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Objective Improved pneumonia diagnostics are needed, particularly in resource-constrained settings. Lung ultrasound (LUS) is a promising point-of-care imaging technology for diagnosing pneumonia. The objective was to explore LUS patterns associated with paediatric pneumonia. Methods We conducted a prospective, observational study among children aged 2 to 23 months with World Health Organization Integrated Management of Childhood Illness chest-indrawing pneumonia and among children without fast breathing, chest indrawing or fever (no pneumonia cohort) at two district hospitals in Mozambique and Pakistan. We assessed LUS and chest radiograph (CXR) examinations, and viral and bacterial nasopharyngeal carriage, and performed a secondary analysis of LUS patterns. Results LUS demonstrated a range of distinctive patterns that differed between children with and without pneumonia and between children in Mozambique versus Pakistan. The presence of LUS consolidation or interstitial patterns was more common in children with chest-indrawing pneumonia than in those without pneumonia. Consolidations were also more common among those with only bacterial but no viral carriage detected (50.0%) than among those with both (13.0%) and those with only virus detected (8.3%; p=0.03). LUS showed high interrater reliability among expert LUS interpreters for overall determination of pneumonia (κ=0.915), consolidation (κ=0.915) and interstitial patterns (κ=0.901), but interrater reliability between LUS and CXR for detecting consolidations was poor (κ=0.159, Pakistan) to fair (κ=0.453, Mozambique). Discussion Pattern recognition was discordant between LUS and CXR imaging modalities. Further research is needed to define and standardise LUS patterns associated with paediatric pneumonia and to evaluate the potential value of LUS as a reference standard., This study explored distinctive lung ultrasound patterns associated with paediatric community-acquired pneumonia in Mozambique and Pakistan, and found reliable pattern recognition critical to identifying pneumonia https://bit.ly/3eWWvXr

Lung ultrasound (LUS) is a promising point-of-care imaging technology for diagnosing and managing pneumonia. We sought to explore serial LUS examinations in children with chest-indrawing pneumonia in resource-constrained settings and compare their clinical and LUS imaging courses longitudinally. We conducted a prospective, observational study among children aged 2 through 23 months with World Health Organization Integrated Management of Childhood Illness chest-indrawing pneumonia and among children without fast breathing, chest indrawing or fever (no pneumonia cohort) at 2 district hospitals in Mozambique and Pakistan. We assessed serial LUS at enrollment, 2, 6, and 14 days, and performed a secondary analysis of enrolled children’s longitudinal clinical and imaging courses. By Day 14, the majority of children with chest-indrawing pneumonia and consolidation on enrollment LUS showed improvement on follow-up LUS (100% in Mozambique, 85.4% in Pakistan) and were clinically cured (100% in Mozambique, 78.0% in Pakistan). In our cohort of children with chest-indrawing pneumonia, LUS imaging often reflected the clinical course; however, it is unclear how serial LUS would inform the routine management of non-severe chest-indrawing pneumonia.

Introduction Improved pneumonia diagnostics are needed in low-resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. The objective was to compare LUS versus chest radiograph (CXR), and among LUS interpreters, to compare expert versus limited training with respect to interrater reliability. Methods We conducted a prospective, observational study among children with World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) chest-indrawing pneumonia at two district hospitals in Mozambique and Pakistan, and assessed LUS and CXR examinations. The primary endpoint was interrater reliability between LUS and CXR interpreters for pneumonia diagnosis among children with WHO IMCI chest-indrawing pneumonia. Results Interrater reliability was excellent for expert LUS interpreters, but poor to moderate for expert CXR interpreters and onsite LUS interpreters with limited training. Conclusions Among children with WHO IMCI chest-indrawing pneumonia, expert interpreters may achieve substantially higher interrater reliability for LUS compared to CXR, and LUS showed potential as a preferred reference standard. For point-of-care LUS to be successfully implemented for the diagnosis and management of pneumonia in LRS, the clinical environment and amount of appropriate user training will need to be understood and addressed.

