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Lung ultrasound in children: What does it give us?

Sara Bobillo-Perez, Monica Girona-Alarcon, Javier Rodriguez-Fanjul, Iolanda

Jordan, Monica Balaguer Gargallo

PII: S1526-0542(19)30087-9
DOI: https://doi.org/10.1016/j.prrv.2019.09.006
Reference: YPRRV 1345

To appear in: Paediatric Respiratory Reviews

Received Date: 1 July 2019

Revised Date: 9 September 2019
Accepted Date: 10 September 2019

Please cite this article as: S. Bobillo-Perez, M. Girona-Alarcon, J. Rodriguez-Fanjul, I. Jordan, M.B. Gargallo, Lung
ultrasound in children: What does it give us?, Paediatric Respiratory Reviews (2019), doi: https://doi.org/10.1016/
j.prrv.2019.09.006

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Title: Lung ultrasound in children: What does it give us?

Authors: Sara Bobillo-Perez 1,2; Monica Girona-Alarcon2 ; Javier Rodriguez-Fanjul3; Iolanda Jordan2,4

; Monica Balaguer Gargallo2

Affiliations:

1Disorders of Immunity and Respiration of the Pediatric Critical Patients Research Group, Institut de

Recerca Hospital Sant Joan de Deu, Barcelona

2Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona,

Barcelona, Spain

3Pediatric Intensive Care Unit Service, Pediatric Department. Hospital Universitari de Tarragona Joan

XXIII. Institut Catala de la Salut Camp de Tarragona.

4Pediatric Intensive Care Unit, Paediatric Infectious Diseases Research Group, Institut Recerca

Hospital Sant Joan de Déu, Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain.

Address correspondence to: Iolanda Jordan, ijordan@sjdhospitalbarcelona.org

Adress: Passeig Sant Joan de Déu.2. 08950. Esplugues de Llobregat, Barcelona. Spain

Tel +34932532-100; Fax +34932033959

Short title: Lung ultrasound in children.

1
Abstract

Lung ultrasound (LUS), a non-invasive non-ionizing radiation tool, has become essential at bedside

in both adults and children, particularly in the critically ill. This manuscript reviews normal LUS

patterns and the most important pathologies that LUS allows to diagnose. Normal LUS is represented

by the pleural line, the lung-sliding and the A-lines and B-lines. These two last findings are artifacts

derived from the pleural line. Pleural effusion appears as an anechoic collection. Pneumothorax is

suspected when only A-lines are present, without lung-sliding and B-lines. Alveolo-interstitial

syndrome is characterized by different degrees of confluent B-lines and can be present in different

pathologies such as pulmonary edema and acute respiratory distress syndrome. The distribution of

B-lines helps to differentiate between them. LUS is useful to evaluate the response to lung

recruitment in pathologies such as acute respiratory distress syndrome or acute chest syndrome.

The distribution of B-lines also appears to be useful to monitor the response to antibiotics in

pneumonia. However, further studies are needed to further ascertain this evidence. LUS is also useful

to guide thoracocentesis.

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Educational Aims

The reader will appreciate that:

 Lung ultrasound offers fast, inexpensive, non-ionizing radiation, real-time imaging at the patient's

bedside.

 Pleural line and the lung-sliding (movement of the visceral and parietal pleura), A-line and B-line

are the hallmarks of a normal LUS evaluation.

 LUS is very useful to monitor treatment responses in ARDS, pneumonia, and acute chest

syndrome among other lung diseases.

 LUS is very useful to perform procedures such a thoracocentesis.

Future research directions

 Larger prospective studies in the PICU setting are needed.

 Better methods to define lung recruitment should be defined.

 More data are also needed to confirm the usefulness of this tool in acute chest syndrome.

Keywords: Ultrasound imaging/Pediatric/Point-of-care/ Pneumonia/Acute chest syndrome.

