Early Human Development 90S2 (2014) S41S43

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Early Human Development

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e a r l h u m d e v

Research article

Lung ultrasound findings in meconium aspiration syndrome

Marco Piastra a, Nadya Yousef b,c, *, Roselyne Brat c, Paolo Manzoni d, Mostafa Mokhtari b, Daniele De Luca a,c
a
Pediatric Intensive Care Unit, Institute of Anesthesiology and Critical Care, University Hospital A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
b
Neonatal and Pediatric Intensive Care Unit, FAME Department, South Paris University Hospitals, Kremlin-Bicetre Medical Center, Paris, France
c d
Division of Pediatrics and Neonatal Critical Care, FAME Department, South Paris University Hospitals, A. Becl`ere Medical Center, Paris, France
Neonatal Intensive Care Unit, OISRM S. Anna, Turin, Italy

article info summary

Keywords: Meconium aspiration syndrome (MAS) is a rare and life-threatening neonatal lung injury induced
Meconium aspiration by meconium in the lung and airways. Lung ultrasound (LUS) is a quick, easy and cheap imaging
Neonate technique that is increasingly being used in critical care settings, also for newborns. In this paper
Lung ultrasound we describe ultrasound findings in MAS.
Six patients with MAS of variable severity were examined by LUS during the first hours of life.
Chest X-rays were used as reference.
The following dynamic LUS signs were seen in all patients: (1) B-pattern (interstitial) coalescent
or sparse; (2) consolidations; (3) atelectasis; (4) bronchograms. No pattern was observed for
the distribution of signs in lung areas, although the signs varied with time, probably due to
the changing localisation of meconium in the lungs. LUS images corresponded well with X-ray
findings.
In conclusion, we provide the first formal description of LUS findings in neonates with MAS. LUS
is a useful and promising tool in the diagnosis and management of MAS, providing real-time
bedside imaging, with the additional potential benefit of limiting radiation exposure in sick
neonates.
2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Meconium aspiration syndrome (MAS) is a rare and life-threatening
neonatal lung injury caused by several patho-physiological mechanisms
induced by meconium in lung tissue and airways [1]. Lung ultrasound
(LUS) is a quick, easy and relatively inexpensive imaging technique that
is slowly gaining popularity as a tool to diagnose and monitor lung
diseases. LUS is increasingly being used in critical care settings and
specific recommendations for bedside use have recently been elaborated
[2]. LUS provides accurate diagnostic information when compared with
conventional lung imaging methods, such as CT scans and chest
radiographs [3], and has the additional advantage of being non-
irradiating, adapted to bedside use and easily repeatable with no side
effects for the patient. LUS is easy to learn, does not require
sophisticated ultrasound machines or settings, and shows low intra- and
interobserver variability when a standardized approach is used [4].
* Corresponding author. Dr. Nadya Yousef, MD, Service de P ediatrie
et Reanimation Neonatale, Groupe Hospitalo-Universitaire Paris Sud,
CHU A. Beclere,` 157 rue de la Porte de Trivaux, 92140 Clamart (Paris),
France. Tel.: +33145374837.
E-mail address: nadya.yousef@bct.aphp.fr (N. Yousef).
LUS can also be used to diagnose neonatal lung disease [46]. The
same LUS signs are found in the lung of a newborn baby as in that of an
adult [7]. Specific LUS findings have been described for some types of
neonatal lung injury, such as neonatal respiratory distress syndrome
[8,9], transient tachypnea of the neonate [9,10] and neonatal pneumonia
[11]. No formal data exist on ultrasound imaging of MAS, although some
of its pathophysiological characteristics produce visible signs on LUS
[4].
Here we provide a first comprehensive description of MAS semiology
using LUS.
2. Methods
Six term neonates presenting with MAS, and recruited from three tertiary
neonatal intensive care units in Italy and France (A. Gemelli Hospital in
Rome, Italy, and the South Paris University Hospitals of Antoine
Beclere` and Bicetre in Paris, France), underwent lung examination
with ultrasound in the first 24 hours after admission. Standard chest
radiographs were performed according to local protocol.
The operators were not blinded; LUS was performed by a
pediatrician/neonatologist skilled in lung and heart sonography who
knew the patients condition and history. The choice of

0378-3782/$ see front matter 2014 Elsevier Ireland Ltd. All rights reserved.
S42 M. Piastra et al. / Early Human Development 90S2 (2014) S41S43

