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com

Original article

Lung ultrasound is an accurate diagnostic tool for the

diagnosis of pneumonia in the emergency department
Francesca Cortellaro,1 Silvia Colombo,1 Daniele Coen,1 Pier Giorgio Duca2
1

Emergency Department,
Niguarda Hospital, Milan, Italy
2
Institute of Biometrics and
Medical Statistics, L. Sacco
Hospital, University of Milan,
Milan, Italy
Correspondence to
Dr Francesca Cortellaro, S.C.
Medicina dUrgenza e Pronto
Soccorso, Ospedale Niguarda
Ca Granda, Piazza Ospedale
Maggiore 3, Milano, Italy;
francesca_cortellaro@
fastwebnet.it
Accepted 22 September 2010
Published Online First
28 October 2010

ABSTRACT
Objective The aim of this study was to evaluate the
diagnostic accuracy of bedside lung ultrasound and chest
radiography (CXR) in patients with suspected pneumonia
compared with CT scan and final diagnosis at discharge.
Design A prospective clinical study.
Methods Lung ultrasound and CXR were performed in
sequence in adult patients admitted to the emergency
department (ED) for suspected pneumonia. A chest CT
scan was performed during hospital stay when clinically
indicated.
Results 120 patients entered the study. A discharge
diagnosis of pneumonia was confirmed in 81 (67.5%).
The first CXR was positive in 54/81 patients (sensitivity
67%; 95% CI 56.4% to 76.9%) and negative in 33/39
(specificity 85%; 95% CI 73.3% to 95.9%), whereas lung
ultrasound was positive in 80/81 (sensitivity 98%; 95% CI
93.3% to 99.9%) and negative in 37/39 (specificity 95%;
95% CI 82.7% to 99.4%). A CT scan was performed in 30
patients (26 of which were positive for pneumonia); in this
subgroup the first CXR was diagnostic for pneumonia in
18/26 cases (sensitivity 69%), whereas ultrasound was
positive in 25/26 (sensitivity 96%). The feasibility of
ultrasound was 100% and the examination was always
performed in less than 5 min.
Conclusions Bedside chest ultrasound is a reliable tool
for the diagnosis of pneumonia in the ED, probably being
superior to CXR in this setting. It is likely that its wider use
will allow a faster diagnosis, conducive to a more
appropriate and timely therapy.

Community-acquired pneumonia (CAP) is a major

health problem. In the United States CAP is
responsible for 1.7 million hospital admissions per
year and is the seventh leading cause of death, with
an age-adjusted mortality rate up to 22%.1 Core
measures that constitute emergency department
(ED) care of CAP patients include blood culture
collection before rst antibiotic administration,
administration of initial antibiotics within 6 h of
ED arrival and appropriate antibiotic selection.2
An adequate treatment is thus reliant on an early
diagnosis of pneumonia, yet the diagnosis is not
always clear at presentation to the ED. In a retrospective chart review of patients admitted with
pneumonia, 22% of patients presented some reason
for diagnostic uncertainty that could result in
delayed antibiotics delivery.3
The accuracy of chest radiography (CXR), which
remains the daily reference for lung imaging and a
cornerstone for the diagnosis of pneumonia
according to the American Thoracic Society criteria,
is 65% when compared with CT scan.4
Thoracic CT scan is the diagnostic gold standard,5 but may not always be available and is
Emerg Med J 2012;29:19e23. doi:10.1136/emj.2010.101584

charged with a high radiation dose and high cost

that preclude its use in the routine diagnostic
process of patients with suspected pneumonia.6
Ultrasound examination is increasingly being
used as a valuable bedside method in the diagnosis
of various thoracic conditions including pleural or
pericardial effusion, empyema, pneumothorax,
pulmonary embolism and pneumonia.7
To date only a few studies have investigated the
use of lung ultrasound in the diagnosis of pneumonia in the ED or intensive care unit.8e10
The aim of our study was to compare the accuracy of bedside lung ultrasound and CXR in
conrming a clinical suspicion of pneumonia in the
ED. Although diagnosis at hospital discharge was
used as the reference standard, CT scan results were
also available for a consistent number of patients.

