Pediatrics and Neonatology (2015) 56, 363e364
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
LETTER TO THE EDITOR
Updated Guidelines for Childhood Pneumonia Management: A Promising Role for Lung Ultrasound To the Editor, We are grateful to read the comments sent to the journal regarding our article “Usefulness of Lung Ultrasound in the Diagnosis of Community-acquired Pneumonia in Children”.1 These comments raised some important points regarding the role of lung ultrasound (LUS) in childhood pneumonia management in some recent publications. We agree with these thoughtful comments and would like to further clarify its updated and growing roles with special emphasis on some current guidelines. Accordingly, the British Thoracic Society (BTS) guideline for community-acquired pneumonia (CAP) in children,2 one of the major references in managing pediatric pneumonia recommends that the diagnosis of pneumonia is based on clinical features such as fever, tachypnea, breathlessness or difficulty in breathing, cough, wheezing, or chest pain, with varied sensitivity. Similarly, another guideline published by both the Infectious Diseases Society of America (IDSA) and Pediatric Infectious Diseases Society (PIDS),3 suggests that the diagnosis of pneumonia should only be based on clinical presentations. LUS or computed tomography (CT) could supply more detailed information for complicated para-pneumonic effusion by multi-plane assessment only when a chest X-ray (CXR) is not conclusive. As for the resource-poor regions of the world, the guidelines set by World Health Organization,4 defines pneumonia primarily as a cough and/or difficult breathing, with or without fever, fast breathing, or lower chest wall in-drawing. All three major guidelines recommend that the diagnosis of pneumonia is based on clinical presentations, and CXR or LUS should not be taken routinely. However, there is growing evidence suggesting the role of LUS in a variety of pulmonary diseases, mostly focused on the diagnosis of CAP.5e7 These studies weighted the benefit of LUS in CAP because of its high sensitive and
specificity for diagnosing CAP, without causing harm to the patient.5,7 Therefore, many believe that LUS is a safer and more convenient imaging modality than CXR and CT, owing to the lack of radiation and its feasibility on the bedside. In line with these studies, our results suggest that, except in certain patients limited by bone tissue and air filled structures, with well-trained techniques LUS is a comparable imaging tool with CXR, and it can be used as a primary diagnostic modality in many pediatric chest diseases. To date, LUS is not regarded as the standard modality for the diagnosis of pneumonia but has an essential and dedicated role in managing complicated pneumonia. BTS guidelines for pneumonia in childhood suggest that effusions are found in as many as 40% of hospitalized children with CAP, and the amount of fluid is best estimated by LUS.2 In addition, in the presence of abscess or empyema, a bedside LUS can be used to guide percutaneous drainage when patients are too critical to be transferred to the CT room.2 Furthermore, IDSA/PIDS guidelines even suggest LUS-guided percutaneous needle aspiration for direct culture of pathogens while sputum culture is difficult or negative.3 Finally, if there is a doubt of pleural fluid versus parenchymal opacification on CXR, further imaging with LUS or CT scan is warranted.3 Taken together, we believe that LUS can not replace CXR in the diagnosis of simple pneumonia as shown in current guidelines. However, its role in providing essential information to confirm and manage complicated pneumonia in children, as compared with CXR or CT, should be addressed in future studies or guidelines.
Conflicts of interest The authors have no conflicts of interest relevant to this article.
http://dx.doi.org/10.1016/j.pedneo.2015.03.005 1875-9572/Copyright ª 2015, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
364
References 1. Ho MC, Ker CR, Hsu JH, Wu JR, Dai ZK, Chen IC. Usefulness of lung ultrasound in the diagnosis of community-acquired pneumonia in children. Pediatr Neonatol 2015;56:40e5. 2. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011;66:ii1e23. 3. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. 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 2011;53:e25e76. 4. Updated guidelines for childhood pneumonia management: A promising role for lung ultrasound. http://www.who.int/ mediacentre/factsheets/fs331/en/. Accessed May 28, 2015. 5. Reissig A, Gramegna A, Aliberti S. The role of lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. Eur J Intern Med 2012;23:391e7. 6. Zompatori M, Ciccarese F, Fasano L. Overview of current lung imaging in acute respiratory distress syndrome. Eur Respir Rev 2014;23:519e30. 7. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of pointof-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 2013;167:119e25.
