Original Contribution| Volume 49, ISSUE 5, P1194-1201, May 2023

Lung Ultrasound Protocol and Quality Control of Image Interpretation Using an Adjudication Panel in the Household Air Pollution Intervention Network (HAPIN) Trial


      Lung ultrasound (LUS) is an alternative to chest radiography to confirm a diagnosis of pneumonia. For research and disease surveillance, methods to use LUS to diagnose pneumonia are needed.


      In the Household Air Pollution Intervention Network (HAPIN) trial, LUS was used to confirm a clinical diagnosis of severe pneumonia in infants. We developed a standardized definition of pneumonia, protocols for recruitment and training of sonographers, along with LUS image acquisition and interpretation. We use a blinded panel approach to interpretation with LUS cine-loops randomized to non-scanning sonographers with expert review.


      We obtained 357 lung ultrasound scans: 159, 8 and 190 scans were collected in Guatemala, Peru and Rwanda, respectively. The diagnosis of primary endpoint pneumonia (PEP) required an expert tie breaker in 181 scans (39%). PEP was diagnosed in 141 scans (40%), not diagnosed in 213 (60%), with 3 scans (<1%) deemed uninterpretable. Agreement among the two blinded sonographers and the expert reader in Guatemala, Peru and Rwanda was 65%, 62% and 67%, with a prevalence-and-bias-corrected kappa of 0.30, 0.24 and 0.33, respectively.