METHODS
Setting
The study was performed at a 90 000 patient/year
metropolitan ED (Niguarda Ca Granda Hospital,
Milan, Italy), between September 2008 and
October 2009.

Patients
We studied a consecutive sample of adult patients
with suspected CAP admitted to the ED during the
duties of an emergency physician with experience
in lung ultrasound. Signs and symptoms considered
as suggestive of CAP were: cough; pleuritic pain;
sputum production; fever; dyspnoea; in accordance
with American Thoracic Society guidelines.2 All
patients were older than 18 years, and were not
pregnant. Walking patients with normal vital signs
were seen in the fast track area of our ED and were
not included in the study; all patients were
admitted to a general or emergency medicine ward
and were followed till discharge (1465 days).

Study design
Lung ultrasound was performed by a single expert
operator (FC) in patients with suspected CAP as
soon as possible after their arrival at the ED and
before CXR. CXR was read by a senior radiologist
on duty. Further CXR or CT scans were obtained
when considered clinically indicated by the senior
physician in charge of the patient. Only for study
purposes, a second expert radiologist later reviewed
CXR that were discordant from lung ultrasound
results. Physicians who followed patients and
discharged them, and all radiologists, were always
blind to ultrasound results.
As ultrasound and CXR are routine examinations, informed consent was obtained only from
patients undergoing a CT scan.
19

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Original article
We prospectively evaluated all patients until discharge,
comparing the ultrasound results with nal the diagnosis made
by physicians in charge of the patients, on the basis of radiological examinations, clinical evolution, markers of inammation and microbiology.

Instrumental examination
Anterolateral and posterior scans of the thorax were performed
with a convex 3.5e5 MHz probe (Esaote Medical Systems,
Firenze, Italy).
All ultrasounds were performed at the bedside by a single
expert physician, with longitudinal and oblique (intercostal)
scans. The posterior areas were studied in the lateral decubitus
or sitting position according to clinical status. The ultrasound
execution time cut-off was 5 min.
In agreement with the literature,8 11 12 each hemithorax was
divided into ve areas: two anterior, two lateral, one posterior,
for a total of 10 areas bilaterally. The anterior chest wall was
marked off from the parasternal line to the anterior axillary line.
This zone was split into an upper region (from the collar bone to
the secondethird intercostal space) and a lower region (from the
third intercostal space to the diaphragm). The lateral area
(anterior to posterior axillary line) was split into upper and
lower halves. Finally, the posterior area was identied from the
posterior axillary line to the paravertebral line.
In normal cases lung ultrasound shows the echoic pleural line,
between two rib shadows, and its sliding with breathing; the airlled lung prevents any visualisation beyond this line.
The wide acoustic impedance between the pleura and underlying areated parenchima creates typical horizontal artifacts
dened as A lines.13
In the presence of variations in the relationship between the
aerated and tissueeuid parts of the lung, vertical artifacts
moving with lung sliding arise from the pleural line, reach the
edge of the screen and erase A lines.14 These vertical artifacts are
called B lines and are dened as an interstitial syndrome when
exceeding three per longitudinal scan area. B lines correlate with
extravascular lung water15 and with tomographic images of
interstitial or alveolareinterstitial oedema.16 Interstitial syndrome
may be focal (pneumonia, lung contusion) or diffuse (cardiogenic
pulmonary oedema, acute lung injury (ALI)/acute respiratory
distress syndrome (ARDS), pulmonary brosis); history and
clinical data, as well as the ultrasound pattern, can help in the
differential diagnosis.12 17
In our study an echographic diagnosis of pneumonia was
made in the presence of subpleural lung consolidation,
presenting a tissular pattern.18
These consolidations may contain dynamic air bronchograms
(branching echogenic structures with centrifuge movement with
breathing) or multiple hyperechogenic spots (air trapped in the
small airway).19 The presence of dynamic bronchogram helps to
rule out obstructive atelectasia.20
We also considered as indicative of pneumonia a focal interstitial syndrome. Depending on the ability of patients to stay
upright, CXR was obtained in the supine or seated anterioreposterior view only, or in the upright posterioreanterior
and lateral views (Siemens Rohere/Tube Optitop 150/40/80 HC
2007). In emergency cases CXR was obtained with a mobile
device (Siemens Mobilett XP Hybrid, 083 94 004 Ed. 02;
Siemens, Spain). CT scans (Siemens Somatom Denition, 6432
slices; Siemens, Germany) were always contrast enhanced.

