NEONATOLOGY

Neonatal lung ultrasound: functional applications and clinical decision – review

 Ecografia pulmonară neonatală: aplicaţii funcţionale şi decizii clinice – review

First published: 30 septembrie 2024

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Gine.45.3.2024.10085

Abstract

In recent years, a series of clinical studies have demonstrated the efficiency of using neonatal lung ultrasound in the diag­no­sis of respiratory pathologies that were previously diag­nosed using radiography and computed tomography. The use of lung ultrasound in neonatal intensive care units has increased considerably in the last decade, thus there has been advance in the immediate therapeutic management of newborns with respiratory pathology, with predilection for premature and early-term newborns. This aspect re­sides in the fact that the imaging is fast and portable, is performed at the patient’s bedside, is noninvasive and it does not ra­diate, having high sensitivity and specificity. Sec­tions are per­formed in all planes, but require experience from the examiner. This review article describes the tech­nique of per­for­ming lung ultrasound, interpretation of results, diag­no­sis and management. The strengths but also the li­mits of the technique are highlighted. The de­velop­ment of res­pi­ra­tory ultrasound scores allowed the quan­ti­fi­ca­tion of di­sease severity and assisted the physician in the manage­ment and clinical follow-up of newborns with respiratory path­ology. Compared to cardiopulmonary radiography, con­si­dered the gold standard in the diagnosis of neonatal res­pi­ra­tory distress syndrome, pulmonary ultrasound can be used as a tool with multiple benefits in monitoring the evo­lu­tion of the patient under treatment, among which we note the performance in dynamics without exposing the pa­tient to ionizing radiation. Finally, we describe the recent re­vo­lu­tio­nary role of neonatal lung ultrasound, considering the fact that this imaging method may become the gold standard in the diagnosis, therapeutic monitoring and a promising prog­nos­tic tool in the respiratory lung pathology.
 

Keywords
lung ultrasound, cardiothoracic radiography, respiratory distress syndrome, ultrasound score, premature newborn, neonatal intensive care, neonatal respiratory disorders

Rezumat

În ultimii ani, o serie de studii clinice au demonstrat efi­ca­ci­ta­tea utilizării ecografiei pulmonare neonatale în diagnosticarea pa­to­lo­giilor respiratorii care erau anterior diagnosticate prin in­ter­me­diul radiografiei sau al tomografiei computerizate. Utilizarea eco­gra­fiei pulmonare în secţiile de terapie intensivă neonatală a sporit considerabil în ultimul deceniu, astfel în­re­gistrându-se un progres în abordarea terapeutică imediată a nou-născuţilor cu patologie respiratorie, cu predilecţie a nou-născuţilor pre­ma­turi şi early-term. Acest aspect rezidă din faptul că ima­gis­ti­ca este rapidă şi portabilă, se realizează la patul pa­cien­tu­lui, este neinvazivă şi nu iradiază, având sen­si­bilitate şi spe­ci­fi­ci­ta­te ridicate. Secţiunile se realizează în toate planurile, dar ne­ce­si­tă experienţă din partea exa­mi­na­to­ru­lui. Acest articol de revizuire descrie tehnica efec­tuă­rii ecografiei pulmonare, in­ter­pre­ta­rea rezultatelor, diag­nos­ti­ca­rea şi sta­bi­li­rea conduitei te­ra­peu­ti­ce. Sunt evidenţiate punctele for­te, dar şi limitele teh­ni­cii. Dezvoltarea scorurilor ecografice res­pi­ra­to­rii a per­mis cuantificarea severităţii bolii şi asistarea medicului în ma­nage­men­tul şi urmărirea clinică la nou-năs­cu­ţii cu patologie res­pi­ra­to­rie. Comparativ cu radiografia car­dio­pul­mo­nară, considerată stan­dard de aur în diagnosticul sin­dro­mu­lui de detresă res­pi­ra­to­rie neonatală, ecografia pul­mo­nară poate fi utilizată ca o unealtă cu multiple beneficii în monitorizarea evoluţiei pa­cien­tu­lui sub tratament, printre aces­tea remarcându-se efec­tua­rea în dinamică, fără a expune pa­cien­tul la radiaţii io­ni­zan­te. În cele din urmă, descriem ro­lul revoluţionar recent al eco­gra­fiei pulmonare neonatale, luând în considerare faptul că această metodă imagistică poa­te deveni standardul de aur în diagnosticul, monitorizarea te­ra­peu­ti­că şi stabilirea prog­nos­ti­cu­lui patologiei pulmonare res­pi­ra­torii. 
 

