Lung ultrasound for detecting pneumothorax in injured children: preliminary experience at a community-based Level II pediatric trauma center

POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

[CT in pediatric trauma patients]

The decision as to whether to perform a computed tomography (CT) examination in severe pediatric trauma poses a challenge. The therapeutic benefit of computed tomography in injured children is lower compared to adults, while the potential negative effects of ionizing radiation may be higher. Thus, the threshold for CT should be higher. Centers that less frequently treat pediatric cases tend to conduct more whole-body CT examinations than dedicated pediatric trauma centers, indicating a clinical overestimation of injury severity with subsequently unnecessary imaging due to inexperience. On the other hand, a CT scan that is not performed but is actually necessary can also have negative consequences if an injury is detected with a delay. An injured child presents a challenging situation for all involved healthcare providers, and thus requires a structured approach to decision-making.Selective literature review of the benefits and risks of CT in injured children, as well as indications for whole-body and region-specific CT imaging.This article provides an overview of current guidelines, recent insight into radiation protection and the benefits of CT in injured children, and evidence-based decision criteria for choosing the appropriate modality based on the mechanism of injury and the affected body region. · Whole-body CT has less of an influence on treatment decisions and mortality in severely injured children than in adults.. · For radiation protection reasons, the indication should be determined more conservatively in children than in adult trauma patients.. · The indication for CT should ideally be determined separately for each region of the body.. · Ultrasound and MRI are a good alternative for the primary diagnostic workup in many situations.. · Appelhaus S, Schönberg SO, Weis M. CT in pediatric trauma patients. Rofo 2025; DOI 10.1055/a-2341-7559.

[Diagnosis and management of idiopathic spontaneous pneumothorax in adolescents]

INTRODUCTION

Due to the absence of consensual definition and agreed-upon pediatric treatment, pneumothorax (PNO) in children and adolescents often remains difficult to properly apprehend.

STATE OF THE ART

While initial diagnostic suspicion is clinical, confirmation necessitates chest imaging, and lung ultrasound has become increasingly prevalent, often at the expense of chest radiography. The goal of treatment is twofold, on the one hand to a fully re-expand the lungs, and on the other hand to forestall PNO recurrence. Depending on PNO severity and clinical tolerance, it may be advisable to envision conservative management, oxygen supplementation, needle exsufflation, or chest tube drainage.

PERSPECTIVES

In order to harmonize clinical practices, guidelines for the precise definition and graduated management of PNO in children and adolescents are highly advisable.

CONCLUSIONS

Idiopathic spontaneous PNO frequently occurs in teenage populations, and its likewise frequent recurrence is not satisfactorily predicted by chest CT findings. It is of paramount importance that patients be fully informed of the risk of recurrence.

Objective structured clinical examination in basic thoracic ultrasound: a European study of validity evidence

BACKGROUND

Basic thoracic ultrasound is being used more frequently by clinicians in several settings due to its high diagnostic accuracy for many common causes of respiratory failure and dyspnoea. However, ultrasound examinations are operator-dependent, and sufficient competences are needed to obtain high sensitivity and specificity of examinations. Additionally, it is crucial for ultrasound operators to perceive the competence to interpret the images and integrate them into the patient history and other examinations. This study aims to explore and gather validity evidence for an objective structured clinical examination test of basic thoracic ultrasound competences and establish a pass/fail score.

METHODS

An expert panel created the test which included two theoretical and five practical stations representing cases with different diagnoses that cause respiratory symptoms and which are possible to establish by basic thoracic ultrasound. Twenty-five participants with different levels of experience in basic thoracic ultrasound completed the test. Data of the test scores were used for item analysis, and exploring validity evidence was done according to Messick's framework which is recommended. The contrasting groups' standard setting method was used to establish a pass/fail score.

RESULTS

The summarised internal consistency reliability was high with a Cronbach's alpha of 0.87. The novice group (n = 4) had a mean test score of 42 ± 10.1 points, the intermediate group (n = 8) scored 79.1 ± 8.1 points, and the experienced group (n = 13) 89.0 ± 6.2 points (one-way ANOVA, p < 0.001). A pass/fail score of 71 points was thus derived (maximum test score = 105 points).

CONCLUSION

We developed a test for the assessment of clinical competences in basic thoracic ultrasound with solid validity evidence, and a pass/fail standard with no false positives or false negatives.

Visual Rounds Based on Multiorgan Point-of-Care Ultrasound in the ICU

Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.

