Application of Lung Ultrasonography in the Diagnosis of Childhood Lung Diseases

Predictive value of lung ultrasound score in weaning from mechanical ventilation in neonatal respiratory distress syndrome

BACKGROUND

To explore the predictive value of lung ultrasound score (LUS) in weaning from mechanical ventilation in neonatal respiratory distress syndrome (RDS).

METHODS

A total of 111 neonates with RDS who received mechanical ventilation in the neonatal intensive care unit (NICU) of Sichuan Provincial People's Hospital were selected as the subjects. Before weaning, the LUS was performed by the 12-region ultrasound score of the lungs. Those neonates were divided into the weaning success group (n = 95) and weaning failure group (n = 16) according to whether they received mechanical ventilation again 48 h after weaning. Oxygenation index (OI) before weaning and arterial blood gas indexes after weaning were collected. The correlation of LUS with OI or arterial blood gas was analyzed, and the difference in LUS between the two groups was compared. The receiver operating characteristic (ROC) curve of LUS in predicting the weaning outcome of mechanical ventilation in neonatal RDS was drawn and its predictive value was verified.

RESULTS

LUS of all neonates before weaning was significantly correlated with OI and arterial blood gas indexes, which was positively correlated with OI value (r = 0.671, p < 0.001) and arterial partial pressure of carbon dioxide (r = 0.461, p < 0.001), and negatively correlated with arterial partial pressure of oxygen (r = -0.531, p < 0.001). The LUS in the weaning success group was significantly lower than that in the weaning failure group (5(3,8) points vs. 12.5(10,16.75) points, p < 0.001). The ROC curve showed that the AUC was 0.898. The optimal cut-off value of LUS was 9.5 as the predictive value of successful weaning, with a sensitivity of 0.875 and a specificity of 0.811.

CONCLUSION

LUS is a convenient, sensitive, and accurate predictor of successful weaning of mechanical ventilation in NRDS, and can be used as an important tool for clinical guidance of weaning.

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).

Neonatal intensive care unit nurse training in identifying ultrasound landmarks in the neonatal mediastinum. Α training program for nurses in North-Eastern Greece

PURPOSE

To demonstrate methods and landmarks for mediastinum ultrasound as part of ultrasound examination of the lung for nurses. This will be the first step in their education to detect finally the tubes and lines malpositioning in order to distinguish emergency conditions of the lungs in neonates hospitalized in neonatal intensive care units.

DESIGN AND METHODS

Theoretical and practical interventions were developed to create a 3-month training program based on similar medical courses. The study was approved by the hospital's ethics committee.The program was performed in the neonatal intensive care unit of a single academic institution. Participating nurse was supervised by a paediatric surgeon and trained in lung ultrasound (a safe method without radiation) by a paediatric radiologist.

RESULTS

During the practical period (2 months), the neonatal intensive care unit nurse examined 50 neonates (25 + 6-40 + 4 weeks gestational age; 21 males) separated into two subgroups of 25 neonates each for each training month. In the first month under supervision, the nurse was trained to recognise the aortic arch, the right pulmonary artery, the esophagus, the tracheal air, and the 'sliding lung sign' in the anterior, lateral, and posterolateral aspects of the thoracic cage. In the second month, the nurse recorded the ultrasound examinations. The identified structures were then assessed and graded by the supervising radiologist. The overall estimated success rate (5 landmarks × 25 neonates = 125) was 90.4%.

CONCLUSIONS

Although this is the first report of the design of a 'hands-on', lung ultrasound training program for neonatal intensive care unit nurses, our findings demonstrate that it is a safe and useful program for all neonatal intensive care unit nurses because theoverall success rate of the 3-month program was determined by accurate identification of basic anatomical structures (90,4%) by the nurse.

PRACTICE IMPLICATIONS

This study describes the first educational training program for NICU nurses designed to recognise basic structures in the neonatal mediastinum. If the program is effective, NICU nurses will be able to identify respiratory emergencies. NICU nurses can inform doctors about emergencies according to tubes and lines malpositioning in a timely manner to avoid negative consequences.

