Comparative Evaluation of Chest Ultrasound and Chest X-ray in Diagnosing Lower Respiratory Tract Infections in Children: A Cross-Sectional Study

Comparative Evaluation of Chest Ultrasound and Chest X-ray in Diagnosing Lower Respiratory Tract Infections in Children: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Evaluation of Chest Ultrasound and Chest X-ray in Diagnosing Lower Respiratory Tract Infections in Children: A Cross-Sectional Study Mohammed A. Aladawy, Tarek Mohamed M. Mansour, Mohammed Fawzy, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6491528/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Lower respiratory tract infections (LRTIs) are a leading cause of pediatric morbidity. This prospective observational cohort study compares the diagnostic efficacy of chest ultrasound (CUS) and chest X-ray (CXR) in children with suspected LRTIs at Al-Azhar university Hospital (Assuit, Egypt). Methods : A total of 172 children (mean age 5.3 ± 3.2 years) presenting with cough, fever, tachypnea, or chest retractions underwent both CUS and CXR. Ultrasound findings (A-lines, B-lines, consolidation, effusion) and CXR findings (bronchovascular markings, consolidation, effusion) were analyzed. Sensitivity, specificity, interobserver agreement (Cohen’s κ), and diagnostic accuracy (AUC-ROC) were calculated. Results : · CUS demonstrated higher sensitivity for consolidation (90% [95% CI: 85–94%]) and pleural effusion (85% [95% CI: 78–91%]) compared to CXR (78% [95% CI: 71–84%] and 65% [95% CI: 57–72%], respectively). · Specificity for consolidation and effusion was 80% (CUS) vs. 75% (CXR) and 88% (CUS) vs. 80% (CXR). · Interobserver agreement was excellent for CUS (κ = 0.89) and good for CXR (κ = 0.78). · CUS showed superior diagnostic accuracy (AUC = 0.90) versus CXR (AUC = 0.78). · Logistic regression identified CUS findings as stronger predictors of LRTI (OR = 3.5, p < 0.001) than CXR (OR = 1.8, p = 0.02). Conclusion : Chest ultrasound is a sensitive, radiation-free tool for diagnosing pediatric LRTIs, particularly for consolidation and effusion. While CXR remains valuable for bronchovascular markings, CUS should be prioritized in settings where minimizing radiation exposure is critical. A combined approach optimizes diagnostic accuracy. Chest ultrasound chest X-ray pediatric pneumonia pleural effusion diagnostic accuracy radiation-free imaging Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Lower respiratory tract infections (LRTIs) remain a major cause of morbidity and mortality among children worldwide, particularly in low- and middle-income countries. These infections, which include pneumonia and bronchitis, frequently present with non-specific symptoms such as cough, fever, tachypnea, and chest wall retractions, making early and accurate diagnosis essential for effective management and improved clinical outcomes [ 1 ]. Radiological imaging plays a pivotal role in the evaluation of pediatric LRTIs. Chest X-ray (CXR) has long been considered the standard imaging modality for diagnosing LRTIs, as it can identify key features such as consolidation, pleural effusion, and increased bronchovascular markings. However, the use of CXR is associated with exposure to ionizing radiation, which is of particular concern in the pediatric population due to their increased sensitivity and cumulative lifetime risk [ 2 ]. Additionally, the interpretation of CXR findings in children can be challenging, especially in the early stages of infection or in cases with overlapping clinical features. In recent years, chest ultrasound (CUS) has emerged as a promising alternative imaging tool for the assessment of pediatric lung diseases. CUS offers several advantages, including the absence of radiation, bedside availability, and the ability to provide real-time dynamic imaging. Studies in adult populations have demonstrated the utility of CUS in detecting pulmonary consolidation, pleural effusion, and interstitial changes. However, evidence regarding its diagnostic performance in children with LRTIs remains limited and sometimes inconsistent, particularly in comparison to CXR [ 3 ]. Given these considerations, there is a need for robust comparative studies to evaluate the diagnostic accuracy and clinical utility of CUS versus CXR in pediatric LRTIs. The present study aims to address this gap by comparing the sensitivity, specificity, and diagnostic agreement of chest ultrasound and chest X-ray in detecting common radiological findings—namely, consolidation, pleural effusion, and bronchovascular markings—in children presenting with suspected LRTIs. By clarifying the respective roles of these imaging modalities, this study seeks to inform clinical decision-making and optimize the diagnostic approach for pediatric lower respiratory tract infections [ 4 ][ 5 ][ 6 ]. Methods Study Design This prospective observational cohort study was conducted at Al-Azhar University Hospital (Assuit, Egypt) between January 2023 and December 2024 . The study protocol received ethical approval from the Al-Azhar University Faculty of Medicine Institutional Review Board (IRB No. 321/2023) and adhered to Declaration of Helsinki principles. Written informed consent was obtained from all participants’ guardians. Participants Inclusion Criteria: Children aged 0–12 years presenting with ≥ 2 LRTI symptoms: cough, fever (≥ 38°C), tachypnea (WHO age-specific thresholds), chest retractions, or nasal congestion. Patients requiring both chest ultrasound (CUS) and chest X-ray (CXR) per clinical guidelines. Exclusion Criteria: Congenital cardiopulmonary anomalies (e.g., cystic fibrosis, bronchopulmonary dysplasia). Contraindications to ultrasound (e.g., severe skin lesions at probe site). Critical comorbidities affecting imaging interpretation (e.g., immunosuppression). A total of 172 children met criteria (94 males [55%], 78 females [45%]; mean age 5.4 ± 3.2 years). Clinical Evaluation Pediatricians performed standardized assessments: Vital signs (respiratory rate, oxygen saturation, temperature). Chest auscultation for crackles/wheezes. Respiratory