Lung Ultrasound to Diagnose Pneumonia in Neonates with Fungal Infection

Use of Lung Ultrasound in Reducing Radiation Exposure in Neonates with Respiratory Distress: A Quality Management Project

Background and Objectives: Our quality management project aims to decrease by 20% the number of neonates with respiratory distress undergoing chest radiographs as part of their diagnosis and monitoring. Materials and Methods: This quality management project was developed at Life Memorial Hospital, Bucharest, between 2021 and 2023. Overall, 125 patients were included in the study. The project consisted of a training phase, then an implementation phase, and the final results were measured one year after the end of the implementation phase. The imaging protocol consisted of the performance of lung ultrasounds in all the patients on CPAP (continuous positive airway pressure) or mechanical ventilation (first ultrasound at about 90 min after delivery) and the performance of chest radiographs after endotracheal intubation in any case of deterioration of the status of the patient or if such a decision was taken by the clinician. The baseline characteristics of the population were noted and compared between years 2021, 2022, and 2023. The primary outcome measures were represented by the number of X-rays performed in ventilated patients per year (including the patients on CPAP, SIMV (synchronized intermittent mandatory ventilation), IPPV (intermittent positive pressure ventilation), HFOV (high-frequency oscillatory ventilation), the number of X-rays performed per patient on CPAP/year, the number of chest X-rays performed per mechanically ventilated patient/year and the mean radiation dose/patient/year. There was no randomization of the patients for the intervention. The results were compared between the year before the project was introduced and the 2 years across which the project was implemented. Results: The frequency of cases in which no chest X-ray was performed was significantly higher in 2023 compared to 2022 (58.1% vs. 35.8%; p = 0.03) or 2021 (58.1% vs. 34.5%; p = 0.05) (a decrease of 22.3% in 2023 compared with 2022 and of 23.6% in 2023 compared with 2021). The frequency of cases with one chest X-ray was significantly lower in 2023 compared to 2022 (16.3% vs. 35.8%; p = 0.032) or 2021 (16.3% vs. 44.8%; p = 0.008). The mean radiation dose decreased from 5.89 Gy × cm2 in 2021 to 3.76 Gy × cm2 in 2023 (36% reduction). However, there was an increase in the number of ventilated patients with more than one X-ray (11 in 2023 versus 6 in 2021). We also noted a slight annual increase in the mean number of X-rays per patient receiving CPAP followed by mechanical ventilation (from 1.80 in 2021 to 2.33 in 2022 and then 2.50 in 2023), and there was a similar trend in the patients that received only mechanical ventilation without a statistically significant difference in these cases. Conclusions: The quality management project accomplished its goal by obtaining a statistically significant increase in the number of ventilated patients in which chest radiographs were not performed and also resulted in a more than 30% decrease in the radiation dose per ventilated patient. This task was accomplished mainly by increasing the number of patients on CPAP and the use only of lung ultrasound in the patients on CPAP and simple cases.

No Critical Ultrasound, No Life: The Value of Point-of Care Critical Ultrasound in the Rescue of Critically Ill Infants

Point-of-care critical ultrasound (POC-CUS) screening plays an increasingly important role in the treatment of critically ill infants. Without POC-CUS, the lives of many infants would not be saved in time and correctly. A premature infant with systemic multiple organ system dysfunction caused by fungal sepsis was treated and nursed under the guidance of POC-CUS monitoring, and the infant was ultimately cured. This premature infant had systemic multiple organ system dysfunction and disseminated intravascular coagulation (DIC) caused by fungal sepsis. In the hypercoagulable state of early-stage DIC, cardiac thrombosis could be found using ultrasound screening. For this case, right renal artery thrombosis was found via renal artery Doppler ultrasound examination. Due to the severity of this disease, ultrasound-guided peripherally inserted central catheter (PICC) insertion and ultrasound checks of the PICC tip's position were performed, which ensured the success of this one-time catheterization and shortened the catheterization time. Lung ultrasound is used for the diagnosis and differential diagnosis of pulmonary diseases, and to guide the application of mechanical ventilation. Because the abdominal circumference of the patient's markedly enlarged abdominal circumference, bloody stool, and absence of bowel sounds, abdominal ultrasonography was performed, which revealed a markedly enlarged liver, significant peritoneal effusion, and necrotizing enterocolitis. Guided by POC-CUS monitoring, we had the opportunity to implement timely and effective treatment that ultimately saved this critically ill patient's life. The successful treatment of this newborn infant fully reflects the importance of carrying out POC-CUS screening.