Word Count: 2,186

Introduction

Ultrasound has gained evidence in recent years as a diagnostic and monitoring tool in intensive care

units. Lung ultrasound (LUS) offers a fast inexpensive non-ionizing radiation real-time image at the

patient's bedside (1). LUS is operator-dependent but the learning curve is fast as demonstrated by

low intra-inter-observer variability (2,3). Lung evaluation is the result of artifacts generated by the

interaction of the ultrasound beam between the air and fluid interface. The air-liquid ratio varies in

each disease, from only liquid in pleural effusion to only air in pneumothorax. LUS is easier to

perform in pediatric and neonatal patients than in adults due to its greater acoustic window

secondary to their partially ossified chest and lower subcutaneous tissue that provide a better

acoustic window. The aim of this review is to provide a practical summary of pediatric LUS, from

3
normal to abnormal patterns and describe its use as a functional tool.

Methods

Articles published up to April 2019 were reviewed. The search was performed in PubMed, Embase,

Web of Science, and the Cochrane Central Register of Controlled Trials. Studies of the adult

population have been included due to the lack of data for pediatric patients in some situations.

Practical aspects

Examination mode

A high frequency linear probe (10 MHz or higher) should be used due to its better resolution,

although other probes can be used if linear probes are not available. The high frequency probe allows

scanning surface structures with good resolution, which generally suffices in pediatrics. It is

important to disinfect the probe before and after its use to reduce the risk of nosocomial infection.

The probe must be placed perpendicular to the thorax and moved perpendicularly or in parallel

direction from the ribs. The examination must follow a systematic procedure to avoid overlooking

areas. Each hemithorax is divided into three areas: anterior, lateral and posterior, delimited by

parasternal line, anterior axillary line, and posterior axillary line (4,5). The scan must reach the

diaphragm to confirm the complete exploration of the lung and differentiate between intra-

abdominal and intrathoracic pathology.

LUS: normal lung characteristics

Pleural line

In a longitudinal scan, the rib and its acoustic shadow can be easily recognized. The adjacent shadows

of the ribs and the pleural line draw the ‘bat sign’ ensuring the correct perpendicular position of the

probe (6). The ultrasound easily crosses the subcutaneous tissue, but when it reaches the air

interface, the ultrasound disperses. This reflection between the soft muscular tissues and the

pulmonary tissues draws a hyperechoic line called the pleural line. All LUS signs arise from the

pleural line. The normal pleural line is usually regular, thin and smooth. Its theoretical width is less

than 0.5 mm (7,8). Its thickness is rarely measured in clinical practice. In fact, there is no consensus

regarding the pleural line normal thickness.

Lung-sliding

Lung-sliding is the sliding movement of the visceral pleura over the parietal pleura during

respiration (9). A well-positioned probe, perpendicular to the thorax and with no external movement,

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is fundamental for evaluating this. This is a dynamic sign which absence indicates pathology. The

‘seashore sign’, obtained using the M-mode image, marks the difference between the linear pattern

(superficial tissues, ‘sea’) and the parenchyma pattern (lung, ‘sand’) divided by the pleural line. It

may be decreased in several situations such as atelectasis, acute respiratory distress syndrome

(ARDS), and abdominal hypertension (10,11).

A-Lines

A-lines are horizontal, hyperechogenic and equidistant lines under the pleural line (Figure 1). In fact,

A-lines constitute the reverberation artifact of the pleural line, and the distance between the A-lines

is constant. The presence of A-lines and lung-sliding in an area of lung ensures the absence of

pathology in that area (12).

B-Lines

The B-lines are vertical hyperechoic lines that start perpendicularly from the pleural line (13). These

lines erase the images that go through their path, including the A-lines. They are dynamic and

accompany the lung-sliding. Their presence is related to the expansion of the interlobular septae and

the accumulation of fluid in the lung. Fewer than 3 B lines between two ribs in the anterior and lateral

lung fields is normal in healthy lung, especially in posterior areas. The B-lines are nonspecific and not

useful per se to differentiate pulmonary diseases (14,15). However, as it has been described in adults,

based on the distance between two B-lines at the pleural edge some pathologies’ may be more likely:

a distance of 3 mm correlates with subpleural ground-glass lesions and a distance of 7 mm with

thickened subpleural interlobular septa (16).

