Article Review Christian Timbol, PGY-1 October 31, 2016 Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: an RCT Article Review Christian Timbol, PGY-1 October 31, 2016

Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial Brittany Pardue Jones, MD; Ee Tein Tay, MD; Inna Elikashvili, DO; Jennifer E. Sanders, MD; Audrey Z. Paul, MD, PhD;Bret P. Nelson, MD; Louis A. Spina, MD; and James W. Tsung, MD, MPH Icahn School of Medicine at Mount Sinai, NY Published July 2016 in Chest

BACKGROUND Pneumonia (PNA) is the leading cause of death in children worldwide (WHO 2008) Chest radiography (CXR) is the test of choice for diagnosing pneumonia POC lung ultrasonography (LUS) has been shown to be highly accurate in diagnosing pneumonia in children US is : Portable Cheaper Does not use radiation In the developing world, access to diagnostic imaging such as CXR may be limited Objective: compare lung ultrasound vs CXR in evaluating children for pneumonia

MATERIALS AND METHODS August 1, 2012 to July 31, 2013 Urban pediatric ED, convenience sample Sonologists: 15 PED attending physicians and fellows

Inclusion Criteria Exclusion Criteria Age: birth to 21yo presenting to PED w/ clinical suspicion of pneumonia Fever Cough Tachypnea Abnormal findings at auscultation Exclusion Criteria Hemodynamically unstable Previously performed CXR

MATERIALS AND METHODS PNA on lung ultrasound: lung consolidation w/ air bronchogram Viral in etiology: B-lines, confluent B-lines, and small subpleural consolidation w/ no air bronchograms

Primary Outcome Secondary Outcomes Determine whether US can be a safe substitute for CXR Stratify based on experience (≤25 vs >25 scans) Secondary Outcomes Unscheduled healthcare visits w/in 1-2wks after ED visit Rates of antibiotic use ED LOS Hospital admission rates

ANALYSIS Intention to treat Sample size 60 subjects/arm (80% power to detect an absolute reduction in CXR use of 15% or more in investigational group)

RESULTS

RESULTS 38.8% reduction in CXR in investigational arm (67% reduction if CXR after conclusive LUS are included) NNT 2.5 For novice and experienced sonologists, 30.0% and 60.6% reduction in CXR use, respectively No statistically significant differences w/ respect to missed PNA, unscheduled healthcare visits, rates of antibiotic use, ED LOS, or hospital admission rates

DISCUSSION Lung ultrasound with selective CXR decreased CXR use No missed PNA or adverse outcome among those who underwent LUS alone Overall cost reduction of $9200 (no formal economic analysis) Nonsignificant 26.5 minute reduction in ED LOS

LIMITATIONS Single-center study (academic center) Unable to calculate test performance characteristics (Standards for Reporting of Diagnosing Accuracy) In control arm, sonologists were not blinded to CXR results Possibly not sufficient power to detect statistically significant differences in secondary outcomes

CONCLUSION LUS can be used effectively to diagnose PNA in children This study fails to show non-inferiority of LUS to CXR Validation studies are needed to demonstrate generalizability Suspect LUS can be utilized as cost-effective, non-radiation alternative imaging modality to diagnosing pneumonia in children

REFERENCES Jones BP, Tay ET, Elikashvili I, Sanders JE, Paul AZ, Nelson BP, Spina LA, Tsung JW. Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial. Chest. 2016 Jul;150(1):131-8. "Point-Of-Care Ultrasonography For Diagnosis Of Pneumonia In Children And Young Adults". YouTube. N.p., 2016. Web. 30 Oct. 2016.