Lung ultrasound completely replaced chest X-ray for diagnosing neonatal lung diseases: a 3-year clinical practice report from a neonatal intensive care unit in China

BACKGROUND AND OBJECTIVE

Lung ultrasound (LUS) has been widely used in the diagnosis and differential diagnosis of neonatal lung diseases (NLDs), but whether it can replace the routine use of chest X-ray (CXR) in neonatal intensive care units (NICUs) remains controversial. This paper summarizes the clinical practice of our neonatal intensive care unit (NICU) during the past three years to explore the feasibility and necessity of using LUS instead of CXR to diagnose NLDs in the NICU setting.

METHODS

The clinical data and LUS examination results from 1,381 newborn infants with respiratory difficulty who were hospitalized in our NICU from March 2017 to February 2020 were retrospectively collected to analyze the types of lung diseases diagnosed and the reliability of LUS for diagnosing NLDs.

RESULTS

(1) During this period, 1381 newborn infants with dyspnea were admitted to our NICU, accounting for 41.2% of all hospitalized children. (2) Among the 1381 infants, 17 patients with respiratory distress were confirmed as having severe heart disease by echocardiography, while the remaining 1364 patients had different kinds of lung diseases: pneumonia (697 patients, 51.1%), respiratory distress syndrome (251 patients, 17.4%), transient tachypnea of the newborn (197 patients, 13.3%), atelectasis (89 patients, 5.6%), pneumothorax (46 patients, 3.2%), pulmonary hemorrhage (69 patients, 4.5%), severe pleural effusion (18 patients, 1.32%), congenital pulmonary sequestration (3 patients, 0.22%), bullae of the lung (2 patients, 0.15%), and congenital cystic adenomatoid malformation (2 patients). (5) Among the 1381 infants, 217 received CXR examination before admission, which resulted in misdiagnosis in 45 patients (20.7%) and missed diagnosis in 12 patients (5.5%); the missed diagnosis and misdiagnosis rate was 26.3%.

CONCLUSION

Our 3-year clinical practice experience indicated that LUS could completely replace chest X-ray for the diagnosis and differential diagnosis of NLDs in the NICU. Compared with X-ray, LUS had higher accuracy and reliability in diagnosing NLDs.

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

Ten Years of Pediatric Lung Ultrasound: A Narrative Review

Lung diseases are the most common conditions in newborns, infants, and children and are also the primary cause of death in children younger than 5 years old. Traditionally, the lung was not thought to be a target for an ultrasound due to its inability to penetrate the gas-filled anatomical structures. With the deepening of knowledge on ultrasound in recent years, it is now known that the affected lung produces ultrasound artifacts resulting from the abnormal tissue/gas/tissue interface when ultrasound sound waves penetrate lung tissue. Over the years, the application of lung ultrasound (LUS) has changed and its main indications in the pediatric population have expanded. This review analyzed the studies on lung ultrasound in pediatrics, published from 2010 to 2020, with the aim of highlighting the usefulness of LUS in pediatrics. It also described the normal and abnormal appearances of the pediatric lung on ultrasound as well as the benefits, limitations, and possible future challenges of this modality.

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.

Nanobubble Lung Ultrasound Application in the Treatment of Neonatal Pneumonia

This article studies the effect of pulmonary ultrasound in the diagnosis and treatment of neonatal pneumonia. In this experiment, 33 children with pneumonia diagnosed and treated in the hospital were selected as the research objects, and all were performed by X-ray examination and lung ultrasound. After the test was completed, the diagnostic accuracy of the two examination methods was analyzed, the performance of the chest X-rays of the children were observed, and the lung ultrasound examination was recorded at the same time. The results showed that the diagnostic accuracy of lung ultrasound examination was 93.00%, which was higher than 75.00% of X-ray examination, and the difference was statistically significant (P < 0.05). In the experiment, the paired chi-square test was performed on the results of LUS and bedside CXR diagnosis of IPN, and the value was 0.687. The two have a good consistency in the diagnosis of IPN in NICU. The Pearson correlation test results of LUS score and neonatal pneumonia case score showed that there was a significant negative correlation between LUS score and neonatal pneumonia case score. The LUS scores between the control group, non-risk recombination, and risk recombination were tested by rank sum test of multiple independent samples. The results showed that the LUS scores of the three groups were statistically significant (P < 0.05). The LUS scores of the risk recombination were significantly higher than the non-risk recombination. Two independent sample rank sum tests were performed between each two groups. After Bonferroni correction of P value, the difference between each group was statistically significant. In the end, we have concluded that for the diagnosis of neonatal pneumonia, pulmonary ultrasound can be used for diagnosis. Combining pulmonary ultrasound with X-rays can improve the diagnosis accuracy of pneumonia. During the treatment, ultrasound is used for dynamic monitoring. By observing the pleural line and pulmonary consolidation it can be used to clarify the treatment effect of children. LUS and bedside CXR have a good agreement for the diagnosis of IPN. The LUS score can effectively assess the severity of IPN. The greater the severity of the disease in children with IPN, the higher the LUS score.

