Lung ultrasound findings in meconium aspiration syndrome

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

OBJECTIVE

Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved.

DESIGN AND INTERVENTION

International online survey.

RESULTS

Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%-98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had <2 years of experience, and only 71 units (13%) had >5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique.

CONCLUSIONS

Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline.

Meconium aspiration syndrome: from pathophysiology to treatment

Meconium aspiration syndrome (MAS) is a clinical condition characterized by respiratory distress in neonates born through meconium-stained amniotic fluid (MSAF). Despite advances in obstetric practices and perinatal care, MAS remains an important cause of morbidity and mortality in term and post-term newborns. Since the 1960s, there have been significant changes in the perinatal and postnatal management of infants born through MSAF. Routine endotracheal suctioning is no longer recommended in both vigorous and non-vigorous neonates with MSAF. Supportive care along with new treatments such as surfactant, inhaled nitric oxide, and high-frequency ventilation has significantly improved the outcome of MAS patients. However, determining the most appropriate approach for this condition continues to be a topic of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management, and prognosis of infants with MAS.

Neonatal point-of-care lung ultrasound: what should be known and done out of the NICU?

Lung ultrasound is rapidly becoming a useful tool in the care of neonates: its ease of use, reproducibility, low cost, and negligible side effects make it a very suitable tool for the respiratory care of all neonates. This technique has been extensively studied by different approaches in neonatal intensive care unit (NICU), both for diagnostic and prognostic aims and to guide respiratory treatments. However, many neonates are being born in level I/II hospitals without NICU facilities so all pediatricians, not just neonatal intensivists, should be aware of its potential. This is made possible by the increasing access to ultrasound machines in a modern hospital setting. In this review, we describe the ultrasonographic characteristics of the normal neonatal lung. We also discuss the ultrasound features of main neonatal respiratory diseases: transient tachypnea of the neonate (TTN), respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS), pneumothorax (PNX), pleural effusion (PE), or pneumonia. Finally, we mention two functional approaches to lung ultrasound: 1. The use of lung ultrasound in level I delivery centers as a mean to assess the severity of neonatal respiratory distress and request a transport to a higher degree structure in a timely fashion. 2. The prognostic accuracy of lung ultrasound for early and targeted surfactant replacement.

CONCLUSION

 LU is still a useful tool in level I/II neonatal units, both for diagnostic and functional issues.

WHAT IS KNOWN

• Neonatal lung ultrasound has been recently introduced in the usual care in many Neonatal Intensive Care Units.

WHAT IS NEW

• It also has many advantages in level I/II neonatal units, both for neonatologist or even pediatricians that treat neonates in those sites.

Combining lung ultrasound and oscillatory mechanics for assessing lung disease in very preterm infants

BACKGROUND

We investigated whether combining lung ultrasound scores (LUSs) and respiratory system reactance (Xrs) measured by respiratory oscillometry explains the severity of lung disease better than individual parameters alone.

METHODS

We performed a prospective observational study in very preterm infants. Forced oscillations (10 Hz) were applied using a neonatal mechanical ventilator (Fabian HFOi, Vyaire). We used the simultaneous respiratory severity score (RSS = mean airway pressure × FIO2) as a primary outcome. We built linear mixed-effect models to assess the relationship between Xrs z-score, LUS and RSS and compared nested models using the likelihood ratio test (LRT).

RESULTS

We enrolled 61 infants (median (Q1, Q3) gestational age = 30.00 (26.86, 31.00) weeks) and performed 243 measurements at a postnatal age of 26 (13, 41) days and postmenstrual age of 33.14 (30.46, 35.86) weeks. Xrs z-score and LUS were independently associated with simultaneous RSS (p < 0.001 for both). The model including Xrs and LUS explained the RSS significantly better than Xrs (p value LRT < 0.001) or LUS alone (p value LRT < 0.001).

CONCLUSIONS

Combining LUS and Xrs z-score explains the severity of lung disease better than each parameter alone and has the potential to improve the understanding of the underlying pathophysiology.

IMPACT

Combining respiratory system reactance by oscillometry and lung ultrasound score explains the respiratory support requirement (e.g., proxy of the severity of lung disease) significantly better than each parameter alone. We assessed the relationship between lung ultrasound and respiratory system reactance in very preterm infants for the first time. Combining respiratory oscillometry and lung ultrasound has the potential to improve the understanding of respiratory pathophysiology.

The future of neonatal lung ultrasound: Validation of an artificial intelligence model for interpreting lung scans. A multicentre prospective diagnostic study

BACKGROUND

Artificial intelligence (AI) is a promising field in the neonatal field. We focused on lung ultrasound (LU), a useful tool for the neonatologist. Our aim was to train a neural network to create a model able to interpret LU.

METHODS

Our multicentric, prospective study included newborns with gestational age (GA) ≥ 33 + 0 weeks with early tachypnea/dyspnea/oxygen requirements. For each baby, three LU were performed: within 3 h of life (T0), at 4-6 h of life (T1), and in the absence of respiratory support (T2). Each scan was processed to extract the region of interest used to train a neural network to classify it according to the LU score (LUS). We assessed sensitivity, specificity, positive and negative predictive value of the AI model's scores in predicting the need for respiratory assistance with nasal continuous positive airway pressure and for surfactant, compared to an already studied and established LUS.

RESULTS

We enrolled 62 newborns (GA = 36 ± 2 weeks). In the prediction of the need for CPAP, we found a cutoff of 6 (at T0) and 5 (at T1) for both the neonatal lung ultrasound score (nLUS) and AI score (AUROC 0.88 for T0 AI model, 0.80 for T1 AI model). For the outcome "need for surfactant therapy", results in terms of area under receiver operator characteristic (AUROC) are 0.84 for T0 AI model and 0.89 for T1 AI model. In the prediction of surfactant therapy, we found a cutoff of 9 for both scores at T0, at T1 the nLUS cutoff was 6, while the AI's one was 5. Classification accuracy was good both at the image and class levels.

CONCLUSIONS

This is, to our knowledge, the first attempt to use an AI model to interpret early neonatal LUS and can be extremely useful for neonatologists in the clinical setting.

Modified lung ultrasound score for bronchopulmonary dysplasia predicts late respiratory outcomes in preterm infants

OBJECTIVE

Lung ultrasound (LUS) is a useful and radiation-free diagnostic tool for predicting bronchopulmonary dysplasia, which is a risk factor for late respiratory disease. However, data on the relationship of LUS with late respiratory disease was scarce. This study aims to determine whether LUS is associated with late respiratory disease during early childhood.

