Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Kurian et al.
Ultrasound and CT in Evaluation of Pneumonia

Pediatric Imaging
Original Research

Comparison of Ultrasound and

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CT in the Evaluation of Pneumonia

Complicated by Parapneumonic
Effusion in Children
Jessica Kurian1 OBJECTIVE. The purpose of our study was to compare chest ultrasound and chest CT in
Terry L. Levin1 children with complicated pneumonia and parapneumonic effusion.
Bokyung K. Han 2 MATERIALS AND METHODS. We retrospectively compared chest ultrasound and
Benjamin H. Taragin1 chest CT in 19 children (nine girls and 10 boys; age range, 8 months–17 years) admitted with
Samuel Weinstein 3 complicated pneumonia and parapneumonic effusion between December 2006 and January
2009. Images were evaluated for effusion, loculation, fibrin strands, parenchymal consolida-
Kurian J, Levin TL, Han BK, Taragin BH, tion, necrosis, and abscess. In the subset of patients who underwent surgical management, im-
Weinstein S aging findings were correlated with operative findings.
RESULTS. Eighteen of 19 patients had an effusion on both chest ultrasound and chest
CT. The findings of effusion loculation as well as parenchymal consolidation and necrosis or
abscess were similar between the two techniques. Chest ultrasound was better able to visual-
ize fibrin strands within the effusions. Of the 14 patients who underwent video-assisted tho-
racoscopy, five had surgically proven parenchymal abscess or necrosis. Preoperatively, chest
ultrasound was able to show parenchymal abscess or necrosis in four patients, whereas chest
CT was able to show parenchymal abscess or necrosis in three.
CONCLUSION. In our series, chest ultrasound and chest CT were similar in their abil-
ity to detect loculated effusion and lung necrosis or abscess resulting from complicated pneu-
monia. Chest CT did not provide any additional clinically useful information that was not
also seen on chest ultrasound. We suggest that the imaging workup of complicated pediatric
pneumonia include chest radiography and chest ultrasound, reserving chest CT for cases in
which the chest ultrasound is technically limited or discrepant with the clinical findings.
Keywords: CT, empyema, parapneumonic effusion,
pediatric, pneumonia, ultrasound Community-acquired pneumonia in the and is often required before surgery to char-
DOI:10.2214/AJR.09.2791
pediatric population is common, with 40 acterize anatomy and evaluate for coexisting
cases per 1,000 children under 5 years old pulmonary abscess [3].
Received March 24, 2009; accepted after revision diagnosed annually in Europe and North In light of increasing awareness of radiation
May 16, 2009. America [1]. Up to 53% of hospitalized cas- exposure risks, particularly in children, we
es are complicated by parapneumonic effu- retrospectively compared the information ob-
Presented at the 2009 annual meeting of the Society of
Pediatric Radiology, Carlsbad, CA. sion, empyema, and pulmonary necrosis or tained from chest ultrasound and chest CT in
pulmonary abscess [2]. Both the diagnosis children with pneumonia and parapneumonic
1
Department of Radiology, Albert Einstein College of and therapy of complicated pneumonia are effusion to determine if chest ultrasound could
Medicine and Montefiore Medical Center, 111 E 210th St., guided by imaging. Although initial evalu- serve as a useful alternative to chest CT. In
Bronx, NY 10467. Address correspondence to T. L. Levin
(tlevin@montefiore.org).
ation is based on chest radiography, chest those patients who underwent surgical man-
CT has traditionally been used to evaluate agement, operative findings were reviewed
2
Department of Radiology, Mount Sinai Medical Center, the disease process in children before chest and correlated with imaging findings.
New York, NY. tube drainage (with or without thrombolyt-
3 ics), video-assisted thoracoscopy (VAT), or Materials and Methods
Department of Pediatric Cardiothoracic Surgery, Albert
Einstein College of Medicine and Montefiore Medical open thoracotomy and decortication. The Patient Population
Center, Bronx, NY. British Thoracic Society (BTS) guidelines The study met requirements for exemption
for the management of pediatric empyema from institution review board approval. Children
AJR 2009; 193:1648–1654
recommend the use of chest ultrasound for diagnosed with complicated pneumonia (pneu-
0361–803X/09/1936–1648 detecting pleural effusion and guiding drain monia and effusion) on the basis of clinical ex-
placement. However, the guidelines note that amination and chest radiography, who underwent
© American Roentgen Ray Society chest CT plays a role in complicated cases both chest CT and chest ultrasound during their

