RESUMEN
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.
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Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.
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Manejo de la Vía Aérea , Entrenamiento Simulado , Recién Nacido , Humanos , Intubación Intratraqueal/métodos , Evaluación Educacional , TecnologíaRESUMEN
Background: Pronation ameliorates oxygenation in adults with acute respiratory distress syndrome (ARDS); the effect in neonates with ARDS or other types of respiratory failure is unknown. We aimed to verify if pronation has similar respiratory and haemodynamic effects in three common types of neonatal respiratory failure. Methods: Prospective, physiologic, crossover, quasi-randomised, controlled cohort study performed in a tertiary academic neonatal intensive care unit. We enrolled neonates with: 1) recovering respiratory distress syndrome (RDS, mild restrictive pattern); 2) neonatal ARDS (NARDS, severe restrictive pattern); or 3) evolving bronchopulmonary dysplasia (BPD), that is chronic pulmonary insufficiency of prematurity (mixed restrictive/obstructive pattern). Neonates with other lung disorders, malformations or haemodynamic impairment were excluded. Patients were started prone or supine and then shifted to the alternate position for 6h; measurements were performed after 30' of "wash out" from the positioning and at the end of 6h period. Primary outcomes were respiratory (PtcCO2, modified ventilatory index, PtcO2/FiO2, SpO2/FiO2, oxygenation index, ultrasound-assessed lung aeration) and haemodynamic (perfusion index, heart rate, arterial pressure, cardiac output) parameters. Findings: Between May 1st, 2019, and May 31st, 2021, 161 participants were enrolled in this study, and included in the final analysis. Pronation improved gas exchange and lung aeration (p always <0.01) and these effects were overturned in the alternate position, except for lung aeration in NARDS where the improvement persisted. The effects were greater in patients recovering from RDS than in those with evolving BPD than in those with NARDS, in this order (p always <0.01). Pronation produced a net recruitment as lung ultrasound score decreased in patients shifted from supine (16.9 (standard deviation: 5.8)) to prone (14.1 (standard deviation: 3.3), p < 0.01) and this reduction correlated with oxygenation improvement. Haemodynamic parameters remained within normal ranges. Interpretation: 6h-pronation can be used to improve gas exchange and lung aeration in neonates with recovering RDS, evolving BPD or NARDS without relevant haemodynamic effects. Funding: None.
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Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a "crashing" neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention.Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? ⢠Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? ⢠The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained "crashing" neonates. ⢠The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.
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Sistemas de Atención de Punto , Resucitación , Recién Nacido , Humanos , Pruebas en el Punto de Atención , Unidades de Cuidado Intensivo Neonatal , Ultrasonografía/métodos , Literatura de Revisión como AsuntoRESUMEN
Lung ultrasound score (LUS) is increasingly diffused in neonatal critical care but scanty data are available about its use during transfer of severely ill neonates. We aimed to clarify the effect of ground transportation on LUS evolution, conformity of interpretation, and relationships with oxygenation and clinical severity. This is a single-center, blinded, observational, cross-sectional study. Neonates of any gestational age with respiratory distress appearing within 24 h from birth were transferred by a mobile unit towards neonatal intensive care unit (NICU) of a tertiary referral center. Calculation of LUS prior to the transportation (T1), in the mobile unit (T2), at the end of transportation (T3), and finally upon NICU admission. LUS in the mobile unit and in the NICU was performed by different physicians blinded to each other's results. LUS did not change overtime (T1: 6.3 (3.5), T2: 6.1 (3.5), T3: 5.8 (3.4); p = 0.479; adjusted for gestational or postnatal age or transport duration: p = 0.951, p = 0.424, and 0.266, respectively) but reliably predicted surfactant need (AUC at T1: 0.833 (95%CI: 0.72-0.92); AUC at T2: 0.82 (95%CI: 0.70-0.91); AUC at T3: 0.82 (95%CI: 0.70-0.90); p always < 0.0001). There were significant agreement (ICC = 0.912 (95%CI: 0.83-0.95); p < 0.001) and correlation (r = 0.905, p < 0.001) between LUS calculated during transportation and in the NICU. LUS during transportation was also significantly correlated with oxygenation index (r = 0.321, p = 0.026; standardized B = 0.397 (95%CI: 0.03-0.76), p = 0.048) and TRIPS-II score (r = 0.302, p = 0.008; standardized B = 0.568 (95%CI: 0.04-1.1), p = 0.037). CONCLUSION: LUS during ground transportation of neonates with respiratory failure is suitable and not influenced by the transportation itself. It has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity. WHAT IS KNOWN: ⢠Lung ultrasound is a part of the point-of-care ultrasound, which is becoming an essential tool, to manage critically ill neonates and children in an accurate, non-invasive and quick way. WHAT IS NEW: ⢠Lung ultrasound score (LUS) is suitable during transportation of critically ill neonates with respiratory failure and is not influenced by the transportation itself. ⢠LUS has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity of respiratory failure.
