European Journal of Pediatrics

, Volume 178, Issue 9, pp 1369–1377 | Cite as

Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions

  • Tiago Henrique de Souza
  • José Antonio Hersan NadalEmail author
  • Andressa Oliveira Peixoto
  • Ricardo Mendes Pereira
  • Marina Pavan Giatti
  • Ana Carolina Siqueira Soub
  • Marcelo Barciela Brandão
Original Article


The objective of this study was to evaluate the interoperator agreement of lung ultrasonography (LUS) on specific thoracic regions in children diagnosed with pneumonia and to compare the findings of the LUS with the chest X-ray. Participants admitted to the ward or PICU underwent LUS examinations performed by an expert and a novice operator. A total of 261 thoracic regions in 23 patients were evaluated. Median age and weight of participants were 30 months and 11.6 kg, respectively. A substantial overall agreement between operators was found for normal lung tissue (κ = 0.615, 95% confidence interval (95% CI) = 0.516–0.715) and for consolidations (κ = 0.635, 95% CI = 0.532–0.738). For B-lines, a moderate agreement was observed (κ = 0.573, 95% CI = 0.475–0.671). An almost perfect agreement was found for pleural effusion (κ = 0.868, 95% CI = 0.754–0.982). The diagnosis of consolidations by LUS showed a high sensitivity (93% for both operators) but a low specificity (14% for expert and 25% for novice operator). While intubated patients presented significantly more consolidations, nonintubated patients presented more normal ultrasound patterns.

Conclusion: Even when performed by operators with very distinct degrees of experience, LUS had a good interoperator reliability for detecting sonographic patterns on specific thoracic regions.

What is Known:

• Lung ultrasound is feasible, safe, and highly accurate for the diagnosis of pneumonia in children; however, it does not allow global visualization of the thorax in a single moment as in chest X-rays, and, similar to the stethoscope, partial thorax assessments must be performed sequentially.

What is New:

• This is the first study evaluating the agreement of LUS on specific thoracic regions between operators with distinct degrees of experience performing the sonograms.

• There is a good agreement between an expert operator and a novice operator who underwent a brief theoretical-practical training program on LUS.


Ultrasound Ultrasonography Pneumonia Pediatrics Children 



Lung ultrasonography


Chest X-ray


Positive predictive value


Negative predictive value


Interquartile range


Confidence interval



Thank you to Carolina Grotta Ramos Telio for her review of the manuscript.

Authors’ contributions

T.H.dS. conceptualized and designed the study, collected data, drafted the initial manuscript, carried out the statisticalanalysis and reviewed and revised the manuscript. A.O.P. and J.A.H.N. designed the data collection instruments, collected data, and reviewed and revisedthe manuscript. M.P.G., A.C.S.S. and R.M.P. collected data. M.B.B. coordinated and supervised data collection, and critically reviewed the manuscript forimportant intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Compliance with ethical standards

The study was approved by UNICAMP’s Research Ethics Committee (registration number 38170714.9.0000.5404), and a written informed consent was obtained from the participants’ legal guardians.

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

431_2019_3428_MOESM1_ESM.tif (517 kb)
ESM 1 (TIF 517 kb)
431_2019_3428_Fig3_ESM.png (1.9 mb)

High Resolution Image (PNG 1926 kb)


