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Received: 2 June 2022 | Revised: 14 October 2022 | Accepted: 18 October 2022

DOI: 10.1111/apa.16578

REVIEW ARTICLE

Lung ultrasound systematic review shows its prognostic and

diagnostic role in acute viral bronchiolitis

Christos Kogias1 | Spyridon Prountzos2 |

2
Efthymia Alexopoulou | Konstantinos Douros3

1
Faculty of Medicine, National and
Kapodistrian University of Athens, Athens,
Greece
2
2nd Department of Radiology, National
and Kapodistrian University of Athens,
Faculty of Medicine, University General
Hospital ‘Attikon’, Athens, Greece
3
3rd Department of Paediatrics, National
and Kapodistrian University of Athens,
Faculty of Medicine, University General
Hospital ‘Attikon’, Athens, Greece
Correspondence
Christos Kogias, National and Kapodistrian
University of Athens, Faculty of Medicine,
University General Hospital ‘Attikon’,
Rimini 1, Chaidari 12462, Athens, Greece.
Email: christoskogias.ped@gmail.com
Abstract
Aim: Lung ultrasound (LUS) has not been included in the current guidelines for the
diagnosis of bronchiolitis so far, even though data concerning its effectiveness have
been published.
Methods: A systematic literature review was carried out to determine the role of
LUS scores in the diagnosis and prognosis of patients aged 0–­2 years with bronchi-
olitis, using MEDLINE, Scopus and ScienceDirect databases from their inception to
December 2021.
Results: A total of 18 studies matching our eligibility criteria were analysed for the
purposes of this review and 1249 patients with bronchiolitis were included. The sono-
graphic and radiological findings were comparable and chest radiography was found
to have a higher sensitivity in ruling out severe complications such as concomitant
pneumonia. The LUS scores were correlated to the clinical course of bronchiolitis and
it was able to predict the need of admission in paediatric intensive care unit, the dura-
tion of hospitalisation and the need for respiratory support.
Conclusion: This review suggests that LUS could have both a diagnostic and a prog-
nostic role in bronchiolitis during first evaluation in the emergency department and
hospitalisation. Physicians could adjust management according to sonographic find-
ings as a useful adjunct to the clinical ones.

KEYWORDS
bronchiolitis, diagnosis, infants, lung ultrasound, prognosis

1 | I NTRO D U C TI O N of the tracheobronchial tree, along with increased mucus produc-

Acute viral bronchiolitis is a clinical syndrome with varying symp-
toms. In developed countries, bronchiolitis is the most common
1,2
reason for hospitalisation in the first 12 months of life.
6% of these patients require admission to the paediatric intensive
care unit (PICU).3 It is characterised by inflammation and oedema
tion and apoptosis of airway epithelial cells.4 A diagnosis of bron-
chiolitis is based on medical history and physical examination. 5 The
disease lacks a pathognomonic radiological pattern.6 Radiographic
Up to features suggesting viral bronchiolitis when using chest radiography
may include lung hyperinflation, peribronchial wall thickening often
symmetrical and bilateral, lack of focal consolidation in the lungs,

Abbreviations: CPAP, continuous positive airway pressure; HFNC, high flow nasal cannula; LUS, lung ultrasound; OR, odds ratio; PED, paediatric emergency department; PICU,
paediatric intensive care unit.

© 2022 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd

222 | 
wileyonlinelibrary.com/journal/apa Acta Paediatrica. 2023;112:222–232.