METHODS

This prospective cohort study enrolled preterm infants born before 32 weeks of gestation. LUS was performed at 36 weeks' postmenstrual age. The predictive values of a modified lung ultrasound (mLUS) score based on eight standard sections were assessed to predict late respiratory disease, defined as a physician diagnosis of bronchopulmonary dysplasia deterioration, asthma, reactive airway disease, bronchiolitis, pneumonia, or respiratory-related hospitalization during the first 2 years of life.

RESULTS

A total of 94 infants completed follow-up, of whom 74.5% met the late respiratory disease criteria. The mLUS scores were significantly associated with late respiratory disease (adjusted odds ratio: 1.23, CI: 1.10-1.38, p < 0.001). The mLUS scores also well predicted late respiratory disease (AUC = 0.820, 95% CI: 0.733-0.907). These scores were superior to the classic lung ultrasound score (p = 0.02) and as accurate as the modified NICHD-defined bronchopulmonary dysplasia classification (p = 0.91). A mLUS score ≥14 was the optimal cutoff point for predicting late respiratory disease.

CONCLUSION

The modified lung ultrasound score correlates significantly with late respiratory disease and well predicts it in preterm infants during the first 2 years of life.

Monitoring of the Healthy Neonatal Transition Period with Serial Lung Ultrasound

Ultrasound has been used to observe lung aeration and fluid clearance during the neonatal transition period, but there is no consensus regarding the optimal timing of lung ultrasound. We aimed to monitor the trend of the serial lung ultrasound score (LUS) and extended LUS (eLUS) throughout the neonatal transition period (≤1, 2, 4, 8, 24, and 48 h after birth), assess any correlation to the clinical presentation (using the Silverman Andersen Respiratory Severity Score (RSS)), and determine the optimal time of the ultrasound. We found both LUS and eLUS decreased significantly after 2 h of life and had similar statistical differences among the serial time points. Although both scores had a positive, moderate correlation to the RSS overall (Pearson correlation 0.499 [p < 0.001] between LUS and RSS, 0.504 [p < 0.001] between eLUS and RSS), the correlation was poor within 1 h of life (Pearson correlation 0.15 [p = 0.389] between LUS and RSS, 0.099 [p = 0.573] between eLUS and RSS). For better clinical correlation, the first lung ultrasound for the neonate may be performed at 2 h of life. Further research is warranted to explore the clinical value and limitations of earlier (≤1 h of life) lung ultrasound examinations.

Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians

Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.

Lung Ultrasound in the Early Diagnosis and Management of the Mild Form of Meconium Aspiration Syndrome: A Case Report

MAS is a common cause of neonatal respiratory distress in term and post-term neonates. Meconium staining of the amniotic fluid occurs in about 10-13% of normal pregnancies, and about 4% of these infants develop respiratory distress. In the past, MAS was diagnosed mainly on the basis of history, clinical symptoms, and chest radiography. Several authors have addressed the ultrasonographic assessment of the most common respiratory patterns in neonates. In particular, MAS is characterised by a heterogeneous alveolointerstitial syndrome, subpleural abnormalities with multiple lung consolidations, characterised by a hepatisation aspect. We present six cases of infants with a clinical history of meconium-stained fluid who presented with respiratory distress at birth. Lung ultrasound allowed the diagnosis of MAS in all the studied cases, despite the mild clinical picture. All children had the same ultrasound pattern with diffuse and coalescing B-lines, pleural line anomalies, air bronchograms, and subpleural consolidations with irregular shapes. These patterns were distributed in different areas of the lungs. These signs are specific enough to distinguish between MAS and other causes of neonatal respiratory distress, allowing the clinician to optimise therapeutic management.

Cardiopulmonary Ultrasound Patterns of Transient Acute Respiratory Distress of the Newborn: A Retrospective Pilot Study

Acute transient respiratory distress in the first hours of life is usually defined as transient tachypnea of the newborn (TTN). TTN is a respiratory self-limiting disorder consequent to delayed lung fluid clearance at birth. While TTN is the most common etiology of respiratory distress near term, its pathogenesis and diagnostic criteria are not well-defined. Lung ultrasound and targeted neonatal echocardiography are increasingly being used to assess critically ill infants, although their combined use to improve diagnostic precision in neonatal intensive care units has not yet been described. This retrospective pilot analysis aimed to identify possible cardiopulmonary ultrasound (CPUS) patterns in term and late preterm infants suffering from transient respiratory distress and requiring non-invasive respiratory support. After retrospectively revising CPUS images, we found seven potential sonographic phenotypes of acute neonatal respiratory distress. Up to 50% of the patients presented with signs of increased pulmonary vascular resistance, suggesting that those patients may be diagnosed with mild forms of persistent pulmonary hypertension of the newborn. Approximately 80% of the infants with a history of meconium-stained amniotic fluid displayed irregular atelectasis, indicating that they may have suffered from mild meconium aspiration syndrome. CPUS evaluation may improve accuracy in the approach to the infants presenting with transient acute respiratory distress, supporting communication with the parents and carrying important epidemiological consequences.

Lung Ultrasound Role in Diagnosis of Neonatal Respiratory Disorders: A Prospective Cross-Sectional Study

Lung ultrasound (LUS) has become one of the most exciting applications in neonatal point-of-care ultrasound (POCUS), yet still lacks routine clinical use. This study assesses the utility of LUS for neonatal respiratory disorders (NRDs) diagnosis and follow-up compared to chest X-ray (CXR). A prospective cross-sectional study was conducted on 100 neonates having NRDs with a gestational age ≥28 weeks, excluding those having multiple congenital anomalies, chromosomal aberrations, hydrops fetalis and/or heart failure. CXR and LUS were done on admission for diagnosis and were repeated after 7 days, or if needed earlier within the 7 days. The diagnosis of NRDs by CXR and LUS on admission and after 7 days was comparable (p > 0.05). LUS diagnosis sensitivity and specificity for respiratory distress syndrome, pneumonia, meconium aspiration syndrome, pneumothorax and pulmonary atelectasis were 94.7/100%, 97.5/95%, 92.3/100%, 90.9/98.9% and 100/97.8%, respectively. The total agreement between LUS and CXR was 98.5% with 95% CI (0.88 to 0.92). LUS and CXR had considerable agreement in the diagnosis of NRDs. Being a reliable bedside modality of diagnosis and safer than CXR, LUS may be considered an alternative method for the diagnosis of neonates with NRDs.

Evolution of Ultrasound-Assessed Lung Aeration and Gas Exchange in Respiratory Distress Syndrome and Transient Tachypnea of the Neonate

OBJECTIVE

To use clinical, lung ultrasound, and gas exchange data to clarify the evolution of lung aeration and function in neonates with respiratory distress syndrome (RDS) and transient tachypnea of the neonate (TTN), the most common types of neonatal respiratory failure.

