Pneumonia has remained the leading cause of morbidity and mortality in children. Timely diagnosis and prompt treatment can avert many deaths; however, diagnosis of pneumonia in children still remains a challenge. Chest radiography has been widely used worldwide to diagnose pneumonia in children; however, in recent times, lung ultrasound (LUS) is emerging as a useful tool to diagnose pneumonia. The ease of performing LUS, its bedside availability, no exposure to ionizing radiation, and allowance of real-time monitoring of patients make LUS an attractive tool for the intensivists. In this article, we would elaborate the ultrasound equipment, the technique, normal artifacts, and various sonographic patterns of pneumonia in children. The LUS features of various complications of pneumonia like pleural effusion and pneumothorax will also be discussed. This article also summarizes the current evidence of using LUS in the diagnosis of pediatric pneumonia along with the strengths and limitations of this technique.
World Health Organisation. Maternal, newborn, child and adolescent health. Available from https://www.who.int/maternal_child_adolescent/news_events/news/2011/pneumonia/en/. Accessed April 21, 2020.
UNICEF. One child dies of pneumonia every 39 seconds, agencies warn. Available from https://www.unicef.org/press-releases/one-child-dies-pneumonia-every-39-seconds-agencies-warn. Accessed April 21, 2020.
Johnson J, Kline JA. Intraobserver and interobserver agreement of the interpretation of pediatric chest radiographs. Emerg Radiol 2010;17(4):285–290. DOI: 10.1007/s10140-009-0854-2.
Levinsky Y, Mimouni FB, Fisher D, et al. Chest radiography of acute paediatric lower respiratory infections: experience versus interobserver variation. Acta Paediatr 2013;102(7):310–314. DOI: 10.1111/apa.12249.
Hagaman JT, Panos RJ, Rouan GW, et al. Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. Am J Med Sci 2009;337(4):236–240. DOI: 10.1097/MAJ.0b013e31818ad805.
Stuckey-Schrock K, Hayes BL, George CM. Community-acquired pneumonia in children. Am Fam Physician 2012;86(7):661–667.
Haq IJ, Battersby AC, Eastham K, et al. Community acquired pneumonia in children. BMJ 2017;356:686. DOI: 10.1136/bmj.j686.
Lichtenstein D, Hulot JS, Rabiller A, et al. Feasibility and safety of ultrasound-aided thoracentesis in mechanically ventilated patients. Intensive Care Med 1999;25(9):955–958. DOI: 10.1007/s001340050988.
Lichtenstein DA, Lascols N, Meziere G, et al. Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 2004;30(2):276–281. DOI: 10.1007/s00134-003-2075-6.
Lichtenstein D, Mézière G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156(5):1640–1646. DOI: 10.1164/ajrccm.156.5.96-07096.
Lichtenstein D, Mezière G, Biderman P, et al. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26(10):1434–1440. DOI: 10.1007/s001340000627.
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33(6):1231–1238. DOI: 10.1097/01.CCM.0000164542.86954.B4.
Claes AS, Clapuyt P, Menten R, et al. Performance of chest ultrasound in pediatric pneumonia. Eur J Radiol 2017;88:82–87. DOI: 10.1016/j.ejrad.2016.12.032.
Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Chest 1995;108(5):1345–1348. DOI: 10.1378/chest.108.5.1345.
Piette E, Daoust R, Denault A. Basic concepts in the use of thoracic and lung ultrasound. Curr Opin Anaesthesiol 2013;26(1):20–30. DOI: 10.1097/ACO.0b013e32835afd40.
Martelius L, Heldt H, Lauerma K. B-lines on pediatric lung sonography: comparison with computed tomography. J Ultrasound Med 2016;35(1):153–157. DOI: 10.7863/ultra.15.01092.
Dietrich CF, Mathis G, Blaivas M, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8(6):1356–1365. DOI: 10.21037/jtd.2016.04.55.
Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of care ultrasonography for the diagnosis of pneumonia in children and youngadults. JAMA Pediatr 2013;167(2):119–125. DOI: 10.1001/2013.jamapediatrics.107.
Jones BP, Tay ET, Elikashvili I, et al. Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest 2016;150(1):131–138. DOI: 10.1016/j.chest.2016.02.643.
Benci A, Caremani M, Menchetti D, et al. Sonographic diagnosis of pneumonia and bronchopneumonia. Eur J Ultrasound 1996;4(3):169–176. DOI: 10.1016/S0929-8266(96)00195-4.
Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 2014;15(1):50. DOI: 10.1186/1465-9921-15-50.
Riccabona M. Ultrasound of the chest in children (mediastinum excluded). Eur Radiol 2008;18(2):390–399. DOI: 10.1007/s00330-007-0754-3.
Tomà P, Owens CM. Chest ultrasound in children: critical appraisal. Pediatr Radiol 2013;43(11):1427–1434. DOI: 10.1007/s00247-013-2756-4.
Lichtenstein D, Mezière G, Seitz J. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 2009;135(6):1421–1425. DOI: 10.1378/chest.08-2281.