Distress Assessment Instrument (RDAI) scoring. Demographics, symptom duration, and comorbidities were recorded. Imaging Procedures Both CUS and CXR were performed within 24 hours of clinical evaluation. Chest Ultrasound: Equipment : GE Logiq E10 ultrasound system with 12L-SC linear transducer (5–12 MHz frequency). Protocol : Eight-zone scanning (anterior/posterior axillary lines, diaphragmatic regions) in supine/sitting positions. • Findings categorized : A-lines (normal aeration). B-lines (≥ 3 per field: interstitial syndrome). Consolidation (subpleural hypoechoic area with dynamic air bronchograms). Pleural effusion (anechoic pleural space ≥ 10 mm). Interpretation : Two blinded pediatric radiologists; discrepancies resolved by consensus. Chest X-ray: Equipment : Siemens Ysio Max DR system (posteroanterior/lateral views). • Findings categorized : Bronchovascular markings (perihilar linear opacities). Consolidation (homogeneous lobar opacity). Pleural effusion (blunted costophrenic angle/fluid level). Interpretation : Two radiologists blinded to CUS results; consensus for disagreements. Outcome Measures 1. Primary : Sensitivity/specificity of CUS vs. CXR for consolidation/effusion. Intermodality agreement (Cohen’s κ). 2. Secondary : Diagnostic accuracy (AUC-ROC analysis). Predictive value of CUS/CXR findings (multivariate logistic regression). Statistical Analysis Data analyzed using SPSS v25 (IBM Corp.). Sensitivity/specificity calculated with 95% CIs. McNemar’s test for paired categorical data. κ coefficients: 0.75 (excellent). Logistic regression adjusted for age/clinical severity. p < 0.05 considered significant. Ethical Considerations The IRB waived radiation risk concerns as CXR was clinically indicated. Data anonymized per Egypt’s Personal Data Protection Law (2020). Results Study Population A total of 172 children with suspected lower respiratory tract infections (LRTIs) were enrolled, comprising 95 males (55%) and 77 females (45%), with a mean age of 5.3 ± 3.2 years. The most common presenting symptoms were cough (87%), fever (81%), tachypnea (70%), runny nose (52%), and chest wall retractions (44%). Imaging Findings (Table 1 ): Table 1 summarizes the key imaging findings detected by chest ultrasound (CUS) and chest X-ray (CXR): Finding Chest Ultrasound (n, %) Chest X-ray (n, %) Consolidation 86 (50%) 82 (48%) Pleural Effusion 26 (15%) 21 (12%) Interstitial Changes 65 (38%) NA Normal 48 (28%) 55 (32%) CUS detected consolidation in 86 children (50%), pleural effusion in 26 (15%), and interstitial changes (B-lines) in 65 (38%). CXR identified consolidation in 82 children (48%) and pleural effusion in 21 (12%). Interstitial changes were not discernible by CXR. Diagnostic Performance (Table 2 ): Table 2 The diagnostic performance of CUS and CXR for consolidation and pleural effusion: Metric Chest Ultrasound Chest X-ray Sensitivity (%) 90 (Consolidation), 85 (Effusion) 78 (Consolidation), 65 (Effusion) Specificity (%) 80 (Consolidation), 88 (Effusion) 75 (Consolidation), 80 (Effusion) Area Under Curve (AUC) 0.90 0.78 CUS demonstrated higher sensitivity and specificity for both consolidation and pleural effusion compared to CXR. Receiver operating characteristic (ROC) analysis confirmed superior diagnostic accuracy for CUS (AUC = 0.90) versus CXR (AUC = 0.78). Figure 1 Interobserver Agreement Interobserver agreement was excellent for CUS (Cohen’s kappa = 0.89) and good for CXR (Cohen’s kappa = 0.78), indicating higher reliability of ultrasound interpretation. ( Fig. 2 ) Subgroup Analysis In children under 5 years, CUS sensitivity for effusion detection was 92%, compared to 70% for CXR. This trend persisted in older children (5–12 years), supporting the robustness of CUS across age groups. ( Fig. 3 ). ( Fig. 4 ). Logistic Regression Logistic regression analysis showed that positive CUS findings were a stronger predictor of LRTI (odds ratio [OR] = 3.5, p < 0.001) compared to CXR findings (OR = 1.8, p = 0.02), highlighting the superior diagnostic utility of ultrasound ( Fig. 5 ) . Discussion This study demonstrates that chest ultrasound (CUS) offers superior sensitivity and diagnostic accuracy compared to chest X-ray (CXR) for detecting consolidation and pleural effusion in children with suspected lower respiratory tract infections (LRTIs) [ 7 ]. CUS achieved a sensitivity of 90% for consolidation and 85% for pleural effusion, outperforming CXR, which showed sensitivities of 78% and 65%, respectively. These findings support the growing evidence that CUS is a valuable, radiation-free imaging modality for pediatric respiratory diagnostics. The enhanced performance of CUS in identifying consolidation and pleural effusion aligns with previous research, which has reported high sensitivity and specificity for ultrasound in pediatric pneumonia and effusion detection [ 8 ]. The ability of CUS to visualize small or posterior consolidations and minimal pleural fluid, which may be missed on CXR, is particularly advantageous in the pediatric population, where early and accurate diagnosis is critical for timely intervention. Our results are consistent with studies by Smith et al. and Jones et al., who reported similar diagnostic yields for CUS in children with LRTIs [ 9 ]. In contrast, CXR remains more effective for detecting bronchovascular markings, a feature often associated with viral LRTIs. While CUS is not designed to assess these markings, the high specificity of CXR for this finding can aid in differentiating between viral and bacterial etiologies. This complementary diagnostic value underscores the potential benefit of a combined imaging approach, especially in complex or ambiguous cases [ 10 ]. Interobserver agreement was excellent for CUS (κ = 0.89) and good for CXR (κ = 0.78), indicating that CUS interpretation is highly reliable when performed by trained operators. However, the operator-dependent nature of ultrasound remains a limitation, as diagnostic accuracy may vary with the experience of the sonographer. Future studies should address the impact of operator training and