1648 AJR:193, December 2009

 Ultrasound and CT in Evaluation of Pneumonia

Chest CT Technique
Chest CT was performed on an MX-8000 IDT
16-MDCT scanner (Philips Healthcare) (n = 7), a
Brilliance 16-MDCT scanner (Philips Healthcare
Electronics) (n = 6), or a LightSpeed VCT 64-
MDCT scanner (GE Healthcare) (n = 5). Images
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were obtained from the level of the thoracic inlet

to the diaphragm using a pitch of 1.0, 120 kVp, and
a weight-based low-dose tube current. Thirteen of
the patients underwent CT with the administration
of nonionic IV contrast material (320 mg I/mL io-
dixanol, Visipaque, GE Healthcare) at a dose of
1 mL/kg. CT data were reconstructed at a slice
thickness of either 3 or 5 mm for image review.
For one patient, images from an unenhanced chest
CT performed at an outside hospital on the day of
transfer to our institution were reviewed.

A B
Image Evaluation
Fig. 1—3-year-old boy with pneumonia and loculated effusion. The chest CT and chest ultrasound images were
A and B, Axial contrast-enhanced chest CT image (A) and longitudinal image from chest ultrasound (B) show
retrospectively reviewed in consensus by a board-
loculated pleural effusion (cursors) with lobulated shape and convex margin. Although pleural fluid appears
inhomogeneous on chest CT, numerous fibrin strands are better visualized on chest ultrasound (arrows, B). certified pediatric radiologist and a radiology resi-
dent. The interpreting radiologists were blinded to
admission between December 2006 and January care) (n = 3), or an Acuson Sequoia 512 ultra- the results of the chest CT and chest ultrasound
2009 were included in the study. Nineteen pa- sound system (Siemens Healthcare) (n = 1). Lin- when reviewing either study. Images were exam-
tients (nine boys and 10 girls) with a mean age of ear (5–12 MHz), curved linear (2–5, 4–9, or 5–8 ined for the presence of pleural effusion and fibrin
5.4 years (age range, 8 months–17 years) who met MHz), and vector (5–8 MHz) transducers were strands within the effusion. Pleural effusion was
the study criteria were identified. The mean time used. The chest abnormality was localized on defined as loculated if the collection had a lobulat-
between chest ultrasound and CT was 2.7 days the basis of chest radiography findings. Anteri- ed or lenticular shape with a convex border [4, 5].
(range, 0–8 days). or, posterior, and midaxillary images were ob- Chest CT and chest ultrasound images were
tained using an intercostal approach in transverse also examined for parenchymal consolidation and
Chest Ultrasound Technique and longitudinal planes from the apex to the dia- the presence of lung necrosis or abscess. On chest
Chest ultrasound was performed by two expe- phragm with the patient in a supine or decubitus CT, consolidation was defined as air-space opac-
rienced staff ultrasound technologists on an iU22 position. Color Doppler ultrasound was performed ity with air bronchograms. On chest ultrasound, it
ultrasound system (Philips Healthcare) (n = 15), to evaluate the vascularity of regional parenchy- was defined as replacement of normal reflections
an HDI 5000 ultrasound system (Philips Health- mal abnormalities. of aerated lung by solid-appearing areas, with

A B C
Fig. 2—4-year-old boy with pneumonia and empyema.
A–C, Axial contrast-enhanced chest CT image (A) and longitudinal image from chest ultrasound (B) show parapneumonic effusion. Fibrin strands within pleural fluid are
seen to advantage on chest ultrasound (arrows, B) and correlate with intraoperative findings (C) of empyema and fibrin stranding.

