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PurposeThe objective of this study was to investigate the effectiveness of an original Lung UltraSound Targeted Recruitment (LUSTR) protocol to improve the success of lung recruitment maneuvers (LRMs), performed as a rescue approach in critically ill neonates, as compared to the standard oxygenation-guided LRM.MethodsAll the LUSTR maneuvers, performed in infants with oxygen saturation/fraction of inspired oxygen (S/F) ratio below 200, were included in this retrospective case-control study (LUSTR-group). The LUSTR-group was matched by the initial S/F ratio (which is inversely proportional to the severity of the respiratory insufficiency) and underlying respiratory disease with a control group of lung recruitments performed following the standard oxygenation-guided procedure (Ox-group). The primary outcome was the improvement of the S/F ratio (Delta S/F) throughout the LRM. Secondary outcomes included the variation of the Oxygen Saturation Index (OSI) and the rate of air-leaks.ResultsEach group was constituted by fourteen LRMs. As compared to the standard approach, the LUSTR protocol was associated with a higher success of the procedure in terms of Delta S/F (110±47.3 vs 64.1±54.6, p = 0.02), and OSI (8.2±6.8 vs 2.8±2.2, p = 0.01). These results remained significant after adjusting for confounding variables through multiple linear regressions. All the LRM in the LUSTR group showed signs of lung recruitability and obtained the sonographic resolution of the lung derecruitment. Patient position before and during LRM was modified more frequently in the LUSTR group. A trend towards decreased rates of pneumothorax was observed in the LUSTR-group (0 vs 14.3%, p = 0.15).ConclusionThe LUSTR protocol may be a more effective and potentially safer option than the oxygenation-based procedure to guide open lung ventilation in neonates.