Evaluation of the diagnostic performance of physician lung ultrasound versus chest radiography for pneumonia diagnosis in a peri-urban South African cohort

Background Lung ultrasound (US), which is radiation-free and cheaper than chest radiography (CXR), may be a useful modality for the diagnosis of pediatric pneumonia, but there are limited data from low- and middle-income countries. Objectives The aim of this study was to evaluate the diagnostic performance of non-radiologist, physician-performed lung US compared to CXR for pneumonia in children in a resource-constrained, African setting. Materials and methods Children under 5 years of age enrolled in a South African birth cohort study, the Drakenstein Child Health Study, who presented with clinically defined pneumonia and had a CXR performed also had a lung US performed by a study doctor. Each modality was reported by two readers, using standardized methodology. Agreement between modalities, accuracy (sensitivity and specificity) of lung US and inter-rater agreement were assessed. Either consolidation or any abnormality (consolidation or interstitial picture) was considered as endpoints. In the 98 included cases (median age: 7.2 months; 53% male; 69% hospitalized), prevalence was 37% vs. 39% for consolidation and 52% vs. 76% for any abnormality on lung US and CXR, respectively. Agreement between modalities was poor for consolidation (observed agreement=61%, Kappa=0.18, 95% confidence interval [95% CI]: − 0.02 to 0.37) and for any abnormality (observed agreement=56%, Kappa=0.10, 95% CI: − 0.07 to 0.28). Using CXR as the reference standard, sensitivity of lung US was low for consolidation (47%, 95% CI: 31–64%) or any abnormality (5%, 95% CI: 43–67%), while specificity was moderate for consolidation (70%, 95% CI: 57–81%), but lower for any abnormality (58%, 95% CI: 37–78%). Overall inter-observer agreement of CXR was poor (Kappa=0.25, 95% CI: 0.11–0.37) and was significantly lower than the substantial agreement of lung US (Kappa=0.61, 95% CI: 0.50–0.75). Lung US demonstrated better agreement than CXR for all categories of findings, showing a significant difference for consolidation (Kappa=0.72, 95% CI: 0.58–0.86 vs. 0.32, 95% CI: 0.13–0.51). Conclusion Lung US identified consolidation with similar frequency to CXR, but there was poor agreement between modalities. The significantly higher inter-observer agreement of LUS compared to CXR supports the utilization of lung US by clinicians in a low-resource setting. Graphical Abstract