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Surfactantes Pulmonares , Insuficiencia Respiratoria , Niño , Enfermedad Crítica , Estudios Transversales , Humanos , Recién Nacido , Pulmón/diagnóstico por imagen , Insuficiencia Respiratoria/diagnóstico por imagen , Ultrasonografía/métodosRESUMEN
Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement. CONCLUSION: Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority. WHAT IS KNOWN: ⢠Simulation-based education has traditionally focused on procedural and technical skills. ⢠Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation. WHAT IS NEW: ⢠There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. ⢠Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.
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Neonatología , Entrenamiento Simulado , Competencia Clínica , Humanos , Recién Nacido , Neonatología/educación , Grupo de Atención al Paciente , ResucitaciónRESUMEN
Point-of-care ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications. CONCLUSION: The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. POCUS is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers, and institutions. WHAT IS KNOWN: ⢠The use POCUS by traditionally non-imaging pediatric specialty physicians for both diagnostic and procedural guidance is rapidly increasing. ⢠Although there are international guidelines for its indications, currently there is no standardized guidance on its implementation in clinical practice. WHAT IS NEW: ⢠Although standards for pediatric specialty-specific POCUS curriculum and training to competency have not been defined, POCUS is likely to be most successfully incorporated in clinical care when programmatic infrastructural elements are present. ⢠Risk assessment is a forward-thinking process and requires an imprecise calculus that integrates considerations of the technology, the provider, and the context in which medical care is delivered. Medicolegal considerations vary across countries and frequently change, requiring providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS.
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Curriculum , Sistemas de Atención de Punto , Niño , Humanos , Recién Nacido , Pruebas en el Punto de Atención , Medición de Riesgo , Ultrasonografía/métodosRESUMEN
Rationale: Lung ultrasound scores (LUS) might be useful in monitoring neonates with chronic pulmonary insufficiency of prematurity and in predicting bronchopulmonary dysplasia (BPD). Given their ease of use, accuracy, and lack of invasiveness, LUS have been the subject of several recent studies. Objectives: We sought to clarify whether LUS provide an accurate and early (within the first 2 wk of life) prediction of BPD in preterm infants of gestational age ⩽32 weeks. Methods: This was a systematic review and diagnostic accuracy meta-analysis following PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols), PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis), and QUADAS (QUAlity of Diagnostic Accuracy Studies) guidelines. Studies designed to predict BPD in the first 2 weeks of life using LUS were selected. A classical LUS (calculated for 6 chest areas) and its extended version (eLUS, 10 chest areas) were tested. Results: Seven studies (1,027 neonates) were meta-analyzed. LUS and eLUS showed good diagnostic accuracy in predicting BPD at 7 and 14 days of life (area under the curve, 0.85-0.87; pooled sensitivity, 70-80%; pooled specificity, 80-87%). The diagnostic accuracy of LUS and eLUS did not differ at any time point (area under the curve difference always P > 0.05). Repeating the analyses without outliers or with moderate to severe BPD as the outcome yielded similar results. Meta-regressions showed that prenatal steroid prophylaxis and sex were not significant effect confounders. Conclusions: LUS are accurate for early prediction of BPD and moderate to severe BPD, in an average population of preterm infants ⩽32 weeks' gestation. The diagnostic accuracy is similar for LUS and eLUS, so the use of the simpler score should be advocated. Registration: PROSPERO CRD42021233010.