Statistics
Sensitivity, specicity and likelihood ratios of lung ultrasound
and CXR were calculated. Students t test was used for
20

continuous variables while the c2 test or McNemar test were

used for dicothomic variables when appropriate.21

RESULTS
One hundred and twenty patients, of which 77 (64%) were men,
with a mean age of 69618 years, were enrolled in the study.
Clinical baseline data, signs and symptoms of patients with and
without pneumonia did not differ signicantly. A diagnosis of
pneumonia at discharge was conrmed in 81 of 120 patients
(67%). The nal diagnoses of patients without pneumonia are
shown in table 1.

Ultrasound and CXR compared with diagnosis at discharge

Considering discharge diagnosis as the reference standard, ultrasound showed a sensitivity of 99% (80/81 patients; 95% CI 93.3%
to 99.9%) and a specicity of 95% (37/39 patients; 95% CI
82.7% to 99.4%). The positive likelihood ratio was 19.3 (95%
CI 4.99% to 74.2%), the negative likelihood ratio was 0.01 (95%
CI 0.002 to 0.09).
The only false negative was a patient with both initial
pulmonary oedema and pneumonia, for whom lung ultrasound
showed only an alveolar interstitial syndrome. The patient was
treated with diuretics, vasodilators and antibiotics with an
excellent outcome.
One of the two false-positive patients had a subphrenic
abscess with atelectasia of the right lung just above the diaphragm and a small pleural effusion, whereas the other had
cardiac failure with pleural effusion and atelectasia.
CXR fared much worse, with a sensitivity of 67% (54/81; 95%
CI 56.4% to 76.9%) and a specicity of 85% (33/39; 95% CI
73.3% to 95.9%).
The positive likelihood ratio was 4.3 (95% CI 2.04 to 37.7), the
negative likelihood ratio was 0.39 (95% CI 0.20 to 0.76).
Among the 27 patients with a rst non-diagnostic radiogram,
a second CXR was performed within 72 h in 17 cases and was
diagnostic for pneumonia in 10 (total positive CXR in patients
with pneumonia at discharge: 64/81). In seven patients with
a repeatedly non-diagnostic CXR, pneumonia was diagnosed
with a CT scan.
Among the 10 patients who did not undergo further imaging,
the discharge diagnosis of pneumonia was based on clinical and
laboratory grounds only. Three of these patients had positive but
not diagnostic ndings at rst CXR (pleural effusion in two
cases and atelectasia in one). Ultrasound showed consolidations
with dynamic air bronchograms in all three cases.
In the remaining seven patients with non-diagnostic ndings
at rst CXR ultrasound was positive for a retrocardiac
consolidation.
The rst CXR was obtained only in the anteroposterior view
in 75% of patients because they were not able to stand upright
Table 1 Diagnosis at discharge of the 39 patients
without pneumonia
Chronic obstructive pulmonary disease
Acute bronchitis
Acute pulmonary oedema/congestive
heart failure
Sepsis
Primitive pneumopathy
Acute pericarditis
Acute pancreatitis
Aortic aneurism
Subphrenic abscess

11
8
7
7
2
1
1
1
1

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Original article
in the ED. These constituted 92% of the negative results in
patients with a discharge diagnosis of pneumonia. In only one
case the second radiologist modied the initial result of CXR.
The results of CXR and lung ultrasound compared with the
diagnosis at discharge are summarised in table 2.
The difference in the sensitivities was estimated and tested
considering the matched pairs design (table 3). The result
(sensitivity (ultrasound)dsensitivity (CXR)32.1%, 95% CI
21.4% to 42.8%; Mc Nemar test p2.23107) shows that
ultrasound is preferable to CXR.

