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Purpose To provide an international expert consensus on technical aspects and clinical applications of quantitative lung ultrasound in adult, paediatric and neonatal intensive care. Methods The European Society of Intensive Care (ESICM) and the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) endorsed the project. We selected an international panel of 20 adult, paediatric and neonatal intensive care experts with clinical and research expertise in quantitative lung ultrasound, plus two non-voting methodologists. Fourteen clinical questions were proposed by the chairs to the panel, who voted for their priority (1–9 Likert-type scale) and proposed modifications/supplementing (two-round vote). All the questions achieved the predefined threshold (mean score > 5) and 14 groups of 3 mixed adult/paediatric experts were identified to develop the statements for each clinical question; predefined groups of experts in the fields of adult and paediatric/neonatal intensive care voted statements specific for these subgroups. An iterative approach was used to obtain the final consensus statements (two-round vote, 1–9 Likert-type scale); statements were classified as with agreement (range 7–9), uncertainty (4–6), disagreement (1–3) when the median score and ≥ 75% of votes laid within a specific range. Results A total of 46 statements were produced (4 adults-only, 4 paediatric/neonatal-only, 38 interdisciplinary); all obtained agreement. This result was also achieved by acknowledging in the statements the current limitations of quantitative lung ultrasound. Conclusion This consensus guides the use of quantitative lung ultrasound in adult, paediatric and neonatal intensive care and helps identify the fields where further research will be needed in the future.

Lung ultrasound (LU) has emerged as the imaging technique of choice for the assessment of neonates with respiratory distress syndrome (RDS) at the bedside. Scoring systems were developed to quantify RDS severity and to predict the need for surfactant administration. There is no data on the comparison of the three main LU scores (LUS) proposed by Brat, Raimondi and Rodriguez-Fanjul. Moreover, there is not enough evidence to recommend which score and which cut-off has the best ability to predict surfactant need. The three LUS were compared in terms of ability to predict the need for surfactant and reproducibility in a cohort of very preterm infants. This was an observational, retrospective, multicenter study. Neonates below 32 weeks of gestational age with RDS, on non-invasive ventilation with a LU performed prior to surfactant administration (1–3 h of life) were included. Brat, Raimondi, and Rodriguez-Fanjul’s scores were calculated for each patient. Receiver-operating characteristic (ROC) curve analysis was used to assess the ability to predict surfactant administration. K-Cohen test, Bland–Altman, and intraclass correlation coefficients were used to assess the intra and interobserver variability. Fifty-four preterm infants were enrolled. Brat, Raimondi, and Rodriguez-Fanjul scores showed a strong ability to predict the need for surfactant: the AUCs were 0.85 (95% CI 0.74–0.96), 0.85 (95% CI 0.75–0.96), and 0.79 (95% CI 0.67–0.92), respectively. No significant differences have been found between the AUCs using the DeLong test. Brat and Raimondi’s scores had an optimal cut-off value > 8, while the Rodriguez-Fanjul’s score > 10. The k-Cohen values of intraobserver agreement for Brat, Raimondi, and Rodriguez-Fanjul’s scores were 0.896 (0.698–1.000), 1.000 (1.000–1.000), and 0.922 (0.767–1.000), respectively. The k-Cohen values of interobserver agreement were 0.896 (0.698–1.000), 0.911 (0.741–1.000), and 0.833 (0.612–1.000), respectively. Conclusions : The three LUS had an excellent ability to predict the need for surfactant and an optimal intra and interobserver agreement. The differences found between the three scores are minimal with negligible clinical implications. Since the optimal cut-off value differed, the same score should be used consistently within the same center. What is Known: • Lung ultrasound is a useful bedside imaging tool that should be used in the assessment of neonates with RDS • Scoring systems or lung ultrasound scores allow to quantify the severity of the pulmonary disease and to predict the need for surfactant replacement therapy What is New: • The three lung ultrasound scores by Brat, Raimondi and Rodriguez-Fanjul have an excellent ability to predict the need for surfactant replacement therapy, although with different cut-off values • All three lung ultrasound scores had an excellent intra and interobserver reproducibility