Lung Ultrasound to Detect Pneumothorax in Children Evaluated for Acute Chest Pain in the Emergency Department: An Observational Pilot Study

BACKGROUND

Spontaneous pneumothorax is a relatively uncommon and poorly studied condition in children. While several protocols have been developed to evaluate the use of lung ultrasound for dyspneic adult patients in the emergency department, no specific guidelines are present for pediatric emergency physicians.

OBJECTIVES

We prospectively analyzed children with acute chest pain and clinical suspicion of pneumothorax evaluated at the pediatric emergency department.

METHODS

We consecutively enrolled children aged 5-17 years presenting to the pediatric emergency department with clinically suspected pneumothorax based on sudden onset of acute chest pain. After clinical examination, all children underwent lung ultrasound followed by chest X-ray (reference standard). We enrolled 77 children, of which 13 (16.9%) received a final diagnosis of pneumothorax.

RESULTS

The lung point had a sensitivity of 92.3% (95% CI 77.8-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax. The "barcode sign" had a sensitivity of 100% (95% CI 75.3-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax.

CONCLUSION

Lung ultrasound is highly accurate in detecting or excluding pneumothorax in children with acute chest pain evaluated in the pediatric emergency department. If pneumothorax is suspected, but the lung point is not visible, the barcode sign should always be sought as it could be a form of massive pneumothorax.

The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.

Usefulness of Lung Ultrasound in Paediatric Respiratory Diseases

Respiratory infection diseases are among the major causes of morbidity and mortality in children. Diagnosis is focused on clinical presentation, yet signs and symptoms are not specific and there is a need for new non-radiating diagnostic tools. Among these, lung ultrasound (LUS) has recently been included in point-of-care protocols showing interesting results. In comparison to other imaging techniques, such as chest X-ray and computed tomography, ultrasonography does not use ionizing radiations. Therefore, it is particularly suitable for clinical follow-up of paediatric patients. LUS requires only 5-10 min and allows physicians to make quick decisions about the patient's management. Nowadays, LUS has become an early diagnostic tool to detect pneumonia during the COVID-19 pandemic. In this narrative review, we show the most recent scientific literature about advantages and limits of LUS performance in children. Furthermore, we discuss the major paediatric indications separately, with a paragraph fully dedicated to COVID-19. Finally, we mention potential future perspectives about LUS application in paediatric respiratory diseases.

Thoracostomy Tube Removal in Pediatric Trauma: Film or No Film?

BACKGROUND

Use of routine chest x-rays (CXR) following thoracostomy tube (TT) removal is highly variable and its utility is debated. We hypothesize that routine post-pull chest x-ray (PP-CXR) findings following TT removal in pediatric trauma would not guide the decision for TT reinsertion.

METHODS

Patients ≤ 18 y who were not mechanically ventilated and undergoing final TT removal for a traumatic hemothorax (HTX) and/or pneumothorax (PTX) at a level I pediatric trauma center from 2010 to 2020 were retrospectively reviewed. The outcomes of interest were rate of PP-CXR and TT reinsertion rate following PP-CXR. Clinical predictors for worsened findings on PP-CXR were also assessed.

RESULTS

Fifty-nine patients were included. A CXR after TT removal was performed in 57 patients (97%), with 28% demonstrating worsened CXR findings compared to the prior film. Except for higher ISS (p = 0.033), there were no demographic or clinical predictors for worsened CXR findings. However, they were more likely to have additional films following the TT removal (p = 0.008) than those with stable or improved PP-CXR findings. One (1.8%) asymptomatic child with worsened PP-CXR findings had TT reinsertion based purely on their worsened PP-CXR findings.

CONCLUSIONS

The vast majority of PP-CXR did not guide TT reinsertion after pediatric thoracic trauma. Treatment algorithms may aid to reduce variability and potentially unnecessary routine films.

Sonographic assessment of pediatric chest wall thickness and width of the intercostal space: correlation with anthropometric data and implications for needle decompression

Background

Emergent needle decompression in children is a rare event for emergency medicine and critical care providers. Hereby, risk of injury of intrathoracic structures is high and knowledge of age-specific values of chest wall thickness and width of the intercostal space (ICS) is crucial to avoid injuries. Investigation of the correlation of chest wall thickness and width of the intercostal space with age and body dimension like weight and height could provide guidance on depth of insertion and choice of the needle.

Methods

We performed a prospective observational clinical trial in a pediatric surgery operating room that included a convenient sample of children aged 0–10 years undergoing elective surgery. Chest wall thickness and width of the intercostal space were measured with ultrasound at 2nd ICS midclavicular line (MCL) and 4th ICS anterior axillary line (AAL). Correlation of these measures with age, height, weight, BMI and Broselow color was calculated. Furthermore, intra-class correlation coefficient was calculated as a measure of reproducibility and the presence of vital structures (e.g., heart, thymus gland, large pulmonary vessels) at the possible insertion sites for needle decompression was investigated.

