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Guidelines for the use of lung ultrasound to optimise the management of neonatal respiratory distress: international expert consensus

BMC Medicine volume 23, Article number: 114 (2025) Cite this article

Abstract

Background

Respiratory distress is the main reason for the admission of infants to the neonatal intensive care unit (NICU). Rapid identification of the causes of respiratory distress and selection of appropriate and effective treatment strategies are important to optimise favourable short- and long-term patient outcomes. Lung ultrasound (LUS) technology has become increasingly important in this field. According to the scientific literature, LUS has high sensitivity (92–99%) and specificity (95–97%) in diagnosing neonatal respiratory distress syndrome. This diagnostic power helps guide timely interventions, such as surfactant therapy and mechanical ventilation.

Methods

Our objective was to outline consensus guidelines among an international panel of experts on the use of LUS to support the decision-making process in managing respiratory distress in the NICU. We used a three-round Delphi process. In each Delphi round, 28 panellists rated their level of agreement with each statement using a four-point Likert scale.

Results

In round 1, the panellists reviewed 30 initially proposed statements. In rounds 2 and 3, the statements were redeveloped based on the reviewers’ comments, leading to the final approval of 18 statements. Among the 18 consensus statements, grade A was assigned a value of 10, grade B was assigned a value of 7, and grade C was assigned a value of 1.

Conclusions

A panel of experts agreed on 18 statements regarding managing infants with respiratory distress. Using LUS may help design future interventional studies and improve the benchmarking of respiratory care outcomes.

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Background

Respiratory distress is the main reason that infants are admitted to the neonatal intensive care unit (NICU). Rapid identification of the causes of respiratory distress and selection of appropriate and effective treatment strategies are important to optimise favourable short- and long-term patient outcomes.

Mechanical ventilation (MV) is a cornerstone of therapy in modern NICUs. It has saved the lives of countless critically ill and premature neonates [1]. However, MV can lead to severe complications, including barotrauma, volumetric injury, ventilator-associated pneumonia, air leak syndrome, hyperventilation, and bronchopulmonary dysplasia (BPD) [2,3,4,5]. The current best practice in NICU care is to utilise noninvasive respiratory support, rather than MV, whenever possible. Nevertheless, invasive MV remains indispensable for neonates with severe lung disease [6]. The challenge for NICU clinicians is distinguishing neonates likely to benefit from noninvasive ventilation from those requiring MV [7]. Abundant and emerging evidence suggests that point-of-care lung ultrasound (LUS) can aid assessments of neonates receiving respiratory support by identifying the nature and severity of common lung diseases [8, 9]. LUS can characterise different causes of infant respiratory distress immediately, accurately, and dynamically [10]. Moreover, LUS can diagnose some lung diseases with greater accuracy and specificity than chest X-ray (CXR), and in some NICUs, LUS has entirely replaced the routine use of CXR [11, 12]. Point-of-care LUS is widely available, does not require transfer from the NICU, and does not involve exposure to ionising radiation [13].

LUS can also be used to dynamically assess the efficacy of MV, helping to guide the escalation or weaning of inspiratory and expiratory pressures or tidal volumes. Notably, LUS may improve decisions regarding the optimal time to extubate infants. Despite the best clinical judgement using currently available clinical parameters and physical assessment, approximately 30% of intubated preterm infants fail attempted extubation because of poor respiratory drive, atelectasis, oedema, residual pulmonary function abnormalities, or intercurrent illness [14]. LUS can help clinicians prospectively identify some of these conditions and track their severity in real time to determine the best time to extubate.

Another potential application of LUS is to select candidates for surfactant administration [15, 16]. Exogenous pulmonary surfactant (PS) is an important and effective intervention for treating respiratory distress syndrome (RDS) in premature neonates, as well as other conditions associated with surfactant insufficiency or inactivation [17,18,19,20,21]. However, surfactant administration may cause side effects, including bradycardia, oxygen desaturation, and pulmonary haemorrhage. Therefore, objective criteria are needed to identify the optimal candidates for surfactant administration, and these criteria are currently based almost solely on the amount of oxygen inhaled by neonates [22, 23]. Assessment and scoring by LUS may be a more sensitive tool, enabling earlier surfactant therapy, minimising oxygen exposure, and improving oxygenation after treatment [22].

Overall, LUS allows for more frequent monitoring of treatment results, informing clinicians about the resolution or aggravation of pulmonary pathology in real time. It enables lung function assessment in real time and provides improved evaluation associated with the daily clinical management of neonates with respiratory failure [24,25,26]. Although growing evidence supports the routine use of LUS, consensus regarding published guidelines or syntheses of evidence-based practice on LUS use in the NICU is lacking.

This study aims to outline consensus guidelines among an international panel of experts on the use of LUS to support the decision-making process in managing severe respiratory diseases in the NICU, including the use of MV and the administration of PS.