STUDY DESIGN

In this prospective observational cohort study, lung aeration and function were measured with a semiquantitative lung ultrasound score (LUS) and transcutaneous blood gas measurement performed at 1 hour (time point 0), 6 hours (time point 1), 12 hours (time point 2), 24 hours (time point 3) and 72 hours (time point 4) of life. Endogenous surfactant was estimated using lamellar body count (LBC). LUS, oxygenation index (OI), oxygen saturation index (OSI), and transcutaneous pressure of carbon dioxide (PtcCO₂) were the primary outcomes. All results were adjusted for gestational age.

RESULTS

Sixty-nine neonates were enrolled in the RDS cohort, and 58 neonates were enrolled in the TTN cohort. LUS improved over time (within-subjects, P < .001) but was worse for the RDS cohort than for the TTN cohort at all time points (between-subjects, P < .001). Oxygenation improved over time (within-subjects, P = .011 for OI, P < .001 for OSI) but was worse for the RDS cohort than for the TTN cohort at all time points (between-subjects, P < .001 for OI and OSI). PtcCO₂ improved over time (within-subjects, P < .001) and was similar in the RDS and TTN cohorts at all time points. Results were unchanged after adjustment for gestational age. LBC was associated with RDS (β = -0.2 [95% CI, -0.004 to -0.0001]; P = .037) and LUS (β = -3 [95% CI, -5.5 to -0.5]; P = .019).

CONCLUSIONS

For the first 72 hours of life, the RDS cohort had worse lung aeration and oxygenation compared with the TTN cohort at all time points. CO₂ clearance did not differ between the cohorts, whereas both lung aeration and function improved in the first 72 hours of life.

Lung ultrasound in Italian neonatal intensive care units: A national survey

INTRODUCTION

Lung ultrasound (LU) is a noninvasive, bedside imaging technique that is attracting growing interest in the evaluation of neonatal respiratory diseases. We conducted a nationwide survey of LU usage in Italian neonatal intensive care units (NICUs).

METHODS

A structured questionnaire was developed and sent online to 114 Italian NICUs from June to September 2021.

RESULTS

The response rate was 79%. In the past 4 years (range: 2-6), LU has been adopted in 82% of Italian NICUs. It is the first-choice diagnostic test in 23% of the centers surveyed. The main LU diagnostic applications reported were: pneumothorax (95%), respiratory distress syndrome (89%), transient tachypnea of the newborn (89%), plural effusion (88%), atelectasis (66%), pneumonia (64%), bronchopulmonary dysplasia (43%), congenital pulmonary airway malformation (41%), and congenital diaphragmatic hernia (34%). Thirty percent of participating centers calculated LU score routinely, but only seven units used it to predict the need for surfactant replacement. Sixty-six percent of respondents learned the LU technique via a self-training process, while 34% of them visited an expert in the field for one-to-one tuition.

CONCLUSIONS

LU has a widespread use in Italian NICUs. However, the use of LU is extremely heterogeneous among centers. There is an urgent need to ensure standardization of clinical practice guidelines and to design and implement a formalized and accredited training program.

Ultrasound findings in neonates with alveolar capillary dysplasia with misalignment of the pulmonary veins: report of two cases

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACDMPV) is a rare congenital pulmonary disease that affects newborns. Most patients with ACDMPV are born at full term and are healthy. The main clinical manifestations are refractory pulmonary hypertension and pulmonary failure with gastrointestinal, urinary, or cardiac malformations. ACDMPV often progresses rapidly, but no conventional biological or imaging tests other than genetic testing are available for its diagnosis. Lung biopsy is currently the gold standard for diagnosis. We herein report two cases of ACDMPV confirmed by pathological examination and discuss their ultrasonographic findings.

Early lung ultrasound score to predict noninvasive ventilation needing in neonates from 33 weeks of gestational age: A multicentric study

OBJECTIVE

To propose an early lung ultrasound (LUS) score for the prediction of the need for respiratory assistance in newborns of gestational age (GA) ≥ 33 weeks presenting respiratory distress.

STUDY DESIGN AND SETTING

Multicenter, prospective observational study in third-level neonatal intensive care units.

PATIENT SELECTION

Infants with GA ≥ 33 + 0 weeks with respiratory distress within 3 h of life.

METHODS

Three LUS for each patient were collected: within 3 h of life (T0), at 4-6 h of life (T1), and at the resolution of symptoms (T2). The primary aim was to assess the validity of the early LUS score in predicting the need for continuous positive airway pressure (CPAP). We also evaluated the validity of the score in predicting the need for surfactant, the scores' trend in our population, and any correlation with the duration of ventilation and oxygen therapy.

RESULTS

Sixty-two patients were enrolled in the study. The mean GA was 36 weeks. The receiver operating characteristic analysis for the LUS T0 and T1 yielded area under the curves of 0.91 and 0.82 in predicting the need for CPAP, respectively. LUS score cut off of 6 (sensitivity 84.8%, specificity 86.2%) and 5 (sensitivity 66.7%, specificity 100%) were calculated at T0 and T1, respectively. We found significant correlations between LUS score and respiratory assistance, surfactant administration, and SpO₂ /FiO₂ ratio.

CONCLUSION

An early LUS score is a good noninvasive predictor of the need for respiratory assistance with CPAP and surfactant administration in newborns with GA ≥ 33 weeks.

Semi-quantitative lung ultrasound score during ground transportation of outborn neonates with respiratory failure

Lung ultrasound score (LUS) is increasingly diffused in neonatal critical care but scanty data are available about its use during transfer of severely ill neonates. We aimed to clarify the effect of ground transportation on LUS evolution, conformity of interpretation, and relationships with oxygenation and clinical severity. This is a single-center, blinded, observational, cross-sectional study. Neonates of any gestational age with respiratory distress appearing within 24 h from birth were transferred by a mobile unit towards neonatal intensive care unit (NICU) of a tertiary referral center. Calculation of LUS prior to the transportation (T1), in the mobile unit (T2), at the end of transportation (T3), and finally upon NICU admission. LUS in the mobile unit and in the NICU was performed by different physicians blinded to each other's results. LUS did not change overtime (T1: 6.3 (3.5), T2: 6.1 (3.5), T3: 5.8 (3.4); p = 0.479; adjusted for gestational or postnatal age or transport duration: p = 0.951, p = 0.424, and 0.266, respectively) but reliably predicted surfactant need (AUC at T1: 0.833 (95%CI: 0.72-0.92); AUC at T2: 0.82 (95%CI: 0.70-0.91); AUC at T3: 0.82 (95%CI: 0.70-0.90); p always < 0.0001). There were significant agreement (ICC = 0.912 (95%CI: 0.83-0.95); p < 0.001) and correlation (r = 0.905, p < 0.001) between LUS calculated during transportation and in the NICU. LUS during transportation was also significantly correlated with oxygenation index (r = 0.321, p = 0.026; standardized B = 0.397 (95%CI: 0.03-0.76), p = 0.048) and TRIPS-II score (r = 0.302, p = 0.008; standardized B = 0.568 (95%CI: 0.04-1.1), p = 0.037).