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Displasia Broncopulmonar , Displasia Broncopulmonar/diagnóstico por imagen , Displasia Broncopulmonar/epidemiología , Femenino , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Pulmón/diagnóstico por imagen , UltrasonografíaRESUMEN
Rapid diagnosis of sudden, unexpected, and potentially fatal complications in the neonatal intensive care unit (NICU) is essential for the initiation of prompt and life-saving management. Point-of-care ultrasound (POCUS) protocols are widely used in adult emergency situations to diagnose and guide treatment, but none has been specifically developed for the neonate. We propose a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU for rapid screening for the most common life-threatening complications needing immediate attention. We integrated current knowledge on the use of POCUS for diagnosis of the most critical neonatal complications into the "SAFE-R protocol" (Sonographic Assessment of liFe-threatening Emergencies - Revised). The ultrasound algorithm was evaluated at the bedside for suitability and ease of use. Main features of SAFE-R are the use of standardized ultrasound points and a simple one-probe rule-in/rule-out approach. The flowchart is designed by order of urgency and priority is given to treatable causes. Hence, ruling out cardiac tamponade is the first step in the decision tree, followed by pneumothorax, pleural effusion, then acute critical aortic occlusion, acute abdominal complications, and severe intraventricular hemorrhage.Conclusion: SAFE-R is the first ultrasound algorithm specifically conceived for use in the NICU to screen for the most common urgent neonatal complications leading to sudden deterioration, thereby providing critical information within minutes. The simplified and rapid approach is designed for the neonatologist and is easy to learn and quick to perform. What is Known: ⢠The fields of neonatal and pediatric critical care are undergoing a transformation with the adoption of POCUS and the recent publication of the first international guidelines on POCUS for critically ill children and neonates. ⢠Targeted emergency ultrasound protocols are widely used in adult emergency and critical care medicine, but specific and adapted ultrasound algorithms are lacking for the pediatric and neonatal population. What is New: ⢠We propose the first targeted ultrasound protocol specifically designed for the suddenly decompensating infant in the NICU for rapid screening of the most common life-threatening complications needing immediate attention. ⢠The SAFE-R ultrasound algorithm integrates current knowledge on ultrasound diagnosis of the most critical neonatal complications into a simple and easy-to-perform emergency scanning protocol aimed to guide initial management and resuscitation efforts.
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Unidades de Cuidado Intensivo Neonatal , Neonatólogos , Abdomen , Adulto , Niño , Cuidados Críticos , Humanos , Lactante , Recién Nacido , UltrasonografíaRESUMEN
There is no firm consensus about the optimal technique for the administration of exogenous surfactant in preterm neonates, and different techniques may be equally effective. The intubation-surfactant-extubation (INSURE) procedure has not been fully described, and important details, such as duration and mode of ventilation, remain unclear, leading to significant clinical practice variations and influencing its suitability and feasibility. Since the first INSURE description, our knowledge in respiratory care has largely progressed, but the technique has not been updated according to current evidence-based practice. Thus, our aim is to formally describe a modern way to perform INSURE, based on the current knowledge and technology, to increase its feasibility and patients' safety. We offer ENSURE (Enhanced INSURE) as an updated and standardised technique for surfactant administration, clarifying crucial issues of the original method by applying current state-of-the-art concepts of respiratory care. We performed a cross-sectional observational study enrolling 57 preterm neonates describing ENSURE feasibility and safety. Conclusion: ENSURE can be used as a reference technique in clinical practice, teaching and research. What is Known: ⢠There is no consensus about the optimal method for surfactant administration. INSURE technique has been originally described many years ago without considering modern principles of neonatal respiratory care and the available state-of-the-art technology. What is New: ⢠We here describe a modern way to perform INSURE, based on the current knowledge and technology. We called it ENSURE (Enhanced INSURE) and clarified crucial points of the original technique, in light of the current knowledge. We verified feasibility and safety of ENSURE in a cross-sectional observational study enrolling 57 preterm neonates.
