Pulmonary surfactant therapy is critical for preterm infants with respiratory distress syndrome (RDS). Lung ultrasound (LUS) offers a noninvasive, radiation-free alternative for assessing RDS severity and guiding surfactant therapy.

Eighty-two preterm infants with RDS were randomized to receive surfactant based on either LUS scores or a conventional clinical-radiological assessment, comparing the duration of mechanical ventilation, supplemental oxygen need, NICU stay, incidence of bronchopulmonary dysplasia (BPD), and mortality.

No significant differences were found between the groups in terms of mechanical ventilation duration (average 4.1 vs. 4.3 days), supplemental oxygen need (average 5.7 vs. 6.1 days), or NICU stay (average 15.4 vs. 15.9 days). The incidence of BPD was 4.9% in both groups, and there were no deaths reported.

LUS-directed surfactant treatment did not show significant difference compared to the traditional methods, suggesting its potential as a noninvasive alternative for RDS management in preterm infants.

To evaluate the accuracy and reliability of sternal notch sagittal ultrasound imaging for neonatal endotracheal tube positioning by comparing the ultrasound-measured distance from the endotracheal tube tip to the right pulmonary artery with the electronic bronchoscopy-measured distance from the endotracheal tube tip to the carina.

A prospective, single-center, observational study using a self-controlled design.

Department of Anesthesiology and Perioperative Medicine at Anhui Provincial Children's Hospital, Hefei, China.

Neonates undergoing endotracheal intubation under general anesthesia for both elective and urgent surgeries were included, with all intubations performed in the operating room.

Neonates were evaluated for endotracheal tube position using both electronic bronchoscopy and ultrasound in the median sagittal plane at the sternal notch.

The distance from the endotracheal tube tip to the right pulmonary artery was measured using ultrasound imaging. The distance from the endotracheal tube tip to the carina was measured using electronic bronchoscopy. A high linear correlation was found between the two methods (r = 0.899, p < 0.001). The internal consistency of the three ultrasound measurements was high (Cronbach alpha = 0.985, ICC = 0.985). The precision of ultrasound measurements varied with endotracheal tube size, showing improved consistency with larger tube diameters. The mean absolute deviation (MAD) was 0.18 mm for the 2.5-mm ETT, 0.14 mm for the 3.0-mm ETT, and 0.12 mm for the 3.5-mm ETT, with corresponding coefficient of variation values of 5.60%, 4.50%, and 4.20%, respectively. No adverse events were observed during the ultrasound examination, whereas the incidence of hypoxemia during the electronic bronchoscopy examination was 18.4% (p < 0.001). In terms of operation time, the electronic bronchoscopy examination took (15.43 ± 4.34) seconds, while the ultrasound examination took (10.25 ± 4.27) seconds, with a significant difference between the two methods (p < 0.001).

Sternal notch sagittal ultrasound imaging shows highly consistent measurement results with electronic bronchoscopy for assessing the position of the endotracheal tube in neonates. Additionally, sternal notch sagittal ultrasound is safer and non-invasive, making it a viable alternative method for endotracheal tube positioning in neonates under general anesthesia, with significant clinical application value.

Ventilator-induced diaphragmatic dysfunction is associated with poor patient outcomes. However, the detailed pathophysiology and risk factors underlying the exacerbation of diaphragmatic dysfunction remain unclear. We aimed to evaluate the effect of sedation on diaphragmatic function in extremely preterm infants (EPIs) using ultrasound.

A prospective observational study was conducted on 30 EPIs requiring mechanical ventilation within 6 h of birth between July 2020 and September 2023. Diaphragm ultrasound was performed to measure the end-expiratory and end-inspiratory thicknesses of the diaphragm (Tde and Tdi, respectively) and to calculate diaphragm thickening fraction (DTF) after birth and on day 1 of life. Patients receiving continuous fentanyl administration on day 1 were categorized into the sedated group, whereas those not receiving were categorized into the non-sedated group. Changes in Tde, Tdi, and DTF from day 0 to day 1 were compared between groups.

Baseline Tde, Tdi, and DTF did not differ between groups, and both groups showed significant reductions in Tde, Tdi, and DTF from day 0 to day 1. Analysis of covariance after controlling for gestational age and birth weight revealed that sedation significantly affected the change ratios (Tde, -0.343 vs. -0.157, p = 0.038; Tdi, -0.4 vs. -0.169, p = 0.008; DTF, -0.385 vs. -0.194, p = 0.038).

In this pilot study, we found that sedation may affect Tde, Tdi, and DTF in ventilated EPIs, and that larger, adequately powered studies are required to validate these preliminary findings.

Lung ultrasound is increasingly used in neonatal intensive care units. We summarized the ultrasonographic patterns, features of most neonatal respiratory morbidities, and clinical application in neonates. Lung ultrasound is a non-invasive, radiation-free, and reproducible adjunct tool that can guide the clinical management of neonates presenting with respiratory distress.

Background Bronchopulmonary dysplasia (BPD) is a common cause of morbidity in preterm infants, leading to long-term respiratory complications and risk of neurodevelopmental impairment. Although it has a multifactorial etiology, local inflammation may play a major role.

We aimed to analyze the relationship between nasopharyngeal aspirate (NA) interleukin 6 (IL6) levels and clinical and imaging findings of BPD.

Pilot study in preterm infants < 30 weeks. NA was collected at 7 days of life (DOL) and serial lung ultrasounds (LUS) were performed during admission. NA-IL6 levels were measured using an automated electrochemiluminescence immune-analyzer Cobas-e602 and an IL6 ELISA method.

Forty-two patients were studied. Infants with BPD had significantly lower gestational age and higher levels of NA-IL6 at DOL 7. Both methods showed good agreement: ICC = 0.937 (95%CI 0.908-0.957); p < 0.001) and Passing-Bablok Regression (R2 = 0.961). LUS score (AUC = 0.83) and NA-IL6 (AUC = 0.81) at DOL 7 predicted BPD. The AUC of NA-IL6 as a stand-alone marker of BPD was 0.808 (95% CI 0.67 - 0.94); p = 0.002, with 24 pg/ml being the best cutoff with a sensitivity and specificity of 83.3%. A model including birth weight, LUS score at DOL7, NA-IL6 at DOL7, and days of mechanical ventilation predicted BPD with R2 = 0.600 (p < 0.001).