I-Chen Chen Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Letter to the Editor Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Jong-Hau Hsu Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Jiunn-Ren Wu Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Zen-Kong Dai* Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan *Corresponding author. Department of Pediatrics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Sun-Ming District, Kaohsiung, Taiwan. E-mail address: [email protected] (Z.-K. Dai) Jan 8, 2015
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.pediatr-neonatol.com
LETTER TO THE EDITOR
Updated Guidelines for Childhood Pneumonia Management: A Promising Role for Lung Ultrasound To the Editor, We are grateful to read the comments sent to the journal regarding our article “Usefulness of Lung Ultrasound in the Diagnosis of Community-acquired Pneumonia in Children”.1 These comments raised some important points regarding the role of lung ultrasound (LUS) in childhood pneumonia management in some recent publications. We agree with these thoughtful comments and would like to further clarify its updated and growing roles with special emphasis on some current guidelines. Accordingly, the British Thoracic Society (BTS) guideline for community-acquired pneumonia (CAP) in children,2 one of the major references in managing pediatric pneumonia recommends that the diagnosis of pneumonia is based on clinical features such as fever, tachypnea, breathlessness or difficulty in breathing, cough, wheezing, or chest pain, with varied sensitivity. Similarly, another guideline published by both the Infectious Diseases Society of America (IDSA) and Pediatric Infectious Diseases Society (PIDS),3 suggests that the diagnosis of pneumonia should only be based on clinical presentations. LUS or computed tomography (CT) could supply more detailed information for complicated para-pneumonic effusion by multi-plane assessment only when a chest X-ray (CXR) is not conclusive. As for the resource-poor regions of the world, the guidelines set by World Health Organization,4 defines pneumonia primarily as a cough and/or difficult breathing, with or without fever, fast breathing, or lower chest wall in-drawing. All three major guidelines recommend that the diagnosis of pneumonia is based on clinical presentations, and CXR or LUS should not be taken routinely. However, there is growing evidence suggesting the role of LUS in a variety of pulmonary diseases, mostly focused on the diagnosis of CAP.5e7 These studies weighted the benefit of LUS in CAP because of its high sensitive and
specificity for diagnosing CAP, without causing harm to the patient.5,7 Therefore, many believe that LUS is a safer and more convenient imaging modality than CXR and CT, owing to the lack of radiation and its feasibility on the bedside. In line with these studies, our results suggest that, except in certain patients limited by bone tissue and air filled structures, with well-trained techniques LUS is a comparable imaging tool with CXR, and it can be used as a primary diagnostic modality in many pediatric chest diseases. To date, LUS is not regarded as the standard modality for the diagnosis of pneumonia but has an essential and dedicated role in managing complicated pneumonia. BTS guidelines for pneumonia in childhood suggest that effusions are found in as many as 40% of hospitalized children with CAP, and the amount of fluid is best estimated by LUS.2 In addition, in the presence of abscess or empyema, a bedside LUS can be used to guide percutaneous drainage when patients are too critical to be transferred to the CT room.2 Furthermore, IDSA/PIDS guidelines even suggest LUS-guided percutaneous needle aspiration for direct culture of pathogens while sputum culture is difficult or negative.3 Finally, if there is a doubt of pleural fluid versus parenchymal opacification on CXR, further imaging with LUS or CT scan is warranted.3 Taken together, we believe that LUS can not replace CXR in the diagnosis of simple pneumonia as shown in current guidelines. However, its role in providing essential information to confirm and manage complicated pneumonia in children, as compared with CXR or CT, should be addressed in future studies or guidelines.
Conflicts of interest The authors have no conflicts of interest relevant to this article.
http://dx.doi.org/10.1016/j.pedneo.2015.03.005 1875-9572/Copyright ª 2015, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
364
References 1. Ho MC, Ker CR, Hsu JH, Wu JR, Dai ZK, Chen IC. Usefulness of lung ultrasound in the diagnosis of community-acquired pneumonia in children. Pediatr Neonatol 2015;56:40e5. 2. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011;66:ii1e23. 3. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. 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 2011;53:e25e76. 4. Updated guidelines for childhood pneumonia management: A promising role for lung ultrasound. http://www.who.int/ mediacentre/factsheets/fs331/en/. Accessed May 28, 2015. 5. Reissig A, Gramegna A, Aliberti S. The role of lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. Eur J Intern Med 2012;23:391e7. 6. Zompatori M, Ciccarese F, Fasano L. Overview of current lung imaging in acute respiratory distress syndrome. Eur Respir Rev 2014;23:519e30. 7. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of pointof-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 2013;167:119e25.
I-Chen Chen Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Letter to the Editor Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Jong-Hau Hsu Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Jiunn-Ren Wu Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Zen-Kong Dai* Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan *Corresponding author. Department of Pediatrics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Sun-Ming District, Kaohsiung, Taiwan. E-mail address: [email protected] (Z.-K. Dai) Jan 8, 2015
