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400 oracic ultrasound
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➤ Updated Bibliography
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therapy In subacute shock is associated with change in management and improved outcomes. J Crit Care
2014; [epub ahead of print].
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limited transthoracic echocardiogram is a useful tool to guide therapy for hypothension in the trauma bay.
A pilot study. J Trauma Acute Care Surgery 2013;74:220-223.
Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, Boero E, Nazerian P, Pozzi R,
Francisco ME. Point of care multiorgan ultrasonography for the evaluation of undifferentiated hypotension
in the emergency department. Intensive Care Med 2013;39.1290-1298.
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patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med 2013;31:1208-1214.
402 oracic ultrasound
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Nielsen EW, Edvardsen T. Advantages of strain echocardiography In assessment of myocardial function
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a tissue Doppler study. J Crit Care 2013;28.
Sepsis and integrated ultrasound.
13
Pleural and lung ultrasound in the
neonatal period and in childhood
e writing of this chapter was carried out with the cooperation and contribution of Dr. Luigi Cattarossi (Director
SOC Neonatal Pathology, Azienda Ospedaliera Universitaria, Ospedale Santa Maria della Misericordia, Udine)
Chest radiography is currently the imaging technique commonly used
in the study of respiratory failure in the newborn and child. Nuclear
magnetic resonance and computed tomography should be considered
second-level surveys, and therefore not for routine use. Until now, only
few studies have evaluated the usefulness of lung ultrasound in the diagnosis of respiratory diseases that most commonly affect the newborn and
the children. In any case, before our publications on the sonographic diagnosis of transient tachypnea of the newborn and the hyaline membrane
1-2
disease
through an abdominal transhepatic or transplenic approach (Fig . 1)
is approach greatly limits the potentiality of lung ultrasound, because
no information on changes in the pleural line is obtainable with these
projections. In the setting of neonatal respiratory diseases, more than in
adult chest ultrasound, a lung full of air has been a taboo for long time.
, the few published papers had only examined the lung bases
3-6
.
Chest radiography has many limitations in neonatal and pediatric age. First of all, it involves the
exposure to ionizing radiations. is problem is not negligible, because the risk of developing
neoplasms secondary to radiation exposure is greater the younger the patient7. Echography
is definitely able to reduce the number of radiographs needed8. Chest radiography has also
poor sensitivity in distinguishing carefully the content of an opacity (pleura or parenchyma?
alveolo-interstitial edema or consolidation?). Lung ultrasound is definitely more accurate and
the possibility of obtaining dynamic images gives it an extraordinary potentiality.
e possibility of performing serial and frequent surveys is another important aspect that is
extremely useful in situations of clinical instability.
e execution technique is simple in view of the limited size of the area that needs to be
examined and the reduced thickness of the chest wall. High-resolution linear probes are
obviously necessary (7.5-13 MHz).
e sonographic findings reported here are the results of over ten years of observations on
the most common respiratory diseases in newborns and children. e absolute and constant
reproducibility of the sonographic findings is surprising, so that it can be assumed that certain
findings are often pathognomonic for a particular disease.
403
404 oracic ultrasound
Figure 1 – Transhepatic and transplenic assessement of the lung bases. From: Bober K et al. Diagnostic
utility of ultrasonography for respiratory distress syndrome in neonates.
CR440-446.
Med Sci Monit
2006; 12(10):
➣ Execution technique and echographic anatomy
e examination is performed with the infant in a supine position, through longitudinal and
transverse scans along the anatomical lines of the chest (parasternal and midclavicular lines,
anterior, middle, and posterior axillary lines, and paravertebral lines). e posterior areas may
be better viewed in the lateral decubitus position.
e position with the erect trunk is almost never necessary.
In ultrasound, the normal lung of the newborn does not differ substantially from that of the
adult. e pleural line is easily viewable beneath the ribs and the pleural gliding motion is
easily recognizable (pleural sliding)9 (Clip 1).
Clip 1 – Transverse scan. Pleural sliding in a normal lung (absence of B
Lines, evidence of A Lines).
e presence of horizontal artifacts repeated at constant intervals below the pleural line (A
Lines10) identifies a normal condition (Figs. 2-3).