Utrasound and CXR compared with CT

A chest CT scan was performed in 30 of the 120 enrolled
patients and was diagnostic for pneumonia in 26 cases.
Ultrasound was positive in 25 of 26 patients with CTconrmed pneumonia (sensitivity 96%, 95% CI 0.89% to 0.99%)
and negative in three of four patients without pneumonia.
CXR was positive in 18 of 26 patients with CT-conrmed
pneumonia (sensitivity 69%, 95% CI 51.5% to 87.0%) and
negative in three of four patients without pneumonia at CT
(table 4).

Ultrasound characteristics and feasibility

The feasibility of ultrasound was 100% and the ultrasound
execution was less than 5 min in all patients. The echographic
ndings of the 80 patients with pneumonia are summarised in
table 5.
Pneumonia (gure 1) appeared with a pattern of consolidation
in 73 cases. Dynamic air bronchograms were almost always
present within the consolidation. An interstitial pattern
surrounded the consolidation in 42 cases as an expression of
perilesional inammatory oedema. In all cases of consolidation
lung sliding was reduced.
An interstitial syndrome was the prevailing pattern in the
remaining seven patients (focal and monolateral in three and
bilateral in four cases). In all these cases the ultrasound pattern
showed irregular and thickened pleura, with reduction of sliding
and small subpleural consolidations. In particular the four cases
with bilateral involvement had ultrasound ndings similar to
those decribed by Copetti et al17 in ALI/ARDS. These echographic ndings permitted pulmonary oedema to be ruled out.17
The arterial oxygen tension/fractional inspired oxygen of these
patients in the ED was between 250 and 300, microbiological
data conrmed a primitive pulmonary infection as the cause of
the ALI (Klebsiella pneumoniae, H1N1 inuenza virus and two
cases of Pneumocystis carinii).

DISCUSSION
Lung ultrasound has only recently been appreciated by the
greater medical community,22 because for a long time respected
sources considered ultrasound to be unt for assessing the

Table 3 Significance test of the difference of sensitivity for matched

pairs (CXR and lung ultrasound)
BPN +

Lung ultrasound +

Lung ultrasound L

Total

CXR +
CXR 
Total

53
27
80

1
0
1

54
27
81

BPN, pneumonia; CXR, chest x-ray.

pulmonary parenchyma.23 On the contrary, during the past

decade, lung ultrasound has been shown to be a very useful tool
in the hands of intensivists and emergency physicians for the
diagnosis of pneumothorax, pleural effusions and other thoracic
conditions. Its use in the diagnosis of pneumonia has also been
investigated in consideration of the great limitations of CXR.
This is of particular importance when CXR is performed in the
ED, where many patients are critically ill and can be examined
only in the supine position, often with bedside equipment.5
The comparative accuracy of ultrasonography and chest
radiology has been investigated in one study on patients with
ARDS24 and in a few small studies on patients with
pneumonia.9 10 25
In their CT controlled study on 32 patients admitted to the
intensive care unit for ARDS of different causes and 10 healthy
volunteers, Lichtenstein et al24 showed that bedside CXR had
a diagnostic accuracy of 47% for pleural effusion, 75% for alveolar consolidation and 72% for alveolareinterstitial syndrome.
In the same patients lung ultrasound had a diagnostic accuracy
of 93% for pleural effusion, 97% for alveolar consolidation and
95% for alveolareinterstitial syndrome.
Parlamento et al10 came to similar results investigating a series
of 49 patients with suspected CAP at rst clinical evaluation in
the ED. In the group of 32 patients with a conrmed diagnosis
of pneumonia, ultrasound was positive in 96.9% of patients,
whereas CXR was diagnostic in only 75%. The eight patients
with a positive ultrasound but a non-diagnostic CXR were
further studied with a CT scan, which conrmed the presence of
pneumonia in all cases. In our study CT scans were not routinely
performed in all cases in which ultrasound and CXR results
conicted, but were required by senior physicians in charge of
patients (blind to ultrasound results) when considered clinically
necessary. In this way it was possible to compare the performance of ultrasound and CXR with CT scan in 30 patients.
Once again, chest ultrasound comes out as a more accurate
diagnostic tool than CXR, with a sensitivity of 96% in CT
controlled patients against 69% of CXR. Similar results are
obtained when ultrasound and x-ray imaging results are
compared with the discharge diagnosis.
The fact that a high number of CXR (75% of all patients and
92% of the negative CRX with diagnosis of pneumonia at
discharge) have been taken in the supine position with a single
anteroposterior view might partly explain the bad performance
of x-rays in the ED setting. Nevertheless, seven out of 10 of the