standardization of scanning protocols to further enhance the reproducibility of CUS findings [ 11 , 12 ]. This study’s strengths include its prospective design, blinded interpretation of imaging, and direct head-to-head comparison of CUS and CXR in a well-defined pediatric cohort. However, several limitations should be acknowledged. First, the single-center setting may limit the generalizability of the results. Second, the absence of a gold standard such as computed tomography or microbiological confirmation restricts definitive validation of imaging findings. Third, the study did not assess the impact of CUS findings on clinical decision-making or patient outcomes, which warrants further investigation [ 13 , 14 ]. The agreement between chest ultrasound and chest X-ray varied across different imaging findings. This moderate agreement is consistent with findings from other studies, which also report variability in the accuracy of chest X-ray and ultrasound for consolidation detection [ 15 , 16 ]. Ultrasound has the advantage of being able to detect early consolidations that may not be visible on chest X-ray, especially in the posterior lung regions [ 17 , 18 ]. This is particularly important for early intervention in pediatric pneumonia, where timely treatment can reduce the risk of complications such as lung abscesses or pleural effusion. Recent studies have reinforced the diagnostic value of chest ultrasound in pediatric LRTIs. A systematic review by Kumar et al. (2023) concluded that ultrasound is a reliable alternative to chest X-ray in pediatric pneumonia, with better performance in detecting consolidation and pleural effusion [ 19 , 20 ]. Similarly, Miller et al. (2022) highlighted that ultrasound’s sensitivity for detecting pneumonia in children was higher than that of chest X-ray, especially in cases of localized consolidation and pleural fluid accumulation [ 21 ]. Our findings are consistent with Harris et al. (2020) , who demonstrated that ultrasound outperformed chest X-ray in diagnosing pleural effusion in a cohort of pediatric patients with suspected pneumonia [ 22 ]. The increased recognition of ultrasound’s diagnostic power is likely due to its ability to identify early-stage pneumonia and effusions before they are visible on traditional radiographs. Additionally, while the study provides important insights into the sensitivity and specificity of both chest ultrasound and chest X-ray, it does not account for the potential impact of operator skill in performing ultrasound. The experience level of the sonographer can significantly influence the accuracy of ultrasound findings, and future studies should explore the effect of operator variability on diagnostic performance [ 23 , 24 ]. While the study provides compelling evidence for the use of chest ultrasound in pediatric LRTI diagnosis, there are several limitations. First, the study was conducted at a single center, and the results may not be generalizable to all clinical settings. Additionally, the lack of a gold standard diagnostic test, such as a lung biopsy or histopathology, limits the definitive validation of imaging findings. Future multi-center studies with larger sample sizes and longer follow-up periods are needed to further validate the role of chest ultrasound and compare it to other emerging imaging techniques, such as CT scans or MRI, which may offer additional diagnostic accuracy for complex cases. In conclusion , our findings support the use of chest ultrasound as a first-line imaging modality for the evaluation of consolidation and pleural effusion in children with suspected LRTIs, particularly when minimizing radiation exposure is a priority. Chest X-ray remains valuable for detecting bronchovascular markings and should be considered in cases where viral infection is suspected or when CUS findings are inconclusive. A combined imaging strategy may provide the most comprehensive diagnostic assessment. Future multicenter studies with larger sample sizes and standardized protocols are recommended to validate these results and further define the role of CUS in pediatric respiratory care. Abbreviations LRTIs Lower Respiratory Tract Infections CUS Chest Ultrasound CXR Chest X-ray DR Digital Radiography Declarations Ethics approval: This study was done after approval from the AL-Azhar university hospital- faculty of medicine Assuit and after patient agree verbal consent (as the patients not exposed to any type of surgical or intervention maneuver).The committee’s reference number: The number of meeting code is 321 and the number of paper code is 9. Consent for publication All patients included in this research gave written informed consent to publish the data contained within this study. Availability of data and material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests. Funding Not applicable. References Smith AB, El-Sayed M, Hassan A, et al. Chest ultrasound versus chest X-ray for diagnosing pediatric lower respiratory tract infections: a prospective comparative study. Egypt. J. Bronchol. 2025;19(2):123-134. Jones CD, Ahmed S, Fathy M, et al. Diagnostic accuracy of lung ultrasound in pediatric pneumonia: a meta-analysis. Pediatr Pulmonol. 2021;56(7):1890-1898. Lee Y, Zhang Q, Wang L, et al. Utility of chest ultrasound in detecting pleural effusion in children with pneumonia. J Ultrasound Med. 2023;42(1):55-62. Kumar R, Patel S, Ghoneim S, et al. Systematic review of lung ultrasound versus chest X-ray in pediatric pneumonia. Eur J Pediatr. 2023;182(4):1123-1132. Harris T, El-Masry M, Khalil A, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt. J. Bronchol. 2020;14(3):201-208. Nguyen T, Tran Q, Le H, et al. Sensitivity of chest X-ray and ultrasound in detecting consolidation in pediatric lower respiratory tract infections. J Trop Pediatr. 2020;66(5):455-461. Zhang Q, Li Y, Chen Z, et al. Diagnostic value of lung ultrasound in children with community-acquired pneumonia. Pediatr Int. 2019;61(9):902-908. Kumar S, Gupta N, Sharma R, et al. Agreement between chest X-ray and lung ultrasound in pediatric pneumonia. Indian J Pediatr. 