KOGIAS et al.
atelectasis and small lobular air-­trapping. Chest radiography can be
helpful in severe cases. The sensitivity of chest radiography for find-
ings consistent with bronchiolitis fluctuates and has been estimated
between 20% and 96%.7 In typical cases, it does not add significantly
8 guidelines for the diagnosis of bronchiolitis so far, even
to the diagnostic process. Nevertheless, it is performed in 50% or
more of admitted infants with bronchiolitis,9,10 mainly to rule out
bacterial pneumonia, resulting in exposure to ionising radiation11
and unnecessary antibiotic prescription.12
Lung ultrasound (LUS) has been proposed as a diagnostic tool for
many neonatal and paediatric conditions.13-­15 It is performed using
either a high-­frequency linear probe (5–­15 MHz) when examining
superficial structures or a low-­frequency micro-­convex probe (5–­
16-­19
7.5 MHz) when assessing deeper structures. When using LUS to
diagnose bronchiolitis, suggestive findings may include liver-­like hy-
poechoic consolidations either small subpleural <10 mm in diameter
or >10 mm in diameter with air bronchogram, interstitial syndrome
with B-­lines and pleural effusion.17
The objective of our systematic review is to determine whether
definite conclusions can be made about the role of LUS scores in the
diagnosis and prognosis of patients aged 0–­2 years with bronchiolitis.
2 | M E TH O D S
2.1 | Search process
Systematic literature research was carried out in three different da-
tabases, MEDLINE, Scopus and ScienceDirect. The search included
the keywords ‘bronchiolitis’, ‘acute bronchiolitis’, ‘acute viral bron-
chiolitis’, ‘lung ultrasound’, ‘lung ultrasonography’ and the Boolean
operators AND and OR. The initial search yielded 39 papers in
MEDLINE, 56 in Scopus and 104 in ScienceDirect databases that
were scanned for relevance. All databases were searched from
their inception to December 2021, and no restriction was imposed
on language and date of publication. A manual search of the refer-
ences found in the selected papers and reviews was also performed.
Inclusion criteria were papers including patients with bronchiolitis
and presented original data from the use of LUS in diagnosis and
prognosis of the patients with bronchiolitis. Exclusion criteria were
papers without relation to the field of interest and without relevant
conclusions and specific types of papers such as comments, reviews,
conference abstracts, case reports, contents, editorials, letters.
2.2 | Statistics
The diagnostic value of LUS was assessed by comparing LUS with
chest radiography as for their sensitivity, specificity, receiver oper-
ating characteristic curve, positive likelihood ratio (+LR) and area
under the curve (AUC). Its prognostic value was defined by compar-
ing clinical scores with ultrasound scores and predicting the need for
respiratory support and hospital stay using odds ratio (OR), Cohen's κ
coefficient (k or K) and Spearman's rank correlation coefficient (rho or
|
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223
Key Notes
• Lung ultrasound (LUS) has not been included in current
though data concerning its effectiveness have been
published.
• A systematic search identified 199 papers published up
to December 2021, of which 18 were eligible for the
review.
• Sonographic findings as a useful adjunct to the clinical
ones could have both a diagnostic and prognostic role in
bronchiolitis.
rs). After the first screening, the role of LUS in assessing the need for
PICU admission was added as an objective of the review. Ultimately,
the diagnostic and prognostic value of the LUS was assessed by an-
swering five individual questions about whether LUS and chest radi-
ography findings were comparable, whether LUS could predict the
admission to PICU, whether there was a correlation between LUS
scores and clinical course and whether LUS scores could predict the
length of hospital stay and the need for respiratory support.
2.3 | Appraisal tools
All potentially relevant full texts identified in the three electronic
databases were screened by two authors (CK, SP) independently of
one another and a third author (KD) confirmed the data obtained.
Discrepancies were resolved by discussion. No attempts were made
to contact the study authors for identifying missing and confusing
data. Each study was evaluated based on the strength of the scien-
tific evidence provided, using the levels of evidence from the Centre
for Evidence-­Based Medicine in Oxford. Level I included validat-
ing cohort studies with good reference tests that applied blindly
or objectively to all patients. Level II included exploratory cohort
studies with good reference tests. Level III included studies with
non-­consecutive patients, or with the reference test not applied
to all patients. Level IV included case–­control studies, poor or non-­
independent reference tests that were not applied to all patients but
still interpreted independently of the index test. Level V included
expert opinion without explicit critical appraisal, or based on physi-
ology, bench research or first principles. This review has been con-
ducted according to the Preferred Reporting Items for Systematic
Review and Meta-­Analyses guidelines. 20
3 | R E S U LT S
We identified 199 studies, of which 152 were screened by title and
abstract after removing duplicates (Figure 1). Twenty-­six (26) pa-
pers were assessed for eligibility by full text. Five (5) of them were
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224 KOGIAS et al.