Methods

A three-step conventional Delphi process [27] was developed via e-mail [28]. A core group of investigators assembled and invited an expert panel to provide additional opinions. The selection criteria for panellists were that they had either authored published articles with a wealth of experience in this area or were representative members of the Division of Critical Ultrasound, Asia–Pacific Health Association Paediatric Medicine Branch, the World Interactive Network focused on Critical Ultrasound China Branch, China National Health Association Lung Ultrasound Technology Extension Expert Group, Beijing Association of Holistic Integrative Medicine Neonatal Critical Care Medicine Branch and the Neonatal Lung Ultrasound Training Centre in Beijing Obstetrics and Gynaecology Hospital Affiliated with Capital Medical University. Each core group member invited other experts using a ‘snowball sampling’ approach. The panel consisted of neonatologists and radiologists directly involved in the care and diagnostic imaging of infants in the NICU. It included members from different countries worldwide to minimise converging opinions and cross-contamination of ideas. The panellists were selected based on their publications and active clinical involvement in neonatal care. A minimum of 5 years of experience in thoracic ultrasound was mandatory for panellists. The guiding consensus has been registered on the Practice guideline REgistration for transPAREncy (http://guidelines-registry.cn/) with a registration number of PREPARE-2025CN011. Based on published methodologies, we aimed for a panel of approximately 30 participants [27, 29,30,31,32,33,34].

The core group proposed a series of pertinent statements supported by relevant references during an e-mail brainstorming process. The first round included a qualitative open-ended questionnaire to generate extensive data. Panel members were invited to comment on the statements, expose their concerns, or reformulate the presented options. In further Delphi rounds, we asked for qualitative feedback at the end of each section and general feedback at the end of the questionnaire. In each Delphi round, panellists were required to rate their level of agreement with each statement using a four-point Likert scale [27]. Therefore, the options ‘essential’, ‘important but not essential’, ‘somewhat important’, and ‘unimportant/irrelevant’ were offered, whereas a neutral middle point was excluded, compelling respondents to express an opinion. The statements’ content that achieved consensus in each round was merged and integrated with the proposed suggestions [27, 29]. Statements that did not reach consensus in the previous round were screened for redundancy or modified according to the feedback received.

Data collection and management

The list of statements in each Delphi round was compiled in a Microsoft Forms (© Microsoft 2022) document, and the link to the document was distributed to the panellists by e-mail. The panellists returned their opinions using the same Microsoft platform. Queries involved the following roles of LUS in the NICU:

  1. A.

    Management of lung diseases, with primary manifestations of lung consolidation on LUS

  2. B.

    Management of lung diseases, with primary manifestations of lung oedema on LUS

  3. C.

    Diagnosing and managing pneumothorax via LUS

  4. D.

    Guiding the adjustment of MV settings

  5. E.

    Managing the initiation and discontinuation of MV

  6. F.

    Guiding the administration of PS

The data were exported into an Excel spreadsheet for statistical analysis. Descriptive statistics were used to summarise the panellists’ responses to each item. The median and mode are reported; we did not calculate the mean because Likert survey data are traditionally considered an ordinal scale. The interquartile range (IQR) was calculated as an index of the dispersion of responses [34]. We used the IQR to measure dispersion because it captures the spread of the middle 50% of observations, making it more robust and less sensitive to outliers than the standard deviation. Additionally, the IQR is more appropriate for ordinal data, such as Likert scales, where an IQR of 1 or less on a 4- or 5-point scale or two or fewer on a 10-point scale is generally considered indicative of consensus [34]. For these reasons, the IQR was chosen over the standard deviation to represent dispersion and consensus in our analysis.

We further quantified consensus using a system previously described in other studies using the Delphi methodology. The percentage of participants scoring ≥ 3 on the Likert scale for each item was calculated and assigned a grade: ‘U’ denotes unanimous (100%) agreement, ‘A’ denotes 90–99% agreement, ‘B’ denotes 78–89% agreement, and ‘C’ denotes 67–77% agreement [34,35,36,37].

Results

Twenty-eight panellists from 12 countries were included in this study. The panellists had a mean of 11.4 years of experience (median: 10; SD: 4.6) in using lung ultrasound, a mean of 10.3 years of experience (median: 8; SD: 5.5) specifically in using lung ultrasound in neonates, and 8.6 years (median: 8; SD: 3.7) in applying lung ultrasound for the management of neonatal respiratory distress.

Round 1 initially proposed 30 statements. After the panellists’ feedback, the number of statements in round 2 included 23, and round 3 submitted 19 statements to the panellists, leading to a final approval of 18 statements. Through the rounds of review, statements were adjusted, added, deleted, and combined based on comments by the reviewers about precision, applicability, completeness, and/or redundancy.