This study aimed to evaluate the predictive ability of lung ultrasound (LU) in the development of bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) infants. A total of 130 VLBW infants with gestational age < 32 weeks were included; LU was performed at days 1, 2, 3, 6, 9, 12, and 15 postnatally. We calculated the LU score by 12-region, 10-region, and 6-region protocols. The incidence of BPD according to the National Institutes of Health (NIH) 2001 definition and 2019 criteria was 38.5% and 64.6%, respectively. By 12-region and 10-region protocols, LU predicted BPD from the 9th to 15th days of life (DOLs) regardless of the criteria used, with an area under the curve (AUC) ranging from 0.826 (95% confidence interval (CI): 0.750–0.887) to 0.877 (95% CI: 0.807–0.928). According to the 2019 BPD definition, the LU score incorporated gestational age, and invasive mechanical ventilation >6 days predicted BPD on the 6th DOL with an AUC of 0.862 (95% CI: 0.790–0.916). The 6-region protocol had significantly smaller AUC values on the 6th and 9th DOLs than the other two protocols.Conclusion: The 12-region and 10-region LU scoring protocols are superior to the 6-region protocol in the prediction of BPD. LU can predict the development of BPD from the 9th to 15th DOLs. With the addition of clinical variables, the earliest prediction time was the 6th DOL. What is Known:• Bronchopulmonary dysplasia is the most common and adverse complication of prematurity. Recent four studies found that lung ultrasound score or findings predicted the development of bronchopulmonary dysplasia.What is New:• We present analysis by classical 6-region and the other two lung ultrasound score (10-region and 12-region) which include an assessment of the posterior lung to allow to understand what is the best score to be used. In addition, we explore whether LU-incorporated clinical variables could improve the predictive value for BPD.

Background: Point-of-care lung ultrasound (LUS) score is a semiquantitative score of lung damage severity. High-resolution computed tomography (HRCT) is the gold standard method to evaluate the severity of lung involvement from the novel coronavirus disease (COVID-19). Few studies have investigated the clinical significance of LUS and HRCT scores in patients with COVID-19. Therefore, the aim of this study was to evaluate the prognostic yield of LUS and of HRCT in COVID-19 patients. Methods: We carried out a multicenter, retrospective study aimed at evaluating the prognostic yield of LUS and HRCT by exploring the survival curve of COVID-19 inpatients. LUS and chest CT scores were calculated retrospectively by 2 radiologists with >10 years of experience in chest imaging, and the decisions were reached in consensus. LUS score was calculated on the basis of the presence or not of pleural line abnormalities, B-lines, and lung consolidations. The total score (range 0–36) was obtained from the sum of the highest scores obtained in each region. CT score was calculated for each of the 5 lobes considering the anatomical extension according to the percentage parenchymal involvement. The resulting overall global semiquantitative CT score was the sum of each single lobar score and ranged from 0 (no involvement) to 25 (maximum involvement). Results: One hundred fifty-three COVID-19 inpatients (mean age 65 ± 15 years; 65% M), including 23 (15%) in-hospital deaths for any cause over a mean follow-up of 14 days were included. Mean LUS and CT scores were 19 ± 12 and 10 ± 7, respectively. A strong positive linear correlation between LUS and CT scores (Pearson correlation r = 0.754; R 2 = 0.568; p < 0.001) was observed. By ROC curve analysis, the optimal cut-point for mortality prediction was 20 for LUS score and 4.5 for chest CT score. According to Kaplan-Meier survival analysis, in-hospital mortality significantly increased among COVID-19 patients presenting with an LUS score ≥20 (log-rank 0.003; HR 9.87, 95% CI: 2.22–43.83) or a chest CT score ≥4.5 (HR 4.34, 95% CI: 0.97–19.41). At multivariate Cox regression analysis, LUS score was the sole independent predictor of in-hospital mortality yielding an adjusted HR of 7.42 (95% CI: 1.59–34.5). Conclusion: LUS score is useful to stratify the risk in COVID-19 patients, predicting those that are at high risk of mortality.

To study a new method for establishing animal models of prenatal bronchopulmonary dysplasia (BPD), we used lung ultrasound score (LUS) to semi-quantitatively assess the severity of lung lesions in model rats. Lipopolysaccharide (LPS) was injected into the right lung of the fetus of the rat under ultrasound-guided, and the right lung of the neonates were scanning for LUS. Specimens were collected for pathological scoring and detection of pulmonary surfactant-associated glycoprotein (SP)-C and vascular endothelial growth factor (VEGF) expression quantity. The correlation between LUS and pathological scores was analyzed. (1) The animal models were consistent with the pathological manifestations of BPD. (2) It showed a strong positive correlation between LUS and pathological scores in animal models ( r  = 0.84, P  < 0.005), and the expression quantity of SP-C and VEGF in lung tissue were decreased (both P  < 0.05). Animal models established by ultrasound-guided puncture of the lung of rats and injection of LPS were consistent with the manifestation of BPD. This method could be used to establish animal models of BPD before birth, and the severity of BPD could be assessed by using LUS.