The B-lines must be differentiated from the Z-lines that are artifacts without clinical significance. The

Z-lines are thicker and shorter, and they do not erase the A-lines.

LUS: pathological findings

Pleural effusion

The presence, volume, and etiology of effusions can be evaluated by LUS (17). Imaging frequently

reveals an anechoic collection and LUS allows the determination of septation and loculation. In

addition, LUS is helpful to decide the optimal place to perform a thoracentesis (18,19). LUS can detect

effusions smaller than 10 mL. In contrast, chest radiograph (CXR) detects only larger effusions (200

mL). Pleural effusions tend to accumulate in dependent areas. The collection of free fluid is no always

anechoic. The presence of multiple mobile echoes in the effusion (’the plankton’ sign) can be

5
observed in patients with hemothorax, chylothorax, and pleurisy (20). The ‘jellyfish’ sign can be

present in larger effusions. This sign represents the lung flapping in the effusion (Figure 2). The

‘sinusoid’ sign is specific to pleural effusions. It is obtained with the M-mode image and indicates

variation of the pleural line during the respiratory cycle.

Pneumothorax

The parietal and visceral pleura are not in contact. In the conventional mode there is no lung-sliding

or B-lines. The only image obtained is the reverberation of A-lines. The presence of B-lines rules out

pneumothorax (100% negative predictive value). The M-mode image will reveal the ‘stratosphere’

sign instead of the ‘seashore’ sign of the normal lung. The ‘stratosphere’ sign has a sensitivity and

specificity greater than 90% with negative predictive value of 100% (21). The ‘lung point’ is where

the transition between the normal lung (with lung sliding and A-lines) and pneumothorax (only A-

lines) occurs, and its presence has a specificity of 100% for pneumothorax (22–25). It can be

evaluated using the conventional mode and the M-mode.

Consolidation

Consolidation pattern is defined as a hypoechogenic area with poorly defined edges and with vertical

artifacts in the adjacent areas. The lower borders may be more hyperechogenic and irregular in some

cases (26). Lung parenchyma resembles the liver tissue and is called ‘lung hepatization’. Lung sliding

may be absent. Air sonograms are represented as branching echogenic structures present in the

consolidated area (26). Even with LUS, it is still difficult to distinguish between pneumonia and

atelectasis. Moreover, the consolidation pattern can also be seen in pulmonary thromboembolisms

and lung contusions. Several recent publications have studied LUS differentiation between

pneumonia and atelectasis and results are not definitive (27–35). Two meta-analyses suggested

excellent sensitivity and specificity of LUS for the diagnosis of pneumonia (36,37). However, the

current pediatric recommendation is to correlate clinical and LUS findings (38,39). In pneumonias,

the consolidation may show a dynamic air bronchogram similar to a tree shape that is not always

visible. Blood flow can be present, visible with the echo-Doppler mode. Resolving pneumonias

usually have irregular borders (shred sign) as shown in Figure 3. Of note, perihilar consolidations

that do not reach the pleural line can be missed by LUS (40). Atelectasis is presented as

consolidations with linear static air bronchograms and usually clear borders. Blood flow is absent.

Alveolo-interstitial syndrome

6
This is an ultrasonographic entity. In a longitudinal view, lung rockets are defined as the presence of

3 or more B-lines in an intercostal space. These lung rockets represent interstitial involvement,

which is different from interstitial disease, and seem to be secondary to water excess in the

interalveolar septa. The confluence of these pathologic B-lines defines alveolar involvement. The

alveolar compromise is inversely correlated with B-line distance (<3mm in adults), as may be seen

in alveolar edema.

Alveolo-interstitial syndrome is a non-specific sign that may be present in different pathologies. Lung

rockets can be limited to an area (as seen in pneumonias or atelectasis) or diffuse (as seen in

pulmonary fibrosis or interstitial diseases) (41). In critically ill patients, LUS can evaluate

extravascular pulmonary water, represented as multiple confluent B-lines in a diffuse bilateral

distribution (42). This can be seen in two different entities: cardiogenic pulmonary edema and ARDS.