excluded as reviews, 21-­25 2 due to lack of sonographic data, 26,27 and
1 as non-­relevant to the topic because it presents diaphragm ultra-
28 29-­4 6
sound data. Finally, 18 of them were eligible for use in this
systematic review. For detailed characteristics of each study see
Table 1.
The quality assessment showed that none of the studies met
level I evidence criteria, 2 met level II, 5 met level III and the remain-
ing 11 level IV criteria. Thus, the majority of studies had a low quality
of evidence. Of these studies, fifteen were prospective observa-
tional studies,30,31,32,33,34,35,36,37,38,40,41,42,43,45,46 one was retrospec-
tive observational study40 and two were cross-­sectional studies. 29,44
37
Except for one multi-­centre study, all others were single-­centre
studies. One study was published in French,41 one in Spanish,38 and
the remainder were published in English.
Lung ultrasound was performed using either a high-­frequency lin-
ear probe when examining superficial structures or a low-­frequency
micro-­convex probe when assessing deeper structures. Different
LUS scoring systems were used among the studies included in this
review, which can be found in Table 2 in detail. While the number
of scoring systems used in the studies was high (n = 6) each scoring
system in its essence was scrutinising the B-­line pattern, its occur-
rence and density per intercostal space and the presence of sub-
pleural consolidations. LUS findings interpretation was performed
only by non-­radiologists/sonographers in six studies, 30,36,37,38,40,42
only by radiologists/sonographers in five studies31,34,35,43,46
Identification
and by both paediatricians and radiologists/sonographers in six
studies.32,33,39,41,44,45 One study did not state the interpretation
method. 29 We sorted these studies into groups according to the ob-
jective for further stratification of the results in our review.
3.1 | LUS and chest radiography
findings comparison
Seven studies examined the accuracy of the two diagnostic methods
(Table 3). 29,31,35,39,40,43,46 Five of them showed that LUS was more
accurate than chest radiography in identifying lung consolidations as
a marker of bronchiolitis. 29,31,35,40,46 LUS was found to be more sen-
sitive than chest radiography. Two prospective observational stud-
ies showed that LUS could recognise more accurately a pathological
pattern in patients with bronchiolitis indicating that it was more val-
uable as a diagnostic tool compared to chest radiography.35,46 One 46
found that nine patients whose clinical scores was consistent with
the diagnosis of bronchiolitis had negative chest radiography, though
a positive LUS. The other study included 76 infants with bronchioli-
tis, seventy-­four (97%) had a positive LUS and forty-­t wo (55.3%) had
positive chest radiography.35 A strong correlation between chest
radiography and LUS (rs = 0.638) and good accuracy of LUS in diag-
nosing bacterial pneumonia in children with clinical bronchiolitis was
shown. When only consolidation size >1 cm was considered positive

Records identified from: Records removed before

MEDLINE (n = 39) screening:
Scopus (n = 56) Duplicate records removed
ScienceDirect (n = 104) (n = 47)

Records screened Records excluded

(n = 152) (n = 122)

Reports sought for retrieval Reports not retrieved

(n = 30)
Screening

(n = 4)

Full-text articles assessed for Reports excluded:

eligibility reviews (n = 5)
(n = 26) did not report sonographic
data (n = 2)
diaphragm ultrasound (n = 1)

Studies included in review

Included

(n = 18)
F I G U R E 1 Preferred reporting items
for systematic reviews flow diagram of
selection process
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KOGIAS et al. 225

TA B L E 1 Characteristics of studies reported

Gender
Level of
References Country Study design N Age Males Females evidence

Elkhazragy et al. 29 Egypt Comparative 36 IV

cross-­sectional
Bobillo-­Perez et al.30 Spain Prospective, observational, 80 53 daysb 37 43 II
single-­centre
Regina et al.31 Italy Single-­centre, longitudinal, 63 2.7 monthsa 41 22 IV
prospective
Ruiz et al.32 Spain Observational 200 5.7 monthsa 116 84 IV
5 monthsb
Ingelse et al.33 Netherlands Prospective, observational 17 2.7 monthsb 6 11 III
34 a
Di Mauro et al. Italy Prospective, observational 83 4.5 months III
single-­centre 3 monthsb
Özkaya et al.35 Turkey Prospective observational 76 7.4 monthsa 46 30 II
6 monthsb
Supino et al.36 Italy Prospective 76 90 daysb 41 35 III
37 b
Bueno-­C ampaña et al. Spain Prospective multicentre 145 1.7 months 76 69 III
Garrote et al.38 Spain Prospective, observational 59 90 daysb 37 22 III
39 b
Biagi et al. Italy Prospective 87 5.7 months IV
Jaszczolt et al.40 Poland Retrospective 26 7.3 monthsa IV
7 monthsb
Taveira et al.41 France Prospective, observational 47 32 daysb 27 20 IV
single-­center
Cohen et al.42 USA Prospective, observational 29 291 daysa 18 11 IV
43 a
Kader et al. Egypt Prospective, observational 25 6.94 months 7 18 IV
Varshney et al.44 Canada Prospective cross-­sectional 94 11.1 monthsb 62 32 IV
45 a
Basile et al. Italy Observational cohort 106 87.4 days 59 47 IV
71 daysb
Caiulo et al.46 Italy Prospective observational 52 2.1 monthsb 28 24 IV
a
Value expressed as mean.
b
Value expressed as median.