Point-of-care assessment of NA-IL6 is feasible and reliable compared with a reference method and can be useful in managing BPD. Predictive models of BPD in the first week of life, including clinical, biological, and imaging biomarkers must be tested in larger cohorts.

Steroid treatment is well-known for producing clinically significant improvements in respiratory support requirements. In this study, we utilized lung ultrasound and respiratory oscillometry to objectively assess this response and determine if the combination of these methods can serve as a valuable tool for comparing different treatment strategies.

We conducted a retrospective observational study including preterm infants with a gestational age below 32 weeks and/or a birth weight below 1500 g. We measured lung ultrasound score (LUS) and respiratory system reactance (Xrs) by respiratory oscillometry before and after treatment with either systemic dexamethasone or inhaled budesonide.

We analyzed 46 treatments (9 dexamethasone, 37 budesonide) administered to 40 infants (median (Q1, Q3) postnatal age = 30 (18, 49) days, postmenstrual age = 33.29 (30.14, 35.00) weeks). All treatments were associated with a notable reduction in respiratory support and a concurrent improvement in either Xrs, LUS, or both. On average, Xrs improved from 3.13 (1.09, 5.41) to 0.44 (-0.90, 1.59) z-score (p < 0.001) and LUS from 10 (7, 12) to 5 (3, 8) (p < 0.001).

Xrs and LUS proved sensitive to lung function changes associated with corticosteroids; combining the two better described the response and its variability.

We found that respiratory system reactance (Xrs) and lung ultrasound score (LUS) are sensitive biomarker for monitoring changes in lung function associated with corticosteroids; Combining Xrs and LUS enhances evaluation compared to each method alone; These results have valuable implications in clinical practice, particularly in personalizing and monitoring corticosteroid treatment; The present paper suggests that the combined use of respiratory oscillometry and lung ultrasound holds value as a research tool in future studies investigating various treatment regimens, molecules, or administration routes.

Quantitative lung ultrasound is increasingly being used in neonatology. The aim of this study is to identify the lung ultrasound scores (LUS) available for use in neonates, describe their characteristics and determine which LUS are most used and validated.

A systematic review of the literature was conducted following PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols extension for reporting literature searches in systematic reviews) guidelines. Articles describing LUS in newborn animals and human neonates, published up to March 2024, were searched in the PubMed and Embase databases.

Out of 757 identified studies, 121 were included. Most of the articles were published in the past 5 years, predominantly by European investigators. They described 32 different LUS. Only 10 (31.4%) of these LUS had undergone at least one validation attempt and only 15 (48.4%) used the four-step scoring scale (i.e. scored from 0 to 3) based on classical lung ultrasound patterns originally described and well established in adult critical care medicine. The most common (49 (40.5%) of all the articles) neonatal score (published by Brat et al. in 2015) was based on this classical grading system. The most commonly used score was also validated using the greatest number of techniques and applied to all major neonatal respiratory disorders. Its simplified version is used to analyse six chest areas (anterior and lateral) to guide surfactant administration, while its extended version includes 10 areas by adding four posterior ones.

The most commonly used and validated score, consistent with adult critical care practice, should be the standard for assessing lung aeration in neonates.

Our survey aimed to compare information on respiratory care in Neonatal Intensive Care Units (NICUs) in Italy and in the European and Mediterranean region.

Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs.

The response rate was 75% (397/528 units). The median number of NICU beds and the admission rate per unit/year of preterm infants < 1500 g was significantly lower in Italy compared with Europe (p < 0.001). In most Italian Delivery Rooms (DR) full resuscitation is given from 22 to 23 weeks gestational age, while 21.0% of the European units initiate from 24 weeks. Initial FiO2 is set as per American Academy of Pediatrics guidelines in 81.1% of Italian units compared to 30.9% of the European ones (p < 0.001). DR surfactant is less often given through Less-Invasive-Surfactant-Administration (LISA) in Italy (53.4% vs. 76.2% of units, p < 0.03). Volume-targeted, synchronized intermittent positive-pressure ventilation (IPPV) is the preferred invasive mechanical ventilation (MV) mode to treat acute RDS across the surveyed units, however 22.9% % of Italian centers vs. 6.8% of the European ones use HFOV as first choice (p < 0.001). During HFOV, 78% of Italian NICUs set mean airway pressure (MAP) following a lung recruitment procedure compared to 41% of the centers in Europe (p < 0.001). In the NICUs, most of the non-invasive (NIV) modes used are nasal CPAP and nasal IPPV. For infants on NIV, LISA strategy is used in 25.6% of Italian vs. 60.0% of European units (p < 0.001). 70% of surveyed units use a brand caffeine. Inhaled steroids are used in 42.3% of Italian vs. 65.4% of European NICUs (p < 0.001).

respiratory support strategies among the surveyed Italian and European NICUs are quite dissimilar in some areas, particularly where high-quality evidence is lacking. We believe that hese data will allow stakeholders to make comparisons and to identify opportunities for improvement.

Background/Objectives: Precision medicine is a state-of-the-art medicine tactic that tailors information about people's genes, environment, and lifestyle to aid the prevention, diagnosis, and treatment of various diseases to provide an overview of the currently available knowledge and applicability of precision medicine in the diagnosis of different cases admitted to the NICU, such as encephalopathies, respiratory distress syndrome of prematurity, hemodynamic instability, acute kidney injury, sepsis, and hyperbilirubinemia. Methods: The authors searched databases, such as PubMed and PubMed Central, for the terms neonatal "precision medicine", "personalized medicine", "genomics", and "metabolomics", all related to precision medicine in the diagnosis of neonatal illness. The related studies were collected. Results: The review highlights the diagnostic approach that serves to implement precision medicine in the NICU and provide precision diagnosis, monitoring, and treatment. Conclusions: In this review, we projected several diagnostic approaches that provide precision identification of health problems among sick neonates with complex illnesses in the NICU; some are noninvasive and available in ordinary healthcare settings, while others are invasive or not feasible or still in ongoing research as machine learning algorithms. Future studies are needed for the wide implementation of artificial intelligence tools in the diagnosis of neonatal illnesses.