CONCLUSION

LUS during ground transportation of neonates with respiratory failure is suitable and not influenced by the transportation itself. It has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity.

WHAT IS KNOWN

• Lung ultrasound is a part of the point-of-care ultrasound, which is becoming an essential tool, to manage critically ill neonates and children in an accurate, non-invasive and quick way.

WHAT IS NEW

• Lung ultrasound score (LUS) is suitable during transportation of critically ill neonates with respiratory failure and is not influenced by the transportation itself. • LUS has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity of respiratory failure.

Lung Ultrasound to Diagnose Pneumonia in Neonates with Fungal Infection

With the improvement in survival rates of low-birthweight and very premature infants, neonatal fungal infection, especially fungal pneumonia, is becoming more and more common, but the diagnosis is always challenging. Recently, lung ultrasound (LUS) has been used to diagnose pneumonia in newborn infants, but not fungal pneumonia. This paper summarizes the ultrasonographic features of seven cases of neonatal fungal pneumonia, such as lung consolidation with air bronchograms, shred signs, lung pulse, pleural line abnormalities, and different kinds of B-lines. It was confirmed that LUS plays an important role in the diagnosis of fungal pneumonia in newborn infants.

A modified lung ultrasound score to evaluate short-term clinical outcomes of bronchopulmonary dysplasia

Background

Lung ultrasound (LUS) is a useful tool for assessing the severity of lung disease, without radiation exposure. However, there is little data on the practicality of LUS in assessing the severity of bronchopulmonary dysplasia (BPD) and evaluating short-term clinical outcomes. We adapted a LUS score to evaluate BPD severity and assess the reliability of mLUS score correlated with short-term clinical outcomes.

Methods

Prospective diagnostic accuracy study was designed to enroll preterm infants with gestational age < 34 weeks. Lung ultrasonography was performed at 36 weeks postmenstrual age. The diagnostic and predictive values of new modified lung ultrasound (mLUS) scores based on eight standard sections were compared with classic lung ultrasound (cLUS) scores.

Results

A total of 128 infants were enrolled in this cohort, including 30 without BPD; 31 with mild BPD; 23 with moderate BPD and 44 with severe BPD. The mLUS score was significantly correlated with the short-term clinical outcomes, superior to cLUS score. The mLUS score well correlated with moderate and severe BPD (AUC = 0.813, 95% CI 0.739–0.888) and severe BPD (AUC = 0.801, 95% CI 0.728–0.875), which were superior to cLUS score. The ROC analysis of mLUS score to evaluate the other short-term outcomes also showed significant superiority to cLUS score. The optimal cutoff points for mLUS score were 14 for moderate and severe BPD and 16 for severe BPD.

Conclusions

The mLUS score correlates significantly with short-term clinical outcomes and well evaluates these outcomes in preterm infants.

Chest ultrasound in neonates: What neonatologists should know

For many years, ultrasound was thought to have no indications in pulmonary imaging because lungs are filled with air, creating no acoustic mismatch, as encountered by ultrasound wave beam. Lung ultrasound (LUS) was started in adult critical care settings to detect pleural effusion and acquired more indications over time. In the neonatal intensive care unit (NICU), the use of chest ultrasound has gained more attention during the last two decades. Being a radiation-free, bedside, rapid, and handy tool, LUS started to replace chest X-rays in NICU. Using LUS depends upon understanding the nature of normal lungs and the changes induced by different diseases. With the help of LUS, an experienced neonatologist can detect many of the respiratory problems so fast that interventional therapy can be introduced as early as possible. LUS can diagnose pleural effusion, pneumothorax, pneumonia, transient tachypnoea of the newborn, respiratory distress syndrome, pulmonary atelectasis, meconium aspiration syndrome, bronchopulmonary dysplasia, and some other disorders with very high accuracy. LUS will be helpful in initial diagnosis, follow-up, and predicting the need for further procedures such as mechanical ventilation, diuretic therapy, surfactant therapy, etc. There are some limitations to using LUS in some respiratory disorders such as bullae, interstitial emphysema, and other conditions. This review will highlight the importance of LUS, its uses, and limitations.

Application of ultrasonography in neonatal lung disease: An updated review

Lung disease is often life-threatening for both preterm and term newborns. Therefore, an accurate and rapid diagnosis of lung diseases in newborns is crucial, as management strategies differ with different etiologies. To reduce the risk of radiation exposure derived from the conventionally used chest x-ray as well as computed tomography scans, lung ultrasonography (LUS) has been introduced in clinical practice to identify and differentiate neonatal lung diseases because of its radiation-free characteristic, convenience, high accuracy, and low cost. In recent years, it has been proved that LUS exhibits high sensitivity and specificity for identifying various neonatal lung diseases. Here, we offer an updated review of the applications of LUS in neonatal lung diseases based on the reports published in recent years (2017 to present).

Limitations of Bedside Lung Ultrasound in Neonatal Lung Diseases

Lung ultrasound is a technique that has rapidly developed in recent years. It is a low-cost, radiation-free, and easy-to-operate tool that can be repeatedly performed at the bedside. Compared to chest X-ray, lung ultrasound has high sensitivity and specificity in the diagnosis of neonatal respiratory distress syndrome, transient tachypnoea of newborns and pneumothorax. Lung ultrasound has been widely used in neonatal intensive care units. However, due to the physical barriers of air, where ultrasonic waves cannot pass and therefore reflection artifacts occur, it has limitations in some other lung diseases and cannot fully substitute for chest X-rays or CT/MRI scanning. This review describes these limitations in detail and highlights that if clinical symptoms are not effectively alleviated after medical treatment or the clinical presentation is not compatible with the ultrasound appearances, then chest X-rays or CT/MRI scanning should be performed to avoid misdiagnosis and mistreatment.

The Role of Lung Ultrasound as an Early Diagnostic Tool for Need of Surfactant Therapy in Preterm Infants with Respiratory Distress Syndrome

OBJECTIVE

This study aimed to determine the accuracy of neonatal lung ultrasound (LUS) in predicting the need for surfactant therapy compared with chest X-ray (CXR) in preterm infants.

STUDY DESIGN

A prospective double-blind study was conducted in infants with a gestational age <34 weeks with respiratory distress syndrome (RDS) by evaluation with LUS and CXR on admission.