AJR:193, December 2009 1649

 Kurian et al.

bright linear and branching echoes representing

sonographic air bronchograms [6, 7]. On chest CT,
pulmonary necrosis was assessed on contrast-en-
hanced scans and was defined as a low-density area
within a consolidated lung that had diminished en-
hancement relative to the adjacent parenchyma [4,
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8]. On chest ultrasound, pulmonary necrosis was

defined as a focal rounded area of decreased echo-
genicity within a portion of consolidated lung [9].
Although the use of color Doppler ultrasound in the
evaluation of necrotizing pneumonia has not been
well studied, a lack of central color Doppler flow
within the hypoechoic pulmonary lesions was used
to support the diagnosis of necrosis because it has
been suggested that necrosis is related to areas of
ischemic lung arising from adjacent inflammation
[8]. Abscess was defined as an intrapulmonary cav-
ity containing fluid or air, with no central enhance- A B
ment on chest CT or no central color Doppler flow
Fig. 3—7-year-old girl with pulmonary necrosis due to complicated pneumonia.
on chest ultrasound [4, 10]. A, Axial contrast-enhanced chest CT image shows loculated effusion, with adjacent consolidated lung
containing multiple areas of diminished enhancement.
Surgical Correlation B, Findings from A correspond to focal, round echo-poor lesions on longitudinal chest ultrasound image
(arrows). Lesions show some peripheral but no central color Doppler flow.
In addition to antibiotics, therapeutic options
for the treatment of pneumonia complicated by ef-
fusion include chest tube placement with instilla- were reviewed for the presence of pleural fluid, sound, and one had no effusion on either ex-
tion of fibrinolytics into the pleural space, or VAT empyema, and lung necrosis or abscess. The chest amination. Fifteen effusions were loculated
[11, 12]. At our institution, VAT is the preferred CT and chest ultrasound findings were compared on chest CT, and 13 were loculated on chest
method in patients who fail antibiotic therapy ei- with operative findings. ultrasound; in one patient, loculation seen on
ther with or without chest tube drainage. Typical- chest CT could not be determined on chest
ly, the decision to proceed to surgery is based on Results ultrasound because of scan quality limita-
assessment of the patient by a surgeon in conjunc- Pleural Findings tions. Fibrin strands were identified in all pa-
tion with a multidisciplinary clinical team. Labo- Of the 19 patients in whom pneumonia tients with effusion on chest ultrasound except
ratory and radiologic data are taken into account. with parapneumonic effusion was diagnosed for one patient with only trace fluid; some
For the patients in our study who were managed on chest radiography, 18 had an effusion con- patients showed few fibrin strands, whereas
surgically, operative and histopathology reports firmed on both chest CT and chest ultra- others showed numerous strands of variable

A B C
Fig. 4—2-year-old boy with complicated pneumonia and surgically proven lung abscess.
A, Chest radiograph shows abnormal collection of air (arrows).
B, Axial contrast-enhanced chest CT image shows that abnormal collection of air seen in A corresponds to abscess (arrowheads).
C, Transverse chest ultrasound image shows abscess as amorphous collection of fluid and air (asterisk) within lung. Hyperechoic line (arrow) represents air–fluid
interface.