We aimed to review the physiology and evidence behind cardiorespiratory interactions during the transitional circulation of extremely preterm infants with fragile physiology and to propose a framework for future research. Cord clamping strategies have a great impact on initial haemodynamic changes, and appropriate transition can be facilitated by establishing spontaneous ventilation before cord clamping. Mechanical ventilation modifies preterm transitional haemodynamics, with positive pressure ventilation affecting the right and left heart loading conditions. Pulmonary vascular resistances can be minimized by ventilating with optimal lung volumes at functional residual capacity, and other pulmonary vasodilator treatments such as inhaled nitric oxide can be used to improve ventilation/perfusion mismatch. Different cardiovascular drugs can be used to provide support during transition in this population, and it is important to understand both their cardiovascular and respiratory effects, in order to provide adequate support to vulnerable preterm infants and improve outcomes. Current available non-invasive bedside tools, such as near-infrared spectroscopy, targeted neonatal echocardiography, or lung ultrasound offer the opportunity to precisely monitor cardiorespiratory interactions in preterm infants. More research is needed in this field using precision medicine to strengthen the benefits and avoid the harms associated to early neonatal interventions. IMPACT: In extremely preterm infants, haemodynamic and respiratory transitions are deeply interconnected, and their changes have a key impact in the establishment of lung aireation and postnatal circulation. We describe how mechanical ventilation modifies heart loading conditions and pulmonary vascular resistances in preterm patients, and how hemodynamic interventions such as cord clamping strategies or cardiovascular drugs affect the infant respiratory status. Current available non-invasive bedside tools can help monitor cardiorespiratory interactions in preterm infants. We highlight the areas of research in which precision medicine can help strengthen the benefits and avoid the harms associated to early neonatal interventions.

To evaluate the accuracy of the lung ultrasound score (LUS) in predicting ventilatory weaning failure during neonatal hospitalization in the NICU and to identify factors associated with weaning failure, including corrected gestational age (CGA). This prospective, longitudinal, pragmatic and observational cohort study included neonates on mechanical ventilation for at least 48 h. The primary outcome was the accuracy of lung ultrasound in predicting 3-day weaning failure, with the ROC curve used to determine the best LUS cutoff (sensitivity and specificity). Among 55 neonates, the pre-extubation LUS did not show statistical significance in predicting weaning failure (AUC 0.61; 95% CI: 0.46-0.76, p = 0,169). In the subgroup analysis, a score ≥ 4 suggests the need for ventilatory support after extubation (area under the curve [AUC] = 0.91, 95% CI: 0.80-1.0, p < 0.001) in neonates with GA ≥ 28 weeks. In extremely preterm infants, the pre-extubation LUS was not statistically significant in predicting weaning failure (AUC = 0.38, 95% CI: 0-0.77, p = 0.535). In contrast, CGA ≥ 28.7 weeks at extubation was predictor of successful weaning within 3 days (AUC = 0.95, 95% CI: 0.85-1.0, p < 0.001).

LUS show promise in predicting weaning failure, though its accuracy may be limited in extremely preterm infants, highlighting the need for further well-powered studies. CGA at extubation also emerges as a key consideration in this population, warranting confirmation through robust future research.

• Identifying the optimal timing for extubation is crucial, as both prolonged mechanical ventilation and failed extubation are linked to increased morbidity. • Lung ultrasound plays a well-established role in diagnosing various neonatal lung pathologies, allowing clinicians to make rapid, bedside decisions for the treatment of newborns.

• LUS appears to be accurate in predicting weaning failure, though its accuracy may be lower in extremely preterm infants. • In extremely preterm infants, CGA may play an important role in extubation decision-making. • These findings are hypothesis-generating and warrant further investigation in future studies.

(1) To demonstrate feasibility and safety of surfactant administration via laryngeal mask airway (LMA) as a first-line therapy. (2) To measure treatment success, defined as avoidance of intubation/invasive mechanical ventilation, and determine if specific clinical variables could predict success/failure.

Observational cohort with eligible infants given surfactant using one type of LMA via standardized protocol. Data was captured prospectively followed by retrospective chart review.

120 infants ≥1250 g and 28.3-41.1 weeks gestation were included. First-line LMA surfactant therapy was successful in 70% of the infants and those infants weaned to room air significantly quicker than infants requiring subsequent intubation/mechanical ventilation (p = 0.002 by 72 h, p = 0.001 by 96 h). Clinical variables assessed could not predict treatment success/failure. Complications were infrequent and did not differ between groups.

First-line LMA surfactant is feasible and safe for certain infants. Prediction of treatment success was not possible in our cohort.

Transient tachypnoea of the neonate (TTN) is the commonest neonatal respiratory disorder, but it is quite mild and so has been the subject of relatively little academic and educational work. Recent animal studies and the introduction of new bedside monitoring techniques (e.g. quantitative lung ultrasound and electrical cardiometry) have clarified its pathogenesis. Given its high incidence, TTN is a relevant public health issue and its clinical management should be considered in an era of resource constraints. This review focuses on the latest data on TTN in terms of its pathophysiology, biology, diagnosis, imaging, therapy and cost-effectiveness, so as to optimise clinical care at the bedside. The need for a new pathophysiology-based definition of TTN is also highlighted and the available therapeutics are analysed considering the associated public health issues. This updated knowledge can help to improve the management of TTN and impact positively on its relevant public health consequences. This is particularly important since the mortality of TTN is virtually nil and so cannot be used to evaluate any clinical innovation. We also aim to give some practical guidance for the real-world clinical management of TTN and contribute to the training of neonatologists who care for TTN patients.