for pneumonia, the correlation in the study grew further (rs = 0.684)
and specificity of LUS was higher than CXR (98.4% vs. 87.1%) with
39
+LR = 5, comparable to the CXR's. These data suggested that a
positive lung ultrasound with consolidations >1 cm may avoid the
need to perform chest radiography in these patients.
(87.5%) of infants needing non-­invasive ventilation in PICU upon
arrival and at 48 h had an abnormal LUS pattern. 32 Interstitial pat-
tern along with consolidation tended to be the main predictor of
worse outcome.

3.3 | LUS scores and clinical course correlation

3.2 | LUS scores and PICU admission
Four prospective studies attempted to evaluate the usefulness
30,32,36,38
of LUS as a predictor of PICU admission (Table 4).
scores and the need of PICU admission was found to correlate
38
with OR = 2.5. A study from Spain concluded that LUS scores
could predict the PICU admission more accurately than clini-
cal scores with both sensitivity and specificity close to 90% and
30
+LR = 8.19. Moreover, a significant difference in LUS score was
found between infants who needed advanced respiratory support
on admission and those who did not. 36 Patients with a greater
LUS score were in need of respiratory support. The vast majority
Nine studies examined the correlation between sonographic and clini-
cal scores in children with bronchiolitis (Table 5).31,34,35,36,38,41,43,45,46
LUS Four of them estimated a strong31,35,38,45 and two of them a weak34
or no statistically significant correlation.41 A parallel correlation
was found between the clinical improvement or deterioration and
the decrease or the increase in the number of consolidations.43,46
Moreover, a prospective study from Italy noted a more severe sono-
graphic and clinical score in infants who needed high flow nasal can-
nula (HFNC) or helmet continuous positive airway pressure (CPAP)
compared to those who did not need it.36 LUS score showed a mar-
ginally better performance in predicting hospital admission with
 TA B L E 2 Lung ultrasound scoring systems
| 226

No. of papers using

Author Ultrasound scoring system the scoring system

Basile et al.45 LUS Score 0 1 2 4

Anterolateral Normal lung sliding with Diffuse and Diffuse and dishomogeneous
data horizontal artefacts dishomogeneous interstitial syndrome and/or
(A-­lines) interstitial syndrome subpleural lung consolidations
with confluent, multiple
B-­lines and spared areas
Vertical artefacts (B-­lines)
in limited number or
absent
Paravertebral/ Interstitial Individual B-­line or absent Focal, multiple B-­lines Confluent, multiple B-­lines
posterior syndrome
data Extension on 0–­6 bilaterally involved 6–­12 bilaterally involved >12 bilaterally involved intercostal
interstitial intercostal spaces intercostal spaces spaces
syndrome
Presence of Absent Subcentimeter-­subpleural Subpleural lung consolidation of
subpleural lung lung consolidation 1 cm or more
consolidation
Copetti et al.14 LUS findings Alveolar-­interstitial Pleural-­line abnormalities Presence of ‘spared areas’ Presence of large consolidations Bilateral ‘white 10
syndrome lung’
Enghard et al.47 LUS Score 0 1–­5 6 7 8
LUS findings No B-­lines/ICS 1–­5 B-­lines/ICS Confluent B-­lines >50% Confluent B-­lines >75% ICS Confluent B-­lines 1
ICS 100% ICS
Taveira et al.41 LUS Score 0 1 2 1
LUS Finding Normal lung Severe AIS Consolidation
parenchyma or
Moderate AIS
Bobillo-­Perez LUSBRO 0 1 2 3 1
et al.30 Score
LUS Findings A-­line pattern with Non-­coalescent B-­line Coalescent B-­line Areas with >1 cm sub pulmonary
lung sliding. pattern. pattern without loss consolidation or presence of
of aeration or with atelectasis.
<1 cm sub pulmonary
consolidations.
KOGIAS et al.