1650 AJR:193, December 2009

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TABLE 1:  Patient Characteristics and Pleural, Parenchymal, and Surgical Findings
Pleural Effusion Parenchymal Findings
Patient
No. Age Sex Chest CT Chest CT Chest Ultrasound Chest CT Chest Ultrasound Surgical Findings
1 3y M Contrast-enhanced Loculated, left Loculated, left, fibrin Multilobar, left consolidation Multilobar, left consolidation Empyema
2 4y F Contrast-enhanced Loculated, left Loculated, left, fibrin Multilobar, left consolidation, Multilobar, left, consolidation, Empyema, LUL abscess
LUL necrosis LUL necrosis

AJR:193, December 2009

3 6y M Contrast-enhanced Loculated, right Loculated, right, fibrin Multilobar, right consolidation Multilobar, right consolidation Empyema
4 7y F Contrast-enhanced Loculated, left Loculated, left, fibrin LLL consolidation, necrosis LLL consolidation, necrosis Empyema, LLL necrosis, abscess
5 4y M Contrast-enhanced Loculated, right Loculated, right, fibrin LLL, multilobar, right LLL, RLL consolidation Empyema
consolidation
6 8 mo F Contrast-enhanced Loculated, left Nonloculated, left, fibrin LLL consolidation LLL consolidation Empyema, LLL abscess
7 2y M Contrast-enhanced Loculated, right Loculated, right, fibrin RML/RLL abscess RML–RLL abscess Empyema, RLL necrosis, RLL
abscess
8 4y M Contrast-enhanced Loculated, right Loculated, right, fibrin RLL abscess RLL consolidation Empyema
9 4y F Contrast-enhanced Nonloculated, left Nonloculated, left, fibrin Multilobar, right consolidation Multilobar, right consolidation Empyema
10 11 mo F Contrast-enhanced Trace Trace LLL consolidation, necrosis LLL consolidation, necrosis LLL cystic lung, possibly
congenital
11 12 y F Unenhanced Loculated, left Loculated, left, fibrin LLL consolidation LLL consolidation Empyema
12 3y F Unenhanced Loculated, right Loculated, right, fibrin Multilobar, right consolidation RLL consolidation, necrosis Empyema, two RLL abscesses
13 3y F Unenhanced Loculated, right Loculated, right, fibrin Multilobar, right consolidation RLL consolidation Empyema
14 2y F Unenhanced Loculated, right Loculated, right, fibrin Multilobar, right consolidation RLL consolidation Empyema
15 3y M Contrast-enhanced Nonloculated, left Nonloculated, left, fibrin LLL consolidation, necrosis LLL consolidation, necrosis
16 5y M Contrast-enhanced Loculated, right Loculated, right, fibrin Multilobar, right consolidation, RLL consolidation, necrosis
RLL necrosis
17 16 y M Contrast-enhanced None None Multilobar, right consolidation, Multilobar, right consolidationb
RML necrosis
18 5y F Unenhanced Loculated, right Loculated, right, fibrin RUL consolidation Undetermineda
Ultrasound and CT in Evaluation of Pneumonia

19 17 y M Unenhanced Loculated, right Righta, fibrin RLL consolidation RLL consolidation

Note—LUL = left upper lobe, LLL = left lower lobe, RML = right middle lobe, RLL = right lower lobe, RUL = right upper lobe.
aUnable to determine loculation or consolidation due to suboptimal scan quality.
b Linear transducer not used in this chest ultrasound.

1651
 Kurian et al.

thickness. Although presumably present, fi-
brin strands could not be clearly delineated on
any of the chest CT images (Figs. 1 and 2).
Parenchymal Findings
Of the 19 chest CT examinations, 13
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There were two false-positive parenchy-
mal diagnoses. In one patient, an abscess was
identified on chest CT but not chest ultra-
sound, and abscess was not confirmed at sur-
gery (patient 8, Table 1 and Fig. 5). In another
patient, necrosis was diagnosed on both chest
children. In many centers, patients routine-
ly undergo chest CT for characterization of
pleural effusion and underlying parenchymal
disease before chest tube placement or sur-
gery for drainage and decortication. Although
chest CT allows rapid image acquisition, the