Table 2 Results of CXR and lung ultrasound compared

with the diagnosis at discharge
BPN + (81)
CXR
Positive
Negative
Ultrasound
Positive
Negative

BPN L (39)

54 (67%)
27 (33%)

6 (15%)
33 (85%)

80 (99%)
1 (1%)

2 (5%)
37 (95%)

BPN, pneumonia; CXR, chest x-ray.

Emerg Med J 2012;29:19e23. doi:10.1136/emj.2010.101584

Table 4 Results of thoracic CXR and ultrasound compared with CT

CXR +
CXR 
Lung ultrasound +
Lung ultrasound 
Total

CT + (26/30)

CT L (4/30)

Total

18
8
25
1
26

1
3
1
3
4

19
11
26
4
30

CXR, chest x-ray.

21

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Original article
Table 5

Lung ultrasound findings

(a) Echographic findings in the 80 patients with pneumonia (BPN+) and US+
Ultrasound findings
Alveolar consolidation
Right lung
Left lung
Retrocardiac
Bilateral
Dynamic air bronchogram
Fluid bronchogram
Perilesional interstitial pattern
Interstitial pattern
Bilateral
Monolateral
Pleural effusion
Normal pattern

BPN+(80)
73 (91%)
37 (51%)
30 (41%)
8 (11%)
6 (8%)
71 (97%)
28 (39%)
42 (57%)
7 (9%)
4 (57%)
3 (43%)
31 (42%)
0 (0%)

(b) Echographic findings in the 37 patients without pneumonia (BPNL) and USL
Ultrasound findings
Alveolar consolidation
Interstitial pattern
Bilateral

BPNe(37)
0 (0%)
10 (27%)
10 (100%)
8 Pulmonary oedema
2 Pulmonary fibrosis
0 (0%)
4 (11%)
27 (72%)

Monolateral
Pleural effusion
Normal pattern
BPN, pneumonia; US, lung ultrasound.

repeated x-rays who became positive for pneumonia at 72 h

were also taken in the supine position.
Ultrasound has a clear advantage over CXReanteroposterior
views in the diagnosis of retrocardiac consolidations. It may also
be speculated that an earlier diagnosis is possible with ultrasound due to its higher sensitivity to lung extravascular water,
as demonstrated for ARDS and lung contusions.24 26 The diagnostic performance of CXR was in accordance with previous