Neonatal respiratory distress syndrome (RDS) is a common and potentially life-threatening condition in preterm infants, primarily due to surfactant deficiency. Early and accurate diagnosis is critical to guide timely interventions such as surfactant administration and respiratory support. Traditionally, chest X-rays have been used for diagnosis, but lung ultrasound (LUS) has gained prominence due to its non-invasive, radiation-free, and bedside applicability. Compared to chest X-rays and CT scans, LUS demonstrates superior sensitivity and specificity in diagnosing RDS, particularly in identifying surfactant need and predicting CPAP failure. Additionally, LUS offers real-time imaging without radiation exposure, an advantage over other modalities. However, its broader adoption is limited by challenges in standardizing training, ensuring diagnostic reproducibility, and validating scoring systems, especially in resource-limited settings. This narrative review aims to evaluate the role of LUS in the diagnosis and management of neonatal RDS over the past decade, focusing on its clinical utility, scoring systems, and emerging applications. We reviewed the literature from 2013 to 2023, focusing on studies evaluating LUS' diagnostic accuracy, scoring systems, and its potential role in guiding surfactant therapy and predicting CPAP failure. Despite its benefits, addressing the variability in operator expertise and integrating artificial intelligence to enhance usability are crucial for ensuring LUS' efficacy across diverse clinical environments. Future research should prioritize standardizing training and scoring protocols to facilitate wider implementation and optimize neonatal respiratory care outcomes.

Neonatal respiratory disorders pose significant challenges in clinical settings, often requiring rapid and accurate diagnostic solutions for effective management. Lung ultrasound (LUS) has emerged as a promising tool to evaluate respiratory conditions in neonates. This evaluation is mainly based on the interpretation of visual patterns (horizontal artifacts, vertical artifacts, and consolidations). Automated interpretation of these patterns can assist clinicians in their evaluations. However, developing AI-based solutions for this purpose is challenging, primarily due to the lack of annotated data and inherent subjectivity in expert interpretations. This study aims to propose an automated solution for the reliable interpretation of patterns in LUS videos of newborns. We employed two distinct strategies. The first strategy is a frame-to-video-level approach that computes frame-level predictions from deep learning (DL) models trained from scratch (F2V-TS) along with fine-tuning pre-trained models (F2V-FT) followed by aggregation of those predictions for video-level evaluation. The second strategy is a direct video classification approach (DV) for evaluating LUS data. To evaluate our methods, we used LUS data from 34 neonatal patients comprising of 70 exams with annotations provided by three expert human operators (3HOs). Results show that within the frame-to-video-level approach, F2V-FT achieved the best performance with an accuracy of 77% showing moderate agreement with the 3HOs. while the direct video classification approach resulted in an accuracy of 72%, showing substantial agreement with the 3HOs, our proposed study lays down the foundation for reliable AI-based solutions for newborn LUS data evaluation.

Newborns with critical congenital heart disease (CCHD) with increased pulmonary blood flow (PBF) are at high risk for congestive heart failure. In this study, we aimed to evaluate the presence and degree of pulmonary edema in newborns with CCHD using lung ultrasound (LUS) during the perioperative period.

Prospective clinical trial, 44 newborn patients with CCHD were evaluated in this prospective clinical trial. LUS was repeatedly performed to determine the course of pulmonary edema during the perioperative period. LUS was performed simultaneously with chest radiography (CXR), which was the main part of patient management. The primary outcome of this study was to identify whether a correlation existed between LUS and CXR findings. The secondary outcomes were to determine the relationship between LUS and the need for respiratory support, diuretic use, vasoactive inotropic score (VIS), and pro-B-type natriuretic peptide (pro-BNP) levels during the perioperative period.

The mean gestational age of the patients was 38.3 ± 1.7 weeks, with a mean birth weight of 3026 ± 432 g. In the preoperative period, both LUS and CXR images were consistent with clinical signs of pulmonary edema. On the first postoperative day, pulmonary edema increased compared to the preoperative period but gradually decreased by the 6th day of surgery (p < 0.05). Positive correlations were observed between the LUS and CXR findings at all study points (p < 0.05). The LUS findings exhibited trends parallel to those of VIS, serum pro-BNP levels, need for respiratory support, and diuretic requirements. As expected, these trends were more pronounced in CCHDs where PBF increased.

In CCHD, serial lung ultrasound (LUS) assessments, particularly in cases with increased PBF, can provide valuable guidance for managing patients during the perioperative period.

Neonatal respiratory distress syndrome (NRDS) is harmful to neonates and the prognosis is variable, ranging from mild to severe forms. This study aims to evaluate the clinical utility of miR-513a-3p in conjunction with arterial blood gas analysis parameters and lung ultrasound (LUS) score in the context of NRDS.

The study included 169 preterm infants, including 106 newborns with NRDS and 63 newborns without NRDS. The relative expression level of miR-513a-3p was detected by quantitative real time polymerase chain reaction (qRT-PCR). Umbilical artery blood gas parameter values and LUS score were recorded, and the clinical significance of miR-513a-3p, umbilical artery blood gas parameter and LUS score in NRDS were evaluated by Receiver Operating Characteristic (ROC) analysis.

Elevated levels of miR-513a-3p were detected in the serum of NRDS, and higher expression of miR-513a-3p was observed in individuals with poor prognosis. Notably, miR-513a-3p exhibited a significant correlation with the parameters of arterial blood gas analysis and LUS score in NRDS patients. Furthermore, miR-513a-3p was one of the risk factors for poor prognosis in NRDS patients. miR-513a-3p levels combined with umbilical artery blood gas parameters and LUS score has diagnostic value for NRDS and is reliable for its prognosis.

Elevated levels of miR-513a-3p in neonatal serum served as a useful tool in the combined assessment with umbilical artery blood gas analysis and LUS score to diagnosis and prognosis of NRDS. Consequently, miR-513a-3p may be served as a biomarker for diagnosis and prognosis of NRDS.

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.

International online survey.

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.

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.

Respiratory distress syndrome (RDS) and transient tachypnoea (TTN) are the two commonest neonatal respiratory disorders. The optimal continuous positive airway pressure (CPAP) to treat them is unknown. We aim to clarify the effect of different CPAP levels on lung aeration and gas exchange in patients with RDS and TTN.

Prospective, observational, pragmatic, physiological cohort study. CPAP was sequentially increased from 4 to 6 and 8 cmH2O and backwards, with interposed wash-out periods. Lung aeration was assessed with a validated neonatal lung ultrasound score. Gas exchange was non-invasively evaluated with transcutaneous monitoring. Ultrasound score and PtcO2/FiO2 ratio were the co-primary outcomes. PtcCO2 and other oxygenation metrics were the secondary outcomes.

