Focus area: Physicians
Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric emergency department
The increasingly widespread use of the "point of care lung ultrasound" in children in the future could open new and fascinating scenarios.
Asthma constitutes one of the most common chronic conditions of childhood and a leading cause for hospital admissions. There are currently no point of care tools that can aid with discriminating the diagnosis of acute asthma from other diagnoses such as pulmonary infection, pleural effusion, lobar atelectasis or a pneumothorax, each of which can present similarly with respiratory distress and wheeze. Chest auscultation, despite near uniformity in its enactment by health care workers’ physical exams, has poor inter-observer reliability and a poor to moderate diagnostic accuracy; thereby limiting its utility for clinicians to guide management. While it is known that lung ultrasound can accurately detect pneumonia in the febrile coughing child, the lung ultrasound patterns of asthmatic children presenting with acute respiratory distress remains to be determined. The primary objective of this study was to characterize lung ultrasound findings in asthmatic children presenting to the pediatric emergency department (PED) with a moderate to severe asthma exacerbation. Secondary objectives were to determine the association between positive lung findings and patient’s final diagnosis, clinical course, and PED resource utilization. Methods: Eligible patients 2-17 years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥ 1 of the following findings: ≥ 3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart. Results: A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p=0.03), prolonged ED length of stay (30% vs. 9%, p=0.04) and admission rate (30% vs 0%, p=0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84-1.00).
In conclusion positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice.
Dankoff S, Li P, Shapiro AJ, Varshney T, Dubrovsky AS, Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED. Am J Emerg Med. 2017 Apr;35(4):615-622.