      Use of standardized imaging protocols, training and an adjudication panel resulted in high confidence for the diagnosis of pneumonia using LUS.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Ultrasound in Medicine and Biology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • McAllister DA
        • Liu L
        • Shi T
        • Chu Y
        • Reed C
        • Burrows J
        • et al.
        Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis.
        Lancet Glob Health. 2019; 7: e47-e57
        • World Health Organization
        Pocket book of hospital care for children.
        2nd ed. Author, Geneva2013
        • Goodman D
        • Crocker ME
        • Pervaiz F
        • McCollum ED
        • Streenland K
        • Simkovich SM
        • et al.
        Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group.
        Lancet Resp Med. 2019; 7: 1068-1108
        • Mahomed N
        • Fancourt N
        • de Campo J
        • de Campo M
        • Akano A
        • Cherian T
        • et al.
        Preliminary report from the World Health Organisation Chest Radiography in Epidemiological Studies project.
        Pediatr Radiol. 2017; 47: 1399-1404
        • Smith KR
        • McCracken JP
        • Weber MW
        • Hubbard A
        • Jenny A
        • Thompson LM
        • et al.
        Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial.
        Lancet. 2011; 378: 1717-1726
        • Komatsu CV
        • Silva CC
        • de Souza LRMF
        • Gonçalves LF
        Excess radiation to newborns hospitalized in the intensive care unit.
        Radiat Prot Dosimetry. 2017; 177: 331-341
        • Ellington LE
        • Gilman RH
        • Chavez MA
        • Pervaiz F
        • Marin-Concha J
        • Compen-Chang P
        • et al.
        Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings.
        Respir Med. 2017; 128: 57-64
        • Iorio G
        • Capasso M
        • Prisco S
        • De Luca G
        • Mancusi C
        • Laganà B
        • et al.
        Lung ultrasound findings undetectable by chest radiography in children with community-acquired pneumonia.
        Ultrasound Med Biol. 2018; 44: 1687-1693
        • Miller LE
        • Stoller JZ
        • Fraga MV
        Point-of-care ultrasound in the neonatal ICU.
        Curr Opin Pediatr. 2020; 32: 216-227
        • Orso D
        • Ban A
        • Guglielmo N
        Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis.
        J Ultrasound. 2018; 21: 183-195
        • Balk DS
        • Lee C
        • Schafer J
        • Welwarth J
        • Hardin J
        • Novack V
        • et al.
        Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: a meta-analysis.
        Pediatr Pulmonol. 2018; 53: 1130-1139
        • Pereda MA
        • Chavez MA
        • Hooper-Miele CC
        • et al.
        Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis.
        Pediatrics. 2015; 135: 714-722
        • Tsou PY
        • Chen KP
        • Wang YH
        • Fishe J
        • Gillon J
        • Lee CC
        • et al.
        Diagnostic accuracy of lung ultrasound performed by novice versus advanced sonographers for pneumonia in children: a systematic review and meta-analysis.
        Acad Emerg Med. 2019; 26: 1074-1088
        • Marini TJ
        • Castaneda B
        • Baran T
        • O'Connor TP
        • Garra B
        • Tamayo L
        • et al.
        Lung ultrasound volume sweep imaging for pneumonia detection in rural areas: piloting training in rural Peru.
        Clin Imaging Sci. 2019; 9: 35
        • Nadimpalli A
        • Tsung JW
        • Sanchez R
        • et al.
        Feasibility of training clinical officers in point-of-care ultrasound for pediatric respiratory diseases in Aweil, South Sudan.
        Am J Trop Med Hyg. 2019; 101: 689-695
        • Pervaiz F
        • Hossen S
        • Chavez MA
        • Miele CH
        • Moulton LH
        • McCollum ED
        • et al.
        Training and standardization of general practitioners in the use of lung ultrasound for the diagnosis of pediatric pneumonia.
        Pediat Pulmonol. 2019; 54: 1753-1759
        • Simkovich SM
        • Underhill LJ
        • Kirby MA
        • Goodman D
        • Crocker ME
        • Hossen S
        • et al.
        Design and conduct of facility-based surveillance for severe childhood pneumonia in the Household Air Pollution Intervention Network (HAPIN) trial.
        ERJ Open Res. 2020; 6: 00308-02019
        • Barr DB
        • Puttaswamy N
        • Jaacks LM
        • Steenland K
        • Rajkumar S
        • Gupton S
        • et al.
        Design and rationale of the biomarker center of the Household Air Pollution Intervention Network (HAPIN) Trial.
        Environ Health Perspect. 2020; 128: 47010
        • Clasen T
        • Checkley W
        • Peel JL
        • Balakrishnan K
        • McCracken JP
        • Rosa G
        • et al.
        Design and rationale of the HAPIN Study: a multicountry randomized controlled trial to assess the effect of liquefied petroleum gas stove and continuous fuel distribution.
        Environ Health Perspect. 2020; 128: 47008
        • Dávila-Román VG
        • Toenjes AK
        • Meyers RM
        • Lenzen PM
        • Simkovich SM
        • Herrera P
        • et al.
        Ultrasound core laboratory for the household Air Pollution Intervention Network Trial: standardized training and image management for field studies using portable ultrasound in fetal, lung, and vascular evaluations.
        Ultrasound Med Biol. 2021; 47: 1506-1513
        • Simkovich SM
        • Thompson LM
        • Clark ML
        • Balakrishnan K
        • Bussalleu A
        • Checkley W
        • et al.
        A risk assessment tool for resumption of research activities during the COVID-19 pandemic for field trials in low resource settings.
        BMC Med Res Methodol. 2021; 21: 68
        • Sim J
        • Wright CC
        The kappa statistic in reliability studies: use, interpretation, and sample size requirements.
        Phys Ther. 2005; 85: 257-268
        • Fancourt N
        • Deloria Knoll M
        • Barger-Kamate B
        • de Campo J
        • de Campo M
        • Diallo M
        • et al.
        Standardized interpretation of chest radiographs in cases of pediatric pneumonia from the PERCH study.
        Clin Infect Dis. 2017; 64: S253-S261
        • McCollum ED
        • Ahmed S
        • Chowdhury NH
        • Rizvi SJR
        • Khan AM
        • Roy AD
        • et al.
        Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study.
        BMJ Open Respir Res. 2019; 6e000393
        • Awasthi S
        • Rastogi T
        • Mishra N
        • Chauhan A
        • Mohindra N
        • Shukla RC
        • et al.
        Chest radiograph findings in children aged 2–59 months hospitalised with community-acquired pneumonia, prior to the introduction of pneumococcal conjugate vaccine in India: a prospective multisite observational study.
        BMJ Open. 2020; 10e034066
        • Gray DM
        • Davies MA
        • Githinji L
        • Levin M
        • Mapani M
        • Nowalaza Z
        • et al.
        COVID-19 and pediatric lung disease: A South African tertiary center experience.
        Front Pediatr. 2020; 8614076