Effective management of neonatal respiratory distress requires timely recognition of when to transition from non-invasive to invasive ventilation. Although the lung ultrasound score (LUS) is useful in evaluating disease severity and predicting the need for surfactants, its efficacy in identifying neonates requiring invasive ventilation has only been explored in a few studies. This study aims to assess the accuracy of LUS in determining the need for invasive ventilation in neonates on non-invasive ventilation (NIV) support. From July 2021 to June 2023, we conducted a prospective study on 192 consecutively admitted neonates with respiratory distress needing NIV within 24 h of birth at our NICU in Hyderabad, India. The primary objective was the diagnostic accuracy of LUS in determining the need for invasive ventilation within 72 h of initiating NIV. We calculated LUS using the scoring system of Brat et al. (JAMA Pediatr 169:e151797, [ 10 ]). Treating physicians’ assessments of the need for invasive ventilation served as the reference standard for evaluating LUS effectiveness. Out of 192 studied neonates, 31 (16.1%) required invasive ventilation. The median LUS was 5 (IQR: 2–8) for those on NIV and 10 (IQR: 7–12) for those needing invasive ventilation. The LUS had a strong discriminative ability for invasive ventilation with an AUC (area under the curve) of 0.825 (CI: 0.75–0.86, p  = 0.0001). An LUS > 7 had 77.4% sensitivity (95% CI: 58.9–90.8%), 75.1% specificity (95% CI: 67.8–81.7%), 37.5% positive predictive value (PPV) (95% CI: 30.15–45.5%), 94.5% negative predictive value (NPV) (95% CI: 89.9–97.1%), 3.1 positive likelihood ratio (PLR) (95% CI: 2.2–4.3), 0.3 negative likelihood ratio (NLR) (95% CI: 0.15–0.58), and 75.5% overall accuracy (95% CI: 68.8–81.4%) for identifying invasive ventilation needs. In contrast, SAS, with a cutoff point greater than 5, has an AUC of 0.67. It demonstrates 62.5% sensitivity, 61.9% specificity, 24.7% PPV, 89.2% NPV, and an overall diagnostic accuracy of 61.9%. The DeLong test confirms the significance of this difference (AUC difference: 0.142, p  = 0.04), underscoring LUS’s greater reliability for NIV failure.   Conclusion: This study underscores the diagnostic accuracy of the LUS cutoff of > 7 in determining invasive ventilation needs during the initial 72 h of NIV. Importantly, while lower LUS values typically rule out the need for ventilation, higher values, though indicative, are not definitive. What is known? • The effectiveness of lung ultrasound in evaluating disease severity and the need for surfactants in neonates with respiratory distress is well established. However, traditional indicators for transitioning from non-invasive to invasive ventilation, like respiratory distress and oxygen levels, have limitations, underscoring the need for reliable, non-invasive assessment tools. What is new? • This study reveals that a LUS over 7 accurately discriminates between neonates requiring invasive ventilation and those who do not. Furthermore, the lung ultrasound score outperformed the Silverman Andersen score for NIV failure in our population.

Lung ultrasound (LUS) has emerged as a valuable tool for assessing bronchiolitis severity, yet the optimal scoring system remains uncertain. This study aimed to compare the predictive performance of two LUS scoring methods—concise vs. extended—for determining the need for respiratory support in infants hospitalized with bronchiolitis. We conducted a prospective observational study including infants < 12 months hospitalized for bronchiolitis. All patients underwent LUS within 12 h of admission, performed by trained pediatricians blinded to clinical outcomes. The concise score assessed three lung regions per hemithorax, whereas the extended score included six regions per hemithorax. The primary outcome was the need for respiratory support (high-flow nasal cannula, noninvasive ventilation, or invasive mechanical ventilation). Interobserver agreement was assessed via the intraclass correlation coefficient (ICC). A total of 160 infants were included, with 87 (54.4%) requiring respiratory support. The extended LUS score demonstrated superior predictive performance (AUC = 0.879, 95% CI 0.824–0.934) compared to the concise score (AUC = 0.761, 95% CI 0.686–0.837, p  < 0.001). The optimal cutoffs were 14 for the extended score (89.7% sensitivity, 78.1% specificity) and 7 for the concise score (79.3% sensitivity, 67.1% specificity). Interobserver reliability was good for both scores (ICC = 0.86 and 0.79). Conclusion : The extended LUS score exhibited higher predictive accuracy but at the expense of increased complexity. While both scores demonstrated clinical utility, further studies should explore the balance between feasibility and precision in bronchiolitis management. What is Known: • Lung ultrasound (LUS) is increasingly used to assess the severity of bronchiolitis in infants. • Several LUS scoring systems exist, but there is no consensus on which score best predicts the need for respiratory support. What is New: • This study prospectively compares a concise and an extended LUS score to predict the need for advanced respiratory support in hospitalized infants. • The extended score had significantly higher diagnostic accuracy and clinically oriented cut-offs to guide triage decisions.