The main difference between the two entities is the distribution: homogeneous or patched. In edema

secondary to acute heart failure, the distribution is uniform with only diffuse and confluent B-lines

located in areas in decline, and with lung-sliding preserved (43). In ARDS, multiple B lines are

observed, and the pattern is usually patched (44). Thickened pleura, abnormal lung-sliding,

subpleural consolidations, lung consolidations, and a normal pattern may also be present in ARDS

(Figure 4).

Manoeuvres with LUS

Lung recruitment.

LUS is a useful tool to monitor lung expansion and collapse. There are other radiological techniques

that are also useful for this purpose, but they are not as innocuous nor as fast. The signs can vary

from isolated or diffuse B-lines to consolidations with static bronchograms. These signs construct a

scale that represents the progressive loss of aeration from fully aerated to complete atelectasis (45).

Bedside LUS can evaluate the progression of lung aeration and the response to therapeutic

interventions (46–49). In ARDS, prone position and recruitment manoeuvres are the main

therapeutic measures (50). CXR is usually done after recruitment manoeuvres to monitor lung

aeration and avoid hyperinflation. LUS allows real-time opening and closing pressures of the lung

during the manoeuvres. However, LUS cannot detect lung overdistention.

Acute chest syndrome

7
Another new benefit of LUS is early detection of lung collapse, which is extremely important in acute

chest syndrome (51). The diagnosis of acute chest syndrome involves the presence of fever and/or

respiratory symptoms and a new radiologic infiltrate. However, CXR can be normal at admission in

almost a third of patients. Hence, LUS is a good tool for the early diagnosis of consolidation in this

disease and can also control and guide lung recruitment (52).

Pneumonias

LUS is useful to diagnose and monitor the response to treatment of pneumonias in adults (53,54).

LUS can evaluate the size of the consolidated area and the improvement in lung aeration (55).

Musolino et al suggested that a deep and fixed air bronchogram in the initial LUS might be able to

predict the development of complicated pneumonia (56). Caiulo et al showed that a correlation

between lack of improvement in the LUS exam and the lack of clinical recovery is possible (35).

However, further research is warranted.

Thoracocentesis

The usefulness of LUS can be indirect or direct. In the indirect mode, LUS is utilized to confirm the

pleural effusion and to localize the optimal thoracocentesis site (17,57,58). The direct mode is the

ultrasonography guided thoracocentesis. This is the optimal way to perform this procedure

especially in small pleural effusions, and in difficult locations (59). The largest possible volume of

pleural effusion should be seen at the selected puncture site. The diaphragm should not cross the

plane during breathing. The probe is then placed parallel to the ribs. The needle/catheter is sled from

the upper extreme of the probe to the lower extreme along the probe’s transversal axis. The probe

can also be placed perpendicular to the ribs. In this case, the needle/catheter is sled across the

longitudinal axis of the probe (60).

Diaphragm motion evaluation

Ultrasound can evaluate diaphragmatic movement. The patient must be in supine position off

respiratory support. There are two positions for this evaluation: subxiphoid and lateral. In the first,

the sectorial probe (or the convex probe, depending on the size of the patient) should be located

transversally at the subxiphoid point with an upwards-angled orientation to compare the two

diaphragm domes. A quantitative evaluation of each dome can be made with the M-mode. The depth

of the diaphragmatic excursion is evaluated by the variation of the movement using the M-mode. In

the lateral evaluation, the probe should be positioned in the posterior axillary line and perpendicular

8
to the ribs (61). In this position, the variation of diaphragmatic excursion can also be evaluated using

the M-mode, and compared with the contralateral excursion. No normal values for the diaphragm

excursion have been described. Normal, hypokinetic, akinetic, or paradoxical motion of the

diaphragm can be easily assessed (62).

Limitations of LUS literature

The main limitation is the paucity of large pediatric trials. More clinical trials are needed to deepen

in its different uses in paediatrics.