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KOGIAS et al. 227

AUC of 0.814 (95%CI 0.71–­0.91, p < 0.001) in comparison with clini-

No. of papers using
the scoring system
cal score with AUC of 0.804 (95%CI 0.71–­0.89, p < 0.001).35

1 3.4 | LUS scores and the length of hospital stay

Eight studies managed to determine the correlation between LUS

scores and hospital stay (Table 6).30,31,34,35,37,38,41,45 A Spanish study
that enrolled 80 patients found a more significant correlation be-
tween the LUS score and the length of hospital stay in comparison
with a clinical score.30 Similarly, a Turkish study found that the most
effective parameter in determining hospital admission among sev-
eral variables was LUS score with OR = 1.859.35 Two studies found
a moderate correlation31,37 and one study a weak correlation34 vali-
dating a previously published ultrasound score for bronchiolitis by
(a) Depth < 10 mm (b)

Basile et al.45 They first underlined the correlation between LUS

Isolated consolidation

Depth ≥ 10 mm

findings and the need for hospital stay. A Spanish prospective study
that enrolled 59 patients estimated that the median LUS score in the
patients who did not require hospital admission was six points (2–­8),
in those who admitted to the ward was nine points (5–­13.7), and
in the patients who needed to be transferred from the ward to the
C

PICU was 17 points (14.5–­18) (p = 0.001).38 Nevertheless, the study

≥4 intercostal spaces) ±
lung consolidation with

of Taveira et al found no such correlation.41

Severe interstitial pattern

lines and/or confluent

B-­lines, which involve
(generalised focal B-­

(b) Severe interstitial

(a) Severe interstitial
pattern without
depth ≥10 mm

consolidation

consolidation
pattern with

3.5 | LUS scores and the need for

respiratory support

Ten studies examined the prognostic value of LUS in predicting the

B2

Abbreviations: AIS, alveolar-­interstitial syndrome; ICS, intercostal space; LUS, lung ultrasound.

need for respiratory support (Table 7).30,31,32,33,34,36,37,38,41,45 It was

B-­lines, which involve
≤3 intercostal spaces)
pattern (focal B-­lines,

found that the need for supplemental oxygen was more frequent in
(b) Moderate interstitial
(a) Moderate interstitial
± small subpleural
intercostal spaces

the patients with higher LUS scores31,33,34,37 and that LUS can identify
Moderate interstitial

which involve <8

and/or confluent

pattern without
(depth < 10 mm)
consolidation

consolidation

consolidation

those infants who require supplementary oxygen with a sensitivity of

pattern with

96.6%, a specificity of 98.7% and +LR of 7.43.45 Four prospective stud-

ies found a positive correlation between LUS score and the duration
of any respiratory support.30,36,37,41 One study found a strong,30 two
B1

studies a medium36,37 and one study a weak41 correlation. A study from

Spain32 that included 200 infants with bronchiolitis estimated that
B-­lines or with a
normal defined

limited number
of focal B-­lines
sliding without
as normal lung
Normal or almost

among infants in need of O2/high flow oxygen, 86.7% had an abnormal

LUS at admission and 77.8% at 48 h after admission. Among the ones
Ultrasound scoring system

in need of non-­invasive ventilation, 87.5% had an abnormal LUS both at

admission and 48 h after admission. Furthermore, a team of research-
A

ers from Spain designed a new LUS score depending on ultrasound

findings along with clinical predictors, such as age <1 month and Wood
LUS Findings

Down-­Ferres score ≥6 points.37 It found that sensitivity improved

to 89.1%, though specificity was reduced to 56% when compared to
Group
TA B L E 2 (Continued)

these same predictors studied individually. The high value of sensitiv-

ity allowed the new LUS score to be used as a screening tool, with a
high negative predictive value (88.7%). A study from Italy that included
63 infants with a mean age of 2.7 months found that the need of oxy-
Ruiz et al.32

gen therapy was more frequent in patients with higher LUS score.31
Author

However, LUS score calculated by Taveira et al on admission did not

correlate significantly with the length of non-­invasive ventilation or the
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228 KOGIAS et al.

