Agreement Between the World Health Organization Algorithm and Lung Consolidation Identified Using Point-of-Care Ultrasound for the Diagnosis of Childhood Pneumonia by General Practitioners.
OBJECTIVE
The World Health Organization (WHO) case management algorithm for acute lower respiratory infections has moderate sensitivity and poor specificity for the diagnosis of pneumonia. We sought to determine the feasibility of using point-of-care ultrasound in resource-limited settings to identify pneumonia by general health practitioners and to determine agreement between the WHO algorithm and lung consolidations identified by point-of-care ultrasound.


METHODS
An expert radiologist taught two general practitioners how to perform point-of-care ultrasound over a seven-day period. We then conducted a prospective study of children aged 2 months to 3 years in Peru and Nepal with and without respiratory symptoms, which were evaluated by point-of-care ultrasound to identify lung consolidation.


RESULTS
We enrolled 378 children: 127 were controls without respiratory symptoms, 82 had respiratory symptoms without clinical pneumonia, and 169 had clinical pneumonia by WHO criteria. Point-of-care ultrasound was performed in the community (n = 180), in outpatient offices (n = 95), in hospital wards (n = 19), and in Emergency Departments (n = 84). Average time to perform point-of-care ultrasound was 6.4 ± 2.2 min. Inter-observer agreement for point-of-care ultrasound interpretation between general practitioners was high (κ = 0.79, 95 % CI 0.73-0.81). The diagnosis of pneumonia using the WHO algorithm yielded a sensitivity of 69.6 % (95 % CI 55.7-80.8 %), specificity of 59.6 % (95 % CI 54.0-65.0 %), and positive and negative likelihood ratios of 1.73 (95 % CI 1.39-2.15) and 0.51 (95 % CI 0.30-0.76) when lung consolidation on point-of-care ultrasound was used as the reference.


CONCLUSIONS
The WHO algorithm disagreed with point-of-care ultrasound findings in more than one-third of children and had an overall low performance when compared with point-of-care ultrasound to identify lung consolidation. A paired approach with point-of-care ultrasound may improve case management in resource-limited settings.
Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, MD, 21205, USA.
Miguel A
MA
Chavez
Neha
N
Naithani
Robert H
RH
Gilman
James M
JM
Tielsch
Subarna
S
Khatry
Laura E
LE
Ellington
J Jaime
JJ
Miranda
Ghanashyam
G
Gurung
Shalim
S
Rodriguez
William
W
Checkley
D000465:Algorithms; D002675:Child, Preschool; D003906:Developing Countries; D005260:Female; D058006:General Practice; D006801:Humans; D007223:Infant; D008297:Male; D009390:Nepal; D015588:Observer Variation; D010568:Peru; D011014:Pneumonia / Q000000981:diagnostic imaging*; D019095:Point-of-Care Systems; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014463:Ultrasonography; D014944:World Health Organization