Successful ultrasound guided percutaneous drainage of pneumatocele in an extremely preterm infant

Pneumatoceles are air filled, thin-walled cystic lesions with in the lung parenchyma that occur infrequently in neonates and infants, often as a complication of positive pressure ventilation, air leak syndrome or ventilator associated pneumonia. Whilst majority of pneumatoceles regress spontaneously over days to weeks, few large pneumatoceles may lead to acute cardiorespiratory insufficiency and may require drainage under computerized tomography or fluoroscopic guidance. We present a case report of an unstable extreme preterm infant with a large pneumatocele and respiratory failure, that was treated successfully by drainage under bedside ultrasound guidance.

Roles of Lung Ultrasound Score in the Extubation Failure From Mechanical Ventilation Among Premature Infants With Neonatal Respiratory Distress Syndrome

Objective: To investigate the predictive value of lung ultrasound score (LUS) in the extubation failure from mechanical ventilation (MV) among premature infants with neonatal respiratory distress syndrome (RDS). Methods: The retrospective cohort study was conducted with a total of 314 RDS newborns who received MV support for over 24 h. After extubation from MV, infants were divided into extubation success and extubation failure groups. Extubation failure was defined as re-intubation within 48 h after extubation. Univariate and multivariate logistic regression analyses were used to identify the predictors of the extubation failure. The predictive effectiveness of the combined model and LUS in the extubation failure was assessed by receiver operating characteristic curve, area under curve (AUC), and internal validation. Results: 106 infants failed extubation from MV. The combined model for predicting the extubation failure was performed according to the predictors of gestational age, body length, birth weight, and LUS. The AUC of this combined model was 0.871 (sensitivity: 86.67%, specificity: 74.31%). The AUC of LUS was 0.858 (sensitivity: 84.00%, specificity: 80.69%), and the cutoff value was 18. There was no statistical difference in the predictive power between the combined model and LUS (Z = 0.880, P = 0.379). The internal validation result showed that the AUC of LUS was 0.855. Conclusions: LUS presented a good ability in predicting the extubation failure among RDS newborns after MV.

The Use of Lung Ultrasound to Monitor the Antibiotic Response of Community-Acquired Pneumonia in Children: A Preliminary Hypothesis

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality among children worldwide. Over the last 10 years, lung ultrasound (US) has been widely studied as an alternative diagnostic tool for adult and pediatric CAP with excellent results. In this case series, we describe clinical and laboratory results as well as detailed lung US findings in 6 children with CAP, showing the potential use of lung US in monitoring the response to antibiotic therapy.

POC-LUS guiding pleural puncture drainage to treat neonatal pulmonary atelectasis caused by congenital massive effusion

Point of care lung ultrasound (POC-LUS) has played important roles in diagnosing neonatal lung diseases and assisting in their treatment. A newborn infant with severe respiratory distress diagnosed as pulmonary atelectasis caused by congenital massive pleural effusion, whose consolidated lung recruitment after pleural puncture drainage under POC-LUS guidance. Lung ultrasound can be performed easily and timely at bed-side with free of radiation exposure, thus it should be used extensively in the neonatal department.

Diagnostic value of lung ultrasound in evaluating the severity of neonatal respiratory distress syndrome

BACKGROUND

It is still unclear whether lung ultrasound (LUS) can be used to evaluate the severity of neonatal respiratory distress syndrome (NRDS).

OBJECTIVE

To evaluate the role of LUS in assessing NRDS.

METHODS

From January 2017 to January 2018, newborns with suspected NRDS were enrolled. The LUS score and lung consolidation areas were determined. The receiver operative curve (ROC) was used to analyze the LUS score and lung consolidation to predict NRDS severity.