TA B L E 3 Characteristics of studies comparing lung ultrasound and chest radiography

Lung consolidations Sensitivity Specificity +LR

Studies N Age LUS CXR LUS CXR LUS CXR LUS CXR
29 c c c c c
Elkhazragy et al. 36 9/36 (25%) 3/36 (8%) 91.7% 77.8% 95.9% 89.7% 22.4 7.55c
Regina et al.31 63 2.7 monthsa 54/63 (85%) 14/23 (61%)
35 a
Özkaya et al. 76 7.4 months 75/76 (99%) 5/76 (6.5%) 50%d 91.2%d 5.68d
6 monthsb
Biagi et al.39 87 5.7 monthsb 100%e 96%e 83.9%e 87.1%e 6.21 e 7.44 e
80%f 98.4%f 5f
Jaszczolt et al.40 26 7.3 monthsa 19/26 (73%) 4/26 (15%)
7 monthsb
Kader et al.43 25 6.94 monthsa 3/25 (12%) 4/25 (16%)
46 b
Caiulo et al. 52 2.1 months 44/63 (70%) 16/63 (25%)

Abbreviations: CXR, chest X-­ray; +LR, positive likelihood ratio; LUS, lung ultrasound; N, number of children with bronchiolitis.
a
Value expressed as mean.
b
Value expressed as median.
c
In diagnosing bronchiolitis.
d
In predicting hospital admission.
e
In identifying children with bronchiolitis affected by a concomitant bacterial pneumonia.
f
When only >1 cm consolidations were considered positive for concomitant pneumonia.

TA B L E 4 Lung ultrasound prognostic

Studies N Age Findings
value for admission to paediatric intensive
Bobillo-­Perez 80 53 daysb AUC: 0.932 (95%CI 0.873–­0.990) for LUS care unit
et al.30 score, 0.675 (95%CI 0.556–­0.794)
for clinical score; Sensitivity: 90,9%,
specificity: 88.9%; +LR: 8.19
Ruiz et al.32 200 5.7 monthsa PICU/NICU admissionc: 2/16 patients
5 monthsb with normal LUS, 14/16 patients with
pathological LUS.
Supino et al.36 76 90 daysb Infants who needed ventilation with
HCPAP had a more severe ultrasound
score [2 (3–­4) vs 1 (1–­3), p = 0.028]
Garrote et al.38 59 90 daysb OR: 2.5 (95%CI 1.1–­5.9, p = 0.035)

Abbreviations: AUC, area under the curve; HCPAP, helmet continuous positive airway pressure;
+LR, positive likelihood ratio; LUS, lung ultrasound; N, number of children with bronchiolitis; NICU,
neonatal intensive care unit; OR, odds ratio; PICU, paediatric intensive care unit.
a
Value expressed as mean.
b
Value expressed as median.
c
16/200 patients admitted to PICU/NICU.

length of low flow nasal cannula.41 Though, a significant correlation
was noted between the number of affected intercostal spaces on the
right and the length of oxygen supply.
4 | DISCUSSION
Our review examined five topics about the diagnostic and prognostic
value of LUS. Topics 3.1 and 3.3 reported on a direct comparison be-
tween LUS scores and both chest radiography and clinical course in di-
agnosing bronchiolitis. LUS compared to chest radiography was found
more sensitive and specific in detecting lung abnormalities compatible
with bronchiolitis or concomitant pneumonia or both. Some LUS find-
ings, such as consolidations sized >1 cm, could be used as a useful tool
to diagnose complex cases of bronchiolitis with concomitant pneu-
monia and avoid the need to perform chest radiography.39,48 Fewer
false-­
negative results indicated that LUS could have a significant
complementary role in the primary assessment of bronchiolitis. Thus,
a greater ability to exclude bronchiolitis as a possible diagnosis in chil-
dren with no sonographic findings. It would be reasonable to consider
LUS as a first-­line examination in children who present with moderate
or severe bronchiolitis in the PED to rule out further adverse complica-
tions such as concomitant pneumonia. Furthermore, LUS served as a
good prognostic tool in the context of predicting the clinical course of
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KOGIAS et al. 229

TA B L E 5 Correlation between lung

Studies N Age Findings
ultrasound score and clinical course
31 a
Regina et al. 63 2.7 months rs = 0.62, p = 0.01
34 a
Di Mauro et al. 83 4.5 months rs = 0.23, p = 0.036c
3 monthsb rs = 0.3, p = 0.01d
Özkaya et al.35 76 7.41 monthsa rs = 0.698, p < 0.001
6 monthsb
Supino et al.36 76 90 daysb Infants who needed ventilation with HCPAP
had a more severe sonographic (2 vs
1, p = 0.028) and clinical score (7 vs 5,
p = 0.004) than the other patients
Garrote et al.38 59 90 daysb rs = 0.504, p < 0.001 e
rs = 0.518, p < 0.001f
Taveira et al.41 47 32 daysb rs = 0.09, p = 0.57
43 a
Kader et al. 25 6.94 months Sonographic signs of improvement correlated
with improved clinical course
Basile et al.45 106 87.4 daysa Κ = 0.8, p < 0.001
71 daysb
Caiulo et al.46 52 2.1 monthsb In 38/44 patients with lung consolidations
improvement of clinical score related to a
decrease in the number of consolidations