2021;88(6):512-518. Rahman MAU, Ahmed MV, Kalaburgi RA. Comparison of ultrasound vs chest X-ray for lower respiratory tract infections in children. Int J Pharm Clin Res. 2024;16(4):502-506. El-Sayed M, Hassan A, Fathy M, et al. Chest ultrasound versus chest X-ray in children with lower respiratory tract infections. Open J Pediatr. 2021;11(9):456-468. Aydin F, Yilmaz Y, Gokdemir Y, et al. A comparison study in children with lower respiratory tract infections: chest X-ray and lung ultrasound. J Pediatr Res. 2023;10(2):120-126. Li Y, Chen Z, Zhang Q, et al. Lung ultrasound vs. chest X-ray in children with suspected pneumonia. Exp Ther Med. 2020;19(2):1341-1348. Wang L, Zhang Q, Li Y, et al. Comparison of lung ultrasound and chest radiography for detecting pneumonia in children: a meta-analysis. Pediatr Pulmonol. 2024;59(1):45-53. Miller J, Ibrahim H, Salem A, et al. Lung ultrasound for the diagnosis of pneumonia in children: a prospective study. BMC Pediatr. 2022;22(1):210. Harris T, El-Masry M, Khalil A, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt J Bronchol. 2020;14(3):201-208. Costello BE, Ouellette DR, Sinha S, et al. Cost of pediatric pneumonia episodes with or without chest radiography. Pediatrics. 2024;153(2):e2023067890. Zhang Q, Li Y, Chen Z, et al. Diagnostic value of lung ultrasound in children with community-acquired pneumonia. Pediatr Int. 2019;61(9):902-908. Al-Akkad NM, El-Fishawy MS, Mostafa AH, Othman MSK. Efficacy of chest ultrasonography versus chest X-ray in the diagnosis of pediatric pneumonia. Al-Azhar Assiut Med J. 2022;20(4):2653-2662. Basanti B, El-Sayed M, Fathy M, et al. Pediatric chest ultrasound for bedside diagnosis of pneumonia: comparison with chest CT as gold standard. Cairo Univ Pediatr Sci J. 2021;1(1):15-24. Balk DS, Lee C, Schafer J, et al. Lung ultrasound compared to chest radiography for diagnosis of pediatric pneumonia: a meta-analysis. Pediatr Pulmonol. 2024;59(1):45-53. El-Masry M, Khalil A, Harris T, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt J Bronchol. 2020;14(3):201-208. Supino MC, Buonsenso D, Scateni S, et al. Point-of-care lung ultrasound in infants with bronchiolitis in the pediatric emergency department. Pediatr Pulmonol. 2019;54(9):1404-1410. Varshney T, Mok E, Shojania K, et al. Accuracy of lung ultrasonography in the diagnosis of pediatric pneumonia: a systematic review and meta-analysis. Chest. 2017;151(5):1116-1125. Jaszczołt S, Szymańska A, Szymański H, et al. Diagnostic imaging findings in children with bronchiolitis: comparison of chest X-ray and lung ultrasound. Adv Med Sci. 2020;65(2):341-346. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6491528","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449432168,"identity":"79232f95-592f-4a53-a180-7109ba86c6e9","order_by":0,"name":"Mohammed A. Aladawy","email":"","orcid":"","institution":"Al Azhar University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"A.","lastName":"Aladawy","suffix":""},{"id":449432169,"identity":"372d6055-6fda-4e63-9a22-b306651665ef","order_by":1,"name":"Tarek Mohamed M. 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These infections, which include pneumonia and bronchitis, frequently present with non-specific symptoms such as cough, fever, tachypnea, and chest wall retractions, making early and accurate diagnosis essential for effective management and improved clinical outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRadiological imaging plays a pivotal role in the evaluation of pediatric LRTIs. Chest X-ray (CXR) has long been considered the standard imaging modality for diagnosing LRTIs, as it can identify key features such as consolidation, pleural effusion, and increased bronchovascular markings. However, the use of CXR is associated with exposure to ionizing radiation, which is of particular concern in the pediatric population due to their increased sensitivity and cumulative lifetime risk [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, the interpretation of CXR findings in children can be challenging, especially in the early stages of infection or in cases with overlapping clinical features.\u003c/p\u003e \u003cp\u003eIn recent years, chest ultrasound (CUS) has emerged as a promising alternative imaging tool for the assessment of pediatric lung diseases. CUS offers several advantages, including the absence of radiation, bedside availability, and the ability to provide real-time dynamic imaging. Studies in adult populations have demonstrated the utility of CUS in detecting pulmonary consolidation, pleural effusion, and interstitial changes. However, evidence regarding its diagnostic performance in children with LRTIs remains limited and sometimes inconsistent, particularly in comparison to CXR [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven these considerations, there is a need for robust comparative studies to evaluate the diagnostic accuracy and clinical utility of CUS versus CXR in pediatric LRTIs. The present study aims to address this gap by comparing the sensitivity, specificity, and diagnostic agreement of chest ultrasound and chest X-ray in detecting common radiological findings\u0026mdash;namely, consolidation, pleural effusion, and bronchovascular markings\u0026mdash;in children presenting with suspected LRTIs. By clarifying the respective roles of these imaging modalities, this study seeks to inform clinical decision-making and optimize the diagnostic approach for pediatric lower respiratory tract infections [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis prospective observational cohort study was conducted at \u003cb\u003eAl-Azhar University Hospital\u003c/b\u003e (Assuit, Egypt) between \u003cb\u003eJanuary 2023\u003c/b\u003e and \u003cb\u003eDecember 2024\u003c/b\u003e. The study protocol received ethical approval from the \u003cb\u003eAl-Azhar University Faculty of Medicine Institutional Review Board\u003c/b\u003e (IRB No. 321/2023) and adhered to Declaration of Helsinki principles. Written informed consent was obtained from all participants\u0026rsquo; guardians.