RESULTS

Neonates with NRDS had higher LUS scores than those with non-NRDS (23.6 ± 3.6 vs. 16.2 ± 1.8, P < 0.05). Among neonates with NRDS, the LUS scores increased with NRDS severity (18.0 ± 2.7 vs. 24.0 ± 1.7 vs. 27.0 ± 1.7, all P < 0.05). There were almost no consolidation areas in non-NRDS, while 1.9 ± 1.7 consolidation areas were observed in the NRDS group (P < 0.05). The number of consolidation areas also increased with NRDS severity (0 vs. 1.5 ± 0.8 vs. 4.1 ± 1.3, all P < 0.05). The LUS score for NRDS vs. non-NRDS showed 80.2% sensitivity and 100% specificity using a cut-off of 21.5 (Area under the ROC curve, AUC = 0.938; P < 0.001). The LUS score for severe vs. mild/moderate NRDS showed 73.1% sensitivity and 95.7% specificity using a cut-off of 25.5 (AUC = 0.944; P < 0.001). The LUS score for predicting mechanical ventilation showed 81.3% sensitivity and 88.8% specificity using a cut-off of 25.5 (AUC = 0.912; P < 0.001). The AUCs of consolidation areas were similar to those of LUS score (all P > 0.05).

CONCLUSION

The LUS score and consolidation areas can discriminate NRDS from non-NRDS and the different grades of NRDS, and predict the application of mechanical ventilation.

[Usefulness of early lung ultrasound in acute mild-moderate acute bronchiolitis. A pilot study]

OBJECTIVE

To determine the correlation between the findings seen in early lung ultrasound with the clinical severity scales, and its association with the subsequent progression of the mild-moderate acute bronchiolitis (AB).

PATIENTS AND METHODS

An observational prospective study conducted on infants with mild-moderate BA, using lung ultrasound in the first 24hours of hospital care. The lung involvement was graded (range 0-50 points) based on an ultrasound score (ScECO) and 2routinely used clinical scales: the modified Wood Downes Ferres (WDFM), and the Hospital Sant Joan de Deu (HSJD). The relationship between the ScECO and the subsequent clinical progression (admission to the Paediatric Intensive Care Unit (PICU), days in hospital, and days of oxygen therapy), was also determined.

RESULTS

The study included a total of 59 patients, with a median age of 90 days (IQR: 30-270 days). The median ScECO score was 6 points (2-8) in the patients that did not require hospital admission, with 9 points (5-13.7) admitted to the ward, and 17 (14.5-18) in the patients who needed to be transferred from the ward to the PICU (P=.001). The ScECO had a moderate lineal association with the WDFM scale (rho=0.504, P<.001) and the HSJD (rho=0.518; P<.001). The ScECO was associated with admission to PICU [OR 2.5 (95% CI: 1.1-5.9); P=.035], longer hospital stay [1.2 days 95% CI: 0.55-1.86); P=.001] and duration of oxygen therapy [0.87 days (95% CI: 0.26-1.48); P=.006].

CONCLUSIONS

There is a moderate correlation between early lung ultrasound findings with the severity of the AB evaluated by the clinical scales, as well as some relationship with the clinical progression.

Lung ultrasonography to diagnose pulmonary hemorrhage of the newborn

OBJECTIVES

This study was aimed to investigate the application of lung ultrasound for the diagnosis of pulmonary hemorrhage of the newborn (PHN).

METHODS

From July 2013 to June 2016, 157 neonates were enrolled in the study. They were divided into two groups: a study group of 57 neonates, who were diagnosed with PHN according to their medical history, clinical manifestations and chest X-ray findings, and a control group of 100 neonates with no lung disease. All subjects underwent bedside lung ultrasound in a quiet state in a supine, lateral or prone position, performed by a single expert physician. The ultrasound findings were compared between the two groups.

RESULTS

The lung ultrasound main findings associated with PHN included lung consolidation with air bronchograms with an incidence of 82.5%, a shred sign with an incidence of 91.2%, pleural effusion with an incidence of 84.2% (pleurocentesis confirmed the fluid was really bleeding), atelectasis with a incidence of 33.3%, pleural line abnormalities, as well as disappearing A-lines with an incidence of 100%, and 11.9% of these patients had the main manifestations of alveolar-interstitial syndrome (AIS). The shred sign exhibited a sensitivity of 91.2% and a specificity of 100% in diagnosing PHN.

