Lancet 377:1264–1275

    Article  PubMed  Google Scholar 

  35. Shah VP, Tunik MG, Tsung JW (2012) Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. Arch Pediatr Adolesc Med 166:1–7. doi:10.1001/2013.jamapediatrics.107

    Article  Google Scholar 

  36. Swingler GH (2001) Observer variation in chest radiography of acute lower respiratory infections in children: a systematic review. BMC Med Imaging 1:1

    PubMed Central  Article  PubMed  Google Scholar 

  37. Syrjala H, Broas M, Suramo I, Ojala A, Lahde S (1998) High-resolution computed tomography for the diagnosis of community-acquired pneumonia. Clin Infect Dis 27:358–363

    Article  CAS  PubMed  Google Scholar 

  38. Virkki R, Juven T, Rikalainen H, Svedstrom E, Mertsola J, Ruuskanen O (2002) Differentiation of bacterial and viral pneumonia in children. Thorax 57:438–441

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  39. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G et al (2012) International evidence-based recommendations for point of care lung ultrasound. Intensive Care Med 38:577–591

    Article  PubMed  Google Scholar 

Download references

Funding source

No external funding was secured for this study.

Financial disclosure

The authors have no financial relationships relevant to this article to disclose.

Conflict of interest

The authors declare that they have no competing interests.

Authors’ contributions

Mattia Guerra: Dr. Guerra planned and designed the study, performed the data collection, drafted the initial manuscript and approved the final manuscript as submitted.

Giovanni Crichiutti: Dr. Crichiutti planned and designed the study, carried out the ultrasound investigations, supervised the data collection, drafted the initial manuscript and approved the final manuscript as submitted.

Paolo Pecile: Dr. Pecile discussed the study design, carried out the ultrasound investigations, reviewed the manuscript and approved the final manuscript as submitted.

Carla Romanello: Dr. Romanello discussed the study design, carried out the ultrasound investigations, reviewed the manuscript and approved the final manuscript as submitted.

Eva Busolini: Dr. Busolini discussed the study design, participated in the initial data collection and approved the final manuscript as submitted.

Francesca Valent: Dr. Valent carried out the statistical analyses, reviewed the manuscript and approved the final manuscript as submitted.

Angelo Rosolen: Prof. Rosolen critically reviewed and revised the study and the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mattia Guerra.

Additional information

Mattia Guerra and Giovanni Crichiutti contributed equally to this work.

Communicated by Jaan Toelen

Electronic supplementary material

Below is the link to the electronic supplementary material.

Ultrasound appearance of a hepatized lung consolidation and its uncomplicated pleural effusion, localized at the left costophrenic angle. LUS shows a marked liver-like appearance of the consolidated lung (WMV 1820 kb)

Ultrasound appearance of normal lung sliding, which is the back-and-forth movement of the bright echogenic parietal and visceral pleura occurring during respiration (WMV 1909 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Guerra, M., Crichiutti, G., Pecile, P. et al. Ultrasound detection of pneumonia in febrile children with respiratory distress: a prospective study. Eur J Pediatr 175, 163–170 (2016). https://doi.org/10.1007/s00431-015-2611-8

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-015-2611-8

Keywords

  • Lung consolidation
  • Chest X-ray
  • Lung ultrasound
  • Paediatrician