RESULTS

Among 45 preterm infants, the median (interquartile range [IQR]) LUS score was 4 (2-8) in the mild RDS group, whereas it was 10 (IQR: 9-12) in the severe RDS group (p < 0.01). The LUS score showed a significant correlation with the need for total surfactant doses (ρ = 0.855; 95% confidence interval [CI]: 0.801-0.902; p < 0.001). A cut-off LUS score of four predicted the need for surfactant with 96% sensitivity and 100% specificity (area under the curve [AUC]: 1.00; 95% CI: 0.97-1.00; p < 0.01). LUS scores predicted continuous positive airway pressure (CPAP) failure accurately (AUC: 0.804; 95% CI: 0.673-0.935; p = 0.001). A significant correlation was observed between LUS scores and positive end-expiratory pressure levels (ρ = 0.782; p < 0.001). During the study period, the CXR number per infant with RDS decreased significantly when compared with preceding months (p < 0.001). The LUS score in the first day of life did not predict the development of bronchopulmonary dysplasia (AUC: 0.274; 95% CI: 0.053-0.495; p = 0.065).

CONCLUSION

The LUS score in preterm infants accurately predicts the severity of RDS, the need for surfactant and CPAP failure. The routine use of LUS can decrease the frequency of CXRs in the neonatal intensive care units.

KEY POINTS

· LUS is a nonhazardous bedside technique.. · LUS predicts the need for surfactant in preterm infants.. · LUS predicts the severity of RDS better than CXR..

Lung Ultrasound in the Neonatal Intensive Care Unit: Does It Impact Clinical Care?

A neonatal point-of-care ultrasound has multiple applications, but its use has been limited in neonatal intensive care units in the Unites States. An increasing body of evidence suggests that lung ultrasound performed by the neonatologist, at the bedside, is reliable and accurate in differentiating neonatal respiratory conditions, predicting morbidity, and guiding invasive interventions. Recent research has shown that a lung ultrasound can assist the clinician in accurately identifying and managing conditions such as respiratory distress syndrome, transient tachypnea of the newborn, and bronchopulmonary dysplasia. In this review, we discuss basic lung ultrasound terminology, evidence for applications of neonatal lung ultrasound, and its use as a diagnostic and predictive tool for common neonatal respiratory pathologies.

Lung Ultrasound in Pediatrics and Neonatology: An Update

The potential role of ultrasound for the diagnosis of pulmonary diseases is a recent field of research, because, traditionally, lungs have been considered unsuitable for ultrasonography for the high presence of air and thoracic cage that prevent a clear evaluation of the organ. The peculiar anatomy of the pediatric chest favors the use of lung ultrasound (LUS) for the diagnosis of respiratory conditions through the interpretation of artefacts generated at the pleural surface, correlating them to disease-specific patterns. Recent studies demonstrate that LUS can be a valid alternative to chest X-rays for the diagnosis of pulmonary diseases, especially in children to avoid excessive exposure to ionizing radiations. This review focuses on the description of normal and abnormal findings during LUS of the most common pediatric pathologies. Current literature demonstrates usefulness of LUS that may become a fundamental tool for the whole spectrum of lung pathologies to guide both diagnostic and therapeutic decisions.

Lung Ultrasound to Monitor Extremely Preterm Infants and Predict Bronchopulmonary Dysplasia. A Multicenter Longitudinal Cohort Study

Rationale: Lung ultrasound is useful in critically ill patients with acute respiratory failure. Given its characteristics, it could also be useful in extremely preterm infants with evolving chronic respiratory failure, as we lack accurate imaging tools to monitor them. Objectives: To verify if lung ultrasound can monitor lung aeration and function and has good reliability to predict bronchopulmonary dysplasia in extremely preterm neonates. Methods: A multicenter, international, prospective, longitudinal, cohort, diagnostic accuracy study consecutively enrolling inborn neonates with gestational age 30⁺⁶ weeks or younger. Lung ultrasound was performed on the 1, 7, 14, and 28 days of life, and lung ultrasound scores were calculated and correlated with simultaneous blood gases and work of breathing score. Gestational age-adjusted lung ultrasound scores were created, verified in multivariate models, and subjected to receiver operator characteristics (ROC) analyses to predict bronchopulmonary dysplasia at 36 weeks postmenstrual age. Measurements and Main Results: Mean lung ultrasound scores are different between infants developing (n = 72) or not developing (n = 75) bronchopulmonary dysplasia (P < 0.001 at any time point). Lung ultrasound scores significantly correlate with oxygenation metrics and work of breathing at any time point (P always < 0.0001). Gestational age-adjusted lung ultrasound scores significantly predict bronchopulmonary dysplasia at 7 (area under ROC curve, 0.826-0.833; P < 0.0001) and 14 (area under ROC curve, 0.834-0.858; P < 0.0001) days of life. Bronchopulmonary dysplasia severity and gestational age-adjusted lung ultrasound scores are significantly correlated at 7 and 14 days (P always < 0.0001). Conclusions: Lung ultrasound scores allow monitoring of lung aeration and function in extremely preterm infants. Gestational age-adjusted scores significantly predict the occurrence of bronchopulmonary dysplasia, starting from the seventh day of life.

Prediction of extubation readiness using lung ultrasound in preterm infants

We aimed to test the hypothesis that a lung ultrasound severity score (LUS) and assessment of left ventricular eccentricity index of the interventricular septum (LVEI) by focused heart ultrasound can predict extubation success in mechanically ventilated infants. We conducted a prospective study on premature infants less than 34 weeks' of gestation. LUS was performed on postnatal Days 3 and 7 by an investigator who was masked to infants' ventilator parameters. LVEI and pulmonary artery pressure (PAP) were measured at postnatal Day 3. A receiver operator curve was constructed to assess the ability to predict extubation success. Spearman correlation was performed between LVEI and PAP. A total of 104 studies were performed to 66 infants; of them 39 had mild and 65 had moderate-severe lung disease. LUS predicted extubation success with a sensitivity and a specificity of 91% and 69%, respectively. Area under the curve was 0.83 (CI: 0.75-0.91). LVEI did not differ between infants that succeeded and failed extubation. It correlated with PAP during systole (r = .66). We conclude that LUS predicts extubation success in mechanically ventilated preterm infants whereas LVEI correlates with high PAP.

Ultrasound performed shortly after birth can predict the respiratory support needs of late preterm and term infants: A diagnostic accuracy study

BACKGROUND

Late preterm and term infants may develop respiratory issues with severe outcomes. Early identification of these diseases shortly after infants' birth can improve their management. Lung ultrasound (LUS) has been used to diagnose neonatal respiratory diseases. However, few LUS methods have been reported to predict the need for respiratory support, the basis of infant respiratory diseases management.