Introduction

Neonatal lung ultrasound represents a current challenge for neonatologists in terms of diagnosing, therapeutic approaches, and dynamic monitoring of neonatal respiratory pathology. Until recently, lungs were thought to be inaccessible to ultrasound due to their air-filled nature, which blocks the transmission of ultrasound waves. As a result, lung ultrasound was initially limited to guiding invasive pulmonary procedures. However, in 1990, the first attempts were made to use it as a diagnostic tool for neonatal respiratory distress syndrome. In 1995, Lichtenstein attempted to diagnose pneumothorax in adults using ultrasound, deciphering artifacts produced when the ultrasound beam encounters the pleural line and reflects off the air-filled lungs(1).

In the following years, a series of clinical studies have demonstrated the effectiveness of neonatal lung ultrasound in diagnosing respiratory pathologies such as neonatal respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, pneumothorax and meconium aspiration syndrome, which were previously diagnosed using radiography and computed tomography(1).

Advantages of ultrasound include real-time imaging, noninvasiveness, absence of ionizing radiation, and high sensitivity and specificity. It allows for cross-sectional views in all planes, but it requires skilled operators with a good understanding of anatomical landmarks and organ exploration techniques(2). All ultrasound diagnostic methods are based on the principle that ultrasound waves are reflected at interfaces between media with different acoustic impedances(3). Ultrasound is limited in normally aerated lungs because no acoustic mismatch occurs in the ultrasound beam when it encounters air(4). The pleural line and repetitive hyperechoic horizontal lines (A-lines) can be visualized with ultrasound. The pleural line is a smooth, regular hyperechoic line that moves with respiration(5). A-lines are represented by parallel lines located at regular intervals below the pleural line. They represent the change in acoustic impedance at the pleura-lung interface and generate horizontal artifacts. B-lines appear when air content decreases and subpleural interstitial edema appears, represented by hyperechoic images originating from the pleural line, moving with respiration(6). B-lines correlate with pulmonary interstitial fluid content, and their number increases with decreasing air content. Multiple B-lines indicate alveolo-interstitial syndrome. The presence of compact B-lines in lung fields suggests severe alveolar-interstitial syndrome, also known as “white lung”. When air content further decreases, lung parenchyma can be directly visualized by opening an acoustic window over the lung(4). Pulmonary consolidation is described as a region with poorly defined, hypoechoic margins or feather-like appearance. Identification of the etiology of pulmonary consolidation may be aided by the presence of air bronchograms or vascular patterns(7).

Pulmonary ultrasound in newborns is preferably performed using a high-frequency linear probe, considering their small chest size and thin chest walls. This allows for better image quality and visualization of the entire lung surface. Ultrasound is conducted with the infant lying in a supine, lateral, or prone position. Each hemithorax is divided into anterior, lateral, and posterior regions relative to the anterior and posterior axillary lines, conducting scans longitudinally and transversely in all quadrants(8).

Clinical applications of ultrasound
in neonatal respiratory pathology

1. Respiratory distress syndrome (RDS)

It represents an important cause of neonatal mortality, specifically affecting premature newborns, due to functional immaturity (surfactant deficiency) and structural lung immaturity. Premature newborns typically show signs of respiratory distress shortly after birth (4-6 hours), and they often require invasive or noninvasive respiratory support. For establishing diagnosis and initiating surfactant replacement therapy, lung ultrasound is the imaging method with the most advantages, capable of visualizing the following at the bedside: “white lung” appearance, presence of more than three consolidated B-lines, thickening of the pleural line, multiple subpleural consolidations suggestive of alveolar collapse. These ultrasound features, described by Copetti et al., have shown 100% sensitivity and specificity for diagnosing respiratory distress syndrome(9).

From a radiological standpoint, pathognomonic signs in respiratory distress syndrome include decreased lung transparency with diffuse atelectasis, classically described as a reticulogranular or ground-glass appearance, progressive blurring of the cardiac silhouette, and the presence of air bronchograms(10).

Another study, published by Vergine et al., compared the specificity and sensitivity of lung ultrasound (95.6% and 94.4%) with that of chest radiography (91.3% and 84.2%) for establishing the diagnosis, concluding that lung ultrasound is superior to radiography(11).