  1. 1.
    Ben Shimol S, Dagan R, Givon-Lavi N, Tal A, Aviram M, Bar-Ziv J, Zodicov V, Greenberg D (2012) Evaluation of the World Health Organization criteria for chest radiographs for pneumonia diagnosis in children. Eur J Pediatr 171:369–374. CrossRefGoogle Scholar
  2. 2.
    Biagi C, Pierantoni L, Baldazzi M, Greco L, Dormi A, Dondi A, Faldella G, Lanari M (2018) Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis. BMC Pulm Med 18:191. CrossRefGoogle Scholar
  3. 3.
    Boursiani C, Tsolia M, Koumanidou C, Malagari A, Vakaki M, Karapostolakis G, Mazioti A, Alexopoulou E (2017) Lung ultrasound as first-line examination for the diagnosis of community-acquired pneumonia in children. Pediatr Emerg Care 33:62–66. CrossRefGoogle Scholar
  4. 4.
    Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America (2011) Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 53:617–630. CrossRefGoogle Scholar
  5. 5.
    Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E (2011) Lung ultrasound in bronchiolitis: comparison with chest X-ray. Eur J Pediatr 170:1427–1433. CrossRefGoogle Scholar
  6. 6.
    Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E, Mele G (2013) Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 48:280–287. CrossRefGoogle Scholar
  7. 7.
    Cardenas-Garcia J, Mayo PH (2015) Bedside ultrasonography for the intensivist. Crit Care Clin 31:43–66. CrossRefGoogle Scholar
  8. 8.
    Copetti R, Cattarossi L (2008) Ultrasound diagnosis of pneumonia in children. Radiol Med 113:190–198. CrossRefGoogle Scholar
  9. 9.
    Elemraid MA, Muller M, Spencer DA, Rushton SP, Gorton R, Thomas MF, Eastham KM, Hampton F, Gennery AR, Clark JE, on behalf of the North East of England Paediatric Respiratory Infection Study Group (2014) Accuracy of the interpretation of chest radiographs for the diagnosis of paediatric pneumonia. PLoS One 9:–e106051.
  10. 10.
    Ellington LE, Gilman RH, Chavez MA, Pervaiz F, Marin-Concha J, Compen-Chang P, Riedel S, Rodriguez SJ, Gaydos C, Hardick J, Tielsch JM, Steinhoff M, Benson J, May EA, Figueroa-Quintanilla D, Checkley W, Lung Ultrasound for Pneumonia Assessment (LUPA) Study Investigators (2017) Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med 128:57–64. CrossRefGoogle Scholar
  11. 11.
    Esayag Y, Nikitin I, Bar-Ziv J et al (2010) Diagnostic value of chest radiographs in bedridden patients suspected of having pneumonia. Am J Med 123:88.e1–88.e5. CrossRefGoogle Scholar
  12. 12.
    Esposito S, Papa SS, Borzani I, Pinzani R, Giannitto C, Consonni D, Principi N (2014) Performance of lung ultrasonography in children with community-acquired pneumonia. Ital J Pediatr 40:1–6. CrossRefGoogle Scholar
  13. 13.
    Gereige RS, Laufer PM (2013) Pneumonia. Pediatr Rev 34:438–456. CrossRefGoogle Scholar
  14. 14.
    Gravel CA, Monuteaux MC, Levy JA, Miller AF, Vieira RL, Bachur RG (2019) Interrater reliability of pediatric point-of-care lung ultrasound findings. Am J Emerg Med.
  15. 15.
    Hall EJ (2002) Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 32:700–706. CrossRefGoogle Scholar
  16. 16.
    Harel-Sterling M, Diallo M, Santhirakumaran S, Maxim T, Tessaro M (2019) Emergency department resource use in pediatric pneumonia: point-of-care lung ultrasonography versus chest radiography. J Ultrasound Med 38:407–414. CrossRefGoogle Scholar
  17. 17.
    Harris M, Clark J, Coote N et al (2011) British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66:ii1–ii23. CrossRefGoogle Scholar
  18. 18.
    Jones BP, Tay ET, Elikashvili I, Sanders JE, Paul AZ, Nelson BP, Spina LA, Tsung JW (2016) Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest 150:131–138. CrossRefGoogle Scholar
  19. 19.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefGoogle Scholar
  20. 20.
    Lichtenstein DA, Lascols N, Mezière G, Gepner A (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30:276–281. CrossRefGoogle Scholar
  21. 21.
    Lissaman C, Kanjanauptom P, Ong C, Tessaro M, Long E, O’Brien A (2018) Prospective observational study of point-of-care ultrasound for diagnosing pneumonia. Arch Dis Child 0:1–7. Google Scholar
  22. 22.