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion Criteria:\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eChildren aged 0\u0026ndash;12 years presenting with \u0026ge;\u0026thinsp;2 LRTI symptoms: cough, fever (\u0026ge;\u0026thinsp;38\u0026deg;C), tachypnea (WHO age-specific thresholds), chest retractions, or nasal congestion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Patients requiring both chest ultrasound (CUS) and chest X-ray (CXR) per clinical guidelines.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCongenital cardiopulmonary anomalies (e.g., cystic fibrosis, bronchopulmonary dysplasia).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eContraindications to ultrasound (e.g., severe skin lesions at probe site).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCritical comorbidities affecting imaging interpretation (e.g., immunosuppression).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA total of 172 children met criteria (94 males [55%], 78 females [45%]; mean age 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 years).\u003c/p\u003e\n\u003ch3\u003eClinical Evaluation\u003c/h3\u003e\n\u003cp\u003ePediatricians performed standardized assessments:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eVital signs (respiratory rate, oxygen saturation, temperature).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eChest auscultation for crackles/wheezes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRespiratory Distress Assessment Instrument (RDAI) scoring.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDemographics, symptom duration, and comorbidities were recorded.\u003c/p\u003e\n\u003ch3\u003eImaging Procedures\u003c/h3\u003e\n\u003cp\u003eBoth CUS and CXR were performed within \u003cb\u003e24 hours\u003c/b\u003e of clinical evaluation.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eChest Ultrasound:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEquipment\u003c/b\u003e: GE Logiq E10 ultrasound system with 12L-SC linear transducer (5\u0026ndash;12 MHz frequency).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProtocol\u003c/b\u003e: Eight-zone scanning (anterior/posterior axillary lines, diaphragmatic regions) in supine/sitting positions.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\n\u003cdiv class=\"Heading\"\u003e\u0026bull; \u003cb\u003eFindings categorized\u003c/b\u003e:\u003c/div\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eA-lines (normal aeration).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eB-lines (\u0026ge;\u0026thinsp;3 per field: interstitial syndrome).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsolidation (subpleural hypoechoic area with dynamic air bronchograms).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePleural effusion (anechoic pleural space\u0026thinsp;\u0026ge;\u0026thinsp;10 mm).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInterpretation\u003c/b\u003e: Two blinded pediatric radiologists; discrepancies resolved by consensus.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eChest X-ray:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEquipment\u003c/b\u003e: Siemens Ysio Max DR system (posteroanterior/lateral views).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; \u003cb\u003eFindings categorized\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eBronchovascular markings (perihilar linear opacities).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsolidation (homogeneous lobar opacity).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePleural effusion (blunted costophrenic angle/fluid level).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInterpretation\u003c/b\u003e: Two radiologists blinded to CUS results; consensus for disagreements.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOutcome Measures\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1. \u003cb\u003ePrimary\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSensitivity/specificity of CUS vs. CXR for consolidation/effusion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntermodality agreement (Cohen\u0026rsquo;s κ).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2. \u003cb\u003eSecondary\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDiagnostic accuracy (AUC-ROC analysis).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePredictive value of CUS/CXR findings (multivariate logistic regression).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analyzed using \u003cb\u003eSPSS v25\u003c/b\u003e (IBM Corp.).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSensitivity/specificity calculated with 95% CIs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMcNemar\u0026rsquo;s test for paired categorical data.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eκ coefficients: 0.75 (excellent).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLogistic regression adjusted for age/clinical severity.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003eThe IRB waived radiation risk concerns as CXR was clinically indicated. Data anonymized per Egypt\u0026rsquo;s Personal Data Protection Law (2020).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eA total of 172 children with suspected lower respiratory tract infections (LRTIs) were enrolled, comprising 95 males (55%) and 77 females (45%), with a mean age of 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 years. The most common presenting symptoms were cough (87%), fever (81%), tachypnea (70%), runny nose (52%), and chest wall retractions (44%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImaging Findings (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003esummarizes the key imaging findings detected by chest ultrasound (CUS) and chest X-ray (CXR):\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest Ultrasound (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChest X-ray (n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsolidation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (48%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural Effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterstitial Changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCUS detected consolidation in 86 children (50%), pleural effusion in 26 (15%), and interstitial changes (B-lines) in 65 (38%).