How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?
When do you use lung POCUS to evaluate for pneumonia?
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Lung ultrasound is a quick, safe, and inexpensive test to perform. If the patient already has a chest X-ray and it is equivocal for pneumonia, I always perform a lung ultrasound. It is useful for evaluating an inflammatory vs. non-inflammatory interstitial process. It is better than an X-ray to determine the presence of pleural effusion and differentiate between effusion and lung consolidation. If the concern is for cavitary or solid central lesions, CT is my choice.
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Lung ultrasound has similar test characteristics as a chest radiograph. I use CT to better evaluate central lesions because ultrasound cannot evaluate for pneumonia unless it is peripherally located adjacent to the pleura. If the lesion is peripheral, then ultrasound can be better than radiography at distinguishing causes. Most notably, the identification of dynamic air bronchograms and increased vascular flow on Doppler differentiates a consolidation from atelectasis.
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I agree with what has been said - my next step would always be a lung ultrasound. If it's positive for PNA, barring anything crazy clinically, it's enough to warrant PNA treatment. If it's negative and PNA suspicion is still high, then I would go for CT.
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