Abbreviations: HFNC, high flow nasal cannula; K, Cohen's κ; LUS, lung ultrasound; N, number of
children with bronchiolitis; rs, Spearman's rs; ΗCPAP, helmet continuous positive airway pressure.
a
Value expressed as mean.
b
Value expressed as median.
c
At admission.
d
At discharge.
e
Using the Wood Down Ferres clinical scale.
f
Using the Hospital San Joan de Deu clinical scale.

TA B L E 6 Lung ultrasound prognostic

Studies N Age Findings
value for length of hospital stay
30 b
Bobillo-­Perez et al. 80 53 days rs = 0.764 for LUS score, rs = 0.477
for clinical score
Regina et al.31 63 2.7 monthsa rs = 0.42, p < 0.01
34 a
Di Mauro et al. 83 4.5 months rs = 0.3, p < 0.001
3 monthsb
Özkaya et al.35 76 7.4 monthsa OR: 1.859 (95%CI 1.016–­3.404,
6 monthsb p = 0.044)
Bueno-­C ampaña et al.37 145 1.7 monthsb rs = 0.401, p < 0.001
Zoido Garrote et al.38 59 90 daysb Each 5-­point increase in the LUS
score was correlated to a longer
hospital stay of 1.2 days (95%CI
0.55–­1.86, p = 0.001)
Taveira et al.41 47 32 daysb rs = 0.13, p = 0.38
Basile et al.45 106 87.4 daysa LUS reflects the clinical respiratory
71 daysb status and can be used as a
screening tool in identifying
infants in need of hospitalisation.

Abbreviations: LUS, lung ultrasound; N, number of children with bronchiolitis; PICU, paediatric
intensive care unit; rs, Spearman's rs.
a
Value expressed as mean.
b
Value expressed as median.

patients and was quicker to interpret compared to chest radiography.46 Though there was a discrepancy of available data, which pointed to
Several studies successfully showed a good correlation between so- the non-­uniformity of bronchiolitis as a disease, possibly due to the
nographic scores and the clinical course of the disease.31,35,36,43,45,46 nature of its causative factors.34,38,41 However, this lack of correlation
 |

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230 KOGIAS et al.

TA B L E 7 Lung ultrasound prognostic

Studies N Age Findings
value for respiratory support
Bobillo-­Perez et al.30 80 53 daysb rs = 0.763 for LUS score, rs = 0.462 for
clinical score
Regina et al.31 63 2.7 monthsa Νo patient with mild LUS score performed
oxygen therapy. 29% of patients
with moderate LUS score performed
oxygen therapy with HFNC or LFNC.
86% of patients with severe LUS score
performed oxygen therapy with HFNC
or LFNC
Ruiz et al.32 200 5.7 monthsa Among patients with normal LUS, 3/89
5 monthsb (3.4%) were in need of respiratory
support at admission and 6/89 (6.7%)
at 48 h
Ingelse et al.33 17 2.7 monthsb rs = 0.517, p = 0.034c; rs = 0.570,
p = 0.017d; no correlation on days 2
and 6
Di Mauro et al.34 83 4.5 monthsa OR: 2.2 (95% CI 1.5–­3.3), p < 0.001
3 monthsb
Supino et al.36 76 90 daysb rs = 0.35, p = 0.003
Bueno-­C ampaña 145 1.7 monthsb rs = 0.448, p < 0.001; RR: 2.5 (95% CI:
et al.37 1.6–­4), p < 0.001
Garrote et al.38 59 90 daysb LUS was associated with the duration of
oxygen therapy: +0.87 days for every
5-­point increase in LUS score (95% CI:
0.26–­1.48), p = 0.006
Taveira et al.41 47 32 daysb rs = 0.318, p = 0.037 e
45 a
Basile et al. 106 87.4 days Sensitivity: 96.6% (95%CI: 82.2%–­99.4%),
71 daysb specificity: 98.7% (95% CI: 93%–­
99.8%), +LR: 7.43