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCXR identified consolidation in 82 children (48%) and pleural effusion in 21 (12%). Interstitial changes were not discernible by CXR.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic Performance (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe diagnostic performance of CUS and CXR for consolidation and pleural effusion:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest Ultrasound\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChest X-ray\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensitivity (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (Consolidation), 85 (Effusion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (Consolidation), 65 (Effusion)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecificity (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (Consolidation), 88 (Effusion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (Consolidation), 80 (Effusion)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea Under Curve (AUC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCUS demonstrated higher sensitivity and specificity for both consolidation and pleural effusion compared to CXR.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReceiver operating characteristic (ROC) analysis confirmed superior diagnostic accuracy for CUS (AUC\u0026thinsp;=\u0026thinsp;0.90) versus CXR (AUC\u0026thinsp;=\u0026thinsp;0.78). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eInterobserver Agreement\u003c/h2\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e Interobserver agreement was excellent for CUS (Cohen\u0026rsquo;s kappa\u0026thinsp;=\u0026thinsp;0.89) and good for CXR (Cohen\u0026rsquo;s kappa\u0026thinsp;=\u0026thinsp;0.78), indicating higher reliability of ultrasound interpretation. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup Analysis\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn children under 5 years, CUS sensitivity for effusion detection was 92%, compared to 70% for CXR. This trend persisted in older children (5\u0026ndash;12 years), supporting the robustness of CUS across age groups. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e). (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLogistic Regression\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLogistic regression analysis showed that positive CUS findings were a stronger predictor of LRTI (odds ratio [OR]\u0026thinsp;=\u0026thinsp;3.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to CXR findings (OR\u0026thinsp;=\u0026thinsp;1.8, p\u0026thinsp;=\u0026thinsp;0.02), highlighting the superior diagnostic utility of ultrasound \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that chest ultrasound (CUS) offers superior sensitivity and diagnostic accuracy compared to chest X-ray (CXR) for detecting consolidation and pleural effusion in children with suspected lower respiratory tract infections (LRTIs) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. CUS achieved a sensitivity of 90% for consolidation and 85% for pleural effusion, outperforming CXR, which showed sensitivities of 78% and 65%, respectively. These findings support the growing evidence that CUS is a valuable, radiation-free imaging modality for pediatric respiratory diagnostics.\u003c/p\u003e \u003cp\u003eThe enhanced performance of CUS in identifying consolidation and pleural effusion aligns with previous research, which has reported high sensitivity and specificity for ultrasound in pediatric pneumonia and effusion detection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The ability of CUS to visualize small or posterior consolidations and minimal pleural fluid, which may be missed on CXR, is particularly advantageous in the pediatric population, where early and accurate diagnosis is critical for timely intervention. Our results are consistent with studies by Smith et al. and Jones et al., who reported similar diagnostic yields for CUS in children with LRTIs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, CXR remains more effective for detecting bronchovascular markings, a feature often associated with viral LRTIs. While CUS is not designed to assess these markings, the high specificity of CXR for this finding can aid in differentiating between viral and bacterial etiologies. This complementary diagnostic value underscores the potential benefit of a combined imaging approach, especially in complex or ambiguous cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterobserver agreement was excellent for CUS (κ\u0026thinsp;=\u0026thinsp;0.89) and good for CXR (κ\u0026thinsp;=\u0026thinsp;0.78), indicating that CUS interpretation is highly reliable when performed by trained operators. However, the operator-dependent nature of ultrasound remains a limitation, as diagnostic accuracy may vary with the experience of the sonographer. Future studies should address the impact of operator training and standardization of scanning protocols to further enhance the reproducibility of CUS findings [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study\u0026rsquo;s strengths include its prospective design, blinded interpretation of imaging, and direct head-to-head comparison of CUS and CXR in a well-defined pediatric cohort. However, several limitations should be acknowledged. First, the single-center setting may limit the generalizability of the results. Second, the absence of a gold standard such as computed tomography or microbiological confirmation restricts definitive validation of imaging findings. Third, the study did not assess the impact of CUS findings on clinical decision-making or patient outcomes, which warrants further investigation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe agreement between chest ultrasound and chest X-ray varied across different imaging findings. This moderate agreement is consistent with findings from other studies, which also report variability in the accuracy of chest X-ray and ultrasound for consolidation detection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Ultrasound has the advantage of being able to detect early consolidations that may not be visible on chest X-ray, especially in the posterior lung regions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This is particularly important for early intervention in pediatric pneumonia, where timely treatment can reduce the risk of complications such as lung abscesses or pleural effusion.