Stadler JAM, Andronikou S, Zar HJ. Lung ultrasound for the diagnosis of community-acquired pneumonia in children. Pediatr Radiol 2017;47(11):1412–1419. DOI: 10.1007/s00247-017-3910-1.
Ho MC, Ker CR, Hsu JH, et al. Usefulness of lung ultrasound in the diagnosis of community-acquired pneumonia in children. Pediatr Neonatol 2015;56(1):40–45. DOI: 10.1016/j.pedneo.2014.03.007.
Mohamed A, Kamel O, Ghazy M. Accuracy of lung ultrasonography in diagnosis of community acquired pneumonia as compared to chest X-ray in pediatric age group. Egypt J Hospital Med 2018;72(8):4977–4983.
Ord HL, Griksaitis MJ. Fifteen-minute consultation: using point of care ultrasound to assess children with respiratory failure. Arch Dis Child Educ Pract Ed 2019;104(1):2–10. DOI: 10.1136/archdischild-2017-313795.
Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics 2015;135(4):714–722. DOI: 10.1542/peds.2014-2833.
Orso D, Ban A, Guglielmo N. Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis. J Ultrasound 2018;21(3):183–195. DOI: 10.1007/s40477-018-0306-5.
Basile V, Di Mauro A, Scalini E, et al. Lung ultrasound: a useful tool in diagnosis and management of bronchiolitis. BMC Pediatr 2015;15(1):63. DOI: 10.1186/s12887-015-0380-1.
Tsung JW, Kessler DO, Shah VP. Prospective application of clinician performed lung ultrasonography during the 2009 H1N1 influenza a pandemic: distinguishing viral from bacterial pneumonia. Crit Ultrasound J 2012;4(1):16. DOI: 10.1186/2036-7902-4-16.
Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound in bronchiolitis: comparison with CXR. Eur J Pediatr 2011;170(11):1427–1433. DOI: 10.1007/s00431-011-1461-2.
Biagi C, Pierantoni L, Baldazzi M, et al. Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis. BMC Pulm Med 2018;18(1):191. DOI: 10.1186/s12890-018-0750-1.
Lissaman C, Kanjanauptom P, Ong C, et al. Prospective observational study of point-of-care ultrasound for diagnosing pneumonia. Arch Dis Child 2019;104(1):12–18. DOI: 10.1136/archdischild-2017-314496.
Najgrodzka P, Buda N, Zamojska A, et al. Lung ultrasonography in the diagnosis of pneumonia in children-A metaanalysis and a review of pediatric lung imaging. Ultrasound Q 2019;35(2):157–163. DOI: 10.1097/RUQ.0000000000000411.
Lichtenstein D, Goldstein I, Mourgeon E, et al. Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in ARDS. Anesthesiology 2004;100(1):9–15. DOI: 10.1097/00000542-200401000-00006.
Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005;12(9):844–849. DOI: 10.1197/j.aem.2005.05.005.
De Luca C, Valentino M, Rimondi M, et al. Use of chest sonography in acute-care radiology. J Ultrasound 2008;11(4):125–134. DOI: 10.1016/j.jus.2008.09.006.
Flori HR, Church G, Liu KD, et al. Positive fluid balance is associated with higher mortality and prolonged mechanical ventilation in pediatric patients with acute lung injury. Critic Care Res Pract 2011. 854142. DOI: 10.1155/2011/854142.
Copetti R, Cattarossi L. Ultrasound diagnosis of pneumonia in children. Radiol Med 2008;113(2):190–198. DOI: 10.1007/s11547-008-0247-8.
Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 2013;48(3):280–287. DOI: 10.1002/ppul.22585.
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011;37(2):224–232. DOI: 10.1007/s00134-010-2079-y.
Kurian J, Levin TL, Han BK, et al. Comparison of ultrasound and CT in the evaluation of pneumonia complicated by Parapneumonic effusion in children. AJR Am J Roentgenol 2009;;193(6):1648–1654. DOI: 10.2214/AJR.09.2791.
Omran A, Eesai S, Ibrahim M, et al. Lung ultrasound in diagnosis and follow up of community acquired pneumonia in infants younger than 1-year old. Clin Respir J 2018;12(7):2204–2211. DOI: 10.1111/crj.12790.
Ianniello S, Piccolo CL, Buquicchio GL, et al. First-line diagnosis of paediatric pneumonia in emergency: lung ultrasound (LUS) in addition to chest-X-ray (CXR) and its role in follow-up. Br J Radiol 2016;89(1061):20150998. DOI: 10.1259/bjr.20150998.
Ambroggio L, Sucharew H, Rattan MS, et al. Lung ultrasonography: a viable alternative to chest radiography in children with suspected pneumonia? J Pediatr 2016;176:93–98.e7. DOI: 10.1016/j.jpeds.2016.05.033.
Bedetti G, Gargani L, Corbisiero A, et al. Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 2006;4(1):34. DOI: 10.1186/1476-7120-4-34.
Monti JD, Younggren B, Blankenship R. Ultrasound detection of pneumothorax with minimally trained sonographers: a preliminary study. J Spec Oper Med 2009;9(1):43–46.