Feasibility of Training Clinical Officers in Point-of-Care Ultrasound for Pediatric Respiratory Diseases in Aweil, South Sudan

Abstract

. Lower respiratory tract infections (LRTIs) are the leading cause of deaths in children < 5 years old worldwide, particularly affecting low-resource settings such as Aweil, South Sudan. In these settings, diagnosis can be difficult because of either lack of access to radiography or clinical algorithms that overtreat children with antibiotics who only have viral LRTIs. Point-of-care ultrasound (POCUS) has been applied to LRTIs, but not by nonphysician clinicians, and with limited data from low-resource settings. Our goal was to examine the feasibility of training the mid-level provider cadre clinical officers (COs) in a Médecins Sans Frontières project in South Sudan to perform a POCUS algorithm to differentiate among causes of LRTI. Six COs underwent POCUS training, and each subsequently performed 60 lung POCUS studies on hospitalized pediatric patients < 5 years old with criteria for pneumonia. Two blinded experts, with a tiebreaker expert adjudicating discordant results, served as a reference standard to calculate test performance characteristics, assessed image quality and CO interpretation. The COs performed 360 studies. Reviewers rated 99.1% of the images acceptable and 86.0% CO interpretations appropriate. The inter-rater agreement (κ) between COs and experts for lung consolidation with air bronchograms was 0.73 (0.63–0.82) and for viral LRTI/bronchiolitis was 0.81 (0.74–0.87). It is feasible to train COs in South Sudan to use a POCUS algorithm to diagnose pneumonia and other pulmonary diseases in children < 5 years old.

Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children

“… Sonographers, who are novices in diagnosing CAP, can acquire high concordance with experienced sonographers relatively quickly [ 56 ]. Many publications agree that the interpretation of LUS findings among doctors is accurate regardless of their specialty [ 27 , 28 , 29 , 52 , 54 , 57 , 60 , 61 , 62 ]. …”

Efficacy of an ultrasound training program for nurse midwives to assess high-risk conditions at labor triage in rural Uganda

“…No prior studies have examined the aptitude of nurse midwives, who conduct the majority of obstetric care in resource-limited environments, to perform point-of care ultrasound (POCUS) at labor triage to identify high-risk conditions just before birth. Previous studies have demonstrated the utility of POCUS training in other LMIC contexts: clinical officers can accurately use ultrasound to evaluate lower respiratory infections after a 12-hour training [12]; emergency nurse practitioners can successfully diagnose a variety of emergency conditions using POCUS [13]. One prior study of nurse midwives in Zambia showed ability to scan pregnant patients at various gestational ages (not at labor triage) for basic information, however with poor ability to perform any gestational age measures [14].…”

Performance of lung ultrasound in the diagnosis of pediatric pneumonia in Mozambique and Pakistan

“…Higher interoperator and interrater reliability for LUS interpretation than for CXR interpretation in identifying pediatric pneumonia is supported by the literature (Figure 4). 14,16–33 We contrasted kappas observed in this study with kappas observed in the literature among other LUS and CXR interpreters. Kappas between LUS interpreters were 0.900 (in Pakistan) and 0.917 (in Mozambique) in this study (expert LUS interpreters) and ranged from 0.635 to 0.930 in the literature, whereas kappa between CXR interpreters ranged from −0.04 to 0.62 in this study and from 0.35 to 0.74 in the literature.…”

“…In considering the differences in LUS performance between the sites in Mozambique and Pakistan and the potential use case for LUS as a diagnostic or screening tool in LRS, we need to consider factors, such as differing epidemiologies, severities, and presentations of disease, various comorbidities, such as HIV, malaria, and malnutrition, variable LUS operator/interpreter skill levels (nonphysician clinicians in Mozambique and technicians with previous ultrasound experience in Pakistan), and varying healthcare levels (low‐volume rural district hospital in Mozambique and high‐volume urban hospital in Pakistan), among others. For example, with minimal training, LUS may be an appropriate tool for use by technicians, while more training may be required for use by some clinicians, 15,16 particularly if they use this tool infrequently. Of note, all the onsite LUS operators after a short, limited but focused training were capable of obtaining quality LUS videos that the expert LUS interpreters could reliably interpret remotely.…”

“…Higher interoperator and interrater reliability for LUS interpretation than for CXR interpretation in identifying pediatric pneumonia is supported by the literature (Figure 4). 14,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] We 6,22,26,28,34,35 Initially, we considered analyzing the data using CXR as the reference standard (Table A5). However, CXR is a poor reference standard, and diagnosing pediatric pneumonia when there is no proven accurate and reliable gold standard is problematic.…”