results.4 5 Ultrasound lung consolidation is a non-specic sign of

pneumonia because it is also present in lung atelectasia, and
differential diagnosis could be difcult. The ultrasound sign that
differentiates pneumonia from obstructive atelectasia is the
presence of a dynamic air bronchogram in the former case
(specicity 94% and positive predictive value 97%).20 The
possibility of a dynamic evaluation gives ultrasound an advantage over CXR, and possibily also over CT scan, which cannot
always clearly differentiate between the two conditions.25 We
found dynamic air bronchograms in 71 of 73 patients. Static air
bronchograms can also be present in consolidation. When this is
the prevalent pattern within a large pneumonic consolidation, in
association with the presence of the lung pulse sign, we are
facing a major obstruction to air ow and urgent bronchoscopic
examination should be considered.27
A minority of patients with pneumonia has a prevalent
ultrasound pattern of interstitial syndrome. While a focal
interstitial pattern is suggestive of pneumonia, the nding of
a bilateral interstitial syndrome of acute onset poses a differential diagnosis with pulmonary oedema or other causes of ALI/
ARDS.17 In our series we found four such cases and we used the
presence of small subpleural consolidations, the absence or
reduction of gliding, the irregularity and thickening of the
pleural line, to rule out pulmonary oedema. The ultrasound
ndings in these four patients were similar to those described by
Copetti et al17 in ALI/ARDS; microbiological results supported
the nal diagnosis of lung infection as the cause of primary ALI.
A pleural effusion was present in 31 of 80 (39%) patients with
a nal diagnosis of pneumonia and in six of 39 (15%) patients
without pneumonia, conrming it to be a non-specic sign.

Limitations
In our study chest CT was performed in a limited number of
non-randomised patients. The advantage of ultrasound over
CXR was thus not conrmed with reference to the imaging gold
standard. In agreement with other authors10 we felt that
performing CT in all patients would not be ethically justied,

Figure 1 A 45-year-old patient

presenting in the emergency department
with cough, pleuritic pain and dyspnoea.
Double-view chest x-ray showed no sign
of pneumonia (A, B). A CT scan (C)
confirmed the presence of a right basal
consolidation shown by lung ultrasound
(D).

B
consolidations
Pleural effusion

air bonchograms

C
22

D
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Original article
therefore we decided to use hospital discharge diagnosis as
a surrogate for CT diagnosis in the wider number of patients
that had no clear clinical indication for further imaging. We
think that our results are consistent with clinical practice and
are unlikely to have been biased by this design.
All ultrasounds have been performed by a single, experienced
operator. Although ultrasound diagnosis was established on the
basis of objective signs, there are no studies documenting what
level of prociency is necessary for a reliable ultrasound diagnosis of pneumonia. Interobserver agreement among physicians
with different levels of experience and prociency should thus be
investigated further. On their sample series of ARDS patients,
Liechtenstein et al24 documented 0.74, 0.77 and 0.73 concordance (k) for the detection of alveolareinterstitial syndrome,
alveolar consolidation and pleural effusion between two physicians of similar experience.
The ultrasound operator was not blind to the clinical
presentation of the patients, which herself was diagnosing as
possibly having pneumonia. On the contrary, the radiologist did
not see the patients but only a very synthetic report of the their
clinical conditions. We cannot exclude that this might have been
an advantage for the physician performing ultrasound, but we
think at the same time that this fact underscores the usefulness
of an imaging procedure that can be performed at the bedside
during the very rst moments of the evaluation of an acute
patient.
Ambulant patients were excluded from our study, we cannot
therefore afrm the superiority of chest ultrasound over two
views standing chest x-rays in this group of patients.

CONCLUSIONS
Bedside chest ultrasound is a reliable tool for diagnosing
pneumonia in the ED, probably being superior to CXR in this
setting. It is likely that its wider use will allow a faster diagnosis of this disease, conducive to a more appropriate and
timely therapy.
Although it is unclear what level of prociency is required to
perform adequate lung ultrasound in the emergency room, the
use of this technique by emergency physicians in the differential
diagnosis of patients with acute respiratory and cardiovascular
symptoms is rapidly expanding. This will probably contribute to
a diffuse increase of skills and competence and to the routine use
of lung ultrasound in the evaluation of patients with suspected
pneumonia in the ED.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.

Emerg Med J 2012;29:19e23. doi:10.1136/emj.2010.101584

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23

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Lung ultrasound is an accurate diagnostic

tool for the diagnosis of pneumonia in the
emergency department
Francesca Cortellaro, Silvia Colombo, Daniele Coen, et al.
Emerg Med J 2012 29: 19-23 originally published online October 28,
2010

doi: 10.1136/emj.2010.101584

Updated information and services can be found at:

http://emj.bmj.com/content/29/1/19.full.html

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