Ultrasound diagnosis and grading criteria of neonatal respiratory distress syndrome

Background: Respiratory distress syndrome (RDS) is a common critical lung disease in newborn infants, especially those in premature infants with higher mortality rate. Early and correct diagnosis is the key to improve its prognosis. Previously, the diagnosis of RDS mainly relied on chest X-ray (CXR) findings, and it has been graded into four stages based on the progression and severity of CXR changes. This traditional diagnosing and grading method may lead to high misdiagnosis rate or delayed diagnosis. Recently, using ultrasound to diagnose neonatal lung diseases and RDS is becoming increasingly popular, and the technology is gaining higher sensitivity and higher specificity. The management of RDS under lung ultrasound (LUS) monitoring has achieved significant results, reducing the misdiagnosis rate of RDS, thereby reducing the probability of mechanical ventilation and the use of exogenous pulmonary surfactant, and making the success rate of treatment of RDS up to 100%.Objective: The purpose of the article was to introduce the ultrasound grading methods and criteria of RDS, in order to promote the application of LUS in the diagnosis and treatment of RDS.Methods: Literature (in English and Chinese) on the use of ultrasound in the diagnosis of neonatal RDS between 2008 and 2022 was selected for inclusion in this study.Results: From the collected literature, the use of ultrasound in the diagnosis of RDS is increasing, and people's understanding of the ultrasound imaging findings of RDS is also changing. Among them, the research on ultrasound grading of RDS is the latest progress.Conclusion: Ultrasound is accurate and reliable in the diagnosis and differential diagnosis of RDS. It is of great clinical value to master the ultrasound diagnosis and grading criteria of RDS.

Pulmonary Invasive Fungal Disease: Ultrasound and Computed Tomography Scan Findings

OBJECTIVE

The importance of ultrasound in diagnosing pulmonary invasive fungal diseases (IFD) has yet to be assessed. Thus, this study aimed to evaluate the frequency of sonographic findings in patients suspected of an invasive pulmonary fungal infection.

MATERIAL AND METHODS

This prospective longitudinal study examined all patients with lung lesions in imaging modalities and suspected IFDs referred to Dr. Sheikh and Akbar pediatric hospitals from 2019 to 2022. Considered variables were the halo sign in the computed tomography (CT) scan; the target sign in the ultrasound and contrast-enhanced CT scan; the cavity; wedge-shaped consoli- dation; and pleuritis and extrapulmonary invasion to the chest wall or subdiaphragmatic invasion in both modalities. All patients who underwent lung CT scans and ultrasounds until the final diagnosis were followed up. The degree of agreement between ultrasound and CT scan findings and the sensitivity, specificity, and diagnostic accuracy of these signs were assessed.

RESULTS

This study involved 40 patients with an average age of 7.16 ± 4.23 years. Acute leukemia was the commonest underlying dis- ease detected in 17 (42.5%) cases. The target sign in ultrasound (61.9%) and the halo sign in CT scan (71.4%) had the highest frequency among the variables in patients with IFD. Cohen's kappa coefficient agreement in both modalities was 0.5 for the cavity, with significant relation (P = .02). The Cohen's kappa was less than .17 for other findings (P > .05). The diagnostic criteria in the simultaneous examina- tion of the fungus target in ultrasound and halo in CT scan showed a sensitivity of 82.4% and specificity of 76.5%, respectively.

CONCLUSION

Combining the characteristic findings of ultrasound and CT-scan provides a higher value in diagnosing pulmonary invasive fungal disease.

The Role of Ultrasound in the Diagnosis of Pulmonary Infection Caused by Intracellular, Fungal Pathogens and Mycobacteria: A Systematic Review

BACKGROUND

Lung ultrasound (LUS) is a widely available technique allowing rapid bedside detection of different respiratory disorders. Its reliability in the diagnosis of community-acquired lung infection has been confirmed. However, its usefulness in identifying infections caused by specific and less common pathogens (e.g., in immunocompromised patients) is still uncertain.

METHODS

This systematic review aimed to explore the most common LUS patterns in infections caused by intracellular, fungal pathogens or mycobacteria.

RESULTS

We included 17 studies, reporting a total of 274 patients with M. pneumoniae, 30 with fungal infection and 213 with pulmonary tuberculosis (TB). Most of the studies on M. pneumoniae in children found a specific LUS pattern, mainly consolidated areas associated with diffuse B lines. The typical LUS pattern in TB consisted of consolidation and small subpleural nodes. Only one study on fungal disease reported LUS specific patterns (e.g., indicating "halo sign" or "reverse halo sign").