Abbreviations: HFNC: high flow nasal cannula; LFNC: low flow nasal cannula; +LR: positive
likelihood ratio; LUS: lung ultrasound; N: number of children with bronchiolitis; RR: risk ratio; rs:
Spearman's rs.
a
Value expressed as mean.
b
Value expressed as median.
c
Correlation between LUS counting B-­line score and OSI on day 1.
d
Correlation between LUS aeration score and OSI on day 1.
e
Correlation between the number of the affected intercostal spaces on the right and the duration
of oxygen supply.

may, at least in part, have been due to the fact that clinical scores had
moderate sensitivity and specificity and thus they could not predict
accurately the severity of the disease.49
Topics 3.2, 3.4 and 3.5 elaborated on the prognostic value
of LUS as a predictor of PICU admission and the need for hos-
pital stay and respiratory support. Four studies supported
that the LUS scores could predict more accurately than the
clinical scores the need for PICU admission or advanced re-
30,32,36,38
spiratory support in patients with bronchiolitis.
30,31,32,33,34,36,37,38,41,46
ies found an evident correlation between
LUS and the need for respiratory support and two found a signif-
icant correlation36,38 between LUS scores and the duration of re-
spiratory support. It seemed that combining lung ultrasonography
findings with oxygen saturation measurements could help predict
the need for oxygen supplementation. Another firm conclusion
was that lung ultrasonography could predict the length of hospital
stay in patients with bronchiolitis. All30,31,34,37,38 but one 41 of the
studies that examined this issue found a correlation between the
severity of LUS scores with the need of hospital stay. One study
estimated the average additional in-­h ospital days for a certain LUS
score increase. 38 Higher LUS scores were correlated with longer
hospital stays. A higher LUS score in the PED could predict a worse
outcome when patients needed hospital admittance30,32,35,36 and
also correlated to the need for advanced respiratory support in
Ten stud- the form of HFNC or helmet CPAP of inpatients. 30
Upon synthesising we came across many LUS scoring systems
with variations. In their essence, they all examined the B-­line pat-
tern, its occurrence, density per intercostal space and the presence
of subpleural consolidations. Factors contributing to limitations of
this study had to be the number of varying clinical and LUS scoring
systems used by each author, which in its turn leaded to the fluc-
tuations in sensitivity and specificity between these scores. To our

KOGIAS et al.
knowledge, there was no concise review examining the differences
in the various LUS scoring systems and the impact these may have
posed when diagnosing bronchiolitis. We firmly believe that such a
study should be implemented to shed light in this direction. High in-
terobserver agreement discrepancy was attributed to the differences
in the level of expertise between healthcare providers who used the
ultrasound machine and their medical background. Moreover, there
was a selection bias in the population used in the studies comprising
this review that favours the sensitivity and specificity of LUS. Due to
the heterogeneity of the included studies, we conducted a system-
atic review and not a meta-­analysis, which could provide statistical
inference and theoretically more robust results. Despite trying to
highlight all the limitations of the included studies they were all given
equal weight in the discussion, regardless of their limitations, since
this was a systematic review and not a meta-­analysis.
5 | CO N C LU S I O N
Bronchiolitis is a pathology whose diagnosis is mostly based on
the clinical history and physical examination. The results show
that LUS could have a role is diagnosing bronchiolitis and prog-
nosing the need of PICU admission, hospital stay and respiratory
support. LUS is considered a simple, safe, quick, non-­invasive, low-­
cost, real-­t ime examination that can be used to evaluate patients
in PED and during their hospital stay and adjust management ac-
cording to sonographic findings as a useful adjunct to the clinical
ones. 50 Future prospective studies are needed to shed light on the
validity of LUS and its proper place in the management of children
with bronchiolitis. To our knowledge, there was no concise review
examining the differences in the various LUS scoring systems and
the impact these may have posed when diagnosing bronchiolitis.
We firmly believe that such a study should be implemented to
shed light in this direction.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no competing interest.
ORCID
Christos Kogias https://orcid.org/0000-0002-0864-9985
Spyridon Prountzos https://orcid.org/0000-0001-9651-8338
Efthymia Alexopoulou https://orcid.org/0000-0001-8466-4127
Konstantinos Douros https://orcid.org/0000-0001-7632-1159
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How to cite this article: Kogias C, Prountzos S, Alexopoulou E,
Douros K. Lung ultrasound systematic review shows its
prognostic and diagnostic role in acute viral bronchiolitis. Acta
Paediatr. 2023;112:222–232. https://doi.org/10.1111/
apa.16578