30 neonates with RDS and 30 with TTN were studied. Each CPAP increment significantly (overall always p < 0.001) improved both lung aeration and oxygenation, but the increase from 6 to 8 cmH2O achieved a small absolute benefit. In RDS patients, the absolute improvements were small and the diagnosis of TTN was significantly associated with greater improvement of lung aeration (β= -1.4 (95%CI: -2.4; -0.3), p = 0.01) and oxygenation (β = 39.6 (95%CI: 4.1; 75.1), p = 0.029). Aeration improved in 16 (53.3%) and 27 (90%) patients in the RDS and TTN groups, respectively (p = 0.034). Lung aeration showed significant hysteresis in TTN patients. Secondary outcomes gave similar results.

Increasing CPAP from 4 to 8 cmH2O improves ultrasound-assessed lung aeration and oxygenation in RDS and TTN. The absolute improvements are small when CPAP is beyond 6 cmH2O or for RDS patients.

Aeration heterogeneity affects lung stress and influences outcomes in adults with acute respiratory distress syndrome (ARDS). The authors hypothesize that aeration heterogeneity may differ between neonatal respiratory disorders and is associated with oxygenation, so its evaluation may be relevant in managing respiratory support.

This was an observational prospective study. Neonates with respiratory distress syndrome, transient tachypnea of the neonate, evolving bronchopulmonary dysplasia, and neonatal ARDS were enrolled. Quantitative lung ultrasound and transcutaneous blood gas measurements were simultaneously performed. Global aeration heterogeneity (with its intra- and interpatient components) and regional aeration heterogeneity were primary outcomes; oxygenation metrics were the secondary outcomes.

A total of 230 (50 respiratory distress syndrome, transient tachypnea of the neonate or evolving bronchopulmonary dysplasia, and 80 neonatal ARDS) patients were studied. Intrapatient aeration heterogeneity was higher in transient tachypnea of the neonate (mean ± SD, 61 ± 33%) and evolving bronchopulmonary dysplasia (mean ± SD, 57 ± 20%; P < 0.001), with distinctive aeration distributions. Interpatient aeration heterogeneity was high for all disorders (Gini-Simpson index, between 0.6 and 0.72) except respiratory distress syndrome (Gini-Simpson index, 0.5), whose heterogeneity was significantly lower than all others (P < 0.001). Neonatal ARDS and evolving bronchopulmonary dysplasia had the most diffuse injury and worst gas exchange metrics. Regional aeration heterogeneity was mostly localized in the upper anterior and posterior zones. Aeration heterogeneity and total lung aeration had an exponential relationship (P < 0.001; adj-R2 = 0.62). Aeration heterogeneity is associated with greater total lung aeration (i.e., higher heterogeneity means a relatively higher proportion of normally aerated lung zones, thus greater aeration; P < 0.001; adj-R2 = 0.83) and better oxygenation metrics upon multivariable analyses.

Global aeration heterogeneity and regional aeration heterogeneity differ among neonatal respiratory disorders. Transient tachypnea of the neonate and evolving bronchopulmonary dysplasia have the highest intrapatient aeration heterogeneity. Transient tachypnea of the neonate, evolving bronchopulmonary dysplasia, and neonatal ARDS have the highest interpatient aeration heterogeneity, but the latter two have the most diffuse injury and worst gas exchange. Higher aeration heterogeneity is associated with better total lung aeration and oxygenation.

To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery.

An electronic survey was disseminated via the GICS (Global Initiative of Children's Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery.

Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available.

Ultrasound is critically important in children's surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance.

To assess the feasibility of implementing a simple point-of-care lung ultrasound (LU) evaluation and reporting protocol in a neonatal intensive care unit (NICU) and its effect on patient management.

Retrospective observational study of LU examinations performed in a level III NICU. Each examination was performed according to a standardized protocol. An independent radiologist-assessed chest X-ray (CXR) was used to compare the LU diagnosis. The impact on patient management was also evaluated.

A total of 206 LU studies in 158 neonates were reviewed. There was significant agreement between LU and CXR diagnoses (84.95%, 95% CI 80.07-89.83%). LU affected patient management in 87.8% of the cases (95% CI 83.33-92.28%).

Implementation of a simplified, sign-based protocol for LU in the NICU is feasible. LU is not inferior to CXR studies and supports patient management as an imaging modality.

Neonatal respiratory distress syndrome (NRDS) is a major cause of morbidity and mortality in newborns, particularly in neonatal intensive care units (NICUs). Until recently, its diagnosis had been based on clinical signs, arterial blood gas analysis, and chest X-ray (CXR). However, the frequent use of CXR exposes newborns to ionizing radiation, which can have long-term negative effects, including an increased risk of cancer, especially among premature infants. Lung ultrasound (LUS) has been proposed as a promising alternative for diagnosing NRDS due to its many advantages: no exposure to radiation, the ability to be performed at the bedside, repeatability, and ease of use. This review compared the diagnostic accuracy of LUS with the reference standard, CXR, in evaluating NRDS in newborns admitted to the NICU. Studies have shown that LUS can identify specific signs of NRDS, such as bilateral "white lung," pleural line abnormalities, and lung consolidations. The method has high sensitivity and specificity for diagnosing this condition and offers several advantages over other diagnostic methods; it does not involve ionizing radiation, thereby eliminating the risk of radiation exposure; it is cost-effective, easy to use, and can be performed at the patient's bedside, making it a viable alternative to CXR for reducing ionizing radiation exposure. Additionally, LUS can be used to monitor the progression of respiratory diseases and guide clinical management, especially in determining the optimal timing for surfactant administration in newborns with respiratory distress syndrome (RDS). We conclude that LUS is an effective and non-invasive alternative method for diagnosing and managing NRDS, with the potential to improve the safety and quality of care in the NICU, where rapid and safe diagnostic tools are essential for managing the health of newborns.