Conclusions

LUS has become an essential bedside tool in pediatrics due to its advantages: easy, fast, free of

ionization radiation and available at bedside. Several pathologies can be diagnosed and monitored

by LUS. In addition, its usefulness in acute chest syndrome in patients with sickle cell anemia is

encouraging because LUS may be more sensitive than CXR. Therefore, LUS may help with early

diagnosis and monitoring However, further LUS pediatric research is needed.

9
REFERENCES

1. Cattarossi L, Copetti R, Poskurica B. Radiation Exposure Early in Life Can Be Reduced by Lung

Ultrasound. Chest [Internet]. 2011;139(3):730. Available from:

http://linkinghub.elsevier.com/retrieve/pii/S0012369211601621

2. See KC, Ong V, Wong SH, Leanda R, Santos J, Taculod J, et al. Lung ultrasound training:

curriculum implementation and learning trajectory among respiratory therapists. Intensive Care

Med. 2016;42(1):63–71.

3. Heiberg J, Hansen L, Wemmelund K, Sørensen A, Ilkjaer C, Cloete E, et al. Point-of-Care

Clinical Ultrasound for Medical Students. Ultrasound Int Open [Internet]. 2015;01(02):E58–66.

Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0035-1565173

4. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al.

International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care

Med. 2012;38(4):577–91.

5. Cattarossi L. Lung ultrasound: Its role in neonatology and pediatrics. Early Hum Dev [Internet].

2013;89(SUPPL.1):S17–9. Available from: http://dx.doi.org/10.1016/S0378-3782(13)70006-9

6. Lichtenstein DA. Lung Ultrasound in the Critically Ill. Ann Intensive Care [Internet].

2014;4(1):1–12. Available from: http://insights.ovid.com/crossref?an=00000539-900000000-

97264

7. Copetti R, Cattarossi L, Macagno F, Violino M, Furlan R. Lung ultrasound in respiratory distress

syndrome: A useful tool for early diagnosis. Neonatology. 2008;94(1):52–9.

8. Sharma D, Farahbakhsh N. Role of chest ultrasound in neonatal lung disease: a review of current

evidences. J Matern Neonatal Med [Internet]. 2017;0(0):1–7. Available from:

https://www.tandfonline.com/doi/full/10.1080/14767058.2017.1376317

9. Lichtenstein DA. Ultrasound examination of the lungs in the intensive care unit. Pediatr Crit Care

Med. 2009;10(6):693–8.

10. Liu J, Chen S-W, Liu F, Li Q-P, Kong X-Y, Feng Z-C. The Diagnosis of Neonatal Pulmonary

Atelectasis Using Lung Ultrasonography. Chest [Internet]. 2015 Apr;147(4):1013–9. Available

from: https://linkinghub.elsevier.com/retrieve/pii/S0012369215389509

11. Lichtenstein DA, Mezière G, Lascols N, Biderman P, Courret JP, Gepner A, et al. Ultrasound

diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231–8.

10
12. Lichtenstein D, Van Hooland S, Elbers P, Malbrain MLNG. Ten good reasons to practice

ultrasound in critical care. Anaesthesiol Intensive Ther [Internet]. 2014;46(5):323–35. Available

from: http://czasopisma.viamedica.pl/ait/article/view/40294

13. Lichtenstein D. Fluid administration limited by lung sonography : the place of lung ultrasound in

assessment of acute circulatory failure (the FALLS-protocol). Expert Rev Respir Med.

2012;6(2):155–62.

14. Tomà P, Owens CM. Chest ultrasound in children: Critical appraisal. Pediatr Radiol.

2013;43(11):1427–34.

15. Martelius L, Heldt H, Lauerma K. B-Lines on Pediatric Lung Sonography: Comparison with

Computed Tomography. J Ultrasound Med. 2016;35(1):153–7.