From round 1 to round 3, ‘essential’ responses increased from 58.7 to 74.5%, whereas ‘essential’ or ‘important but not essential’ responses increased from 82.9 to 96.5%. There was no attrition of panellists. The results are shown in Table 1. Among the 18 consensus statements, grade A was assigned a value of 10, grade B was assigned a value of 7, and grade C was assigned a value of 1.

Table 1 Statements shared by panellists
Full size table

Our panel of experts agreed on various practices for using LUS to optimise neonatal respiratory distress management. These practices involve several important aspects of respiratory care and allow for more evidence-based LUS assistance in decision-making.

Discussion

LUS to support accurate differential diagnosis between the causes of neonatal respiratory failure

Clinicians agree that the role of LUS should be fully considered when determining the cause of neonatal respiratory failure and the clinical signs and symptoms.

In this respect, the misdiagnosis rate based on traditional diagnostic criteria is high, and only 40% of clinical respiratory distress syndrome (RDS) diagnoses were confirmed in a necropsy study [38]. Among differential diagnoses, the consensus focuses on meconium aspiration syndrome (MAS), pneumonia or atelectasis, transient tachypnoea of the newborn (TTN), and pneumothorax. The LUS pattern is characterised by diffuse and coalescing B-lines, pleural line anomalies, subpleural consolidations with irregular shapes, and air bronchograms distributed in different areas of the lungs and is sufficiently specific to distinguish between MAS, pneumonia, and other causes of neonatal respiratory dyspnoea [39].

RDS and TTN have similar histories and clinical presentations, whereas chest X-ray (CXR) has low sensitivity and specificity [40]. Moreover, owing to improvements in standard prenatal and postnatal care, RDS-like CXR images have also become more uncommon [41].

In contrast, LUS easily detects distinctive signs [41,42,43,44,45,46,47,48,49], resulting in extremely high accuracy in RDS diagnosis. A systematic review and meta-analysis revealed that the LUS sensitivity was 99% (95% CI: 96–100%), and the specificity was 97%, whereas these values were 91% and 84% for CXR, respectively [40, 50].

The diagnostic value of LUS in RDS was confirmed by Wu et al. in their meta-analysis; they reported a pooled sensitivity of 0.92 (95% CI, 0.89–0.94), specificity of 0.95 (95% CI, 0.93–0.97), positive likelihood ratio of 20.23 (95% CI, 8.54–47.92), negative likelihood ratio of 0.07 (95% CI, 0.03–0.14), and diagnostic odds ratio of LUS in the diagnosis of RDS of 455.30 (95% CI, 153.01–1354.79) [51].

Therefore, LUS may be a viable and superior alternative to CXR in diagnosing TTN and can help differentiate TTN from other aetiologies of respiratory distress in neonates [52].

In particular, the LUS score is often used in differential diagnosis. Using an LUS score resulted in a sensitivity and specificity of 89.0% and 92.5%, respectively, in the differential diagnosis of neonatal RDS and other lung diseases, whereas the scores were 0.914 and 0.933, respectively, in the differential diagnosis of mild versus moderate RDS and moderate versus severe RDS [53].

Similarly, LUS also has increased sensitivity and specificity for diagnosing pneumothorax (PTX). A recent meta-analysis reported a sensitivity and specificity of 98% and 100%, respectively, for the diagnosis of PTX, whereas the sensitivity and specificity of CXR were 82% and 96%, respectively [54].

Using LUS to guide MV therapy in newborn infants with dyspnoea

As discussed previously and supported by the literature, LUS is crucial in choosing candidates for mechanical ventilation and can guide the management of neonatal MV [15, 55,56,57]. In long-term clinical practice, LUS may support clinicians in formulating an accurate differential diagnosis as a starting point in the decision process for MV administration; it also outperforms conventional radiology in predicting the need for intubation [58] and allowing the monitoring of lung aeration [13].

In particular, a grade A consensus was reached, which stated that LUS allows the assignment of a severity score according to the areas involved that helps define the opportunity to resort to invasive rather than noninvasive MVs. According to Brat et al. [59], each lung can be divided into three areas: upper anterior, lower anterior, and lateral. The lung ultrasound pattern is assessed using a linear microprobe and transverse and longitudinal scans.

A score from 0 to 18 is obtained by assigning each area a score ranging from 0 to 3 points, where 0 indicates an A-line pattern, 1 indicates a B-pattern (≥ 3 B-lines), 2 indicates a coalescent B-line pattern with possible subpleural consolidations, and 3 indicates extended consolidations. A threshold of 8 was recently associated with the greatest global accuracy (82%; 95% CI) when LUS was used as a replacement for other tests [60].