CONCLUSIONS

Considering the preliminary data, LUS appears to be a promising point-of-care tool, showing patterns of atypical pneumonia and TB which seem different from patterns characterizing common bacterial infection. The role of LUS in the diagnosis of fungal disease is still at an early stage of exploration. Large trials to investigate sonography in these lung infections are granted.

Lung ultrasound to diagnose infectious pneumonia of newborns: A prospective multicenter study

INTRODUCTION

Whether lung ultrasound (LUS) can be used for pathogenic diagnosis remains controversial. This study was conducted to clarify whether ultrasound has diagnostic value for etiology.

METHODS

A total of 135 neonatal pneumonia patients with an identified pathogen were enrolled from the newborn intensive care units of 10 tertiary hospitals in China. The study ran from November 2020 to December 2021. The infants were divided into various groups according to pathogens, time of infection, gestational age, and disease severity. The distribution of pleural line abnormalities, B-line signs, and pulmonary consolidation, as well as the incidence of air bronchogram and pleural effusion based on LUS, were compared between these groups.

RESULTS

There were significant differences in pulmonary consolidation. The sensitivity and specificity of the diagnosis of severe pneumonia based on the extent of pulmonary consolidation were 83.3% and 85.2%, respectively. The area under the receiver operating characteristic curve for the identification of mild or severe pneumonia based on the distribution of pulmonary consolidation was 0.776.

CONCLUSION

LUS has good performance in diagnosing and differentiating the severity of neonatal pneumonia but cannot be used for pathogenic identification in the early stages of pneumonia.

The specific signs of lung ultrasound to diagnose pulmonary hemorrhage of the newborns: Evidence from a multicenter retrospective case-control study

OBJECTIVES

Pulmonary hemorrhage (PH) is one kind of critical lung diseases in newborn infants, which is the most difficult one to be diagnosed by ultrasound. This study was to investigate the specific ultrasonic signs of PH in order to better diagnose neonatal PH by using lung ultrasound (LUS).

METHODS

A total 168 newborn infants were enrolled in this study, which included PH, pneumonia, meconium aspiration syndrome, and newborns without lung diseases, there were 42 cases in each group. In a quiet state, infants were placed in the supine, lateral or prone position for the examination. Each lung was divided into the anterior, lateral and posterior regions, then each region of both lungs was scanned with the probe perpendicular to the ribs or parallel to the Intercostal spaces.

RESULTS

The major results showed that: (1) the common LUS manifestation of PH includes lung consolidation, air bronchograms, fluid bronchograms, pleural effusion, shred signs, pleural line abnormality and B-lines, while fibrin deposition sign is a rare sign of PH. (2) Co-existing of lung consolidation with fluid bronchograms and pleural effusion is the specific sign of PH with a sensitivity of 81.0%, specificity of 98.4% and the positive predictive value (PPV) was 94.4%. (3) Fibrin deposition sign is an uncommon specific LUS sign of PH with a sensitivity 28.6%, specificity of 100% and the PPV was 100%. (4) Nine patients (21.4%) were diagnosed with PH based on ultrasound findings before oronasal bleeding. (5) The survival rate of infants with PH was 100% in this study.

CONCLUSION

LUS is helpful for the early diagnosis of neonatal PH and may therefore improve the prognosis. The lung consolidation with fluid bronchograms and pleural effusion as well as fibrin deposition sign are specific to diagnose PH by using LUS.

Lung Ultrasound Monitoring of Legionella Ventilator-Associated Pneumonia in an Extremely Low-Birth-Weight Infant

Ventilator-associated pneumonia (VAP) is a common complication of different severe lung diseases that need to be treated with mechanical ventilation in newborn infants. However, VAP due to Legionella pneumophila infection is rarely reported in the literature, especially in extremely low-birth-weight (ELBW) infants. Lung ultrasound (LUS) has been used in the diagnosis of neonatal pneumonia, but there is no literature on the ultrasound characteristics of Legionella-VAP in ELBW infants. This paper introduced the typical LUS findings of Legionella-VAP in ELBW infants, which mainly includes severe and large-area lung consolidation and atelectasis in the bilateral lungs; whether there is blood supply in the consolidated area has an important reference value for predicting the prognosis. In addition, the treatment and management experience were also introduced together, thereby helping us to deepen the understanding of the disease and avoid missed diagnoses.