METHODS

We conducted a prospective diagnostic accuracy study following the Standards for the Reporting of Diagnostic Accuracy Studies guidelines at a tertiary academic hospital between 2019 and 2020. A total of 310 late preterm and term infants with mild respiratory symptoms were enrolled. The LUS assessment was performed for each participant at one of the following times: 0.5, 1.0, 2.0, or 4.0 h after birth. Predictive reliability was tested by receiver operating characteristic curve analysis. The main outcome was the need for any respiratory support determined according to international guidelines.

RESULTS

Seventy-four infants needed respiratory support, and 236 were healthy according to a 3-day follow-up confirmation. Six LUS imaging patterns were found. Two "high-risk" patterns were strongly correlated with respiratory support needs (area under the curve [AUC] = 0.95; 95% confidence interval [CI]: 0.92-0.98, p < .001). The optimal cut-off value for "high-risk" patterns was 2 (sensitivity = 87.8% and specificity = 91.1%). The predictive value of LUS was greater than that of a symptom-based method (the Acute Care of at-Risk Newborns assessment score) (AUCs' p < .01).

CONCLUSIONS

LUS can be used to predict the need for respiratory support in late preterm and term infants and is more reliable than tools based on respiratory symptoms.

Evaluation of Different Types of Natural Surfactants by Lung Ultrasound in Respiratory Distress Syndrome

OBJECTIVE

This study aimed to compare the lung ultrasonography (LUS) scores after two different natural surfactant administration as a parameter reflecting lung inflation.

STUDY DESIGN

Preterm infants of 32 gestational weeks and below who were diagnosed with respiratory distress syndrome (RDS) were randomly assigned to be administered either poractant alfa or beractant, prospectively. Serial LUS scans were obtained by an experienced neonatologist in a standardized manner before and after (2 and 6 hours) surfactant administration. The LUS scans were evaluated by protocols based on scores and lung profiles.

RESULTS

Thirty-seven infants received poractant alfa and 36 received beractant. The baseline characteristics and presurfactant LUS scores were similar in groups. The scores were significantly decreased after surfactant administration in both groups (2 hours, p = < 0.001; 6 hours, p = < 0.001). LUS scores in poractant group were significantly lower than beractant group when compared at each time point. At the end of 6 hours, the number of infants with the normal profile was significantly higher in the poractant group (∼65%) than the beractant group (22%).

CONCLUSION

LUS is beneficial for evaluating lung aeration after surfactant treatment in preterm infants with RDS. A better lung aeration can be achieved in the early period with the use of poractant alfa.

Ultrasound-guided lung lavage for life-threatening bronchial obstruction due to meconium plug

We present a case of life-threatening airway obstruction caused by meconium aspiration, a condition with significant neonatal mortality and morbidity. Lung ultrasound detected the obstruction and helped in the clinical management allowing to perform a quick and selective bronchoalveolar lavage with diluted surfactant.

Lung Ultrasound: Its Findings and New Applications in Neonatology and Pediatric Diseases

Lung ultrasound has become increasingly used in both adult and pediatric populations, allowing the rapid evaluation of many lung and pleura diseases. This popularity is due to several advantages of the method such as the low cost, rapidity, lack of ionizing radiation, availability of bedside and repeatability of the method. These features are even more important after the outbreak of the SARS-CoV-2 pandemic, given the possibility of recognizing through ultrasound the signs of interstitial lung syndrome typical of pneumonia caused by the virus. The purpose of this paper is to review the available evidence of lung ultrasound (LUS) in children and its main applications in pediatric diseases.

Neonatal lung diseases: lung ultrasound or chest x-ray

Chest X-ray (CXR) examination is a well-recognized imaging modality in the diagnosis of neonatal lung diseases. On the other hand, lung ultrasound (LUS) has been an emerging and increasingly studied modality. However, the role of LUS as well as its potential to replace CXRs in the detection of neonatal lung diseases has been debated. We combine the present research progress and our own clinical experience to elaborate on various aspects of the potential routine use of lung ultrasound in neonatal intensive care units. We conclude that both LUS and CXR have a number of advantages and disadvantages. They should serve as complementary diagnostic methods in providing accurate, timely, and reliable information.

Modern pulmonary imaging of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a complex and serious cardiopulmonary morbidity in infants who are born preterm. Despite advances in clinical care, BPD remains a significant source of morbidity and mortality, due in large part to the increased survival of extremely preterm infants. There are few strong early prognostic indicators of BPD or its later outcomes, and evidence for the usage and timing of various interventions is minimal. As a result, clinical management is often imprecise. In this review, we highlight cutting-edge methods and findings from recent pulmonary imaging research that have high translational value. Further, we discuss the potential role that various radiological modalities may play in early risk stratification for development of BPD and in guiding treatment strategies of BPD when employed in varying severities and time-points throughout the neonatal disease course.

Meconium Aspiration Syndrome: A Narrative Review

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome.

Modified lung ultrasound score predicts ventilation requirements in neonatal respiratory distress syndrome

Background

We propose a modified lung ultrasound (LUS) score in neonates with respiratory distress syndrome (RDS), which includes posterior instead of lateral lung fields, and a 5-grade rating scale instead of a 4-grade rating scale. The purpose of this study was to evaluate the reproducibility of the rating scale and its correlation with blood oxygenation and to assess the ability of early post-birth scans to predict the mode of respiratory support on day of life 3 (DOL 3). As a secondary objective, the weight of posterior scans in the overall LUS score was assessed.

Methods

We analyzed 619 serial lung scans performed in 70 preterm infants < 32 weeks gestation and birth weight < 1500 g. Assessments were performed within 24 h of birth (LUS₀) and on days 2, 3, 5, 7, 10, 14, 21 and 28. LUS scores were correlated with oxygen saturation over fraction of inspired oxygen (S/F) and mode of respiratory support. Interrater agreement was determined with the intraclass correlation coefficient (ICC) and Cronbach’s alpha. Probabilities of the need for various respiratory support modes on DOL 3 were assessed with ordinal logistic regression. Least square (ls) means of the posterior and anterior pulmonary field scores were compared.

Results

The LUS score correlated significantly with S/F (Spearman rho = −0.635; p < 0.0001) and had excellent interrater agreement (ICC = 0.94, 95% CI 0.93–0.95; Cronbach’s alpha = 0.99). Significant predictors of ventilation requirements on DOL 3 were LUS₀ (p < 0.016) and birth weight (BW) (p < 0.001). In the ROC analysis, LUS₀ had high reliability in prognosing invasive ventilation on DOL 3 (AUC = 0.845 (95% DeLong CI: 0.738–0.951; p < 0.001)). Invasive ventilation was the most likely mode of respiratory support for LUS₀ scores: ≥7 (in infants with BW 900 g), ≥ 10 (in infants with BW 1050 g) and ≥ 15 (in infants with BW 1280 g). Posterior fields exhibited significantly higher average scores than anterior fields. Respective ls means (confidence levels) were 4.0 (3.8–4.1) vs. 2.2 (2.0–2.4); p < 0.001.