Lung ultrasound scores (LUSs) have been demonstrated to accurately predict moderate-to-severe bronchopulmonary dysplasia (msBPD). This study attempted to explore the additional value of LUSs for predicting msBPD compared to clinical multivariate models in different gestational age (GA) groups. The study prospectively recruited preterm infants with GA < 32 weeks. Lung ultrasound was performed on days 3, 7, 14, and 21 after birth. A linear mixed-effects regression model was used to evaluate LUS evolution in infants born before and after 28 weeks. The receiver operating characteristic (ROC) procedure was used to analyze the reliability of LUS and clinical multivariable models for predicting msBPD. The optimal time to predict msBPD in all infants was 7 days with a cut-off point of 5 (area under the ROC (AUROC) curve: 0.78, 95% confidence interval (CI): 0.71–0.84). In infants with GA ≥ 28 weeks, LUSs provided a moderate diagnostic accuracy for all four time points (AUROC curve: 0.74–0.78), and the AUROC curve for the clinical multivariable model on day 14 was 0.91 (95% CI: 0.84–0.96), which was significantly higher than that of LUSs (AUROC curve: 0.77, 95% CI: 0.68–0.85, P  < 0.05). In infants born at 23–27 weeks, LUSs showed a low diagnostic accuracy with higher cut-off points to predict msBPD, and the AUROC curve for GA to predict msBPD was 0.75 (95% CI: 0.59–0.85), providing diagnostic accuracy similar to that of LUSs.   Conclusion : The contribution of LUSs to predict msBPD in infants with different GAs remains controversial and requires further investigation. What is Known: • Lung ultrasound scores (LUSs) have been demonstrated to accurately predict moderate-to-severe bronchopulmonary dysplasia in infants with gestational age (GA)＜32 weeks. What is New: • The LUSs evolution differed between extremely preterm infants born before 28 weeks and preterm infants born at 28–32 weeks of gestation. • LUSs provided similar moderate predictive performance as GA-adjusted LUS and clinical multivariate models in infants born after 28 weeks, while LUSs seem to be less helpful in infants born before 28 weeks.

Meconium aspiration syndrome is a common cause of severe respiratory failure in term and post-term neonates. The timing for administering surfactant remains non-standardized. This study aimed to evaluate the predictive value of the lung ultrasound score for the need for surfactant therapy in infants with Meconium aspiration syndrome. This prospective multicenter study enrolled 218 neonates with meconium aspiration syndrome. Lung ultrasound was performed within 30 min of admission using a six-zone scoring system (0–18). Surfactant was given based on oxygenation criteria (FiO₂ > 0.5 or OI > 8), with clinicians blinded to ultrasound findings. Predictive performance of the lung ultrasound score for surfactant need was assessed by ROC analysis and compared with traditional indices. Multivariable regression and decision curve analysis were performed. Lung ultrasound score demonstrated near-perfect diagnostic accuracy for predicting surfactant need: at the optimal cutoff of 6 points, AUC was 0.999 (95% CI, 0.997–1), with 100% sensitivity. Performance was superior to pH (AUC 0.906) and chest radiograph grade (AUC 0.539), and consistent across subgroups by respiratory support, gestational age, and presence of persistent pulmonary hypertension. Multivariable analysis identified lung ultrasound as an independent predictor of surfactant use. Decision curve analysis confirmed greater net clinical benefit for lung ultrasound-based strategies over a wide range of threshold probabilities. A lung ultrasound score of ≥ 6 exhibited near-perfect predictive capacity for guiding surfactant administration decisions (AUC 0.999). This technique provides rapid, non-invasive pulmonary morphological information, facilitating the identification of neonates meeting the criteria for surfactant therapy.

Lung ultrasound (LUS) is widely used as a diagnostic and monitoring tool in critically ill patients. Lung ultrasound score (LUSS) based on the examination of twelve thoracic regions has been extensively validated for pulmonary assessment. However, it has revealed significant limitations: when applied to heterogeneous lung diseases with intermediate LUSS pattern (LUSS 1 and 2), for instance, intra-observer consistency is relatively low. In addition, LUSS is time-consuming and a more rapid overview of the extent of lung pathology and residual lung aeration is often required, especially in emergency setting. We propose a Visual Lung Ultrasound Protocol (VLUP) as a rapid monitoring tool for patients with acute respiratory failure. It consists of a probe sliding along the mid-clavicular, mid-axillary and scapular lines in transversal scan. VLUP allows a visualization of a large portion of the antero-lateral and/or posterior pleural surface. Serial assessments of two clinical cases are recorded and visually compared, enabling rapid understanding of lung damage and its evolution over time. VLUP allows a semi-quantitative and qualitative point-of-care assessment of lung injury. Through this standardized approach it is possible to accurately compare subsequent scans and to monitor the evolution of regional parenchymal damage. VLUP enables a quick estimation of the quantitative-LUSS (qLUSS) as the percentage of pleura occupied by artifacts, more suitable than LUSS in inhomogeneous diseases. VLUP is designed as a standardized, point-of-care lung aeration assessment and monitoring tool. The purpose of the paper is to illustrate this new technique and to describe its applications.