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Extubación Traqueal , Síndrome de Dificultad Respiratoria del Recién Nacido , Presión de las Vías Aéreas Positiva Contínua/métodos , Estudios Transversales , Humanos , Recién Nacido , Recien Nacido Prematuro , Intubación Intratraqueal/métodos , Estudios Observacionales como Asunto , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , TensoactivosRESUMEN
OBJECTIVE: Semiquantitative lung ultrasound improves the timeliness of surfactant replacement, but its financial consequences are unknown. We aim to investigate if the ultrasound-guided surfactant administration influences the general costs of surfactant therapy for preterm neonates affected by respiratory distress syndrome. STUDY DESIGN: This is a pharmacoeconomic, retrospective, and before-and-after study investigating the impact of ultrasound-guided surfactant replacement (echography-guided Surfactant THERapy [ESTHER]) on pharmaceutical expenditure within the ESTHER initiative. Data extracted from the institutional official database hosted by the hospital administration for financial management were used for the analysis. We analyzed the number of surfactant administrations in neonates of gestational age ≤326/7 weeks, and the number of surfactant vials used from January 1, 2014 to June 30, 2014 (i.e., during the period of standard surfactant administration policy) and from July 1, 2016 to December 31, 2018 (that is during ESTHER policy). RESULTS: ESTHER did not modify surfactant use, as proportion of treated neonates with RDS receiving at least one surfactant dose (Standard: 21.3% vs. ESTHER: 20.9%; p = 0.876) or as proportion of used vials over the total number of vials opened for neonates of any gestational age (Standard: 37% vs. ESTHER: 35%; p = 0.509). CONCLUSION: Ultrasound-guided surfactant replacement using a semiquantitative lung ultrasound score in preterm infants with RDS does not change the global use of surfactant and the related expenditure. KEY POINTS: · ESTHER is able to increase the timeliness of surfactant replacement.. · The ultrasound-guided surfactant administration does not increase the cost of surfactant therapy.. · The ultrasound-guided surfactant administration does not change the global surfactant utilization..
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Surfactantes Pulmonares , Síndrome de Dificultad Respiratoria del Recién Nacido , Gastos en Salud , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Preparaciones Farmacéuticas , Síndrome de Dificultad Respiratoria del Recién Nacido/diagnóstico por imagen , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , Estudios Retrospectivos , Tensoactivos , Ultrasonografía , Ultrasonografía IntervencionalRESUMEN
Evolving bronchopulmonary dysplasia (BPD) is characterized by impaired alveolarization leading to lung aeration inhomogeneities. Hyperoxia-exposed preterm rabbits have been proposed to mimic evolving BPD; therefore, we aimed to verify if this model has the same lung ultrasound and mechanical features of evolving BPD in human neonates. Semiquantitative lung ultrasound and lung mechanics measurement was performed in 25 preterm rabbits (28 days of gestation) and 25 neonates (mean gestational age ≈ 26 wk) with evolving BPD. A modified rabbit lung ultrasound score (rLUS) and a validated neonatal lung ultrasound score (LUS) were used. Lung ultrasound images were recorded and evaluated by two independent observers blinded to each other's evaluation. Lung ultrasound findings were equally heterogeneous both in rabbits as in human neonates and encompassed all the classical lung ultrasound semiology. Lung ultrasound and histology examination were also performed in 13 term rabbits kept under normoxia as further control and showed the absence of ultrasound and histology abnormalities compared with hyperoxia-exposed preterm rabbits. The interrater absolute agreement for the evaluation of lung ultrasound images in rabbits was very high [ICC: 0.989 (95%CI: 0.975-0.995); P < 0.0001], and there was no difference between the two observers. Lung mechanics parameters were similarly altered in both rabbits and human neonates. There were moderately significant correlations between airway resistances and lung ultrasound scores in rabbits (ρ = 0.519; P = 0.008) and in neonates (ρ = 0.409; P = 0.042). In conclusion, the preterm rabbit model fairly reproduces the lung ultrasound and mechanical characteristics of preterm neonates with evolving BPD.NEW & NOTEWORTHY We have reported that hyperoxia-exposed preterm rabbits and human preterm neonates with evolving BPD have the same lung ultrasound appearance, and that lung ultrasound can be fruitfully applied on this model with a brief training. The animal model and human neonates also presented the same relationship between semiquantitative ultrasound-assessed lung aeration and airway resistances. In conclusion, this animal model fairly reproduce evolving BPD as it is seen in clinical practice.