Therefore, the panellists proposed that invasive MV can be considered when LUS has a score ≥ 8, which indicates that at least two areas examined have a type 2 pattern [59]. For lower scores, however, noninvasive MV should initially be used. Because LUS scores could be early predictors of treatment response [61], the panellists claimed that LUS imaging can guide invasive or noninvasive mechanical ventilation adjustments, ensuring that the lung is fully expanded for the adopted ventilation parameters.

Given the outstanding advantages of guiding MV application under LUS monitoring, according to the expert consensus in Table 1, we summarise the following guidance opinions. Simply, invasive MV treatment should be provided if moderate or severe RDS is diagnosed on LUS, whereas noninvasive MV can initially be provided if the diagnosis is mild RDS on LUS (Fig. 1). Bronchoalveolar lavage (BAL) using 0.9% NaCl is proposed before MV is initiated if LUS suggests a diagnosis of severe meconium aspiration syndrome (MAS), severe pneumonia, or severe atelectasis; if BAL leads to the complete disappearance of a consolidation, MV is not required (Fig. 2); in contrast, in the case of a significant but incomplete reduction, noninvasive MV should be provided (Fig. 3). Invasive ventilation should be provided if the image of large consolidations shows no significant changes after BAL. Although MV is generally unnecessary in mild MAS, pneumonia, or atelectasis cases when the infant is clinically stable and breathing spontaneously. However, if severe lung consolidation occurs in a patient with pulmonary haemorrhage, invasive ventilator therapy with higher parameters should be used instead of BLA (Fig. 4 and Video 1). Another crucial differential diagnosis that may lead to improper use of MV is between TTN and RDS [40,41,42,43,44,45]. Specifically, lung oedema may depend on TTN, especially in infants with dyspnoea shortly after birth. When identification is unclear, clinicians tend to treat TTN as RDS, leading to an expansion of the administration of MV. In general, invasive MV is unnecessary if the diagnosis is TTN on LUS unless disease progression leads to secondary RDS. Moreover, noninvasive MV can be given if the patient has severe dyspnoea (Fig. 5). PTX is also a common lung disease that threatens the safety of newborns in the NICU. Generally, MV is usually not required if LUS presents as mild PTX (Fig. 6 and Video 2). Invasive MV should be provided if moderate–severe PTX is observed via LUS and if the infant appears to be in significant clinical distress (Fig. 7). However, in this case, we should choose invasive high-frequency oscillatory ventilation instead of conventional invasive ventilation.

Fig. 1
figure 1

MV is needed if the diagnosis is RDS on LUS. A: A female infant with a GA of 28+5 Weeks, cesarean section with birth weight of 1090g. She was admitted to NICU at 11 minutes because of breath difficulty immediately after birth. Arterial blood gas analysis showed PaCO2 57.7 mmHg, PaO2 41.2 mmHg, SaO2 75.4%. LUS showed typical groundless opacity signs, which suggesting the Grade I RDS. The noninvasive MV can be given to this infant firstly, then we dynamically observe the lung condition changes using LUS. B: Another infant with gestational age of 34+1Weeks, cesarean section with birth weight of 2010g. Who was admitted to NICU at 20 minutes after birth due to dyspnea 15 minutes. Arterial blood gas analysis showed PaCO2 70.6mmHg, PaO2 25.4 mmHg, SaO2 43.7%. LUS showed snowflake-like lung consolidation, which was the typical LUS manifestations of Grade II or III RDS. This infant should accept invasive MV treatment

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Fig. 2
figure 2

No need MV after BAL. This was a premature infant with a gestational age of 30 weeks and a birth weight of 1430g. Re-invasive MV was needed because of reemergence of severe dyspnea during hospitalization. LUS showed large area of lung consolidation and atelectasis in the right lung (A). After several times of BAL, re-examination of LUS showed that the lung consolidation completely disappeared, only a few B-lines existed (B), and thus the invasive MV could be removed

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Fig. 3
figure 3

Need noninvasive MV after BAL. LUS (extend view) showed significant atelectasis involving more than 5 intercostal spaces which need invasive MV treatment to the patient before BAL (A), while only small consolidations involved two intercostal spaces remained after BAL (B). Therefore, noninvasive MV is required for this infant. Please also refer to video 1

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Fig. 4
figure 4

Invasive MV should be implemented as quickly as possible for Pulmonary hemorrhage. Examination of the lung showed large area of lung consolidation with air bronchograms (the highperechoic reflection within consolidation area), fluid bronchograms (the linear hypoechoic reflection within the consolidation area) and shred signs (the highperechoic reflection on the edge of consolidation area) in both lungs (A: left lung, B: right lung), which are consistent with ultrasound imaging findings of pulmonary hemorrhage. The invasive MV should be implemented as soon as possible in this case