At birth it is possible to highlight vertical artifacts (B Lines10). ese artifacts, that indicate
disease in the adult (interstitial syndrome)
resent residual liquid of the fetal lung. is finding is evident both in infants born by vaginal
delivery and Caesarean section. In newborns by the Caesarean section, B Lines are more
frequent because of the greater quantity of lung fluid in the lungs. e lower pressure over
11-15
, appear in absolutely healthy infants and rep-
Pleural and lung ultrasound in the neonatal period and in childhood 405
A Lines
Ribs and acoustic shadow cone
Pleural line
A Lines
Figure 2 – Normal lung: transverse scan.
Hyperechoic pleural line and horizontal
artifacts (A Lines).
Figure 3 – Normal lung: longitudinal scan.
Acoustic shadow cones produced by the ribs
and hyperechoic pleural line immediately
below the ribs. Horizontal artifacts (A Lines).
the rib cage during the transit through the birth canal is probably a causal factor. Newborn
B-Lines, though numerous, are not coalescing and are more detectable at the lung bases.
Wathever the delivery takes place, there is generally a complete disappearance of the interstitial
syndrome within the following 36 hours (Figs. 4-6).
2 hours
2 hours
B Lines
B Lines
Figure 4 – Transverse scan in healthy newborn by Caesarean section 2 hours earlier. Evidence of
numerous non-coalescing B Lines.
➣ Transient tachypnea of the newborn
e transient tachypnea of the newborn (TTN) is a common pathological situation, well
known to pediatricians and neonatologists. Infants with TTN, within the first hour of life,
406 oracic ultrasound
18 hours
Fig. 5 – Transverse scan in the same healthy
newborn after 18 hours from birth. Marked
reduction in B Lines.
Fig. 6 – Transverse scan in healthy newborn born
by vaginal delivery 2 hours earlier. Presence of
some B Lines.
B Lines
show tachypnea and hypoxemia in the absence of carbon dioxide retention. A clinical deterioration such as to require mechanical ventilation is very rare. In serious cases the real problem
lies in the clinical differential diagnosis with other pathologies.
TTN is due to a delayed clearance of the liquid in the fetal lung, which involves the retention
of fluids in the alveoli and interstitium. In vivo studies have shown that the lung epithelium
secretes Cl-and fluids throughout pregnancy, but that the capacity to reabsorb Na+ and
consequently fluids, occurs only in the late stages of gestation16. At birth the mature lungs
reabsorb Na+ and fluids instead of secreting them with Cl. e circulating catecholamines
are important in governing this reversal of activity. e increase in oxygen tension that occurs
at birth determines an increased capacity of the epithelium to actively absorb sodium and
fluids. e concept of pulmonary immaturity at birth expresses the inability to activate these
mechanisms. ose born by Caesarean section are more at risk of developing this disease,
also for the reduced levels of catecholamines produced during labor, compared with those
born by vaginal delivery.
e frequency of TTN is identical throughout the world. About 1% of newborns is suffering
from some form of respiratory distress not attributable to infectious diseases. Of this 1%,
33-50% is attributable to TTN. It is more frequent in infants at or near term and tends to
resolve spontaneously within 24-72 hours. is disease has low morbidity.
As already said, it is observed more frequently in infants born by Cesarean section for the
reduced levels of circulating catecholamines, but also for the non-compression of the rib cage,
while during vaginal delivery there is a real “squeezing” of the lung. Milner and colleagues
17
reported that the average volume of gas contained in the chest was 32.7 ml/kg in infants
born by vaginal delivery compared to 19.7 ml/kg of births by Caesarean section (same chest
circumference). In contrast, the quantity of fluid in the interstitium and alveoli was markedly
higher in infants born by Caesarean section.
A higher incidence of TTN has finally been described in infants of asthmatic mothers18.
Chest radiograph is still considered the diagnostic standard.
Pleural and lung ultrasound in the neonatal period and in childhood 407
e characteristic findings of Chest X-ray are the presence of prominent perihilar striae attributed to lymphatic congestion and the presence of fluid in the fissures. More rarely there
are areas of pulmonary infiltrates and small pleural effusions. ese alterations are resolved
within 72 hours.