16. Lichtenstein DA, Mezière G, Lagoueyte J-F, Biderman P, Goldstein I, Gepner A. A-Lines and B-

Lines. Lung Ultrasound as a Bedside Tool for Predicting pulmonary artery occlusion pressure in

the critically ill. Chest. 2009;136:1014–1020.

17. Brogi E, Gargani L, Bignami E, Barbariol F, Marra A, Forfori F, et al. Thoracic ultrasound for

pleural effusion in the intensive care unit : a narrative review from diagnosis to treatment. Crit

Care. 2017;21(135):1–11.

18. Gryminski J, Krakowka P, Lypacewicz G. The diagnosis of pleural effusion by ultrasonic and

radiologic techniques. Chest. 1976;70(1):33–7.

19. A. Lichtenstein D, Mauriat P. Lung Ultrasound in the Critically Ill Neonate. Curr Pediatr Rev

[Internet]. 2012;8(3):217–23. Available from:

http://www.eurekaselect.com/openurl/content.php?genre=article&issn=1573-

3963&volume=8&issue=3&spage=217

20. Salamonsen M, Lo A, Ng A, Bashirzadeh F, Wang W, DIK F. Novel Use of Pleural Ultrasound

Can Identify Malignant Entrapped Lung Prior to Eff usion Drainage. Chest [Internet].

2014;146(5):1286–93. Available from: http://dx.doi.org/10.1378/chest.13-2876

21. Volpicelli G, Boero E, Sverzellati N, Cardinale L, Busso M, Boccuzzi F, et al. Semi-

quantification of pneumothorax volume by lung ultrasound. Intensive Care Med.

2014;40(10):1460–7.

22. Raimondi F, Rodriguez Fanjul J, Aversa S, Chirico G, Yousef N, De Luca D, et al. Lung

Ultrasound for Diagnosing Pneumothorax in the Critically Ill Neonate. J Pediatr. 2015;175:74–

11
 78.e1.

23. Moreno-Aguilar G, Lichtenstein D. Lung ultrasound in the critically ill (LUCI) and the lung

point: A sign specific to pneumothorax which cannot be mimicked. Crit Care [Internet].

2015;19(1):19–20. Available from: http://dx.doi.org/10.1186/s13054-015-1030-6

24. Cattarossi L, Copetti R, Brusa G, Pintaldi S. Lung Ultrasound Diagnostic Accuracy in Neonatal

Pneumothorax. Can Respir J. 2016;2016(1).

25. Frankel H, Kirkpatrick A, Elbarbary M, Blaivas M, Desai H, Evans D, et al. Guidelines for the

appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill

patients - Part I: General Ultrasonography. Crit Care Med. 2015;43(11):2479–502.

26. Stadler JAM, Andronikou S, Zar HJ. Lung ultrasound for the diagnosis of community-acquired

pneumonia in children. Pediatr Radiol. 2017;47:1412–9.

27. Claes AS, Clapuyt P, Menten R, Michoux N, Dumitriu D. Performance of chest ultrasound in

pediatric pneumonia. Eur J Radiol [Internet]. 2017;88:82–7. Available from:

http://dx.doi.org/10.1016/j.ejrad.2016.12.032

28. Ibrahim M, Omran A, Ibrahim M, Bioumy N, El-Sharkawy S. Lung Ultrasound in Early

Diagnosis of Neonatal Ventilator Associated Pneumonia before Any Radiographic or Laboratory

Changes. Case Rep Pediatr [Internet]. 2016;2016:1–4. Available from:

https://www.hindawi.com/journals/cripe/2016/4168592/

29. Mongodi S, Via G, Girard M, Rouquette I, Misset B, Braschi A, et al. Lung ultrasound for early

diagnosis of ventilator-associated pneumonia. Chest [Internet]. 2016;149(4):969–80. Available

from: http://dx.doi.org/10.1016/j.chest.2015.12.012

30. Guerra M, Crichiutti G, Pecile P, Romanello C, Busolini E, Valent F, et al. Ultrasound detection

of pneumonia in febrile children with respiratory distress: a prospective study. Eur J Pediatr.

2016;175(2):163–70.