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Fig. 5
figure 5

Noninvasive ventilation is required for severe TTN. LUS showed confluent B-lines and alveolar-interstitial syndrome (AIS) in both lungs (A:left lung, B:right lung), and no consolidation with air bronchograms were found, which was consistent with the ultrasound imaging features of TTN. Patients may have a certain degree of dyspnea, and noninvasive MV can be given firstly

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Fig. 6
figure 6

MV is generally unnecessary for mild pneumothorax. For pneumothorax patient, if spared area (the area that pleural line and A line clearly display surrounded by edema)(A) or lung point (B) exists in the LUS images. It could be mostly mild pneumothorax, usually no MV treatment needed, the real-time ultrasound examination clearly display the presence of lung point, which was a mild pneumothorax involves less than one intercostal space. Please also refer to Video 2

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Fig. 7
figure 7

MV is often used for severe pneumothorax. LUS showed clear presence of pleural line and A-line on B-mode image (A) and a stratospheric sign on M-mode (B), lung sliding disappeared under real-time ultrasound scanning, while there are no spared area and lung point in the entire lung field. Which was consistent with the ultrasound imaging characteristics of severe pneumothorax. In most cases, the infants with severe pneumothorax need for invasive high-frequency oscillatory ventilation treatment

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For lavage methods, we recommend the following steps: (1) Place the patients in an appropriate position. (2) Connect electrocardiogram monitoring and transcutaneous oxygen saturation monitor. (3) Connect invasive ventilator and adjust the parameters to the optimal condition. (4) 0.9% NaCL1.0–2.0 ml/kg was injected into the endotracheal tube per-times and maintain positive pressure ventilation for 20–30 min. (5) Perform continuous tapping the lung lesion site for 3–5 min, and then the sputum and secretion suction with negative pressure, and each suction period lasts no more than 10 s. (6) The reexamination by LUS should be performed immediately after the lavage and aspiration, and it is determined whether further lavage needed or not is based on the lung re-expansion situation. (7) The times of continuous lavage should not exceed 3 times. (8) For critically ill patients who failed to achieve satisfactory results after 2–3 circles lavage with 0.9% NaCL, lavage with diluted pulmonary surfactant (PS) can be given, or PS treatment can be administered after lavage.

LUS can also be used to monitor changes and responses during MV and treatment for respiratory failure [62]. Specifically, in RDS patients treated with invasive MV, lung changes must be monitored by LUS every 2–4 h. Indeed, LUS is effective in detecting lung overexpansion in neonatal patients. Overlapping the median borders of the lungs (transternal transverse section) is an easy-to-detect, specific, and sensitive sign of excessive lung volume. LUS, in addition to overdistension, can easily detect atelectrauma, a type of ventilator-induced lung injury caused by the repetitive opening and closing of collapsed alveoli and small airways within atelectatic areas during MV.

Using LUS to guide the adjustment of MV settings and weaning from MV

Maintaining normal oxygenation in infants with minimum ventilator parameters is not appropriate for administering ventilator applications under LUS monitoring, whereas the fundamental principle of guiding the ventilator parameter adjustments under ultrasound monitoring is to ensure that the lung can fully expand under the parameter settings (Fig. 8).

Fig. 8
figure 8

LUS to guide the adjustting of MV settings. A preterm infant with a gestational age of 31 weeks and a birth weight of 1700g was treated with invasive MV for severe RDS. When the peak inspiratory pressure (PIP) was 0 cm H2O, LUS showed severe snowflake sign-like lung consolidation (A). LUS showed that the degree of consolidation decreased slightly when PIP increased to 20 cm H2O (B). However, the lung consolidation almost disappeared when PIP increased to 30 cm H2O (C). Therefore, the 30 cm H2O of PIP is the most appropriate parameter for this patient

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LUS-guided recruitment manoeuvres (RMs) in ventilated preterm neonates with respiratory distress syndrome (RDS) demonstrated superior outcomes compared with non-LUS-guided RMs. LUS guidance resulted in earlier optimal oxygenation with lower FiO requirements and shorter durations of oxygen dependency, invasive ventilation, and NICU stay. Additionally, LUS-guided RM significantly reduced lung inflammation, as evidenced by decreased tracheal IL-6 levels, likely due to minimised atelectrauma and optimised lung recruitment parameters [63].

LUS also supports the decision-making process when weaning from MV, which is a critical issue, especially in mechanically ventilated preterm infants, because each additional week of MV increases the risk of ventilator-induced lung injury, ventilator-associated pneumonia, bronchopulmonary dysplasia (BPD), long-term neurodevelopmental impairment, or even death [64]. The panellists proposed that weaning from noninvasive or invasive MV can be performed when lung consolidation disappears on LUS or when lung oedema shows signs of significant absorption (Figs. 9 and 10).

