Bedside lung ultrasound for the diagnosis of pneumonia in children presenting to an emergency department in a resource-limited setting.

BACKGROUND: Lung ultrasound (LUS) is an effective tool for diagnosing pneumonia; however, this has not been well studied in resource-limited settings where pneumonia is the leading cause of death in children under 5 years of age. OBJECTIVE: The objective of this study was to evaluate the diagnostic accuracy of bedside LUS for diagnosis of pneumonia in children presenting to an emergency department (ED) in a resource-limited setting. METHODS: This was a prospective cross-sectional study of children presenting to an ED with respiratory complaints conducted in Nepal. We included all children under 5 years of age with cough, fever, or difficulty breathing who received a chest radiograph. A bedside LUS was performed and interpreted by the treating clinician on all children prior to chest radiograph. The criterion standard was radiographic pneumonia, diagnosed by a panel of radiologists using the Chest Radiography in Epidemiological Studies methodology. The primary outcome was sensitivity and specificity of LUS for the diagnosis of pneumonia. All LUS images were later reviewed and interpreted by a blinded expert sonographer. RESULTS: Three hundred and sixty-six children were enrolled in the study. The median age was 16.5 months (IQR 22) and 57.3% were male. Eighty-four patients (23%) were diagnosed with pneumonia by chest X-ray. Sensitivity, specificity, positive and negative likelihood ratios for clinician's LUS interpretation was 89.3% (95% CI 81-95), 86.1% (95%CI 82-90), 6.4, and 0.12 respectively. LUS demonstrated good diagnostic accuracy for pneumonia with an area under the curve of 0.88 (95% CI 0.83-0.92). Interrater agreement between clinician and expert ultrasound interpretation was excellent (k = 0.85). CONCLUSION: Bedside LUS when used by ED clinicians had good accuracy for diagnosis of pneumonia in children in a resource-limited setting.

Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting.

BACKGROUND: Lung ultrasound (LUS) is helpful for the evaluation of patients with dyspnea in the emergency department (ED). However, it remains unclear how much training and how many LUS examinations are needed for ED physicians to obtain proficiency. The objective of this study was to determine the threshold number of LUS physicians need to perform to achieve proficiency for interpreting LUS on ED patients with dyspnea. METHODS: A prospective study was performed at Patan Hospital in Nepal, evaluating proficiency of physicians novice to LUS. After eight hours of didactics and hands-on training, physicians independently performed and interpreted ultrasounds on patients presenting to the ED with dyspnea. An expert sonographer blinded to patient data and LUS interpretation reviewed images and provided an expert interpretation. Interobserver agreement was performed between the study physician and expert physician interpretation. Cumulative sum analysis was used to determine the number of scans required to attain an acceptable level of training. RESULTS: Nineteen physicians were included in the study, submitting 330 LUS examinations with 3288 lung zones. Eighteen physicians (95%) reached proficiency. Physicians reached proficiency for interpreting LUS accurately when compared to an expert after 4.4 (SD 2.2) LUS studies for individual zone interpretation and 4.8 (SD 2.3) studies for overall interpretation, respectively. CONCLUSIONS: Following 1 day of training, the majority of physicians novice to LUS achieved proficiency with interpretation of lung ultrasound after less than five ultrasound examinations performed independently.

Establishing a Low-Resource Simulation Emergency Medicine Curriculum in Nepal.

Introduction: High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods: We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results: All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion: Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potentially play a supportive role in developing an emergency medicine curriculum.

Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal.

BACKGROUND: Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal. METHODS: A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management. RESULTS: Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%). CONCLUSIONS: In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.

Diagnostic use of lung ultrasound compared to chest radiograph for suspected pneumonia in a resource-limited setting.

BACKGROUND: Lung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country. METHODS: Patients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar's test for paired samples. Diagnostic characteristics for each test were calculated. RESULTS: Of 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively. CONCLUSIONS: Bedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov, registration number NCT02949141 . Registered 31 October 2016.