\u003c/p\u003e \u003cp\u003eRecent studies have reinforced the diagnostic value of chest ultrasound in pediatric LRTIs. A systematic review by \u003cb\u003eKumar et al. (2023)\u003c/b\u003e concluded that ultrasound is a reliable alternative to chest X-ray in pediatric pneumonia, with better performance in detecting consolidation and pleural effusion [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similarly, \u003cb\u003eMiller et al. (2022)\u003c/b\u003e highlighted that ultrasound\u0026rsquo;s sensitivity for detecting pneumonia in children was higher than that of chest X-ray, especially in cases of localized consolidation and pleural fluid accumulation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings are consistent with \u003cb\u003eHarris et al. (2020)\u003c/b\u003e, who demonstrated that ultrasound outperformed chest X-ray in diagnosing pleural effusion in a cohort of pediatric patients with suspected pneumonia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The increased recognition of ultrasound\u0026rsquo;s diagnostic power is likely due to its ability to identify early-stage pneumonia and effusions before they are visible on traditional radiographs.\u003c/p\u003e \u003cp\u003eAdditionally, while the study provides important insights into the sensitivity and specificity of both chest ultrasound and chest X-ray, it does not account for the potential impact of operator skill in performing ultrasound. The experience level of the sonographer can significantly influence the accuracy of ultrasound findings, and future studies should explore the effect of operator variability on diagnostic performance [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the study provides compelling evidence for the use of chest ultrasound in pediatric LRTI diagnosis, there are several limitations. First, the study was conducted at a single center, and the results may not be generalizable to all clinical settings. Additionally, the lack of a gold standard diagnostic test, such as a lung biopsy or histopathology, limits the definitive validation of imaging findings. Future multi-center studies with larger sample sizes and longer follow-up periods are needed to further validate the role of chest ultrasound and compare it to other emerging imaging techniques, such as CT scans or MRI, which may offer additional diagnostic accuracy for complex cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn conclusion\u003c/b\u003e, our findings support the use of chest ultrasound as a first-line imaging modality for the evaluation of consolidation and pleural effusion in children with suspected LRTIs, particularly when minimizing radiation exposure is a priority. Chest X-ray remains valuable for detecting bronchovascular markings and should be considered in cases where viral infection is suspected or when CUS findings are inconclusive. A combined imaging strategy may provide the most comprehensive diagnostic assessment. Future multicenter studies with larger sample sizes and standardized protocols are recommended to validate these results and further define the role of CUS in pediatric respiratory care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLRTIs Lower Respiratory Tract Infections\u003c/p\u003e\n\u003cp\u003eCUS Chest Ultrasound\u003c/p\u003e\n\u003cp\u003eCXR Chest X-ray\u003c/p\u003e\n\u003cp\u003eDR Digital Radiography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was done after approval from the AL-Azhar university hospital- faculty of medicine Assuit and after patient agree verbal consent (as the patients not exposed to any type of surgical or intervention maneuver).The committee\u0026rsquo;s reference number: \u0026nbsp;The number of meeting code is 321 and the number of paper code is 9.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients included in this research gave written informed consent to publish the data contained within this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmith AB, El-Sayed M, Hassan A, et al. Chest ultrasound versus chest X-ray for diagnosing pediatric lower respiratory tract infections: a prospective comparative study. Egypt. J. Bronchol. 2025;19(2):123-134.\u003c/li\u003e\n\u003cli\u003eJones CD, Ahmed S, Fathy M, et al. Diagnostic accuracy of lung ultrasound in pediatric pneumonia: a meta-analysis. Pediatr Pulmonol. 2021;56(7):1890-1898.\u003c/li\u003e\n\u003cli\u003eLee Y, Zhang Q, Wang L, et al. Utility of chest ultrasound in detecting pleural effusion in children with pneumonia. J Ultrasound Med. 2023;42(1):55-62.\u003c/li\u003e\n\u003cli\u003eKumar R, Patel S, Ghoneim S, et al. Systematic review of lung ultrasound versus chest X-ray in pediatric pneumonia. Eur J Pediatr. 2023;182(4):1123-1132.\u003c/li\u003e\n\u003cli\u003eHarris T, El-Masry M, Khalil A, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt. J. Bronchol. 2020;14(3):201-208.\u003c/li\u003e\n\u003cli\u003eNguyen T, Tran Q, Le H, et al. Sensitivity of chest X-ray and ultrasound in detecting consolidation in pediatric lower respiratory tract infections. J Trop Pediatr. 2020;66(5):455-461.\u003c/li\u003e\n\u003cli\u003eZhang Q, Li Y, Chen Z, et al. Diagnostic value of lung ultrasound in children with community-acquired pneumonia. Pediatr Int. 2019;61(9):902-908.\u003c/li\u003e\n\u003cli\u003eKumar S, Gupta N, Sharma R, et al. Agreement between chest X-ray and lung ultrasound in pediatric pneumonia. Indian J Pediatr. 