Fig. 9
figure 9

Weaning from MV in patients with significant lung consolidation. We can withdraw MV when consolidation disappeared in patients with lung consolidation as the main ultrasound manifestation, such as RDS (A), pneumonia or atelectasis (B) even if the image has not fully returned to normal (C)

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Fig. 10
figure 10

Weaning from MV in patients with severe lung edema. MV could be withdrawed when lung edema absorbed almostly in patients with severe edema as the major performance on LUS. When edema absorption happens, confluent B-lines, compact B lines or white lung (A) will gradually become general B-lines (B) on LUS

Full size image

A prospective, multicentre cohort study showed that LUS may predict weaning success [65]. The clinicians who participated in this survey propose that in the decision to wean from MV, the reduction in pathological signs on LUS must be evaluated in the context of the overall clinical picture. Extubation failure is defined as the need for reintubation in the first 2–7 days after extubation and occurs in as many as 10–80% low birth weight infants of different populations [66, 67]. Any tool potentially useful to improve this rate must be carefully considered because reintubation is significantly associated with increased risks of respiratory morbidities and death or BPD [64].

Using LUS to assess the lung water content

Despite an ongoing debate on the effective utility of LUS in the semiquantitative estimation of the extravascular lung water index (EVLWI) at lower thresholds, higher thresholds (> 20 ml/kg) of the EVLWI have acceptable sensitivity and specificity in a paediatric population [68].

Moreover, LUS can be used to evaluate the lung water content in very-low-birth-weight preterm neonates [69]. B-line protocols provide an accurate noninvasive evaluation of lung water in critically ill patients by predicting lung oedema with an EVLWI ≥ 10 and severe pulmonary oedema with an EVLWI ≥ 15 [70]. A randomised controlled trial recently confirmed that lung ultrasound is a noninvasive and convenient tool for predicting fluid overload in neonatal septic shock patients [71].

Therefore, based on clinical experience, the panellists have suggested the use of LUS to stratify the need for MV in patients with pulmonary oedema. In particular, noninvasive respiratory support may be needed if the estimated lung water content is > 10–15 ml/kg, whereas invasive MV should be reserved for patients with an estimated lung water content > 15–20 ml/kg. Further studies are necessary to confirm the validity of these statements in neonates affected by pulmonary oedema.

Using LUS to guide PS administration in newborn infants with severe dyspnoea

LUS can support the selection of patients to receive PS and timing of PS administration. Supplementation with PS represents an important measure for treating severe neonatal breathing difficulties in newborns, especially for patients with RDS [15, 16, 24,25,26,27]. Specifically, the panellists stated that exogenous PS should be provided if the diagnosis is RDS on LUS (Figs. 1, 8, 9A), whereas a significant decrease or disappearance of lung consolidation after BAL should discourage PS administration (Figs. 2, 3). Of course, if the diagnosis is TTN on LUS, PS is usually unnecessary (Figs. 5, 10A).

Surfactant administration is currently guided only by the newborn’s need for oxygen therapy based on a cut-off, which can be considered entirely arbitrary and cannot accurately reflect the patient’s oxygenation [72]. In contrast, some studies reported a strong correlation between LUS findings and the need for surfactant therapy [59, 73]. The reported sensitivity and specificity of LUS in predicting and guiding PS administration are 0.86 and 0.82, respectively [50, 74]. Similarly, a recent prospective study confirmed that LUS improved the timeliness of PS administration [75]. When used under ultrasound guidance, the dose of PS is usually one-half the dose recommended by the European guidelines for managing RDS. A recent meta-analysis concluded that LUS is a powerful technique for customising the first dose of surfactant in infants with RDS [76].

In line with the European guidelines [77], the panellists proposed that noninvasive ventilation and less invasive surfactant administration (LISA) are the most suitable initial management methods when LUS is consistent with mild RDS, leaving MV for those with insufficient respiratory drive or higher oxygen requirements. Instead, invasive MV treatment with surfactant administration should be chosen if the sonography diagnosis is grade II-III RDS.

Limitations and challenges of LUS

Neonatal LUS is an increasingly utilised diagnostic tool because of its diagnostic potential, ability to perform repeated examinations without exposure to ionising radiation, and ability to provide real-time imaging. However, compared with CXR, this technique presents several significant limitations that restrict its applicability and effectiveness in specific clinical settings. First, LUS has limited utility in hyperinflated lungs and does not allow visualisation of deep focal lesions when the peripheral lung is normally aerated. Moreover, unlike chest X-ray, which provides a comprehensive anatomical overview of thoracic structures, ultrasound produces sectorial images, creating limitations in diagnosing diffuse diseases and conditions involving the chest wall. Additionally, LUS is limited in assessing bony abnormalities or lesions, such as rib fractures or spinal deformities, which can be easily identified through radiography. Therefore, while LUS provides high sensitivity for detecting certain neonatal lung conditions, CXR remains preferable in specific scenarios, such as severe lung trauma or when assessing conditions requiring comprehensive thoracic visualisation.

