How ‘Uncertain’ is Our Reference Standard for Respiratory Rate Measurement?

by J. Mark Ansermino, Guy Dumont, and Amy Sarah Ginsburg

Published in the American Journal of Respiratory and Critical Care Medicine, 23 January 2019.



"Current World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines rely on respiratory rate (RR) measurement for childhood pneumonia diagnosis. However, an increased RR is not specific to pneumonia and occurs with many different childhood respiratory and febrile conditions. Manual RR counting, while widely utilized, lacks reproducibility and accuracy compared to automated measurements, and can be significantly influenced by user bias. Given the increasing interest in automated RR technologies that provide continuous, convenient, non-invasive, and even non-contact estimates of RR, we recently reviewed the wide variety of RR measurement methodologies. 

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Multicentre pilot study evaluation of lung ultrasound for the management of paediatric pneumonia in low-resource settings: a study protocol

by Jennifer Lenahan, Giovanni Volpicelli, Alessandro Lamorte, Fyezah Jehan, Quique Bassat, and Amy Sarah Ginsburg

Published in BMJ Journals: BMJ Open Respiratory Research, 28 December 2018.


Pneumonia is the leading infectious cause of death among children under 5 years of age worldwide. However, pneumonia is challenging to diagnose. Lung ultrasound (LUS) is a promising diagnostic technology. Currently, in low-resource settings (LRS), pneumonia is diagnosed using WHO Integrated Management of Childhood Illness (IMCI) guidelines that rely on assessing variable and subjective clinical signs like respiratory rate and chest indrawing. Given the limitations of these non-specific clinical signs, it is not fully understood how effective WHO IMCI guidelines are in identifying pneumonia. Further evidence is needed to better understand the role of LUS as a tool for the diagnosis of childhood pneumonia in low-resource settings. 


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Chest ultrasound for the diagnosis of paediatric pulmonary diseases: a systematic review and meta-analysis of diagnostic test accuracy

by Heuvelings CC, Bélard S , Familusi MA, Spijker R, Grobusch MP, and Zar HJ.

Published in British Medical Bulletin, 17 Dec 2018. doi: 10.1093/bmb/ldy041



Chest ultrasound is an emerging imaging modality, for several paediatric pulmonary diseases. MEDLINE and EMBASE (1946-47 to 10 March 2017) were searched to collect evidence on the diagnostic accuracy of chest ultrasound, compared to other imaging modalities, for the diagnosis of paediatric pulmonary diseases.

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Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trial

by Thomas Althaus, MD; Rachel C Greer, MRCGP; Myo Maung Maung Swe, MPH; Joshua Cohen, MD; Ni Ni Tun, MD; James Heaton, MD; Supalert Nedsuwan, MD; Daranee Intralawan, MD; Nithima Sumpradit, MD; Sabine Dittrich, PhD; Zoë Doran, SRN; Naomi Waithira, MSc; Hlaing Myat Thu, PhD; Han Win, MD; Janjira Thaipadungpanit, PhD; Prapaporn Srilohasin, PhD; Mavuto Mukaka, PhD; Pieter W Smit, PhD; Ern Nutcha Charoenboon, BSc; Marco Johannes Haenssgen, PhD; Tri Wangrangsimakul, MRCP; Stuart Blacksell, PhD; Direk Limmathurotsakul, PhD; Prof Nicholas Day, FRCP; and Frank Smithuis, PhD

Published in The Lancet Global Health, 01 January 2018. DOI:


 In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. Researchers performed a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with, number NCT02758821, and is now completed. Between June 8, 2016 and Aug 25, 2017, 2410 patients were recruited, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio of 0·80 and risk difference of −5·0 percentage points between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86; risk difference −3·3 percentage points). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention. This study was funded by the Wellcome Trust Institutional Strategic Support Fund grant (105605/Z/14/Z) and Foundation for Innovative New Diagnostics (FIND) funding from the Australian Government.  

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Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis

by Biagi C, Pierantoni L, Baldazzi M, Greco L, Dormi A, Dondi A, Faldella G, and Lanari M.

Published in BMC Pulmonary Medicine, 07 Dec 2018. doi: 10.1186/s12890-018-0750-1


Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients.


Researchers enrolled children admitted to our hospital in 2016-2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient's clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines.

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