Point-of-Care Ultrasound: A Case of Pneumonia
A Case
It's 10:30 a.m. on a busy Thursday in your primary care clinic. Mrs. Smith, a 52-year-old patient, arrives for a sick visit. She has been having a cough, fatigue, and mild shortness of breath for 5 days. She did have a sore throat and rhinorrhea preceding her symptoms. Her oxygen saturation is 94%, and you hear coarse breath sounds on the right. You wonder if she has a viral infection or a bacterial pneumonia that requires antibiotics. You’d normally send her out for a chest X-ray, but instead, you reach for your point-of-care ultrasound (POCUS) device. Figure 1 shows the patient’s right lung base. What do you see?
Figure 1 (a): Right lung base showing pleural effusion and consolidation.
Figure 1 (b): Right lung base consolidation (white circle) and effusion (white arrows). Notice the presence of a spine sign, visualization of the spine superior to the diaphragm (black arrows).
Figure 2 below shows a normal right lung base from a different patient.
Figure 2: Right lung base showing a mirror image artifact of the liver being reflected over the diaphragm (black arrows). The spine stops at the diaphragm, thus confirming lack of consolidation or effusion at the right lung base.
Evidence
The evidence consistently shows that lung ultrasound is superior to chest X-ray in detecting pneumonia. Lung ultrasound typically has a sensitivity ranging from 85-95%, while chest X-ray’s sensitivity is around 70 percent. [1-4] A study on 96 elderly patients in an inpatient ward found abysmal results for a chest X-ray, showing 47% sensitivity as compared to 92% for a lung ultrasound. [5]
Ultrasound Findings for Pneumonia
Pneumonia can come with various findings on ultrasound. More on this in future posts. Here are a few common findings:
Focal B-lines – nonspecific, but suggestive of pneumonia in the right clinical scenario.
Subpleural consolidation, pleural irregularity, & shred sign.
Hepatization of the lung. The lung looks consolidated, just like the liver.
Pleural effusion as present in Figure 1.
Dynamic air bronchograms – pathognomonic for pneumonia!
If pneumonia is present in an area of a lung that you are scanning, you will not see the normal artifacts (a mirror image artifact or A-lines). Note, if you have a high suspicion of pneumonia, it is important to scan all of the lungs, not just the typical 6-8 segments.
Case Resolution
Within a few minutes, you visualize a consolidation in the right lower lobe that confirms your suspicion of bacterial pneumonia. You start her on appropriate antibiotics, thus saving time, reducing costs, and avoiding unnecessary radiation. You also show Ms. Smith exactly what’s going on in her lungs, and she walks away fully committed to taking her medications as prescribed.
This case highlights how POCUS can revolutionize diagnostics in primary care settings, providing real-time, actionable insights at the bedside. For more information on how to implement POCUS in your urgent care practice, or to learn about upcoming training opportunities, visit Hello Sono. Let’s advance patient care together!
Authored by Tatiana Havryliuk, MD
References
1. Amatya, Y., Rupp, J., Russell, F.M. et al. Diagnostic use of lung ultrasound compared to chest radiograph for suspected pneumonia in a resource-limited setting. Int J Emerg Med 11, 8 (2018). https://doi.org/10.1186/s12245-018-0170-2
2. Chavez, M.A., Shams, N., Ellington, L.E. et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 15, 50 (2014). https://doi.org/10.1186/1465-9921-15-50
3. Alzahrani, S.A., Al-Salamah, M.A., Al-Madani, W.H. et al. Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia. Crit Ultrasound J 9, 6 (2017). https://doi.org/10.1186/s13089-017-0059-y
4. Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One. 2015 Jun 24;10(6):e0130066. doi: 10.1371/journal.pone.0130066. PMID: 26107512; PMCID: PMC4479467.
5. Ticinesi, A., Lauretani, F., Nouvenne, A., Mori, G., Chiussi, G., Maggio, M., & Meschi, T. (2016). Lung ultrasound and chest x-ray for detecting pneumonia in an acute geriatric ward. Medicine, 95(27), e4153. https://doi.org/10.1097/MD.0000000000004153