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Displasia Broncopulmonar , Hiperoxia , Animales , Animales Recién Nacidos , Displasia Broncopulmonar/diagnóstico por imagen , Modelos Animales de Enfermedad , Humanos , Hiperoxia/diagnóstico por imagen , Recién Nacido , Pulmón/diagnóstico por imagen , Conejos , Mecánica RespiratoriaRESUMEN
Persistent pulmonary hypertension of the neonate (PPHN) refractory to inhaled nitric oxide still represents a frequent clinical challenge with negative outcomes in neonatal critical care. Several pulmonary vasodilators have become available thanks to improved understanding of pulmonary hypertension pathobiology. These drugs are commonly used in adults and there are numerous case series and small studies describing their potential usefulness in neonates, as well. New vasodilators act on different pathways, some of them can have additive effects and all have different pharmacology features. This information has never been summarized so far and no comprehensive pathobiology-driven algorithm is available to guide the treatment of refractory PPHN.Conclusion: We offer a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge. What is Known: ⢠Refractory PPHN occurs in 30-40% of iNO-treated neonates and represents a significant clinical problem. Several pulmonary vasodilators have become available thanks to a better understanding of pulmonary hypertension pathobiology. What is New: ⢠Available vasodilators have different pharmacology, mechanisms of action and may provide additive effect. We provide a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge.
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Hipertensión Pulmonar , Síndrome de Circulación Fetal Persistente , Administración por Inhalación , Algoritmos , Humanos , Hipertensión Pulmonar/tratamiento farmacológico , Recién Nacido , Óxido Nítrico/uso terapéutico , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Vasodilatadores/uso terapéuticoRESUMEN
Lung ultrasound (LUS) is the latest amongst imaging techniques: it is a radiation-free, inexpensive, point-of-care tool that the clinician can use at the bedside. This review summarises the rapidly growing scientific evidence on LUS in neonatology, dividing it into descriptive and functional applications. We report the description of the main ultrasound features of neonatal respiratory disorders and functional applications of LUS aiming to help a clinical decision (such as surfactant administration, chest drainage etc). Amongst the functional applications, we propose SAFE (Sonographic Algorithm for liFe threatening Emergencies) as a standardised protocol for emergency functional LUS in critical neonates. SAFE has been funded by a specific grant issued by the European Society for Paediatric Research. Future potential development of LUS in neonatology might be linked to its quantitative evaluation: we also discuss available data and research directions using computer-aided diagnostic techniques. Finally, tools and opportunities to teach LUS and expand the research network are briefly presented.
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Pulmón/diagnóstico por imagen , Neonatología , Sistemas de Atención de Punto , Ultrasonografía , Humanos , Recién Nacido , Enfermedades del Recién Nacido/diagnóstico por imagen , Surfactantes Pulmonares/metabolismoRESUMEN
BACKGROUND: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
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Cuidado Intensivo Neonatal , Sistemas de Atención de Punto , Ultrasonografía , Cuidados Críticos/métodos , Enfermedad Crítica , Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal , Cuidado Intensivo Neonatal/métodos , Cuidado Intensivo Neonatal/normas , Sistemas de Atención de Punto/normas , Revisiones Sistemáticas como Asunto , Ultrasonografía/métodos , Ultrasonografía/normasRESUMEN
We studied the relationship between ultrasound-assessed lung aeration and inflammation in a particular population of ventilated preterm neonates with mild-to-moderate lung inflammation and no congenital heart defect. Lung aeration estimated by a semiquantitative lung ultrasound score significantly correlated with several inflammatory markers both at cellular (neutrophil count in bronchoalveolar lavage: ρâ¯=â¯0.400, pâ¯=â¯0.018) and molecular level (total proteins: ρâ¯=â¯0.524, pâ¯=â¯0.021; interleukine-8: ρâ¯=â¯0.523, pâ¯=â¯0.021; granulocytes-macrophages colony stimulating factor: ρâ¯=â¯0.493, pâ¯=â¯0.020; all measured in bronchoalveolar lavage and expressed as epithelial lining fluid concentrations). Lung ultrasound might detect changes in lung aeration attributable to mild-to-moderate local inflammation if cardiogenic lung edema is excluded. Thus, it is possible to describe some levels of lung inflammation with semiquantitative lung ultrasound.
