ACCURACY OF CHEST ULTRASOUND IN DIAGNOSING PNEUMONIA IN PEDIATRIC PATIENTS AT MULAGO NATIONAL REFERRAL HOSPITAL, KAMPALA, UGANDA.
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ackground. Pneumonia is a major health threat worldwide and a leading infectious cause of death in children under 5 years causing more deaths than AIDS, malaria, and measles. The current guidelines suggest that the diagnosis of pneumonia in pediatric patients can mainly be made clinically using WHO criteria for diagnosing pneumonia with chest X-ray (CXR) reserved for severe or complicated cases of pneumonia. However, it has relatively low accuracy, is associated with delays in diagnosis and exposes children to ionizing radiation. Some studies have shown that chest ultrasonography (CUS) is accurate at diagnosing community acquired pneumonia (CAP) in children. It is also cheaper, more readily available, safer than chest radiography and a good tool for easy bedside use and follow up of patients. However, very few studies have been done in children and none in our settings. Objective of the study. The aim of this study was to establish the accuracy of chest ultrasound in diagnosing pneumonia in pediatric patients at Mulago National Referral Hospital. Method and materials. This was a cross sectional study conducted at acute Care Unit(ACU), MNRH. Children aged 2 months to 12 years admitted with a clinical suspicion of pneumonia were prospectively enrolled for the study and underwent both chest X-ray and chest ultrasound (performed by the principal investigator blinded to CXR findings). Both investigations were performed within 24 hrs. of admission. Chest sonography was carried out using a high frequency (7-12 MHz) linear probe. Different CUS findings including; B-lines, lung consolidation, CXR findings; alveolar process, interstitial process and/or pleural effusion were assessed. The final discharge diagnosis was based on history and physical examination and CXR findings. The final diagnosis was based on overall clinical findings and CXR findings and was used as a reference standard compared with CUS to determine the accuracy of chest ultrasound in diagnosing pneumonia. The bivariate and multivariate analysis were done to determine the association between radiological and clinical findings. Results. Of the 280 patients enrolled, 252 patients had complete data for analysis. The mean age was 21.4 months with more male participants 131(52%).CUS was positive in 164(64.7%) cases; 149(59.0%) consolidation and 62(24.6%) B-lines; 115(46.0%) had at least one patterns; 48(19.0%) 13 had both; 29(12.0%) pleural effusion. CXR was positive in 95(37.7%) cases; 82(32.5%) alveolar process; 18(7.1%); 90(35.7%) had at least one pattern; 5(2.0%) had both patterns; 9(3.6%) pleural effusion. 205(81.3%) had a final clinical diagnosis of pneumonia. CUS sensitivity was 72%(95% CI [65-78]), specificity 67%(95% CI [52-81]), PPV 91%(95% CI [85-95]), NPV 35%(95% CI [25-46]), likelihood ratios, 2.2 (95% CI [1.44-3.37]) for positive and 0.42(95% CI [0.31-0.56], for negative, ROC 0.7(95% CI [0.62-0.77]). When compared to CXR findings alone, CUS sensitivity was 96% [95% CI, 90-99], specificity of 54% [95% CI, 46-62], PPV of 56% [95% CI, 48-64], NPV of 96% [95% CI, 89-99]. Hypoxia (SP 02 <93%) showed a strong association with both CUS and CXR, tachypnea with only CUS and inability to feed with only CXR, with p-values <0.05. The odds of diagnosing pneumonia by CUS in children with cough was 3.9; [95% CI; 1.19-9.62; p-0.022], and those with with hypoxia 1.9; [95% CI; 1.05-3.33; p-0.035]. The odds of diagnosing pneumonia by CXR in children with hypoxia 1.9 [95% CI; 1.07-3.26; p-0.028]. Conclusion CUS was found to have a high sensitivity and therefore be used as a screening tool or add- on tool to CXR to diagnose pneumonia especially when CXR is negative. Hypoxia and tachypnea are the main predictors of pneumonia radiologically using CUS and CXR in children with clinical suspicion of pneumonia