    Llor C, Bjerrum L (2014) Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv drug Saf 5:229–241. CrossRefGoogle Scholar
  23. 23.
    Mazrani W, McHugh K, Marsden PJ (2007) The radiation burden of radiological investigations. Arch Dis Child 92:1127–1131. CrossRefGoogle Scholar
  24. 24.
    Moncada DC, Rueda ZV, Marcías A et al (2011) Reading and interpretation of chest X-ray in adults with community-acquired pneumonia. Braz J Infect Dis 15:540–546. CrossRefGoogle Scholar
  25. 25.
    Pereda MA, Chavez MA, Hooper-Miele CC, Gilman RH, Steinhoff MC, Ellington LE, Gross M, Price C, Tielsch JM, Checkley W (2015) Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics 135:714–722. CrossRefGoogle Scholar
  26. 26.
    Pietersen PI, Madsen KR, Graumann O, Konge L, Nielsen BU, Laursen CB (2018) Lung ultrasound training: a systematic review of published literature in clinical lung ultrasound training. Crit Ultrasound J 10:23. CrossRefGoogle Scholar
  27. 27.
    Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, Aliberti S, Neumann R, Kroegel C, Hoyer H (2013) Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. Chest 142:965–972. CrossRefGoogle Scholar
  28. 28.
    Shah VP, Tunik MG, Tsung JW (2013) Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 167:119–125. CrossRefGoogle Scholar
  29. 29.
    Sim J, Wright CC (2005) The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 85:257–268Google Scholar
  30. 30.
    Svigals PZ, Chopra A, Ravenel JG, Nietert PJ, Huggins JT (2017) The accuracy of pleural ultrasonography in diagnosing complicated parapneumonic pleural effusions. Thorax 72:94–95. CrossRefGoogle Scholar
  31. 31.
    Swingler GH, Zwarenstein M (2008) Chest radiograph in acute respiratory infections. Cochrane Database Syst Rev.
  32. 32.
    Tripathi S, Ganatra H, Martinez E, Mannaa M, Peters J (2018) Accuracy and reliability of bedside thoracic ultrasound in detecting pulmonary pathology in a heterogeneous pediatric intensive care unit population. J Clin Ultrasound 47:1–8. Google Scholar
  33. 33.
    Tsung JW, Kessler DO, Shah VP (2012) Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic : distinguishing viral from bacterial pneumonia. Crit Ultrasound J 4:1–9. CrossRefGoogle Scholar
  34. 34.
    Volpicelli G, Elbarbary M, Blaivas M et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591. CrossRefGoogle Scholar
  35. 35.
    Wardlaw TM, Johansson EW, Hodge M, World Health Organization & UNICEF. (2006) Pneumonia: the forgotten killer of children. GenevaGoogle Scholar
  36. 36.
    Williams GJ, Macaskill P, Kerr M, Fitzgerald DA, Isaacs D, Codarini M, McCaskill M, Prelog K, Craig JC (2013) Variability and accuracy in interpretation of consolidation on chest radiography for diagnosing pneumonia in children under 5 years of age. Pediatr Pulmonol 48:1195–1200. CrossRefGoogle Scholar
  37. 37.
    World Health Organization (2001) Model chapter for textbooks : IMCI Integrated Management of Childhood Illness. World Health Organization, GenevaGoogle Scholar
  38. 38.
    World Health Organization Pneumonia Vaccine Trial Investigator’ group (2001) Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. In: WHO/V&B/01.35. Accessed 2 Dec 2018
  39. 39.
    Yousefifard M, Baikpour M, Ghelichkhani P et al (2016) Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion; a meta-analysis. Emerg (Tehran, Iran) 4:1–10Google Scholar
  40. 40.
    Zimmerman DR, Kovalski N, Fields S, Lumelsky D, Miron D (2012) Diagnosis of childhood pneumonia: clinical assessment without radiological confirmation may lead to overtreatment. Pediatr Emerg Care 28:646–649. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Tiago Henrique de Souza
    • 1
  • José Antonio Hersan Nadal
    • 1
    Email author
  • Andressa Oliveira Peixoto
    • 2
  • Ricardo Mendes Pereira
    • 1
  • Marina Pavan Giatti
    • 1
  • Ana Carolina Siqueira Soub
    • 1
  • Marcelo Barciela Brandão
    • 1
  1. 1.Pediatric Intensive Care Unit, Department of PediatricsState University of Campinas (UNICAMP)CampinasBrazil
  2. 2.Discipline of Pediatric Pulmonology, Department of PediatricsState University of Campinas (UNICAMP)CampinasBrazil

Personalised recommendations