2. Transient tachypnea of the newborn (TTN)

First described in 1966, TTN is the result of decreased clearance of fetal lung fluid. It most commonly affects late preterm and term newborns.

Radiologically, interstitial edema is found predominantly perihilar, with small pleural effusions, rarely mild to moderate cardiomegaly, and in severe cases, perihilar alveolar opacities. Chest X-rays performed dynamically at 48-72 hours postpartum are often normal(12).

From an ultrasound perspective, TTN is distinguished from respiratory distress syndrome (RDS) by identifying the number and location of B-lines. TTN presents with a symmetrical bilateral distribution of B-lines with a regular pleural line. The double lung point, the area between the upper and lower lung fields where spaced B-lines are adjacent to confluent B-lines, has high specificity but low sensitivity for TTN and is not necessary for diagnosis. It’s crucial to remember that TTN is an “extrinsic” edema and thus appears as such, although with spared lung zones featuring A-lines (which is not the case in RDS due to primary surfactant deficiency) or consolidations. A meta-analysis from 2021, including over 1500 newborns, concluded that lung ultrasound (LUS) has high specificity and sensitivity for diagnosing TTN. A multicenter study evaluated newborns with TTN, and found that 47.6% had the double lung point sign and all had a regular pleural line without consolidation on LUS. The LUS score also predicted the need for intubation in newborns with respiratory failure on day 1 after birth with a sensitivity, specificity, and positive predictive value of 77.7%, 100% and 100%, respectively, for predicting the need for respiratory support. Based on available data, LUS can be used to diagnose TTN, and it has been proposed as a means to predict which newborns should be transferred to a higher level of care. Mixed RDS/TTN situations occur when impaired pulmonary fluid reabsorption is associated with a relative surfactant deficiency, but these can be identified through the LUS score(13).

3. Pneumothorax

Pneumothorax is defined by the presence of air between the two layers of the pleura (parietal and visceral). The incidence of pneumothorax in newborns is around 1-2%, but it rises to 5-7% among premature newborns weighing less than 1500 grams. Symptomatic pneumothorax occurs in 0.08% of all live births(14).

Pneumothorax can occur spontaneously, with air collecting in the pleural cavity in the absence of intubation, positive pressure ventilation, or associated respiratory conditions. It can also be secondary, with risk factors including respiratory distress syndrome, meconium aspiration syndrome, neonatal sepsis, congenital pneumonia, or as a result of resuscitation maneuvers at birth or mechanical ventilation(15).

Despite advances in neonatal intensive care units in the early diagnosis and management of pneumothorax, such as the use of antenatal steroids, surfactant administration, and lung-protective ventilation strategies, pneumothorax remains a respiratory complication contributing to increased perinatal morbidity, particularly in critically ill premature newborns who also suffer from conditions like intraventricular hemorrhage and bronchopulmonary dysplasia, which further increase mortality(16).

Sonographically, four signs are described for the ultrasound diagnosis of pneumothorax: absence of lung sliding (which corresponds to the stratosphere sign or bar-code sign in M-mode examination), absence of B-lines with presence of A-lines, presence of a lung point, and absence of a lung pulse(17).

Air movement (lung sliding) is characterized by the sliding of one pleural layer over the other during breathing. In the case of pneumothorax, this movement cannot be observed because the visceral pleura is not visible due to the accumulated air in the pleural space. This sign is pathognomonic for pneumothorax, and its presence excludes the diagnosis of pneumothorax(16,17).

Chest X-ray has traditionally been the gold standard for diagnosing pneumothorax, with a sensitivity of 82% and specificity of 96%(18).

In a recent systematic review and meta-analysis, ultrasound has shown superiority over chest X-ray in diagnosing pneumothorax. A major advantage of ultrasound is its ability to be repeated, which is crucial for newborns requiring frequent dynamic monitoring. Studies have indicated that lung ultrasound’s sensitivity in diagnosing pneumothorax, using chest X-ray as the reference standard, was 98%, and specificity was 100%, demonstrating significantly higher accuracy compared to chest X-ray(19).

Another multicenter international study has demonstrated that lung ultrasound can efficiently and safely detect pneumothorax and guide thoracic drainage, without the need for repeated chest X-rays(20).

