Accuracy of History, Physical Exam, Laboratory Findings and Lung Ultrasound Compared to Chest Radiograph for the Diagnosis of Pneumonia in Pediatric Patients Presenting to Patan Hospital in Nepal

Background Pneumonia is the leading cause of death in children under five years of age worldwide.1 These deaths may be prevented by early detection and targeted antibiotic therapy.2 However, the diagnosis is not always clear on presentation to health care facilities. Missed diagnosis may lead to increased morbidity and mortality, while over-diagnosis may lead to unnecessary antibiotic use, which may further lead to increased antibiotic resistance, cause allergic reactions, and create unnecessary costs for patients. Therefore, using clinical tools and diagnostic capabilities to better improve diagnosis is critical.

Many studies have evaluated clinical signs and symptoms that may predict pneumonia.3-6 A recent meta-analysis found that no singular physical exam finding predicted pneumonia.5 The World Health Organization (WHO) Criteria diagnose pneumonia based on fast breathing; however, tachypnea has not been shown to strongly predict pneumonia.7 Additionally, most children with fever have compensatory tachypnea as a result, making the criteria of fast breathing difficult to diagnose pneumonia alone.8 In Nepal, one study evaluating the WHO criteria for pneumonia found a sensitivity of only 69.6% and specificity of 59.6%.9 Despite this, many providers rely on clinical exam findings and the WHO criteria for diagnosing pneumonia.

When available, diagnostic imaging is used regularly to confirm suspected pneumonia. Chest x-ray has been the standard for diagnosis in most facilities worldwide. However, remote facilities in resource-limited settings often lack radiographic imaging capabilities. Many facilities have bedside ultrasound available as it is easily portable, repeatable, and not associated with radiation. Ultrasound has been shown to be sensitive and specific for the diagnosis of pneumonia, yet few studies have evaluated the accuracy of lung ultrasound for pneumonia in pediatric patients in a resource-limited setting.10-14

The objective of this study is to evaluate the diagnostic accuracy of clinical history, physical exam, laboratory findings, and lung ultrasound compared to chest x-ray for the diagnosis of pneumonia in pediatric patients in a resource-limited setting. Determining diagnostic accuracy of these findings may help derive a clinical decision rule that may more accurately predict which children have pneumonia than current WHO guidelines.

Study Design