were contrast-enhanced and six were unen- ultrasound and chest CT, and at surgery un- rising use of CT in the pediatric population
hanced. All chest CT examinations showed derlying cystic lung disease without necrosis raises the concern of an increasing ionizing
parenchymal consolidation. The contrast-en- was seen (patient 10, Table 1 and Fig. 6). radiation burden. Because the risk of radia-
hanced examinations identified six patients There were no cases in which a surgical- tion-induced cancer in children from medical
with coexisting necrosis and two with coex- ly confirmed parenchymal abnormality was imaging is estimated to be as high as one in
isting abscess. Of the 19 chest ultrasound ex- seen preoperatively on chest CT but not also 500 [13], it is incumbent on the radiologist to
aminations, 18 showed parenchymal consoli- seen on chest ultrasound. investigate alternative imaging strategies.
dation. Six of these had coexisting necrosis, Few studies have compared the efficacy of
and one had a coexisting abscess. Discussion chest ultrasound and chest CT in patients with
Consolidation was shown in all patients No consensus exists on the optimal tech- complicated pneumonia and parapneumonic
on both chest CT and chest ultrasound except nique for imaging complicated pneumonia in effusion. Prior investigations in both children
for one chest ultrasound in which technical
limitations precluded evaluation of the lung.
Chest CT and chest ultrasound concurred on
the presence of necrosis in five patients (Fig.
3) and differed in two; necrosis was identi-
fied on chest CT in one patient for whom the
ultrasound was limited by lack of evaluation
with a linear transducer (patient 17, Table 1),
and necrosis was identified on chest ultra-
sound in another patient for whom the chest
CT was unenhanced (patient 12, Table 1).

Surgical Findings
Fourteen patients underwent VAT, and five
were treated with antibiotics with or without
chest tube drainage. In the surgically man-
aged group, 13 patients were found to have
empyema; of these, five also had pulmonary
abscess or necrosis, and one was found to A B
have underlying cystic lung disease.
Loculation seen preoperatively on chest
ultrasound or chest CT correlated with the
presence of empyema in 12 of the 13 patients
(12 loculated effusions on chest CT and 11
on chest ultrasound). One patient with empy-
ema did not have loculation on either imag-
ing examination but did have fibrin stranding
on chest ultrasound. All patients with em-
pyema had debris and fibrin strands within
pleural fluid on chest ultrasound.
Of the five patients with parenchymal ab-
scess (Fig. 4) or necrosis at surgery, either ne-
crosis or abscess was seen preoperatively on
chest ultrasound in four patients and on chest
CT in three patients (in one patient, necrosis
could not be determined on an unenhanced C D
chest CT). Fig. 5—4-year-old boy with complicated pneumonia and false-positive diagnosis of lung abscess on chest CT.
There was one false-negative imaging di- A–D, Contrast-enhanced axial CT images with mediastinal (A) and lung (B) windows and coronal (C) and
agnosis in which a surgically diagnosed ab- sagittal (D) CT images with lung windows show air-filled collection in right hemithorax. Initially interpreted
as intrapulmonary, this collection may have represented loculated pleural air in major fissure because no
scess was not seen on either chest ultrasound pulmonary abscess was identified at surgery. Collection was not identified on preoperative chest ultrasound,
or chest CT (patient 6, Table 1). possibly due to acoustic shadowing from air in pleural space.

1652 AJR:193, December 2009

 Ultrasound and CT in Evaluation of Pneumonia

[14, 15] and adults [16, 17] have focused pri-
marily on the ability of chest ultrasound or
chest CT to correlate with effusion stage or
to predict clinical outcome and have shown
variable results. Neither chest ultrasound nor
chest CT has been shown to accurately pre-
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The most recent BTS recommendations
encourage the use of chest ultrasound to con-
firm the presence of pleural effusion, but the
guidelines note that contrast-enhanced chest
CT is useful for evaluation of advanced pa-
renchymal disease [3]. This can be clinically
pected bronchopleural fistula (Fig. 5). The
process was not appreciated on chest ultra-
sound, possibly because of acoustic shadow-
ing from air within the pleural space. In an-
other patient, lung necrosis shown on both
chest ultrasound and chest CT correspond-

