Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED

Emergency Department, S. Antonio Abate Hospital, 33028 Tolmezzo, Italy.
The American journal of emergency medicine (Impact Factor: 1.27). 06/2009; 27(4):379-84. DOI: 10.1016/j.ajem.2008.03.009
Source: PubMed


The aim of this study is to assess the ability of bedside lung ultrasound (US) to confirm clinical suspicion of pneumonia and the feasibility of its integration in common emergency department (ED) clinical practice.
In this study we performed lung US in adult patients admitted in our ED with a suspected pneumonia. Subsequently, a chest radiograph (CXR) was carried out for each patient. A thoracic computed tomographic (CT) scan was made in patients with a positive lung US and a negative CXR. In patients with confirmed pneumonia, we performed a follow-up after 10 days to evaluate clinical conditions after antibiotic therapy.
We studied 49 patients: pneumonia was confirmed in 32 cases (65.3%). In this group we had 31 (96.9%) positive lung US and 24 (75%) positive CXR. In 8 (25%) cases, lung US was positive with a negative CXR. In this group, CT scan always confirmed the US results. In one case, US was negative and CXR positive. Follow-up turned out to be always consistent with the diagnosis.
Considering that lung US is a bedside, reliable, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of pneumonia in the ED, even if no sensitivity nor specificity can be inferred from this study because the real gold standard is CT, which could not be performed in all patients.

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Available from: Stefano Parlamento, May 14, 2014
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    • "Lung ultrasound has recently been found to be a highly effective tool in the diagnosis and follow-up of pneumonia in adults as well as in children. Lung ultrasound detects more (12%–25%) pneumonias than X-ray confirmed by chest CT (Copetti and Cattarossi 2008; Parlamento et al. 2009). Lung ultrasound is a noninvasive , bedside-available tool used for high-accuracy (sensitivity 5 93.4%, specificity 5 97.7%) diagnosis of community-acquired pneumonia. "
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    ABSTRACT: The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that the ventilated lungs and the bones of the rib cage constitute impermeable obstacles to ultrasound. However, a variety of pathologies of the chest wall, pleurae and lungs result in altered tissue composition, providing substantially increased access and visibility for ultrasound examination. It is a great benefit that the pleurae and lungs can be non-invasively imaged repeatedly without discomfort or radiation exposure for the patient. Ultrasound is thus particularly valuable in follow-up of disease, differential diagnosis and detection of complications. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can tolerably be performed under real-time ultrasound guidance. In this article, an updated overview is given presenting not only the benefits and indications, but also the limitations of pleural and pulmonary ultrasound.
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    • "But CT is not always easily available in all emergency departments and is limited by exposure risks and costs [11] [12]. Lung ultrasonography (LUS) has also been proposed for detection of pneumonia [13] [14] [15] [16] [17], but it is still not widely accepted in clinical practice [18] [19]. This is because LUS has been generally validated by comparison with CXR, which is recognized to have low specificity, whereas CT was only sporadically used as comparator. "
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    ABSTRACT: Background and Objective. Chest X-ray is recommended for routine use in patients with suspected pneumonia, but its use in emergency settings is limited. In this study, the diagnostic performance of a new method for quantitative analysis of lung ultrasonography was compared with bedside chest X-ray and visual lung ultrasonography for detection of community-acquired pneumonia, using thoracic computed tomography as a gold standard. Methods. Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia, undergoing computed tomography examination, were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. Results. Quantitative ultrasonography showed higher sensitivity (93%), specificity (95%), and diagnostic accuracy (94%) than chest X-ray (64%, 80%, and 69%, resp.), visual ultrasonography (68%, 95%, and 77%, resp.), or their combination (77%, 75%, and 77%, resp.). Conclusions. Quantitative lung ultrasonography was considerably more accurate than either chest X-ray or visual ultrasonography in the diagnosis of community-acquired pneumonia and it may represent a useful first-line approach for confirmation of clinical diagnosis in emergency settings.
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    • "Therefore, reliance on CXR to diagnose pneumonia may lead to significant rates of misdiagnosis. Lung ultrasonography (LUS) is a bedside diagnostic tool that showed high sensitivity for the diagnosis of various pulmonary conditions, including pneumonia [4] [5] [6] [7] [8] [9]. However, an important limitation of some of these previous studies is that not always CT was used as the gold standard to confirm a pulmonary consolidation. "
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    ABSTRACT: Despite emerging evidences on the clinical usefulness of lung ultrasound (LUS), international guidelines still do not recommend the use of sonography for the diagnosis of pneumonia. Our study assesses the accuracy of LUS for the diagnosis of lung consolidations when compared to chest computed tomography (CT). This was a prospective study on an emergency department population complaining of respiratory symptoms of unexplained origin. All patients who had a chest CT scan performed for clinical reasons were consecutively recruited. LUS was targeted to evaluate lung consolidations with the morphologic characteristics of pneumonia, and then compared to CT. We analyzed 285 patients. CT was positive for at least one consolidation in 87 patients. LUS was feasible in all patients and in 81 showed at least one consolidation, with a good inter-observer agreement (k = 0.83), sensitivity 82.8% (95% CI 73.2%-90%) and specificity 95.5% (95% CI 91.5%-97.9%). Sensitivity raised to 91.7% (95% CI 61.5%-98.6%) and specificity to 97.4% (95% CI 86.5%-99.6%) in patients complaining of pleuritic chest pain. In a subgroup of 190 patients who underwent also chest radiography (CXR), the sensitivity of LUS (81.4%, 95% CI 70.7%-89.7%) was significantly superior to CXR (64.3%, 95% CI 51.9%-75.4%) (P<.05), whereas specificity remained similar (94.2%, 95% CI 88.4%-97.6% vs. 90%, 95% CI 83.2%-94.7%). LUS represents a reliable diagnostic tool, alternative to CXR, for the bedside diagnosis of lung consolidations in patients with respiratory complains. Copyright © 2015 Elsevier Inc. All rights reserved.
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