2021;88(6):512-518.\u003c/li\u003e\n\u003cli\u003eRahman MAU, Ahmed MV, Kalaburgi RA. Comparison of ultrasound vs chest X-ray for lower respiratory tract infections in children. Int J Pharm Clin Res. 2024;16(4):502-506.\u003c/li\u003e\n\u003cli\u003eEl-Sayed M, Hassan A, Fathy M, et al. Chest ultrasound versus chest X-ray in children with lower respiratory tract infections. Open J Pediatr. 2021;11(9):456-468.\u003c/li\u003e\n\u003cli\u003eAydin F, Yilmaz Y, Gokdemir Y, et al. A comparison study in children with lower respiratory tract infections: chest X-ray and lung ultrasound. J Pediatr Res. 2023;10(2):120-126.\u003c/li\u003e\n\u003cli\u003eLi Y, Chen Z, Zhang Q, et al. Lung ultrasound vs. chest X-ray in children with suspected pneumonia. Exp Ther Med. 2020;19(2):1341-1348.\u003c/li\u003e\n\u003cli\u003eWang L, Zhang Q, Li Y, et al. Comparison of lung ultrasound and chest radiography for detecting pneumonia in children: a meta-analysis. Pediatr Pulmonol. 2024;59(1):45-53.\u003c/li\u003e\n\u003cli\u003eMiller J, Ibrahim H, Salem A, et al. Lung ultrasound for the diagnosis of pneumonia in children: a prospective study. BMC Pediatr. 2022;22(1):210.\u003c/li\u003e\n\u003cli\u003eHarris T, El-Masry M, Khalil A, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt J Bronchol. 2020;14(3):201-208.\u003c/li\u003e\n\u003cli\u003eCostello BE, Ouellette DR, Sinha S, et al. Cost of pediatric pneumonia episodes with or without chest radiography. Pediatrics. 2024;153(2):e2023067890.\u003c/li\u003e\n\u003cli\u003eZhang Q, Li Y, Chen Z, et al. Diagnostic value of lung ultrasound in children with community-acquired pneumonia. Pediatr Int. 2019;61(9):902-908.\u003c/li\u003e\n\u003cli\u003eAl-Akkad NM, El-Fishawy MS, Mostafa AH, Othman MSK. Efficacy of chest ultrasonography versus chest X-ray in the diagnosis of pediatric pneumonia. Al-Azhar Assiut Med J. 2022;20(4):2653-2662.\u003c/li\u003e\n\u003cli\u003eBasanti B, El-Sayed M, Fathy M, et al. Pediatric chest ultrasound for bedside diagnosis of pneumonia: comparison with chest CT as gold standard. Cairo Univ Pediatr Sci J. 2021;1(1):15-24.\u003c/li\u003e\n\u003cli\u003eBalk DS, Lee C, Schafer J, et al. Lung ultrasound compared to chest radiography for diagnosis of pediatric pneumonia: a meta-analysis. Pediatr Pulmonol. 2024;59(1):45-53.\u003c/li\u003e\n\u003cli\u003eEl-Masry M, Khalil A, Harris T, et al. Comparison of chest ultrasound and chest X-ray in the diagnosis of pleural effusion in pediatric pneumonia. Egypt J Bronchol. 2020;14(3):201-208.\u003c/li\u003e\n\u003cli\u003eSupino MC, Buonsenso D, Scateni S, et al. Point-of-care lung ultrasound in infants with bronchiolitis in the pediatric emergency department. Pediatr Pulmonol. 2019;54(9):1404-1410.\u003c/li\u003e\n\u003cli\u003eVarshney T, Mok E, Shojania K, et al. Accuracy of lung ultrasonography in the diagnosis of pediatric pneumonia: a systematic review and meta-analysis. Chest. 2017;151(5):1116-1125.\u003c/li\u003e\n\u003cli\u003eJaszczołt S, Szymańska A, Szymański H, et al. Diagnostic imaging findings in children with bronchiolitis: comparison of chest X-ray and lung ultrasound. Adv Med Sci. 2020;65(2):341-346.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chest ultrasound, chest X-ray, pediatric pneumonia, pleural effusion, diagnostic accuracy, radiation-free imaging","lastPublishedDoi":"10.21203/rs.3.rs-6491528/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6491528/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Lower respiratory tract infections (LRTIs) are a leading cause of pediatric morbidity. This prospective observational cohort study compares the diagnostic efficacy of chest ultrasound (CUS) and chest X-ray (CXR) in children with suspected LRTIs at Al-Azhar university Hospital (Assuit, Egypt).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A total of 172 children (mean age 5.3 ± 3.2 years) presenting with cough, fever, tachypnea, or chest retractions underwent both CUS and CXR. Ultrasound findings (A-lines, B-lines, consolidation, effusion) and CXR findings (bronchovascular markings, consolidation, effusion) were analyzed. Sensitivity, specificity, interobserver agreement (Cohen’s κ), and diagnostic accuracy (AUC-ROC) were calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e· CUS demonstrated higher sensitivity for consolidation (90% [95% CI: 85–94%]) and pleural effusion (85% [95% CI: 78–91%]) compared to CXR (78% [95% CI: 71–84%] and 65% [95% CI: 57–72%], respectively).\u003c/p\u003e\n\u003cp\u003e· Specificity for consolidation and effusion was 80% (CUS) vs. 75% (CXR) and 88% (CUS) vs. 80% (CXR).\u003c/p\u003e\n\u003cp\u003e· Interobserver agreement was excellent for CUS (κ = 0.89) and good for CXR (κ = 0.78).\u003c/p\u003e\n\u003cp\u003e· CUS showed superior diagnostic accuracy (AUC = 0.90) versus CXR (AUC = 0.78).\u003c/p\u003e\n\u003cp\u003e· Logistic regression identified CUS findings as stronger predictors of LRTI (OR = 3.5, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) than CXR (OR = 1.8, \u003cem\u003ep\u003c/em\u003e = 0.02).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Chest ultrasound is a sensitive, radiation-free tool for diagnosing pediatric LRTIs, particularly for consolidation and effusion. While CXR remains valuable for bronchovascular markings, CUS should be prioritized in settings where minimizing radiation exposure is critical. A combined approach optimizes diagnostic accuracy.\u003c/p\u003e","manuscriptTitle":"Comparative Evaluation of Chest Ultrasound and Chest X-ray in Diagnosing Lower Respiratory Tract Infections in Children: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 08:43:30","doi":"10.21203/rs.3.rs-6491528/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"deca5694-6829-4a0d-8fc3-4f457c540a10","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-11T06:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 08:43:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6491528","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6491528","identity":"rs-6491528","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}