31. Jones BP, Tay ET, Elikashvili I, Sanders JE, Paul AZ, Nelson BP, et al. Feasibility and Safety of

Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in

Children: A Randomized Controlled Trial. Chest [Internet]. 2016;150(1):131–8. Available from:

http://dx.doi.org/10.1016/j.chest.2016.02.643

32. Ambroggio L, Clohessy C, Shah SS, Ambroggio L, Sucharew H, Macaluso M, et al. Lung

Ultrasonography: A Viable Alternative to Chest Radiography in Children with Suspected

12
 Pneumonia? J Pediatr [Internet]. 2016;176:93–98.e7. Available from:

http://dx.doi.org/10.1016/j.jpeds.2016.05.033

33. Esposito S, Papa SS, Borzani I, Pinzani R, Giannitto C, Consonni D, et al. Performance of lung

ultrasonography in children with community-acquired pneumonia. Ital J Pediatr. 2014;40(1):1–6.

34. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the

diagnosis of pneumonia in children and young adults. JAMA Pediatr. 2013;167(2):119–25.

35. Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, et al. Lung ultrasound

characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol.

2013;48(3):280–7.

36. Xin H, Li J, Hu HY. Is Lung Ultrasound Useful for Diagnosing Pneumonia in Children?: A Meta-

Analysis and Systematic Review. Ultrasound Q. 2018;34(1):3–10.

37. Balk DS, Lee C, Schafer J, Welwarth J, Hardin J, Novack V, et al. Lung ultrasound compared to

chest X-ray for diagnosis of pediatric pneumonia : A meta-analysis. Pediatr Pulmonol. 2018;1–

10.

38. Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis of neonatal pulmonary

atelectasis using lung ultrasonography. Chest. 2015;147(4):1013–9.

39. Kurepa D, Zaghloul N, Watkins L, Liu J. Neonatal lung ultrasound exam guidelines. J Perinatol

[Internet]. 2018;38(1):11–22. Available from: http://dx.doi.org/10.1038/jp.2017.140

40. Urbankowska E, Krenke K, Drobczyński Ł, Korczyński P, Urbankowski T, Krawiec M, et al.

Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children.

Respir Med. 2015;109(9):1207–12.

41. Reissig A, Copetti R. Lung ultrasound in community-acquired pneumonia and in interstitial lung

diseases. Respiration. 2014;87(3):179–89.

42. Mongodi S, Pozzi M, Orlando A, Bouhemad B, Stella A, Tavazzi G, et al. Lung ultrasound for

daily monitoring of ARDS patients on extracorporeal membrane oxygenation : preliminary

experience. Intensive Care Med. 2017;44(1):4–5.

43. Lassus J. Evaluating pulmonary congestion with lung ultrasound and the need to take the next

steps in heart failure. Eur J Heart Fail. 2017;19(9):1164–5.

44. Wang X, Ding X, Zhang H, Chen H, Su L, Liu D, et al. Lung ultrasound can be used to predict

the potential of prone positioning and assess prognosis in patients with acute respiratory distress

13
 syndrome. Crit Care [Internet]. 2016;20(385):1–8. Available from:

http://dx.doi.org/10.1186/s13054-016-1558-0

45. Tusman G, Acosta CM, Costantini M. Ultrasonography for the assessment of lung recruitment

maneuvers. Crit Ultrasound J [Internet]. 2016;8(1):8. Available from:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4975737&tool=pmcentrez&rendertyp

e=abstract

46. del Rey Hurtado de Mendoza B, Sanchez-de-Toledo J, Rodríguez-Fanjul J. Chest ultrasound for

guiding lung recruitment maneuvers. Med Intensiva [Internet]. 2017;(xx):5691. Available from:

http://dx.doi.org/10.1016/j.medin.2017.07.001

47. Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment

of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med.

2011;183(3):341–7.

