1. 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

2. 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

3. 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

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

6. 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

7. 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

8. 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

9. 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)

10. RESULTS

11. 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

12. 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

13. 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

14. 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

15. 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 Jul;150(1):131-8.
"Point-Of-Care Ultrasonography For Diagnosis Of Pneumonia In Children And Young Adults". YouTube. N.p., Web. 30 Oct