Additionally, unlike CXR, LUS is highly operator dependent, requiring specialised training and experience to ensure accurate interpretation. This dependency poses challenges in resource-limited settings where access to training and equipment may be restricted. The cost of acquiring and maintaining ultrasound machines, including portable ultrasound machines, and implementing comprehensive training programs can be significant barriers to widespread adoption. Addressing these barriers through low-cost training initiatives and simplified protocols could enhance LUS accessibility. Moreover, while expert consensus supports LUS use, there is a pressing need for large-scale, prospective randomised controlled trials to validate its efficacy and establish standardised protocols. Future research should focus on these areas to strengthen the evidence base for LUS in neonatal respiratory management.

Limitations

On the basis of all the expert opinions and suggestions, the manuscript was revised more than 28 times. Nevertheless, several limitations also remain that need to be clarified. Because the panellists involved in elaborating and voting on the different statements primarily included professionals previously involved in LUS research, their position towards its use might be biased in a positive sense. Another limitation of our consensus might be the number and selection of the participants involved. We aimed to include experts from different areas worldwide, but the expertise level might differ among participants. Important experts in neonatal LUS were not involved in the study. Moreover, some statements of the present consensus are mainly based on the panellists’ clinical experience, and some may need confirmation in further high-quality prospective studies. For example, statements related to the precise estimation of lung water content highlight the need for experimental trials on neonates, and further research is necessary.

However, the clinical perspective remains crucial for guiding practice and clinical research. One of the main strengths of the present study is that the clinicians involved in developing this consensus were from very different backgrounds. Although important differences may exist in the management of neonatal pulmonary disease and the use of LUS among different countries, the inclusion of experts from different specialties and geographical areas has enriched the content of the consensus.

Conclusions

In conclusion, the present study suggests that LUS should play a crucial role in the management of neonatal respiratory diseases, as supported by previous findings of high sensitivity (88%) and specificity (82%) in determining the need for PS treatment or MV in infants with RDS [15, 50]. Furthermore, as a repeatable and dynamic bedside method, LUS allows frequent monitoring of treatment results, resolution of pulmonary pathological signs, and timely identification of worsening pulmonary conditions. LUS enables lung function assessment at the regional level, which may offer the precision currently lacking to clinicians to meaningfully individualise respiratory therapies [24,25,26]. Finally, LUS is an easy-to-learn imaging method with a high degree of interobserver agreement. The time needed for accurate image acquisition was approximately 3 min in highly skilled hands [26].

According to animal model research, microvascular pulmonary capillary haemorrhage (PCH) injury is possible with clinical LUS use, which could introduce extraneous occurrence of the B‐line sign. This possibility is of clinical significance and should be explored in future pathological investigations [78, 79].

The authors propose this document as a starting point for further international discussion of the existing evidence, reliability of the proposed statements, and future perspectives on the use of LUS in optimising the management of neonatal respiratory dyspnoea to obtain shared benefits for research, the health care sector, and patients.

Data availability 

No datasets were generated or analysed during the current study.

Abbreviations

NICU:

Neonatal intensive care unit

PS:

Pulmonary surfactant

RDS:

Respiratory distress syndrome

VAP:

Ventilator-associated pneumonia

BPD:

Bronchopulmonary dysplasia

LUS:

Lung ultrasound

CXR:

Chest X-ray

MAS:

Meconium aspiration syndrome

PTX:

Pneumothorax

MV:

Mechanical ventilation

BAL:

Bronchoalveolar lavage

TTN:

Transient tachypnoea of the newborn

AIS:

Alveolar–interstitial syndrome

GA:

Gestational age

PIP:

Peak inspiratory pressure

VLBW:

Very low birth weight infants

HFOV:

High-frequency oscillatory ventilation

EVLWI:

Extravascular lung water index

IQR:

Interquartile range

LISA:

Less invasive surfactant administration

PCH:

Pulmonary capillary haemorrhage

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Acknowledgements

We thank Dr Haiying Cao from GE Healthcare for providing guidance for lung ultrasound. We thank the NICU staff from Beijing Obstetrics and Gynaecology Hospital Affiliated with Capital Medical University for their work support.

Funding

This project was supported by the Wu Jie-Ping Medical Foundation Research Fund (320.6750.2024–03-32).