Conclusions

Post-birth LUS predicts ventilation requirements on DOL 3. Scores of posterior pulmonary fields have a predominant weight in the overall LUS score.

Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications

Lung ultrasound (LUS) is the latest amongst imaging techniques: it is a radiation-free, inexpensive, point-of-care tool that the clinician can use at the bedside. This review summarises the rapidly growing scientific evidence on LUS in neonatology, dividing it into descriptive and functional applications. We report the description of the main ultrasound features of neonatal respiratory disorders and functional applications of LUS aiming to help a clinical decision (such as surfactant administration, chest drainage etc). Amongst the functional applications, we propose SAFE (Sonographic Algorithm for liFe threatening Emergencies) as a standardised protocol for emergency functional LUS in critical neonates. SAFE has been funded by a specific grant issued by the European Society for Paediatric Research. Future potential development of LUS in neonatology might be linked to its quantitative evaluation: we also discuss available data and research directions using computer-aided diagnostic techniques. Finally, tools and opportunities to teach LUS and expand the research network are briefly presented.

Prone versus Supine Position for Lung Ultrasound in Neonates with Respiratory Distress

OBJECTIVE

To study the feasibility of lung ultrasound (LUS) in prone position and to compare it with supine position in neonates with respiratory distress.

STUDY DESIGN

Neonates ≥ 29 weeks of gestational age with respiratory distress requiring respiratory support within first 12 hours of life were enrolled prospectively. First LUS (fLUS) was done in the position infant was nursed (supine or prone), infant's position changed, a second LUS (sLUS) was performed immediately and a third LUS (tLUS) was done 1 to 2 hours later. Primary outcome was the comparison of LUS scores (LUSsc) between fLUS and sLUS.

RESULTS

Sixty-four neonates were enrolled. Common respiratory diagnoses were transient tachypnea of newborn (TTN; 53%) and respiratory distress syndrome (RDS; 41%). LUSsc was different between fLUS and sLUS (fLUSsc 6 [interquatile range: 4, 7] vs. sLUSsc 7 [4, 10], p < 0.001), while there was no difference between the fLUS and tLUS (fLUSsc 6 [4, 7] vs. tLUSsc 5 [3, 7], p = 0.43). Subgroup analysis confirmed similar findings in neonates with TTN, while in babies with RDS, all the three LUSsc were similar.

CONCLUSION

LUS is feasible in prone position in neonates. LUS scores were higher immediately after a change in position but were similar to baseline 1 hour after the change in position.

Ultrasound for Endotracheal Tube Tip Position in Term and Preterm Infants

BACKGROUND AND OBJECTIVE

Placing an endotracheal tube (ETT) in neonates is challenging and currently requires timely radiographic confirmation of correct tip placement. The objective was to establish the reliability of ultrasound (US) for assessing ETT position in the neonatal intensive care unit (NICU), time needed to do so, and patients' tolerance.

METHODS

A prospective study on 71 newborns admitted to our NICU whose ETT placement was evaluated with US (ETT-echo) and confirmed on chest X-rays (CXR). Data were collected by 3 operators (2 neonatologists and a resident in pediatrics). The right pulmonary artery (RPA) was used as a landmark for US. The distance between the tip of the ETT and the upper margin of the RPA was measured using US and compared with the distance between the tube's tip and the carina on the CXR.

RESULTS

Seventy-one intubated newborns were included in the study (n = 34 < 1,000 g, n = 18 1,000-2,000 g, n = 19 > 2,000 g). Statistical analysis (Bland-Altman plot and Lin's concordance correlation coefficient) showed an excellent consistency between ETT positions identified on US and chest X-ray. The 2 measures (ETT-echo and CXR) were extremely concordant both in the whole sample and in the subgroups. Minimal changes in patients' vital signs were infrequently observed during US, confirming the tolerability of ETT-echo. The mean time to perform US was 3.2 min (range 1-13).

CONCLUSIONS

ETT-echo seems to be a rapid, tolerable, and highly reliable method worth further investigating for future routine use in neonatology with a view to reducing radiation exposure.

Surfactant Injury in the Early Phase of Severe Meconium Aspiration Syndrome

No in vivo data are available regarding the effect of meconium on human surfactant in the early stages of severe meconium aspiration syndrome (MAS). In the present study, we sought to characterize the changes in surfactant composition, function, and structure during the early phase of meconium injury. We designed a translational prospective cohort study of nonbronchoscopic BAL of neonates with severe MAS (n = 14) or no lung disease (n = 18). Surfactant lipids were analyzed by liquid chromatography-high-resolution mass spectrometry. Secretory phospholipase A₂ subtypes IB, V, and X and SP-A (surfactant protein A) were assayed by ELISA. SP-B and SP-C were analyzed by Western blotting under both nonreducing and reducing conditions. Surfactant function was assessed by adsorption test and captive bubble surfactometry, and lung aeration was evaluated by semiquantitative lung ultrasound. Surfactant nanostructure was studied using cryo-EM and atomic force microscopy. Several changes in phospholipid subclasses were detected during MAS. Lysophosphatidylcholine species released by phospholipase A₂ hydrolysis were increased. SP-B and SP-C were significantly increased together with some shorter immature forms of SP-B. Surfactant function was impaired and correlated with poor lung aeration. Surfactant nanostructure was significantly damaged in terms of vesicle size, tridimensional complexity, and compactness. Various alterations of surfactant phospholipids and proteins were detected in the early phase of severe meconium aspiration and were due to hydrolysis and inflammation and a defensive response. This impairs both surfactant structure and function, finally resulting in reduced lung aeration. These findings support the development of new surfactant protection and antiinflammatory strategies for severe MAS.

Introduction of point-of-care neonatal lung ultrasound in a developing country

Despite neonatal lung ultrasound (LU) being diffused worldwide, its introduction in limited-resource areas has not been formally investigated. We conceived a project to introduce it in a level 3 NICU of a developing country and verify if, after a short protocolized training, clinicians may efficaciously use LU. Inter-rater agreement between ultrasound trainees and trainers was analyzed within both the local test and the diffusion phases of the project. High inter-rater agreements were found between expert trainers and the two neonatologists who were trained in a skilled European center (Cohen's Kappa, 0.951; 95%CI, 0.882-0.999), as well as between the two and the second round of locally trained colleagues (Cohen's Kappa, 0.896; 95%CI, 0.797-0.996). Moreover, a high agreement was found between the clinical respiratory diagnosis (used as the "gold standard") and the LU diagnosis given by the first two trainees (intraclass correlation, 0.992; 95%CI, 0.987-0.996) and the locally trained physicians (intraclass correlation, 0.97; 95%CI, 0.95-0.98). A final survey demonstrated that the project was perceived as efficacious and that LU was going to be integrated into routine clinical practice.Conclusions: А short LU training provided sufficient proficiency and allowed the LU introduction in clinical practice in the neonatal intensive care unit in a developing country.What is Known:• Lung ultrasound is a promising technique for evaluating neonatal respiratory distress at least in high-income countries. Previous studies revealed high specificity and sensitivity in diagnosing specific neonatal disorders.• An important barrier to the more extensive use of lung ultrasound in neonatal critical care is a lack of efficient and suitable training solutions.What is New:• Descriptive LU performed by neonatologist in a developing country after a short formal training is feasible with good quality.• A short formal LU training program provided good proficiency and allowed a correct descriptive diagnosis in a neonatal unit in a developing country.

