Comparison among three lung ultrasound scores used to predict the need for surfactant replacement therapy: a retrospective diagnostic accuracy study in a cohort of preterm infants

Diagnostic Accuracy of Lung Ultrasound in Neonatal Diseases: A Systematized Review

Background: Respiratory problems are frequent in newborns, and are mainly studied with chest X-rays, whereas CT scans are usually needed for the evaluation of rare malformations and diseases. Lung ultrasound (LUS] has been proposed as an alternative method of diagnosing a variety of respiratory conditions. In recent years, there has been a rapid increase in LUS studies, thanks to the ability of LUS to rapidly exclude complications and significantly reduce radiation exposure in this fragile population. We aimed to summarize the current knowledge about LUS. Methods: A literature search was conducted on the Medline and Cochrane databases using appropriate terms. The inclusion criteria were: English language and human species. Exclusion criteria were: non-English language, animal species, case reports, case series, non-systematic reviews, and editorials. Results: The search returned 360 results. No Cochrane reviews were found. Titles and abstracts were screened, and 37 were finally considered. Studies concerning the use of lung ultrasound for the following conditions were presented: neonatal respiratory distress syndrome, transient tachypnea of the newborn, pneumothorax, pulmonary hemorrhage, pneumonia, bronchopulmonary dysplasia, and prediction of extubation success. Conclusions: We discussed the utility of LUS for the diagnosis and treatment of neonatal diseases according to the most recent literature.

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.

Lung ultrasound for the sick child: less harm and more information than a radiograph

In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate.  Conclusion: the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: • Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. • Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: • Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. • Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.

Advanced Diagnostics of Respiratory Distress Syndrome in Premature Infants Treated with Surfactant and Budesonide through Computer-Assisted Chest X-ray Analysis

This research addresses the respiratory distress syndrome (RDS) in preterm newborns caused by insufficient surfactant synthesis, which can lead to serious complications, including pneumothorax, pulmonary hypertension, and pulmonary hemorrhage, increasing the risk of a fatal outcome. By analyzing chest radiographs and blood gases, we specifically focus on the significant contributions of these parameters to the diagnosis and analysis of the recovery of patients with RDS. The study involved 32 preterm newborns, and the analysis of gas parameters before and after the administration of surfactants and inhalation corticosteroid therapy revealed statistically significant changes in values of parameters such as FiO2, pH, pCO2, HCO3, and BE (Sig. < 0.05), while the pO2 parameter showed a potential change (Sig. = 0.061). Parallel to this, the research emphasizes the development of a lung segmentation algorithm implemented in the MATLAB programming environment. The key steps of the algorithm include preprocessing, segmentation, and visualization for a more detailed understanding of the recovery dynamics after RDS. These algorithms have achieved promising results, with a global accuracy of 0.93 ± 0.06, precision of 0.81 ± 0.16, and an F-score of 0.82 ± 0.14. These results highlight the potential application of algorithms in the analysis and monitoring of recovery in newborns with RDS, also underscoring the need for further development of software solutions in medicine, particularly in neonatology, to enhance the diagnosis and treatment of preterm newborns with respiratory distress syndrome.

ERS International Congress 2023: highlights from the Paediatrics Assembly

Respiratory health in children is essential for general wellbeing and healthy development in the short and long term. It is well known that many respiratory diseases in adulthood have their origins in early life, and therefore research on prevention of respiratory diseases and management of children with respiratory diseases will benefit patients during the full life course. Scientific and clinical advances in the field of respiratory health are moving at a fast pace. This article summarises some of the highlights in paediatric respiratory medicine presented at the hybrid European Respiratory Society (ERS) International Congress 2023 which took place in Milan (Italy). Selected sessions are summarised by Early Career Members of the Paediatrics Assembly (Assembly 7) under the supervision of senior ERS officers, and cover a wide range of research areas in children, including respiratory physiology and sleep, asthma and allergy, cystic fibrosis, respiratory infection and immunology, neonatology and intensive care, respiratory epidemiology and bronchology.

Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study)

BACKGROUND

The management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT. Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group.

METHODS/DESIGN

In this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks' gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group.

DISCUSSION

Based on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05198375 . Registered on 20 January 2022.