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Pulmón/diagnóstico por imagen , Síndrome de Dificultad Respiratoria del Recién Nacido/diagnóstico por imagen , Biomarcadores/análisis , Lavado Broncoalveolar , Femenino , Factor Estimulante de Colonias de Granulocitos y Macrófagos/análisis , Humanos , Recién Nacido , Recien Nacido Prematuro , Interleucina-8/análisis , Recuento de Leucocitos , Pulmón/patología , Masculino , Neutrófilos , Estudios Prospectivos , Respiración Artificial , Síndrome de Dificultad Respiratoria del Recién Nacido/patología , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , UltrasonografíaRESUMEN
Surfactant is a cornerstone of neonatal critical care, and the presumed less (or minimally) invasive techniques for its administration have been proposed to reduce invasiveness of neonatal critical care interventions. These techniques are generally known as less invasive surfactant administration (LISA) and have quickly gained popularity in some neonatal intensive care units. Despite the increase in the use of LISA, we believe that the pathobiological background supporting its possible clinical benefits is unclear. Similarly, it is unclear whether there are any ignored drawbacks, as LISA has been tested in only a few trials and some physiopathological issues seem to have gone unnoticed. Active research is warranted to fill these knowledge gaps before LISA can be firmly recommended. In this Viewpoint, we provide an in-depth analysis of LISA techniques, based on physiological and pathobiological factors, followed by a critical appraisal of available clinical data, and highlight some possible future research directions.
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Cuidado Intensivo Neonatal/métodos , Enfermedades Pulmonares Intersticiales/complicaciones , Surfactantes Pulmonares/administración & dosificación , Síndrome de Dificultad Respiratoria del Recién Nacido/fisiopatología , Resistencia de las Vías Respiratorias , Humanos , Recién Nacido , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/métodos , Laringoscopía/efectos adversos , Metaanálisis como Asunto , Surfactantes Pulmonares/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Respiración Artificial/efectos adversos , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria del Recién Nacido/epidemiología , Síndrome de Dificultad Respiratoria del Recién Nacido/terapiaRESUMEN
Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLAvoting method. AGREE statement was followed to prepare this document. Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
Asunto(s)
Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal/organización & administración , Servicios de Salud del Niño/organización & administración , Pruebas en el Punto de Atención , Práctica Clínica Basada en la Evidencia/métodosRESUMEN
BACKGROUND: The effect of different probes and operator experience on the reliability of lung ultrasound (LU) interpretation has not been investigated. We studied the effect of probes and operator experience on the interpretation reliability of LU in critically ill neonates. METHODS: This was a prospective, blind, cohort study enrolling patients with basic patterns ("B," "severe B," consolidation). Patients were scanned with microlinear (15 MHz; L15), phased-array sectorial (6-12 MHz; S7), and microconvex (8 MHz; C8) probes, in random order. Static images were acquired in high resolution, anonymized, and included in a pictorial database in random sequences. Seventeen clinicians with different LU experience were asked to blindly assess the pictorial database. Interrater agreement and interpretation reliability were analyzed. Subanalyses according to expertise and probe, and multivariate linear regression (including an "expertise × probe" interaction factor), were also performed. RESULTS: The agreement tends to be lower and more heterogeneous for residents (intraclass correlation coefficient [ICC], 0.82 [95% CI, 0.74-0.9], P < .001; I2, 67%, P = .04) and for fellows (ICC, 0.93 [95% CI, 0.9-0.97], P < .001; I2, 69%, P = .04), especially when using nonlinear probes, compared with senior physicians (ICC, 0.95 [95% CI, 0.93-0.96], P < .001; I2, 0%, P = .433). Area under the curve (AUC) values were high for all probes (L15, 0.96 [95% CI, 0.93-0.99]; C8, 0.91 [95% CI, 0.85-0.98]; S7, 0.86 [95% CI, 0.82-0.91]) and physicians (senior physicians, 0.95 [95% CI, 0.83-0.99]; fellows, 0.95 [95% CI, 0.75-0.99]; residents, 0.86 [95% CI, 0.5-0.99]). Worse reliability and higher heterogeneity were found when the evaluation was performed by residents (AUC, 0.9 [95% CI, 0.85-0.94], P < .01; I2, 93.6%, P < .001) than by fellows (AUC, 0.99 [95% CI, 0.9-0.999], P < .001; I2, 34.3%, P = .09) and/or by senior physicians (AUC, 0.99 [95% CI, 0.9-0.999], P < .001; I2, 18%, P = .236). The "expertise × probe" interaction factor was associated with lower ICC (standardized regression coefficient ß, -0.69; P < .0001; adjusted R2, 0.99) and AUC (standardized regression coefficient ß, -0.76; P < .0001; adjusted R2, 0.98). CONCLUSIONS: LU interpretation in neonates shows good interrater agreement and reliability, irrespective of the probe and rater expertise. The use of nonlinear probes by novice operators is associated with the lowest agreement and reliability.