Lung ultrasound in the neonatal intensive care unit: Review of the literature and future perspectives

Lung ultrasound (LU) has been increasingly used as a point-of-care method in recent years. LU has numerous advantages compared to traditional imaging tools such as chest X-ray (radiography) (CXR): it is faster and portable, does not use ionizing radiation, is performed by the same physician who cares for the patient, and can be repeated to follow the progress of the disease and the response to treatment. There is a large body of evidence that LU has an excellent diagnostic effectiveness compared to CXR, not only in adults and children, but also in neonates. This review article describes how to perform LU, how to interpret findings, and how to use LU to diagnose and differentiate common neonatal pulmonary diseases. Strengths but also limits of the technique are highlighted. Finally, we describe the recent revolutionary role of LU. The development of scoring methods in neonates with respiratory distress syndrome allowed to quantify the severity of the disease and to assist the physician in the clinical management and follow-up.

Defining information needs in neonatal resuscitation with work domain analysis

OBJECTIVE

To gain a deeper understanding of the information requirements of clinicians conducting neonatal resuscitation in the first 10 min after birth.

BACKGROUND

During the resuscitation of a newborn infant in the first minutes after birth, clinicians must monitor crucial physiological adjustments that are relatively unobservable, unpredictable, and highly variable. Clinicians' access to information regarding the physiological status of the infant is also crucial to determining which interventions are most appropriate. To design displays to support clinicians during newborn resuscitation, we must first carefully consider the information requirements.

METHODS

We conducted a work domain analysis (WDA) for the neonatal transition in the first 10 min after birth. We split the work domain into two 'subdomains'; the physiology of the neonatal transition, and the clinical resources supporting the neonatal transition. A WDA can reveal information requirements that are not yet supported by resources.

RESULTS

The physiological WDA acted as a conceptual tool to model the exact processes and functions that clinicians must monitor and potentially support during the neonatal transition. Importantly, the clinical resources WDA revealed several capabilities and limitations of the physical objects in the work domain-ultimately revealing which physiological functions currently have no existing sensor to provide clinicians with information regarding their status.

CONCLUSION

We propose two potential approaches to improving the clinician's information environment: (1) developing new sensors for the information we lack, and (2) employing principles of ecological interface design to present currently available information to the clinician in a more effective way.

Pediatric lung ultrasound - pros and potentials

Lung ultrasound (US) cannot be considered a new diagnostic imaging technique anymore, with some articles dating back 50 years. The question that hovers over it recently is why it is still not widely accepted, like chest radiography. So, have we wasted a lot of time without using lung US, or are we wasting our time using lung US? The main goals of this article are to underline all the advantages, potentials and reasons to use lung US in everyday clinical practice, but also to address the main concerns linked to this imaging tool. From the standpoint of an experienced pediatric radiologist from a tertiary health care children's hospital who has been performing this examination for more than 10 years on a daily basis, this article also addresses the most common applications of lung US, such as detection of pneumonia and neonatal lung diseases.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Neonatal lung ultrasonography score after surfactant in preterm infants: A prospective observational study

OBJECTIVE

To assess changes in neonatal lung ultrasonography score (nLUS) after surfactant administration in preterm infants with respiratory distress syndrome (RDS).

WORKING HYPOTHESIS

The reduction of nLUS score before (nLUSpre), 2 hours (nLUS2h), and 12 hours (nLUS12h) after surfactant administration to identify patients who will not need a second treatment.

STUDY DESIGN AND SETTING

Prospective observational study in the tertiary neonatal intensive care unit.

PATIENTS SELECTION

Forty-six preterm neonates with RDS of 32 weeks median gestational age (IQR 30-33) and mean birth weight of 1650 ± 715 g.

METHODOLOGY

Lung ultrasonography was performed before, 2 hours, and 12 hours after surfactant administration in preterm infants with RDS needing surfactant treatment. Resulting nLUS was analyzed.

RESULTS

The Wilcoxon signed-rank test demonstrated an nLUS lowering after 2 hours (P < .001) and 12 hours (P < .001) from surfactant administration. Sixteen newborns required surfactant retreatment with median gestational age of 32 weeks (IQR 29-33) and mean birth weight of 1519 ± 506 g.The receiver operating characteristic analysis for the nLUS2h yielded an area under the curve of 0.80 (95% confidence interval, 0.76-0.85; P < .001). A nLUS2h ≥7 showed a sensitivity of 94% and a specificity of 60% for needing a second treatment with surfactant.

CONCLUSIONS

In preterm infants with RDS requiring surfactant treatment, nLUS evaluated 2 hours after surfactant administration can be used to identify patients who will not need a second treatment.

Point-of-care lung ultrasound in three neonates with COVID-19

Since March 2020, the world is involved in the COVID-19 pandemic, a disease caused by a novel virus called SARS-CoV-2. Some authors have described the ultrasonographic findings of COVID-19 pneumonia in adults and children, but data on neonates are lacking. Our objective was to describe the ultrasonographic lung pattern on newborns with SARS-CoV-2 infection during the COVID-19 pandemic. Newborns who tested positive for SARS-CoV-2 PCR in respiratory samples and were evaluated with point-of-care lung ultrasound (LU) from March to April 2020 were included. LU was performed bedside by a single investigator at the time of diagnosis and every 48 h during the first week following diagnosis. Six areas were studied. Three neonates were included. Infants' comorbidities included meconium aspiration syndrome, bronchopulmonary dysplasia, and Hirschsprung's disease. One required mechanical ventilation. No deaths occurred. LU showed B-lines, consolidation, and spared areas. No pneumothorax or pleural effusion was observedConclusions: LU could be of value when managing COVID-19 neonates. We describe the findings of lung ultrasound monitoring during the first week following diagnosis in three neonates with SARS-CoV-2 infection. What is known: • Lung ultrasound (LU) is a useful tool in COVID-19 management in adults. To date, no report on LU and neonates with SARS-CoV-2 infection has been published. What is new: • This study adds evidence about LU findings in neonates with SARS-CoV-2 infection.