Lung ultrasound guided pulmonary recruitment during mechanical ventilation in neonates: A case series

Abstract

BACKGROUND: Recently, the first report of lung ultrasound (LUS) guided recruitment during open lung ventilation in neonates has been published. LUS guided recruitment can change the approach to open lung ventilation, which is currently performed without any measure of lung function/lung expansion in the neonatal population. METHODS: We included all the newborn infants that underwent a LUS-guided recruitment maneuver during mechanical ventilation as a rescue attempt for an extremely severe respiratory condition with oxygen saturation/fraction of inspired oxygen (SpO2/FIO2) ratio below 130 or the inability to wean off mechanical ventilation. RESULTS: We report a case series describing 4 LUS guided recruitment maneuvers, underlying crucial aspects of this technique that can improve the effectiveness of the procedure. In particular, we describe a novel pattern (the S-pattern) that allows us to distinguish the recruitable from the unrecruitable lung and guide the pressure titration phase. Additionally, we describe the optimal LUS-guided patient positioning. CONCLUSIONS: We believe that the inclusion of specifications regarding patient positioning and the S-pattern in the LUS-guided protocol may be beneficial for the success of the procedure.

Lung UltraSound Targeted Recruitment (LUSTR): A Novel Protocol to Optimize Open Lung Ventilation in Critically Ill Neonates

“…All the LUS-guided recruitments, starting from a consolidation pattern (C-pattern) and showing signs of lung recruitability performed between January 2019 and August 2021 were included in this case-control study and constituted the Lung UltraSound Targeted Recruitment (LUSTR) group. The recruitable lung was determined by the development of the S-pattern during pressure augmentation; this was based on our previous report [ 7 ]. The S-pattern is characterized by the presence of vertical hyperechoic artifacts starting from the reopening bronchi, representing a sonographic sign of lung recruitability.…”

“…As these linear artifacts resemble the sun rays crossing the clouds, they were named Sunray(S)-lines. The pattern is characterized by the appearance of at least one S-line per field [ 7 ]. LRMs were excluded from the study if no S-pattern was detected during the procedure.…”

“…In the intervention group, LUS was systematically performed on all lung fields: anterior superior, lateral superior, posterior superior, anterior inferior, lateral inferior, and posterior inferior for the right and left sides [ 13 ]. If signs of lung consolidation or derecruitment were detected, after the exclusion of any modifiable causes of lung collapse (e.g., endotracheal tube misplacement), LUS-guided recruitment was initiated [ 7 ]. In accordance with previous reports in adults and children [ 1 , 14 ], the patient was positioned to maintain the most severely affected lung fields on the upper side, with constant ultrasound monitoring to visualize the progressive parenchymal reopening throughout the procedure in the most derecruited lung area.…”

“…Therefore, it is crucial to select the cases that would benefit the most from the procedure, minimizing the risk of pulmonary and hemodynamic side effects. In a recent case series [ 7 ], our group described a novel sonographic pattern, the Sunray(S)-pattern, that develops early during rescue LRMs as a sign of lung recruitability [ 7 , 8 , 9 ]. This study aimed to compare the effectiveness of rescue LUS-guided LRMs, showing signs of lung recruitability to the traditional oxygenation-guided maneuvers in critically ill ventilated neonates.…”

Application of ultrasonography in neonatal lung disease: An updated review

“…It has been reported that LUS can be used to guide pulmonary recruitment maneuvers during mechanical ventilation in neonates ( 170 , 171 ). As the developed artifacts resemble sunrays crossing the clouds, the novel S-lines (“sunray lines”) described in the LUS-guided protocol may improve the efficacy and safety of mechanical ventilation strategies in neonates ( 170 ). In addition, computer-aided image analyses have been developed to interpret LUS findings.…”