Lung ultrasound in TTN
Ultrasound images of TTN are so specific as to be sufficient for its diagnosis1. Despite the
low morbidity of the disease, sometimes the baby shows an early severe respiratory distress
requiring differential diagnosis with more high-risk situations (pneumothorax, pneumonia,
sepsis, HMD, congenital heart defects, etc.).
Lung ultrasound allows the correct diagnosis resolving the problems related to differential
diagnosis. It typically detects the presence of compact B Lines at the bases compared to higher
fields, where they are less numerous or even absent (Figs. 7-8). is aspect involves both lungs,
although not symmetrically. Frequently, this picture appears more striking for the right lung.
Compact B Lines
Apex
B Lines
Figure 7 – TTN: transverse scan at the upper third
of the lung. Numerous but not compact B Lines.
Figure 8 – TTN: transverse scan at the lower
third of the lung. Numerous and compact B Lines.
e transition between the lower lung areas with compact vertical artifacts, and the higher
areas, is most of the time sudden and it gives the lung a peculiar look. We have defined this
sign “double lung point”. is sign is pathognomonic of TTN (Clips 2-6) (Fig. 9).
Clip 2 – TTN: longitudinal scan at the medial third of the right lung. Evident
difference between the base, with compact B Lines, and the apex where they
are less numerous.
Clips 3, 4 – TTN: longitudinal scan at the medial third of the lung showing
double lung point.
408 oracic ultrasound
Clip 5 – TTN: longitudinal scan at the apex of the right lung. Evident paucity
of B Lines.
Clip 6 – TTN: transverse scan at the base of the right lung. Compact B Lines.
e pleural line is regular, hyperechoic, well-defined and not thickened. e occurrence of
pleural effusion is rare.
e artifacts tend to disappear completely within 36-72 hours (Fig. 10).
A
B
C
Figure 9 – TTN: scans at the medial third of the
chest, showing the double lung point. (A, B, C)
Pleural and lung ultrasound in the neonatal period and in childhood 409
2 hours
Figure 10 – TTN: scans at the base of the chest 2 and 36 hours after birth. Note the disappearance
of the compact B Lines.
36 hours
➣ Pulmonary hyaline membrane disease
e pulmonary hyaline membrane disease (HMD) (respiratory distress syndrome, RDS, according to Anglo-Saxon authors) occurs almost exclusively in premature infants. e incidence and
severity are inversely related to the gestational age of the newborn (45-80% in babies below the
28th week). e outcome of the HMD has improved thanks to the antenatal administration
of steroids that accelerate the maturation process of the fetal lung, the early administration
of surfactant at birth and ventilatory techniques that reduce the damage to immature lungs19.
Despite all this, the morbidity is still very high (bronchopulmonary dysplasia, pulmonary
hemorrhage, persistence of patency of the ductus arteriosus, sepsis, intracranial hemorrhage
and/or periventricular leukomalacia, leading to neurological deficits).
HMD is determined by a relative deficiency of surfactant leading to reduced lung compliance
and functional residual capacity, with increased dead space. is causes a severe alteration of
the ventilation-perfusion, with a right to left shunt that can reach 80% of cardiac output.
At microscopic level, the lung shows reduced aeration with distal airway collapse, and large
atelectasis areas alternating with tissue showing hyper-insufflated alveoli.
e progression of atelectasis, associated with barotrauma and oxygen toxicity, cause a damage
to endothelial and epithelial cells of the distal airways with production of fibrinous material.
Hyaline membranes occupying the alveoli are formed within 30 minutes of birth. After 36-72
hours from birth, the epithelium begins the synthesis of surfactant. e healing process is
complex. In extremely immature or critical infants a chronic process often occurs, leading to
the development of bronchopulmonary dysplasia.
Immaturity is a major risk factor of HMD, but also maternal diabetes and asphyxia have a role.
In HDM infants, respiratory distress occur early after birth and consist of dyspnea, expiratory
groan, subcostal and intercostal retractions, nasal flaring and cyanosis.
Over the past ten years, the surfactant therapy has reduced mortality of approximately 50%20.
Chest X-ray shows a diffuse and bilateral ground glass-like image, consolidations with air
bronchograms and reduced expansion of the lungs. Chest radiologic appearance is useful in
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