Surfactant replacement for respiratory distress syndrome (RDS) is currently guided by oxygen (FiO2) requirement in preterm neonates. Lung ultrasound (LUS) has emerged as an important predictive tool; however, there is a paucity of evidence from developing countries. The objective of this study was to determine the diagnostic accuracy of the LUS score in comparison to standard criteria based on FiO2 requirement for prediction of surfactant requirement. In this prospective study, preterm neonates of < 34 weeks' gestation with RDS were included within 2 h of life. Surfactant was administered if the FiO2 requirement exceeded 30%. Baseline characteristics, respiratory parameters, and LUS clips were recorded soon after birth and compared between the surfactant and non-surfactant groups. LUS scoring was later performed by masked assessors which was not used in the management of neonates. Among 82 neonates (mean gestation 30.6 weeks and weight 1375 g) included in the study, 33 (40.2%) received surfactant. The surfactant group had a higher Silverman score, required higher FiO2 and mean airway pressure, and needed invasive ventilation more frequently. The mean (± SD) LUS score was significantly higher in the surfactant (9.4 ± 3.2) compared to the non-surfactant group (5.1 ± 2.1). The diagnostic accuracy of LUS scoring was determined by ROC curve analysis (AUC (95% CI): 0.83 (0.74-0.92), p < 0.01). A cutoff score of ≥ 8 for LUS was considered optimal for the prediction of surfactant requirement (sensitivity and specificity (95% CI) of 70% (51-84) and 80% (66-90), respectively).    Conclusion: Lung ultrasound is a valid diagnostic tool for the prediction of surfactant requirements in resource-limited settings. What is Known: • Lung ultrasound has a good diagnostic accuracy in predicting the need for surfactant administration in preterm neonates in developed countries, but its role in developing countries is unclear. What is New: • Lung ultrasound proved to be a valid diagnostic tool in predicting surfactant replacement therapy in resource-limited settings. • The diagnostic performance of lung ultrasound was better in neonates on non-invasive ventilation, compared to invasive ventilation.

Despite the growing body of literature supporting the use of point-of-care lung ultrasound (POC-LU) in neonates, its adoption in Canadian neonatal intensive care units (NICUs) remains limited. This study aimed to identify healthcare providers' perceptions and barriers to implementing POC-LU in Canadian NICUs. We conducted an electronic survey targeting neonatologists, neonatal fellows, neonatal nurse practitioners, and registered respiratory therapists in 20 Canadian NICUs. The survey comprised a 28-item questionnaire divided into four sections: (1) participants' demographics and availability of POC-LU equipment, (2) experience and interest in POC-LU learning, (3) perception of POC-LU as a diagnostic tool, and (4) barriers to POC-LU implementation in NICUs. A total of 194 participants completed the survey, with neonatologists comprising the majority (45%). Nearly half of the participants (48%) reported prior experience with POC-LU. The most prevalent indications for POC-LU use were diagnosis of pleural effusion (90%), pneumothorax (87%), and respiratory distress syndrome (76%). Participants identified the primary barrier to POC-LU adoption as the lack of trained providers available for both training and clinical integration. Notably, most respondents (87%) expressed keen interest in learning neonatal POC-LU. A subgroup analysis based on the responses collected from NICU-directors of 12 institutions yielded results consistent with those of the overall participant pool.     Conclusion: This survey underscores the perceived importance of POC-LU among NICU healthcare providers. A Canadian consensus is required to facilitate the development of widespread training programs as well as standardized clinical practice guideline for its implementation. What is Known: • In recent years, point-of-care lung ultrasound (POC-LU) has emerged as an important tool in neonatology, revolutionizing the assessment and management of critically ill infants. However, its adoption in Canadian Neonatal Intensive Care Units remains limited. What is New: • Most Canadian healthcare providers showed high level of interest in learning POC-LU techniques. Additionally, POC-LU was perceived as a useful tool for diagnosis and guiding intervention in various neonatal respiratory diseases. Nonetheless, the lack of expertise emerged as the primary barrier to its adoption and practice across different groups of participants regardless of their clinical experience level.

Lung ultrasound (LUS) is an evolving point-of-care tool in the neonatal intensive care unit. LUS score has been evaluated in adults as well as in neonates to characterize and diagnose various respiratory conditions. Recently, the LUS score has been evaluated for predicting clinical respiratory outcomes in neonates.

To assess the association between LUS score and various modes of respiratory support and clinical outcomes among neonates presenting with respiratory distress.

In this prospective, cross-sectional, observational study done in a tertiary care neonatal unit, the LUS score was calculated within three hours of receiving respiratory support. Subsequently, the LUS score was assigned with each escalation and de-escalation of respiratory support. Maximum LUS scores for each clinical outcome were also recorded. Inter-rater agreement was determined with the intraclass correlation coefficient.

A total of 162 LUS scans were performed in 65 babies with a mean gestation of 32.4 ± 3.7 weeks and median (IQR) birth weight of 1480 (1130-2000) grams. The LUS scores (median (IQR)) of babies on continuous positive airway pressure (CPAP), noninvasive positive pressure ventilation (NIPPV), and mechanical ventilation (MV) were 4 (3-6.5), 9 (8-11), and 12 (11-13.5), respectively (p-value < 0.001). The difference in maximum median LUS scores between different clinical outcomes was statistically significant, with a p-value < 0.001. LUS score had an excellent inter-rater agreement (intraclass correlation coefficient = 0.998; p-value < 0.001).

There is an association between LUS score and different modes of respiratory support with scores increasing as the level of support increased. LUS score was also found to be related with clinical outcomes like death, extubation failure, and recovery, which could help in predicting the prognosis.

To determine the effect of different types of probes for lung ultrasound in neonates.

Prospective, blinded, randomized, comparative study between 2020 and 2022.

Single-center study at a third level neonatal unit.

Hemodynamically stable infants with either nasal continuous positive airway pressure, high flow nasal cannula or without respiratory support.

Lung ultrasound using either an echo or microconvex probe. As control, the linear probe was used.

Primary outcome measure was neonatologist performed lung ultrasound (NPLUS) score. Secondary outcome measures were number of B-Lines, thickness of the pleural line and subjective image quality. Furthermore, correlation between NPLUS results and clinical data was assessed.