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p

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BACKGROUND Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED. METHODS We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared. RESULTS The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n=486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%. CONCLUSIONS The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED. TRIAL REGISTRY Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov

Background Presenting signs and symptoms of pulmonary embolism (PE) are nonspecific, favoring a large use of second-line diagnostic tests such as multidetector CT pulmonary angiography (MCTPA), thus exposing patients to high-dose radiation and to potential serious complications. We investigated the diagnostic performance of multiorgan ultrasonography (lung, heart, and leg vein ultrasonography) and whether multiorgan ultrasonography combined to Wells score and D-dimer could safely reduce MCTPA tests. Methods Consecutive adult patients suspected of PE and with a Wells score > 4 or a positive D-dimer result were prospectively enrolled in three EDs. Final diagnosis was obtained with MCTPA. Multiorgan ultrasonography was performed before MCTPA and considered diagnostic for PE if one or more subpleural infarcts, right ventricular dilatation, or DVT was detected. If multiorgan ultrasonography was negative for PE, an alternative ultrasonography diagnosis was sought. Accuracies of each single-organ and multiorgan ultrasonography were calculated. Results PE was diagnosed in 110 of 357 enrolled patients (30.8%). Multiorgan ultrasonography yielded a sensitivity of 90% and a specificity of 86.2%, lung ultrasonography 60.9% and 95.9%, heart ultrasonography 32.7% and 90.9%, and vein ultrasonography 52.7% and 97.6%, respectively. Among the 132 patients (37%) with multiorgan ultrasonography negative for PE plus an alternative ultrasonographic diagnosis or plus a negative D-dimer result, no patients received PE as a final diagnosis. Conclusions Multiorgan ultrasonography is more sensitive than single-organ ultrasonography, increases the accuracy of clinical pretest probability estimation in patients with suspected PE, and may safely reduce the MCTPA burden. Trial registry ClinicalTrials.gov; No.: NCT01635257; URL: www.clinicaltrials.gov

Chronic heart failure is a complex clinical syndrome often characterised by recurrent episodes of acute decompensation. This is acknowledged as a major public health problem, leading to a steadily increasing number of hospitalisations in developed countries. In decompensated heart failure, the redistribution of fluids into the pulmonary vascular bed leads to respiratory failure, a common cause of presentation to the emergency department. The ability to diagnose, quantify and monitor pulmonary congestion is particularly important in managing the disease. Lung ultrasound (US) is a relatively new method that has gained a growing acceptance as a bedside diagnostic tool to assess pulmonary interstitial fluid and alveolar oedema. The latest developments in lung US are not because of technological advance but are based on new applications and discovering the meanings of specific sonographic artefacts designated as B-lines. Real-time sonography of the lung targeted to detection of B-lines allows bedside diagnosis of respiratory failure due to impairment of cardiac function, as well as quantification and monitoring of pulmonary interstitial fluid. Lung US saves time and cost, provides immediate information to the clinician and relies on very easy-to-acquire and highly reproducible data.

Purpose: Use of single organ goal-directed ultrasound (US) of the heart, leg veins and lung showed low sensitivity for the diagnosis of pulmonary embolism (PE). Present study investigated the accuracy of multi-organ US protocol that combines heart, leg veins and lung studies for the diagnosis of PE and evaluated if multi-organ US combined with d-dimer level could reduce multi-detector computed tomography pulmonary angiography (MCTPA) rate in suspected PE. Mehods: Consecutive adult patients presenting to three Emergency Departments with suspected PE and Wells score>4 or a positive D-dimer (>500ng/ml), were prospectively investigated. Final diagnosis was obtained with MCTPA or autopsy. Multi-organ US was considered diagnostic for PE when at least one of the following was detected: deep leg veins thrombosis, right ventricle dilatation, one or more subpleural infarcts. In patients with negative multi-organ US for PE, an alternative US diagnosis such as pneumonia, pleural effusion, diffuse interstitial syndrome, pericardial effusion or aortic dissection was also researched. Accuracies of each single and multi-organ US were calculated. Results: PE was diagnosed in 110 (30.8%) out of 357 patients. Heart US showed a sensitivity of 32.7% and a specificity of 90.9%, leg veins US 52.7% and 97.6%, lung US 60.9% and 95.9% and multi-organ US 90% and 86.2% respectively. Among the 224 patients with multi-organ US negative for PE, an alternative US diagnosis was detected in 106 (47.3%) and a negative d-dimer was present in 50 (22.3%). No patients with multi-organ US negative for PE plus an alternative US diagnosis or plus a negative d-dimer (37% of the overall population) had PE as final diagnosis (sensitivity 100%). Conclusion: Multi-organ US sensitivity for PE is superior to all single organ goal-directed US. A strategy combining multi-organ US negative for PE with the detection of an alternative US diagnosis or a negative d-dimer might safely rule out PE and might reduce of one third the rate of patients that normally undergo MCTPA.