Lung ultrasound in pediatric patients: the clinician’s point of view

Dear Editor, We read with interest the article by Lovrenski [1] on the pros and potentials of lung ultrasound in pediatric patients. We share his enthusiasm for lung ultrasound and we agree that lung ultrasound is not a self-sufficient imaging tool. However, a large body of evidence supports the use of lung ultrasound in everyday clinical practice to evaluate critically ill neonates and children. In our opinion, the article may — as a final result — discourage the use of lung ultrasound in daily clinical practice, limiting the potential of this useful diagnostic tool. Moreover, we believe that additional consideration would be helpful on some important aspects of lung ultrasound in the neonate: 1) The author reported that double lung point is a pathognomonic sign in transient tachypnea of the newborn [2]. Nevertheless, this sign has recently lost some of its importance [3]. More than 50% of patients with transient tachypnea of the newborn never present with double lung point [3]. To discriminate between respiratory distress syndrome and transient tachypnea of the newborn we should probably focus on pleural line, which appears altered in infants with respiratory distress syndrome and normal in those with transient tachypnea of the newborn, as we have recently proposed [4]. Further studies are needed to confirm this observation. 2) The author rightly recognised the need for chest radiography in the suspicion of air leaks. However, it is necessary to underline the importance of lung ultrasound for the diagnosis of pneumothorax. Lung ultrasound has optimal diagnostic accuracy and allows intervention in a more timely manner to resolve this potentially life-threatening condition [5, 6]. 3) The author stated that lung ultrasound is time-consuming, particularly in the intensive care setting, and he believes this is an important drawback of the method. We consider this conclusion unjustified. We showed that the time between the decision to perform lung ultrasound and the diagnosis was shorter, when compared to radiography, in the neonatal intensive care unit [6]. Of note, the lung ultrasound was performed by the attending neonatologist rather than the pediatric radiologist. This opened a completely new perspective: Performance and interpretation of lung ultrasound by the bedside clinician allowed timely diagnosis and easier integration with clinical findings. This new role of lung ultrasound has revolutionized clinical practice and its use has increased significantly in recent years. Based on these considerations, lung ultrasound has become, in some way, the “new stethoscope,” rather than a diagnostic tool exclusively in the experienced hands of radiologists. In conclusion, we believe that lung ultrasound should be performed, in the first instance, by the bedside clinician, both with neonates and children. Collaboration between pediatricians and radiologists remains of paramount importance: Clinicians should remain humble and acknowledge their own limits, seeking the collaboration of radiologists in complex cases. For these reasons, the author should consider not why we should replace conventional imaging with lung ultrasound but rather who should use lung ultrasound and what the limits of this technique are in clinicians’ hands. Therefore, it is essential to define point-of-care lung ultrasound’s main purposes, to establish formal training and to develop guidelines. Collaboration with radiologists in order to implement lung ultrasound training during medical school and lung ultrasound curricula for pediatricians may be the next steps [7].