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Resumen: Objetivo: La ecografía pulmonar es una herramienta útil para el diagnóstico y seguimiento de la patología del paciente crítico neonatal. Su uso está cada vez más extendido gracias a sus ventajas sobre otras pruebas de imagen y el rápido incremento en la evidencia científica a su favor, constituyendo así, un pilar básico de las guías «point of care ultrasound» (POCUS) neonatal. El objetivo de este artículo especial es proporcionar las bases y aplicaciones diagnóstico-terapéuticas establecidas de la ecografía pulmonar, y dar a conocer nuevas aplicaciones. Métodos y resultados: La sección de ecografía pulmonar del Grupo de Trabajo de Ecografía Neonatal de la Sociedad Española de Neonatología resume la evidencia científica actual. Se describen los patrones ecográficos de las principales patologías respiratorias, aborda algunas de sus aplicaciones en la asistencia neonatal (predicción de ingreso, necesidad de surfactante, procedimientos ecoguiados, seguimiento del desarrollo pulmonar en el prematuro, entre otros) y propone su incorporación en otros escenarios actualmente menos establecidos como la reanimación o el manejo ventilatorio.Este artículo reafirma los beneficios de esta herramienta para ayudar en el diagnóstico, toma de decisiones terapéuticas, apoyo en procedimientos y valoración pronóstica. Conclusiones: La ecografía pulmonar debe establecerse como la prueba diagnóstica de elección en la patología respiratoria neonatal. Por ello, su entrenamiento debería formar parte de la formación de los neonatólogos e incluirse en los protocolos diagnóstico-terapéuticos asistenciales. Se deben seguir desarrollando líneas de investigación con estudios sólidos y multicéntricos que aumenten la calidad de la evidencia científica. Abstract: Objective: Lung ultrasound is a useful tool for diagnosis and follow-up of diseases in critically ill neonates. Its use is increasingly widespread thanks to its advantages over other imaging tests and the rapidly growing body of evidence to support it, and «point-of-care ultrasound» (POCUS) has become a key component in neonatal guidelines. The objective of this special article is to present the foundations and the established diagnostic and therapeutic applications of lung ultrasonography as well as introducing new applications. Methods and results: The Lung Ultrasound Section of the Neonatal Ultrasonography Working Group of the Spanish Neonatology Society has summarised the current scientific evidence. The article describes the sonographic features of the most common respiratory diseases, discusses some of the applications of ultrasound in neonatal care (such as prediction of admission and need of surfactant, ultrasound-guided procedures or monitoring of lung development in premature infants) and proposes its introduction in other scenarios in which its use is not quite established at present, such as resuscitation or respiratory management. This article reaffirms the usefulness of lung ultrasound in guiding diagnosis, clinical decision-making and prognosis and facilitating procedures. Conclusions: Lung ultrasound should be established as the gold standard for diagnosis of respiratory diseases in neonates. Therefore, training in lung ultrasound should be included in the educational curriculum of neonatologists and in diagnostic and therapeutic care protocols. Research on the subject should continue to be pursued with performance of rigorous multicentre studies to increase the quality of the evidence.

Objective: Lung ultrasound is a useful tool for diagnosis and follow-up of diseases in critically ill neonates. Its use is increasingly widespread thanks to its advantages over other imaging tests and the rapidly growing body of evidence to support it, and “point-of-care ultrasound” (POCUS) has become a key component in neonatal guidelines. The objective of this special article is to present the foundations and the established diagnostic and therapeutic applications of lung ultrasonography as well as introducing new applications. Methods and results: The Lung Ultrasound Section of the Neonatal Ultrasonography Working Group of the Spanish Neonatology Society has summarised the current scientific evidence. The article describes the sonographic features of the most common respiratory diseases, discusses some of the applications of ultrasound in neonatal care (such as prediction of admission and need of surfactant, ultrasound-guided procedures or monitoring of lung development in premature infants) and proposes its introduction in other scenarios in which its use is not quite established at present, such as resuscitation or respiratory management. This article reaffirms the usefulness of lung ultrasound in guiding diagnosis, clinical decision-making and prognosis and facilitating procedures. Conclusions: Lung ultrasound should be established as the gold standard for diagnosis of respiratory diseases in neonates. Therefore, training in lung ultrasound should be included in the educational curriculum of neonatologists and in diagnostic and therapeutic care protocols. Research on the subject should continue to be pursued with performance of rigorous multicentre studies to increase the quality of the evidence. Resumen: Objetivo: La ecografía pulmonar es una herramienta útil para el diagnóstico y seguimiento de la patología del paciente crítico neonatal. Su uso está cada vez más extendido gracias a sus ventajas sobre otras pruebas de imagen y el rápido incremento en la evidencia científica a su favor, constituyendo así, un pilar básico de las guías «point of care ultrasound» (POCUS) neonatal. El objetivo de este artículo especial es proporcionar las bases y aplicaciones diagnóstico-terapéuticas establecidas de la ecografía pulmonar, y dar a conocer nuevas aplicaciones. Métodos y resultados: La sección de ecografía pulmonar del Grupo de Trabajo de Ecografía Neonatal de la Sociedad Española de Neonatología resume la evidencia científica actual. Se describen los patrones ecográficos de las principales patologías respiratorias, aborda algunas de sus aplicaciones en la asistencia neonatal (predicción de ingreso, necesidad de surfactante, procedimientos ecoguiados, seguimiento del desarrollo pulmonar en el prematuro, entre otros) y propone su incorporación en otros escenarios actualmente menos establecidos como la reanimación o el manejo ventilatorio. Este artículo reafirma los beneficios de esta herramienta para ayudar en el diagnóstico, toma de decisiones terapéuticas, apoyo en procedimientos y valoración pronóstica. Conclusiones: La ecografía pulmonar debe establecerse como la prueba diagnóstica de elección en la patología respiratoria neonatal. Por ello, su entrenamiento debería formar parte de la formación de los neonatólogos e incluirse en los protocolos diagnóstico-terapéuticos asistenciales. Se deben seguir desarrollando líneas de investigación con estudios sólidos y multicéntricos que aumenten la calidad de la evidencia científica.

Abstract Background The management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT. Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group. Methods/design In this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks’ gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group. Discussion Based on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores. Trial registration ClinicalTrials.gov identifier NCT05198375 . Registered on 20 January 2022.