4. Meconium aspiration syndrome (MAS)

Meconium aspiration syndrome primarily affects term/post-term newborns, and it can lead to varying degrees of respiratory distress. The etiology is complex, and various risk factors, such as birth asphyxia and caesarean delivery, have been identified in the development of respiratory distress syndrome. Clinical manifestations, laboratory analyses, and radiographic and ultrasound findings can be used to diagnose meconium aspiration syndrome(21).

Ultrasound signs include pulmonary consolidation with air bronchograms, abnormalities in the pleural line with absence of A-lines, atelectasis, pleural effusion, and interstitial syndrome (B-lines). In this syndrome, patients exhibit multiple ultrasound patterns in different lung fields, and changes in ultrasound features over time are described(22).

Chest X-ray in this syndrome reveals increased lung volume, asymmetric irregular pulmonary opacities, pleural effusions, pneumothorax or pneumomediastinum, and multifocal consolidation(23).

In a prospective observational study involving 117 newborns with meconium aspiration syndrome and 100 newborns in the control group, irregular subpleural consolidations with air bronchograms showed a sensitivity and specificity of 100% in diagnosing this syndrome(24).

Corsini et al. found 100% agreement between lung ultrasound and radiological diagnosis in meconium aspiration, but further data are still needed for its routine recommendation. Therefore, lung ultrasound remains an adjunctive tool for rapid diagnosis, accessible and noninvasive, which should be correlated with other clinical and paraclinical signs(25).

5. Congenital pneumonia

Pneumonia is a condition characterized by a localized inflammatory process in the pulmonary parenchyma, which can lead to significant morbidity and mortality in the neonatal period, especially in developing countries. Epidemiological data analysis has revealed that the prevalence of neonatal pneumonia is higher than previously assumed. Among the risk factors contributing to neonatal pneumonia, there are limited or absent prenatal care, home birth, infections during pregnancy, and prolonged labor. Common pathogens implicated in neonatal pneumonia include bacteria, viruses, or fungi transmitted either intrauterine or acquired postnatally. The primary clinical manifestation in these patients is respiratory distress, making radiographic findings often nonspecific and difficult to differentiate from respiratory distress syndrome or transient tachypnea of the newborn, necessitating additional paraclinical investigations such as routine blood tests, C-reactive protein, and blood culture(26).

Ultrasound signs in neonatal pneumonia include abnormalities in the pleural line, subpleural consolidation (hepatization with air bronchogram present), interstitial syndrome (more than three B-lines in the intercostal space), and disappearance of lung sliding associated with the presence of lung pulse(27).

In a study involving 80 newborns, 40 with severe congenital pneumonia and 40 without respiratory conditions (control group), it was found that the presence of a large area of consolidation with irregular margins had 100% sensitivity and specificity in diagnosing congenital pneumonia. Other ultrasound signs do not have such high specificity for this pathology, but are useful in conjunction with clinical signs and other paraclinical investigations(27). Similar results were obtained in a study conducted in China from 2014 to 2016, involving a larger cohort of 3405 newborns, of which 725 were diagnosed with pneumonia using routine lung ultrasound(28,29).

Discussion

The use of neonatal lung ultrasound in neonatal intensive care units has significantly increased over the past decade, reflecting advancements in the immediate therapeutic approach to newborns with respiratory pathologies, particularly premature and early-term infants. The main advantages of lung ultrasound include its speed and portability, bedside applicability, noninvasiveness, lack of ionizing radiation, and high sensitivity and specificity. While capable of imaging in all planes, lung ultrasound requires expertise for an accurate interpretation of results.

Ultimately, the revolutionary role of neonatal lung ultrasound in neonatal intensive care units is a current topic of interest, as this imaging modality has the potential to become the gold standard for diagnosing, therapeutic monitoring, and for prognosticating respiratory pulmonary conditions in newborns.

Conclusions

Pulmonary ultrasound is an important tool in neonatal intensive care units, both for establishing diagnosis and for guiding management and prognosis. The development of respiratory ultrasound scores has allowed for quantifying disease severity and assisting physicians in clinical management and follow-up of newborns with respiratory pathology.

Compared to cardiopulmonary radiography, considered the gold standard in diagnosing neonatal respiratory distress syndrome, pulmonary ultrasound can be used as a tool with multiple benefits in monitoring patients’ progression under treatment, notably its ability to be performed dynamically without exposing the patients to ionizing radiation. 

 

 

 

Autori pentru corespondenţă: Alexandra-Elena Popa E-mail: alex_7691_andra@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.

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