Point-of-Care Lung Ultrasound to Diagnose the Etiology of Acute Respiratory Failure at Admission to the PICU*

Abstract

Point-of-care lung ultrasound performed within 14 hours of admission to the PICU by physicians blinded to patient history and clinical course. Two physicians, blinded to all clinical information, independently interpreted the point-of-care lung ultrasound and then established a consensus diagnosis (ultrasound diagnosis). The ultrasound diagnosis was compared with an independent, standardized review of the medical record following hospital discharge (final diagnosis). MEASUREMENTS AND RESULTS:Eighty-eight patients were enrolled in the study. Forty-eight patients had a final diagnosis of bronchiolitis/viral pneumonitis (55%), 29 had pneumonia (33%), 10 had status asthmaticus (11%), and one was excluded because of an inability to differentiate the final diagnosis. Point-of-care lung ultrasound correctly identified the etiology of acute respiratory failure in 56% of patients (49/87; 95% CI, 46-66%). It identified bronchiolitis/viral pneumonitis with 44% sensitivity (95% CI, 0.31-0.58) and 74% specificity (95% CI, 0.59-0.85), pneumonia with 76% sensitivity (95% CI, 0.58-0.88) and 67% specificity (95% CI 0.54-0.78), and status asthmaticus with 60% sensitivity (95% CI, 0.31-0.83) and 88% specificity (95% CI, 0.79-0.94). CONCLUSIONS:In contrast to literature demonstrating high utility differentiating the cause of acute respiratory failure in adults, blinded point-of-care lung ultrasound demonstrates moderate sensitivity and specificity in identifying the etiology of pediatric acute respiratory failure at admission to the PICU among children with bronchiolitis, pneumonia, and status asthmaticus.

The Inter‐Rater Reliability of Pediatric Point‐of‐Care Lung Ultrasound Interpretation in Children With Acute Respiratory Failure

“…There was substantial agreement between the expert intensivist and expert emergency medicine physician‐derived ultrasound diagnoses with 67% observed agreement ( k / k max = 0.61, 95% CI 0.49–0.78) (Table 4). Agreement of the expert‐expert consensus ultrasound diagnosis with the final diagnosis was moderate ( k / k max = 0.44; 95% CI 0.21–0.69) as previously reported 17 …”

“…The Institutional Review Board at the University of Wisconsin-Madison approved this planned secondary analysis of a prospective observational study evaluating the sensitivity and specificity of POC-LUS in children admitted to the PICU for ARF (IRB 2018-0711 17 ). Children older than 37 weeks 0 days corrected gestational age and less than or equal to 18 years of age from whom signed, informed parent/ guardian consent, and patient assent (when appropriate for children ≥7 years of age) were enrolled over a 15-month period (December 2018-February 2020).…”

Lung Ultrasound Artifact Findings in Pediatric Patients Admitted to the Intensive Care Unit for Acute Respiratory Failure

“…The Institutional Review Board at the University of Wisconsin-Madison approved this secondary analysis of a prospective observational study (completed December 2018 to February 2020) evaluating the sensitivity and specificity of POC-LUS in determining the etiology of ARF on PICU admission (IRB 2018-0711). The full study protocol has been previously published [ 11 ]. In summary, following informed consent, a POC-LUS was performed by one of three PICU physicians with 1–3 years clinical POCUS experience, who were not providing clinical care to the patient, and who were blinded to historical and clinical subject information (except as apparent at the bedside), scanning 3-zones (anterior, lateral, posterior) per hemi-thorax (Fig.…”

“…However, standardized clinical research in pediatric POC-LUS in the PICU is still lacking [ 10 ]; published pediatric POCUS guidelines recommend use of POC-LUS in critically ill pediatric patients based on low-quality evidence (level B and lower), and primarily on neonatal and adult intensive care unit (ICU) studies [ 8 ]. Given the increasing interest in diagnostic POCUS in pediatric ARF [ 5 ], our objective is to describe POC-LUS artifact findings in a previously published cohort of children admitted to the PICU with ARF to help guide clinicians and inform future POC-LUS research studies [ 11 ].…”

Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

“…Lung point is a specific indicator of pneumothorax characterized by segments of lung sliding and abolished lung sliding in the same ultrasound image ( 58 ). Lung ultrasound is also the gold standard for the diagnosis of pleural effusion ( Figure 5 ); it detects smaller volumes of pleural fluid compared to CXR and spares radiation associated with CT ( 65 ). Ultrasound guided evacuation of pneumothorax and pleural effusion is recommended in neonates, children, and adults to improve success of the procedure and to limit complications ( 3 , 66 , 67 ).…”