dict effusion stage [5]. Most recently, Jaffe
et al. [4] compared chest CT and chest ultra-
sound in 31 children with complicated pneu-
monia and found only a weak correlation in
effusion scores. The study did not include a
comparison of parenchymal findings.
Our results concur with reports published
previously on the use of chest ultrasound in the
evaluation of parapneumonic effusion [3, 5].
Although chest ultrasound may be limited by
its small field of view and shadowing of deep
structures by overlying air, we found that it was
equally able to detect pleural fluid and locula-
tion when compared with chest CT. Chest ultra-
sound was superior to chest CT in its ability to
resolve the internal components of pleural flu-
id including fibrin strands, which may indicate
early organization of an effusion [7]. In our
study, loculation seen on chest CT was also
seen on chest ultrasound in all patients except
one, in whom a delay between the chest ultra-
sound and chest CT may have allowed time for
the effusion to become more organized. In the
subset of patients who underwent VAT, all but
one patient with surgically confirmed empye-
ma showed loculated fluid on both chest ultra-
sound and chest CT when performed within a
few days of each other, and all showed fibrin
stranding on chest ultrasound.
significant because the presence of necrotiz-
ing pneumonia requires a prolonged course
of antibiotics [5]. However, in our patient
group, chest ultrasound was similar to con-
trast-enhanced chest CT in its ability to di-
agnose pulmonary consolidation, lung ne-
crosis, and abscess. Except for one patient in
whom the chest ultrasound was technically
limited, pulmonary consolidation identified
on chest CT was also seen on chest ultra-
sound. Chest CT and chest ultrasound con-
curred on the presence of pulmonary necro-
sis except in two patients, including one in
whom the chest ultrasound was limited by
technique and one in whom the chest CT was
performed without IV contrast administra-
tion. In the subset of patients who underwent
VAT, there were no parenchymal abnormali-
ties found at surgery that were seen on chest
CT but not also seen on chest ultrasound.
Two false-positive imaging diagnoses
were identified. In one patient, an abscess
was diagnosed on chest CT but not on chest
ultrasound, and no abscess was identified at
surgery. On further review of the case, the
amorphous collection of air initially inter-
preted as an abscess on chest CT may have
represented loculated pleural air within the
major fissure in this patient who had a sus-
ed to an area of soft and cystic lung at sur-
gery, without true necrosis and without em-
pyema (Fig. 6). A preexisting lung anomaly
was postulated.
This study is limited by its small sample
size. Additionally, the chest ultrasound im­ages
were not evaluated in real time because of the
retrospective nature of the investigation. We
also acknowledge that, whereas acquisition of
chest CT can be standardized by machine set-
tings, the technical quality of chest ultrasound
was more variable in our sample. Of note, im-
ages obtained with a linear transducer ap-
peared to be superior to those obtained with
a vector transducer in detecting both pleural
and parenchymal abnormalities.
In this series of children with pneumo-
nia complicated by parapneumonic effu-
sion, chest ultrasound provided data simi-
lar to chest CT in the evaluation of pleural
fluid as well as the assessment of underly-
ing parenchymal consolidation, necrosis, or
abscess. Chest CT did not provide any ad-
ditional clinically useful information that
was not also seen on chest ultrasound. The
benefits of chest ultrasound over chest CT
include its portability, absence of need for
patient sedation, and superior ability to de-
tect fibrin strands within an effusion, which
corresponded to the presence of empyema
in our study group. In accordance with the
as low as reasonably achievable principle of
minimizing radiation exposure, we suggest
that the evaluation of children with compli-
cated pneumonia include chest radiography
and chest ultrasound. Chest CT may be re-
served for patients in whom chest ultrasound
is technically difficult or discrepant with the
clinical findings.

Acknowledgment
We thank Betsy Castillo for her help in
performing chest ultrasound.

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1654 AJR:193, December 2009