48. Du J, Tan J, Yu K, Wang R. Lung Recruitment Maneuvers Using Direct Ultrasound Guidance: A

Case Study. Respir Care [Internet]. 2015;60(5):e93–6. Available from:

http://rc.rcjournal.com/cgi/doi/10.4187/respcare.03056

49. Wierzejski W, Adamski J, Weigl W, Gerega A. Modern methods of assessment of lung aeration

during mechanical ventilation. Anaesthesiol Intensive Ther. 2012;44(4):226–31.

50. Tusman G, Acosta CM, Böhm SH, Waldmann AD, Ferrando C, Marquez MP, et al. Postural lung

recruitment assessed by lung ultrasound in mechanically ventilated children. Crit Ultrasound J.

2017;9(1).

51. Rahmouni A, Maître B, Brun-buisson C. Bedside Lung Ultrasound During Acute Chest

Syndrome in Sickle Cell Disease. Medicine (Baltimore). 2016;95(7):1–8.

52. Bobillo-Perez S, Rodriguez-Fanjul J, Girona-Alarcon M, Cambra FJ, Jordan I, Balaguer M.

Ultrasound-guided recruitment maneuvers in pediatric acute chest syndrome due to sickle cell

disease. Med Intensiva [Internet]. 2019;(xx):4–7. doi 10.1016/j.medin.2019.06.002. Available

from: https://linkinghub.elsevier.com/retrieve/pii/S021056911930172X

53. Wang G, Ji X, Xu Y, Xiang X. Lung ultrasound: A promising tool to monitor ventilator-

associated pneumonia in critically ill patients. Crit Care [Internet]. 2016;20(1):1–10. Available

from: http://dx.doi.org/10.1186/s13054-016-1487-y

54. Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, et al. Lung ultrasound in the

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 diagnosis and follow-up of community-acquired pneumonia: A prospective, multicenter,

diagnostic accuracy study. Chest. 2012;142(4):965–72.

55. Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, et al. Ultrasound assessment

of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med.

2010;38(1):84–92.

56. Musolino AM, Tomà P, Supino MC, Scialanga B, Mesturino A, Scateni S, et al. Lung ultrasound

features of children with complicated and noncomplicated community acquired pneumonia: A

prospective study. Pediatr Pulmonol [Internet]. 2019;(June):ppul.24426. Available from:

https://onlinelibrary.wiley.com/doi/abs/10.1002/ppul.24426

57. Peris A, Tutino L, Cianchi G, Gensini G. Ultrasound Guidance for Pleural-Catheter Placement. N

Engl J Med. 2018;378(14):e19(1-5).

58. Abu-Zidan FM, Hefny AF. Point-of-Care Ultrasound in Critically Ill Patients. Acute Care Surg

Handb. 2017;335–60.

59. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of

care among patients undergoing thoracentesis and paracentesis. Chest [Internet].

2013;143(2):532–8. Available from: http://dx.doi.org/10.1378/chest.12-0447

60. Krackov R, Rizzolo D. Real-time ultrasound-guided thoracentesis. J Am Acad Physician Assist.

2017;30(4):32–7.

61. Yahagi N, Watanabe Y, Kumon K. Ultrasound detection of diaphragmatic paralysis after cardiac

operations. Ann Thorac Surg. 1998;65(6):1841.

62. Sanchez De Toledo J, Munoz R, Landsittel D, Shiderly D, Yoshida M, Komarlu R, et al.

Diagnosis of abnormal diaphragm motion after cardiothoracic surgery: Ultrasound performed by

a cardiac intensivist vs. fluoroscopy. Congenit Heart Dis. 2010;5(6):565–72.

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Figure 1. A-lines (White arrow) in a normal lung.

Figure 2. Pleural effusion (White arrow) and the ‘jellyfish’ sign (White star).

Figure 3. Irregular pleural line, with a consolidation (hypoechogenic lung) and

‘shred’ sign. The surrounding parenchyma has an increasing number of coalescent B-lines.

Figure 4. Patient with acute respiratory distress syndrome. LUS with patchy involvement: Thickened

pleural line (Black arrow) and little pleural effusion (White star). Greater number of B-lines and areas

with air bronchogram (White arrow).

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