A total of 1584 video loops from 66 patients, with a mean corrected gestational age of 33.8 weeks (SD 4.23) and weight of 1950g (SD 910), respectively, were analyzed. NPLUS score was estimated lower with the echo- and microconvex probe compared to the linear probe, with a coefficient of -2.95 (p < 0.001) and -1.09 (p = 0.19), respectively. Correlation between the pulse oximetric saturation/fraction of inspired oxygen ratio and NPLUS score was moderately strong and best using the microconvex probe (Spearman's rho = -0.63, p<0.001).

Our results not only confirm the current recommendations, but also demonstrate the extent of the varying results when different probes are used. The differences we discovered call for caution in interpreting scores, especially in the context of guiding therapies and communicating prognoses. Finally, the correlation between NPLUS score and clinical parameters contributes to validating the use of this diagnostic tool.

The use of lung ultrasonography in neonates is increasing at a very fast rate. Evidence-based guidelines on the use of lung ultrasound (LU) in neonates and children have been published and well received across the world. However, there remains a lack of standardized curriculum for lung ultrasound training and standards for its application at the bedside. This article focuses on providing a standardized approach to the application of lung ultrasonography in neonates for the common neonatal conditions and how it can be integrated into bedside clinical decision-making.

The rapid identification and management of air leak syndrome in the neonatal intensive care unit is critical to prevent and/or minimize short- and long-term complications. Traditionally, chest X-ray is used to diagnose pneumothorax or pneumomediastinum. However, point-of-care ultrasound is increasingly being used for procedural and diagnostic purposes. Current ultrasound guidelines recommend specific criteria to diagnose pneumothorax in newborns including sharp A-lines, absence of B-lines, lack of shimmering of the pleural line, and the presence of a lung point. Pneumomediastinum may have similar ultrasound characteristics. In this case report, we present two cases of pneumomediastinum in newborns, describe the associated ultrasound findings, and review some of the criteria to differentiate from pneumothorax, including the presence of a still lung point. A high index of suspicion for pneumomediastinum should be maintained when using ultrasound to diagnose air leak given the overlapping sonographic features with pneumothorax. This distinction is of particular importance if evacuation of air by needle thoracentesis or the placement of a chest tube is under consideration.

Lung ultrasound (LUS) as an assessment tool has seen significant expansion in adult, paediatric, and neonatal populations due to advancements in point-of-care ultrasound over the past two decades. However, with fewer experts and learning platforms available in low- and middle-income countries and the lack of a standardised supervised training programme, LUS is not currently effectively used to the best of its potential in neonatal units.

A cross-sectional survey assessed the efficacy of learning LUS via a mentor-based online teaching module (NEOPOCUS). The questionnaire comprised the clinicians' demographic profile, pre-course skills, and self-assessment of skill acquisition after course completion with ongoing hands-on practice.

A total of 175 clinicians responded to the survey, with the majority (87.9%) working in level 3 and 4 neonatal intensive care units. Clinicians had variable clinical experience. Of them, 53.2% were consultant paediatricians/neonatologists with over 10 years of experience. After the course, there was a significant increase in clinician confidence levels in diagnosing and assessing all LUS pathology, as evidenced by the increase in median cumulative scores [from baseline 6 (interquartile range, IQR, 6-9) to 20 (IQR 16-24), p < 0.001] with half of them gaining confidence within 3 months of the course.

An online curriculum-based neonatal lung ultrasound training programme with clinician image demonstration and peer review of images for image optimisation increases self-reported confidence in diagnosing and managing neonatal lung pathology. Web-based online training in neonatal lung ultrasound has merits that can help with the delivery of training globally, and especially in low- and middle-income countries.

our study aimed to characterize the lung ultrasound (LUS) patterns noted immediately after delivery in term and near-term neonates, and to investigate whether the LUS scores or patterns observed at that point could anticipate the need for respiratory support in the sample of patients studied.

We performed two ultrasound examinations: one in the delivery room and the second at one hour of age. The anterior and lateral regions of both lungs were examined. We assessed the correlation between the LUS scores or patterns and the gestational age, umbilical arterial blood gases, the need for respiratory support (CPAP or mechanical ventilation), the presence of respiratory distress, and the need for the administration of oxygen.

LUS scores were significantly higher in the delivery room examination (8.05 ± 1.95) than at 1 h of age (6.4 ± 1.75) (p < 0.001). There were also statistically significant differences between the LUS patterns observed in different lung regions between the delivery room exam and the exam performed at 1 h of age (p values between 0.001 and 0.017). There were also differences noted regarding the LUS patterns between different lung regions at the exam in the delivery room (the right anterior region LUS patterns were significantly worse than the right lateral LUS patterns (p < 0.004), left anterior LUS patterns (p < 0.001), and left lateral LUS patterns (p < 0.001)). A statistically significant correlation was found between LUS scores and the gestational age of the patients (r = 0.568, p < 0.001-delivery room; r = 4.0443, p < 0.001-one hour of age). There were statistically significant associations between LUS scores, patterns at delivery (p < 0.001) and 1 h of age (p < 0.001), and the need for respiratory support (CPAP or mechanical ventilation).

LUS in the delivery room offers important information regarding lung fluid elimination and aeration of the lungs, and early LUS features are significantly associated with the risk of respiratory distress and the need for respiratory support.

Recent technological strides, including high-frequency probes and lung ultrasound, have become a crucial non-invasive diagnostic tool in neonatal care, revolutionizing how respiratory conditions are assessed in the neonatal intensive care unit (NICU). High-frequency probes and portable devices significantly enhance the effectiveness of lung ultrasound in identifying respiratory distress syndrome (RDS), pneumonia, and pneumothorax, and underscore its growing significance. This comprehensive review explores the historical journey of lung ultrasonography, technological advancements, contemporary applications in neonatal care, emerging trends, and collaborative initiatives, and foresees a future where personalized healthcare optimizes outcomes for neonates.

Respiratory complications in Cystic Fibrosis (CF) are still the leading cause of death nowadays in these patients. High-Resolution Computed Tomography is the gold standard method for staging lung disease in CF. In this study we assessed lung ultrasound findings in asymptomatic preschool patients affected by CF.