CONCLUSIONS

Lung ultrasonography is useful and reliable for diagnosing PHN, which is suitable for routine application in the neonatal intensive care unit.

The significance and the necessity of routinely performing lung ultrasound in the neonatal intensive care units

Various lung diseases are the most common conditions and the leading cause of hospital admission and death in newborns. Historically, the diagnosis and differential diagnosis of lung diseases primarily relied on conventional chest X-ray and computed tomography (CT) scans, however, chest X-ray and CT scans suffer from obvious limitations, while lung ultrasound has many kinds of advantages for the diagnosis and differential diagnosis of lung diseases. The significance and the necessity of lung ultrasound in the diagnosis of neonatal lung diseases will be introduced in this paper.

Lung Ultrasonography to Diagnose Transient Tachypnea of the Newborn

BACKGROUND

This study explored the sensitivity and specificity of ultrasound for diagnosing transient tachypnea of the newborn (TTN).

METHODS

Ultrasound was performed by one export. Patients were placed in a supine, lateral recumbent, or prone position. The probe was placed perpendicular or parallel to the ribs, and each region of the lung was scanned. The scan results were compared with conventional chest radiographic results.

RESULTS

A total of 1,358 infants were included in this study. We identified 412 cases without pulmonary diseases, 228 TTN cases, 358 respiratory distress syndrome (RDS) cases, 85 meconium aspiration syndrome (MAS) cases, 215 infectious pneumonia cases, and 60 other cases. The primary ultrasonic characteristic of TTN was pulmonary edema. "White lung" or a "compact B-line" were only observed in severe cases, whereas TTN primarily presented as pulmonary interstitial syndrome or "double lung point." Furthermore, double lung point could appear during the recovery period of severe TTN or RDS, MAS, and pneumonia. Lung consolidation with air bronchograms was not observed in TTN patients. The results showed that white lung or a compact B-line exhibited a sensitivity of 33.8% and a specificity of 91.3% in diagnosing TTN, whereas double lung point exhibited a sensitivity of 45.6% and a specificity of 94.8% in diagnosing severe TTN.

CONCLUSIONS

Pulmonary edema, alveolar-interstitial syndrome, double lung point, white lung, and compact B-line are the primary ultrasound characteristics of TTN. Ultrasonic diagnosis of TTN based on these findings is accurate and reliable. TTN can be ruled out in the presence of lung consolidation with air bronchograms.

First-line diagnosis of paediatric pneumonia in emergency: lung ultrasound (LUS) in addition to chest-X-ray (CXR) and its role in follow-up

OBJECTIVE

The role of lung ultrasound (LUS) integrated with chest X-ray (CXR) for the first-line diagnosis of paediatric pneumonia; to define its role during the follow-up to exclude complications.

METHODS

We performed a retrospective review of a cohort including 84 consecutive children (age range: 3-16 years; mean age: 6 years; 44 males, 40 females) with clinical signs of cough and fever. All the patients underwent CXR at admission integrated with LUS. Those positive at LUS were followed up with LUS until the complete resolution of the disease.

RESULTS

CXR showed 47/84 pneumonic findings. LUS showed 60/84 pneumonic findings; 34/60 pneumonic findings had a typical pattern of lung consolidation; 26/60 pneumonic findings showed association of multiple B-lines, findings consistent with interstitial involvement, and small and hidden consolidations not achievable by CXR. One case was negative at LUS because of retroscapular location. 60 patients were followed up with LUS; 28/60 patients showed a complete regression of the disease; 23/60 patients had a significant decrease in size of consolidation; 9/60 patients showed disease stability or insignificant decrease in size, thus requiring adjunctive LUS examinations.

CONCLUSION

LUS, integrated with CXR, revealed to be an accurate first-line technique to identify small pneumonic consolidations, especially for "CXR-occult" findings, and for early diagnosis of pleural effusion; furthermore, LUS follow-up allows complications to be verified and additional radiation exposures to be avoided.

ADVANCES IN KNOWLEDGE

The effective role of LUS in the diagnosis and follow-up of lung consolidations and pleural effusions in paediatric patients in an emergency setting.