Could judicious use of lung ultrasound reduce radiographic examinations in pediatric cardiac surgery patients?

Overview of Lung Ultrasound in Pediatric Cardiology

Lung ultrasound (LUS) is increasing in its popularity for the diagnosis of pulmonary complications in acute pediatric care settings. Despite the high incidence of pulmonary complications for patients with pediatric cardiovascular and congenital heart disease, especially in children undergoing cardiac surgery, the use of LUS remains quite limited in these patients. The aim of this review is to provide a comprehensive overview and list of current potential applications for LUS in children with congenital heart disease, post-surgery. We herein describe protocols for LUS examinations in children, discuss diagnostic criteria, and introduce methods for the diagnosis and classification of pulmonary disease commonly encountered in pediatric cardiology (e.g., pleural effusion, atelectasis, interstitial edema, pneumothorax, pneumonia, and diaphragmatic motion analysis). Furthermore, applications of chest ultrasounds for the evaluation of the retrosternal area, and in particular, systematic search criteria for retrosternal clots, are illustrated. We also discussed the potential applications of LUS, including the guidance of interventional procedures, namely lung recruitment and drainage insertion. Lastly, we analyzed current gaps in knowledge, including the difficulty of the quantification of pleural effusion and atelectasis, and the need to differentiate different etiologies of B-lines. We concluded with future applications of LUS, including strain analysis and advanced analysis of diaphragmatic mechanics. In summary, US is an easy, accurate, fast, cheap, and radiation-free tool for the diagnosis and follow-up of major pulmonary complications in pediatric cardiac surgery, and we strongly encourage its use in routine practice.

Effectiveness of postural lung recruitment on postoperative atelectasis assessed by lung ultrasound in children undergoing lateral thoracotomy cardiac surgery with cardiopulmonary bypass

OBJECTIVES

To assess the effects of postural lung recruitment maneuvers on the postoperative atelectasis assessed by lung ultrasound (LUS) compared with supine position recruitment maneuvers in children undergoing right lateral thoracotomy cardiac surgery with cardiopulmonary bypass.

METHODS

In this randomized and controlled trial, 84 patients aged 3 years or younger, scheduled for right lateral thoracotomy cardiac surgery with cardiopulmonary bypass (CPB) were randomly allocated to postural lung recruitment group or control group. The first LUS exam was performed immediately upon completion of the cardiac surgery (T1), and a repeat ultrasound exam started 1 min after lung recruitment maneuvers (T2). The primary outcome was the incidence of significant atelectasis at T2.

RESULTS

The incidence of significant atelectasis at T2 in the postural lung recruitment maneuver group was lower compared with that in the control group (30.2% vs. 58.1%; odds ratio: 0.31; 95% confidence interval: 0.13-0.76; p = .009). The LUS scores for consolidations and B-lines of the left lung were higher than those of the right lung in both groups at T1. More significant reduction of the left LUS scores and sizes of atelectatic areas were found in the postural lung recruitment group than those in the control group.

CONCLUSIONS

Postoperative postural recruitment maneuver was more effective to improve reaeration of lung than supine position recruitment maneuver in children undergoing right lateral thoracotomy cardiac surgery with CPB.

Congenital heart disease in the era of COVID-19 pandemic

The pandemic of COVID-19 presents an unprecedented challenge to identify effective prevention and treatment. Scientific literature has exploded with many news concerning the different experiences and the first studies in the world. To date May 5 2020, if we carry out a search in pubmed with the keyword “COVID-19”, more than 9000 papers appear. While if we carry out a search with the keywords “congenital heart disease and COVID-19”, we find only 4 results. This is a viewpoint in which we summarize the most important problems that emerged with the most recent data in the literature.

Lung ultrasound evaluation of incremental PEEP recruitment maneuver in children undergoing cardiac surgery

AIM

To explore the effect of incremental positive end-expiratory pressure recruitment maneuver (iPEEPRM) in children with congenital heart diseases (CHDs) using lung ultrasound.

METHODS

Thirty-six children aged 3 months to 5 years scheduled for cardiac surgery participated. iPEEPRM was performed with PEEP stepwise increase (0-5-10-15 cmH₂ O) and decrease at the same rate before and after surgery. Atelectatic areas, ultrasound scores, arterial oxygen pressure (PaO₂ ), and respiratory system dynamic compliance per kilogram body weight (CDyn/kg) were analyzed before and after iPEEPRM. The primary outcome is the incidence of atelectasis. Secondary outcomes are oxygenation, ventilation, CDyn/kg, and atelectasis area.

RESULTS

iPEEPRM was successfully applied in 92% (33/36) children before surgery and 71% (24/34) children after surgery. The incidence of atelectasis was significantly reduced by iPEEPRM from 76% to 15% before surgery and from 92% to 38% after surgery, respectively (P < .001). Before surgery, iPEEPRM significantly reduced atelectatic areas and ultrasound scores: 32.5 (0-128.1) mm² vs 0 (0-0) mm² and 8 (3-12) vs 2 (0-4). PaO₂ and CDyn/kg were significantly increased after iPEEPRM: 243 (129-275) mm Hg vs 278 (207-323) mm Hg and 0.6 (0.4-0.7) mL/cmH₂ O/kg vs 0.8 (0.6-1.0) mL/cmH₂ O/kg. After surgery, iPEEPRM significantly reduced atelectatic areas and ultrasound scores: 45.7 (13.1-115.8) mm² vs 0 (0-34.7) mm² , and 9 (6-12) vs 3 (0-5). PaO₂ and CDyn/kg were also significantly increased after iPEEPRM.

CONCLUSIONS

iPEEPRM effectively reduced atelectasis, improved lung aeration, oxygenation, and CDyn/kg in children undergoing cardiac surgery.