This is a case-control study with a total of 70 enrolled patients (20 patients affected by CF, 50 healthy controls) aged from 31 to 6 years. All included patients were without intercurrent lung problems and without antibiotic therapy in the last 30 days. For each patient a lung Point of Care Ultrasound (POCUS) of lung was performed.

B lines < 3 and sub-pleural consolidations < 1 cm were statistically more frequent in CF patients, both in terms of number of affected patients (p 0.02 and p 0.0001 respectively) and frequency (p 0.0181 and p 0.0001 respectively); the prevalence of B lines < 3 in control group was high (47.73%) however the prevalence of sub-pleural consolidations was very low (2.27%). In both groups coalescent B lines affected a greater number of infants and were in higher number of findings than patients aged between 2 and 6 years.

The presence of multiple subpleural pulmonary consolidations < 1 cm in asymptomatic preschool children could be a ultrasound markers of subclinical pulmonary disease such as CF. POCUS of lung is confirmed as a useful tool for the clinician as confirmation of a clinical suspicion, help reduce the use of ionizing radiation.

The purpose of this study was to investigate whether early surfactant administration affects the status of ductus arteriosus (DA) in preterm infants ≤ 32 weeks of gestational age (GA) within 24 h of birth.

It is a prospective study conducted from 1 March 2022 to 31 December 2023 in a tertiary academic center. In-born infants ≤ 32 weeks of gestation (n = 88) were enrolled. The study group was further divided into surfactant (n = 44) and non-surfactant (n = 44) subgroups.

A total of 76% of the preterm infants who received surfactant therapy (RRR = 0.839) recorded an increase in Kindler score at 24 h of life (1 - RR = 1 - 0.24 = 76%). Surfactant administration was significantly associated with decreased pre-ductal diastolic pressure (29.9 mmHg vs. 34.8 mmHg, p = 0.0231), post-ductal diastolic pressure (28.7 mmHg vs. 32.2 mmHg, p = 0.0178), pre-ductal MAP (41.6 mmHg vs. 46.5 mmHg, p = 0.0210), and post-ductal MAP (41.0 mmHg vs. 45.3 mmHg, p = 0.0336). There were no significant changes in ductus arteriosus parameters at 24 h of life.

Early surfactant administration does not affect the status of ductus arteriosus in preterm infants ≤ 32 weeks of gestational age at 24 h of life.

Surfactant administration may be needed in late preterm through full-term neonates, but the pathophysiology of their respiratory failure can be different from that of early preterm neonates. The lung ultrasonography score (LUS) is accurate to guide surfactant replacement in early preterm neonates, but to our knowledge, it has not yet been studied in the late preterm through full-term neonatal population.

To assess whether LUS is equally accurate to predict surfactant need in late preterm through full-term neonates as in early preterm neonates.

This prospective, international, multicenter diagnostic study was performed between December 2022 and November 2023 in tertiary academic neonatal intensive care units in France, Italy, Spain, and the US. Late preterm through full-term neonates (≥34 weeks' gestation) with respiratory failure early after birth were enrolled.

Point-of-care lung ultrasonography to calculate the neonatal LUS (range, 0-18, with higher scores indicating worse aeration), which was registered in dedicated research databases and unavailable for clinical decision-making.

The main outcomes were the area under the curve (AUC) in receiver operating characteristic analysis and derived accuracy variables, considering LUS as a replacement for other tests (ie, highest global accuracy) and as a triage test (ie, highest sensitivity). Sample size was calculated to assess noninferiority of LUS to predict surfactant need in the study population compared with neonates born more prematurely. Correlations of LUS with the ratio of hemoglobin oxygen saturation as measured by pulse oximetry (SpO2) to fraction of inspired oxygen (FiO2) and with the oxygen saturation index (OSI) were assessed.

A total of 157 neonates (96 [61.1%] male) were enrolled and underwent lung ultrasonography at a median of 3 hours (IQR, 2-7 hours) of life; 32 (20.4%) needed surfactant administration (pretest probability, 20%). The AUC was 0.87 (95% CI, 0.81-0.92). The highest global accuracy and sensitivity were reached for LUS values higher than 8 or 4 or lower, respectively. Subgroup analysis gave similar diagnostic accuracy in neonates born late preterm (AUC, 0.89; 95% CI, 0.81-0.97; n = 111) and early term and later (AUC, 0.84; 95% CI, 0.73-0.96; n = 46). After adjusting for gestational age, LUS was significantly correlated with SpO2:FiO2 (adjusted β, -10.4; 95% CI, -14.0 to -6.7; P < .001) and OSI (adjusted β, 0.2; 95% CI, 0.1-0.3; P < .001).

In this diagnostic study of late preterm through full-term neonates with respiratory failure early after birth, LUS accuracy to predict surfactant need was not inferior to that observed in earlier preterm neonates. An LUS higher than 8 was associated with highest global accuracy (replacement test), suggesting that it can be used to guide surfactant administration. An LUS value of 4 or lower was associated with the highest sensitivity (triage test), suggesting it is unlikely for this population to need surfactant.

Bronchopulmonary disease (BPD) is associated with long-term neurodevelopmental and cardiorespiratory complications, often requiring significant use of resources. To reduce this healthcare burden, it is essential that those at high risk of BPD are identified early so that strategies are introduced to prevent disease progression. Our aim was to discuss potential methods for improving early diagnosis in the first week after birth.

A narrative review was undertaken. The search strategy involved searching PubMed, Embase and Cochrane databases from 1967 to 2024. The results of potential biomarkers and imaging modes are discussed. Furthermore, the value of scoring systems is explored.

BPD occurs as a result of disruption to pulmonary vascular and alveolar development, thus abnormal levels of factors regulating those processes are promising avenues to explore with regard to early detection of high-risk infants. Data from twin studies suggests genetic factors can be attributed to 82% of the observed difference in moderate to severe BPD, but large genome-wide studies have yielded conflicting results. Comparative studies are required to determine which biomarker or imaging mode may most accurately diagnose early BPD development. Models which include the most predictive factors should be evaluated going forward.

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.

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

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

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

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach.

There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures.

• Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success.

• A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.