Results

Of 410 potentially eligible patients, 300 were included in the study. Correlation of chest wall thickness was moderate with weight (2nd ICS MCL: r = 0.57; 4th ICS MCL: r = 0.64) and BMI (r = 0.44 and r = 0.6) and was lower with age (r = 0.38 for both intercostal spaces), height (r = 0.42 and r = 0.40) and Broselow color (r = 0.42 and r = 0.38). Correlation of width of the ICS with anthropometric data was generally stronger, with height showing the strongest, albeit not really strong, correlation (r = 0.71 and r = 0.62). Intra-class correlation was excellent with an ICC of 0.93. Vital structures were significantly more often present at 2nd ICS MCL then at 4th ICS AAL (14 vs. 2 patients; p = 0.0042).

Conclusions

Correlation of chest wall thickness and width of the intercostal space with anthropometric data is at most moderate. Insertion depth and width of the intercostal space can therefore not be predicted accurately from anthropometric data. Ultrasound assessment of the thoracic wall appears to be a reliable technique and could therefore assist in reducing the risk of injury and increasing decompression success.

Trial registration German clinical trials register, DRKS00014973, Registered February 11th 2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014973

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00226-6.

Metachronous recurrent pediatric primary spontaneous pneumothorax: A case presentation and literature review

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Pediatric spontaneous pneumothorax is relatively a rare condition.

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A metachronous pneumothorax whether ipsilateral or contralateral side is even rarer.

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Current literature is deficient in a solid consensus for management of this type of pneumothorax.

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Video-assisted thoracoscopic surgery is an excellent therapeutic tool for pediatric pneumothorax.

Introduction

Pediatric primary spontaneous pneumothorax (PSP) is defined as the presence of air in the pleural cavity without underlying lung disease or thoracic trauma. Metachronous recurrence of PSP whether ipsilateral or contralateral is rare. Apical bullae and sub-pleural blebs are found in the majority of PSP patients. As in adults, surgery is indicated in cases with prolonged air leak. Video-assisted thoracoscopic surgery (VATS) is increasingly performed in children and has been reported to be both safe and effective.

Presentation of the case

An 11-years-old girl had bilateral attacks of PSP, the second attack happened one after the first one and this later was associated with her menarche. Chest CT scan detected bilateral apical blebs.

Discussion

Contralateral recurrence in pediatric PSP is a low probability. The decision for surgery in the pediatric age group is a matter of controversy as there are no strict pediatric guidelines for management of PSP. Currently, VATS is superior to open surgery. Pediatric Catamenial pneumothorax is not well described in the literature.

Conclusions

Contralateral recurrence of PSP in children is rarer. No guidelines exist for the management of these cases. The association of pediatric PSP with menarche is not well described in the current literature.

Role of Lung Ultrasound in the Detection of Postoperative Pulmonary Complications in Pediatric Patients: A Prospective Observational Study

OBJECTIVE

To evaluate the incremental benefit of lung ultrasound (LUS) over clinical examination and chest x-rays (CXR) together (clinico-radiologic examination) for the diagnosis of postoperative pulmonary complications (PPC).

DESIGN

Prospective observational study.

SETTING

Tertiary care center.

PARTICIPANTS

One hundred children after corrective congenital cardiac surgery with left-to-right shunts.

INTERVENTION

Participants were independently evaluated with clinico-radiologic examination by the treating team, as well as LUS by an investigator at 12, 24, 48, and 72 hours after surgery. After recording the diagnoses, the LUS findings were disclosed to the treating team and a final diagnosis was made. CXR scores and LUS scores were evaluated for their ability to predict PPC.

MEASUREMENTS AND MAIN RESULTS

A total of 34 cases of PPCs were observed. Of these, 32 each were detected by clinico-radiologic examination and LUS alone. Addition of LUS improved total number of PPCs detected in the early postoperative period but not in the late postoperative period. Preoperative and early postoperative LUS scores were superior to CXR scores in predicting occurrence of PPC (area under receiver operating characteristics curve [AUROC] 0.920 v 0.732; p < 0.001 preoperatively; AUROC 0.987 v 0.858, p = 0.001 at 12 hours postoperatively). Multivariate analysis suggested LUS score as an independent predictor of PPC, and LUS score along with aortic cross-clamp time as independent predictors of duration of mechanical ventilation and intensive care unit stay.

CONCLUSIONS

LUS improves identification of PPC over clinico-radiologic examination in the early postoperative period. Preoperative LUS scores have better predictive ability than CXR scores for the occurrence of PPC.