Author information

Authors and Affiliations

  1. Department of Neonatology and NICU, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251 Yaojiayuan Road, Chaoyang District, Beijing, 100026, China

    Jing Liu, Xiao-Ling Ren & Ya-Li Guo

  2. UOC Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Riccardo Inchingolo

  3. Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, India

    Pradeep Suryawanshi

  4. Department of Ultrasound, Sixth Affiliated Hospital of Harbin Medical University, Harbin, China

    Bin-Bin Guo

  5. Cohen Children’s Medical Center, Northwell Health, New York, USA

    Dalibor Kurepa

  6. Pediatric Intensive Care, Marañón General University Hospital, Madrid, Gregorio, Spain

    Rafael González Cortés

  7. Department of Ultrasound, Zhumadian Central Hospital of Henan Province, Zhumadian, China

    Wei Yan

  8. Senior Department of Pediatrics, The Seventh Medical Centerof , PLA General Hospital, Beijing, China

    Jing-Han Chi

  9. Department of Anesthesia, Hospital Privado de Comunidad, Mar del Plata, Argentina

    Cecilia M. Acosta

  10. Jagiellonian University Collegium Medicum, Krakow, Poland

    Mateusz Jagła

  11. Department of Neonatology, Cradle Children Hospital, Jaipur, Rajasthan, India

    Deepak Sharma

  12. Division of Pediatric Radiology, Department of Radiology, Medical University Graz, Graz, Austria

    Erich Sorantin

  13. Children’s Hospital, China Medical University, Taichung, Taiwan

    Kai-Sheng Hsieh

  14. Unità Operativa Di Pediatria E Neonatologia, Ospedale Santa Maria Delle Croci, Ausl Romagna, Ravenna, Italy

    Giulia Graziani

  15. Unità Operativa Di Radiologia, Ospedale Santa Maria Delle Croci, Ausl Romagna, Ravenna, Italy

    Bruna Malta

  16. King Edward Memorial Hospital, Perth, Australia

    Patricia Woods

  17. Department of Paediatrics, Guangdong Second Provincial General Hospital, Guangzhou, China

    Qiong Meng & Chu-Ming You

  18. Department of Neonatology, Czerwiakowski Hospital at Siemiradzki St., Cracow, Poland

    Piotr Kruczek

  19. Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

    Martin Kneyber

  20. Critical Care, Anaesthesiology, Perioperative & Emergency Medicine (CAPE), University of Groningen, Groningen, the Netherlands

    Martin Kneyber

  21. Simulation Laboratory of Endoscopic and Minimally Invasive Techniques, Medical University of Gdansk, Gdansk, Poland

    Natalia Buda

  22. Dipartimento Neuroscienze, UOC Pneumologia, Organi Di Senso E Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Andrea Smargiassi

  23. Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia

    Jovan Lovrenski

  24. Institute for Children and Adolescents Health Care of Vojvodina, Novi Sad, Serbia

    Jovan Lovrenski

  25. Department of Neonatology, Beijing Chao-Yang District Maternal and Child Healthcare Hospital, Beijing, China

    Xiao-Ling Ren, Ya-Li Guo & Ru-Xin Qiu

  26. Department of Paediatrics, Monash University, Melbourne, VIC, Australia

    Abdul Razak

  27. Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia

    Abdul Razak

  28. The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia

    Abdul Razak

  29. Dipartimento Di Medicina Traslazionale e per la Romagna, Università Di Ferrara, Ferrara, Italy

    Francesco Feletti

Authors
  1. Jing Liu
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  2. Riccardo Inchingolo
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  7. Wei Yan
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  9. Cecilia M. Acosta
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  15. Bruna Malta
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Contributions

JL and FF conceived the study together. JL proposed the first series of statements, invited panellists from Asia and the USA, wrote the article’s first draft, reviewed its concepts, and provided related ultrasound pictures. FF organised and coordinated the Delphi process, invited panellists from other continents, collected and analysed the results, wrote the materials and methods section, and revised the manuscript critically for important intellectual content. KD wrote the statements for round 2 of the Delphi process. BM critically revised the manuscript for important intellectual content. All the authors provided their scores, important comments, and proposals for the statements. All the authors read, corrected, and approved the final manuscript.

Corresponding author

Correspondence to Jing Liu.

Ethics declarations

Ethics approval and consent to participate

This work is a methodological study that does not involve human or animal subjects and does not require ethical approval. Informed consent from guardians or study subjects was not needed.

Consent for publication

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare no competing interests.

Additional information

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Supplementary Information

Additional file 1: Video 1. Before bronchoalveolar lavage (BAL), real-time LUS revealed extensive lung consolidation and atelectasis spanning more than four intercostal spaces, accompanied by air and fluid bronchograms and a lung pulse.

Additional file 2: Video 2. Mild pneumothorax: real-time LUS image showing a lung point located in the last intercostal space of the right lung, indicating mild PTX. The infant displayed no significant respiratory distress, and ventilator support or thoracentesis was not needed.

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Liu, J., Inchingolo, R., Suryawanshi, P. et al. Guidelines for the use of lung ultrasound to optimise the management of neonatal respiratory distress: international expert consensus. BMC Med 23, 114 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-03879-5

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BMC Medicine

ISSN: 1741-7015

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