Table 1
Basic data of the study population

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

Gestational age (weeks) 40 39 40 40 41 40

Body weight (g) 3990 4020 3020 2945 3200 3500
Gender M F M F F F
Apgar score

1 2 3 1 3 1 1

5 4 4 8 5 1 6
SNAPPE-II 41 26 30 23 25 39

Respiratory support during lung US HFOV, iNO HFOV CMV O2 therapy CMV CMV

CMV, conventional mechanical ventilation; HFOV, High-frequency oscillatory ventilation; iNO, inhaled nitric oxide; SNAPPE-II, Score
for Neonatal Acute Physiology Perinatal Extension.

ultrasound device and probe depended on local availability; for patients 1
and 2, an 84 MHz phase array probe was used (Sonosite M-Turbo,
Fujifilm Sonosite Inc.) to obtain transversal and longitudinal scans of the
anterior chest wall; for patients 3 and 4, an 8 MHz curved array probe
(GE Loqiq 7, GE Healthcare, General Electric Company) was used; and
for patients 5 and 6, a high-resolution 1218 MHz linear probe (GE
Logiq E9; GE Healthcare, General Electric Company) was used to scan
the anterior, lateral and posterior chest walls.
3. Study cases
We observed six cases of MAS of variable severity (Table 1). The
following LUS signs were found in all patients: (1) B-pattern (interstitial)
coalescent or sparse; (2) consolidations; (3) at-electasis; (4)
bronchograms (often with irregular borders) and airway inflammation.
We did not find any specific pattern for the distribution of these signs in
the different lung areas.
The signs seen on LUS in the six neonates with MAS using the
different ultrasound probes are shown in Fig. 1 (neonates 1 and 2), Fig. 2
(neonates 3 and 4), Fig. 3 (neonate 5) and Fig. 4 (neonate 6). Chest
radiographs, which are the current imaging gold standard for MAS, are
provided for comparison. The observed LUS images corresponded well
with X-ray findings. LUS signs were dynamic and varied throughout the
clinical course; different signs appeared in the same lung area over time,
reflecting the changing auscultation patterns. We believe this varying
pattern to be due to the changing distribution of meconium and to the
displacement and/or dissolution of meconium plugs.

The concurrent and irregular presence of the above-described signs has

never been formally described in other neonatal respiratory conditions.

Fig. 1. Comparison between chest X-rays and LUS for (A) patient 1 and (B) patient 2. LUS was
performed with an 84 MHz phased array probe. Transversal and longitudinal scans of the
rd
anterior chest wall (3 intercostal space) were obtained in the supine position. Confluent B-
lines and bronchograms (panel A) and irregular consolidation (panel B) are visible. These
correspond with irregular snow-like opacities on the chest-X rays.

Fig. 2. Comparison between chest X-rays and LUS for (A) patient 3 and (B) patient 4.
Transversal and longitudinal scans of the anterior chest wall were made using an 8 MHz curved
array probe with the patient in the supine position. Confluent B-lines and irregular
consolidations are visible in panel A. Panel B shows a patient in a less severe phase (well-
spaced B-lines and A-lines visible). The corresponding chest X-rays were clearly different for
the two cases (snow-like appearance with alveolar opacities for panel A, mild opacities and
aerated lung for panel B).
Fig. 3. Comparison between chest X-rays and LUS for patient 5. LUS was performed on
admission with a 1218 MHz linear probe. Longitudinal and horizontal scans of the anterior and
postero-lateral chest wall were performed in the supine position. LUS showed an irregular and
thickened pleural line (panel A), multiple B-lines (panels AD), with areas of B-line confluence
(panels D, E), as well as multiple consolidations (panels B, C, F) with numerous bronchograms
(panels B, C, E, F) and pleural effusion (panel F). These findings were more severe for the right
lung. The corresponding chest radiograph shows multiple bilateral ill-defined opacities.
 M. Piastra et al. / Early Human Development 90S2 (2014) S41S43
Fig. 4. Comparison between chest X-ray and LUS for patient 6. LUS was performed in the
supine position, with a 1218 MHz linear probe, 24 hours after birth when the patient was
already showing clinical improvement. Compared to patient 5, LUS showed a more aerated
lung with fewer and more widely spaced B-lines, a few sub-pleural consolidations, and some
visible A-lines. A horizontal scan of the postero-lateral chest wall is presented here with the
corresponding chest radiograph, which shows well-aerated lungs and mild opacities.
4. Discussion
LUS is based on the analysis of artifacts that arise from the interaction of
air and interstitial fluid in the lung [35]. In a normal lung the pleura is
seen as a regular hyperechoic line that moves with respiration. The
presence of air in the lungs gives rise to horizontal artifacts called A-
lines, which are seen as a series of echoic parallel lines. An abnormality
of the interstitial or alveolar compartment gives rise to vertical artifacts
defined as B-lines. Lung consolidation has a tissue-like aspect, often
with irregular borders with movement of air in the bronchioles
represented by bronchograms. The normal lung of a newborn has a
black appearance, although B-lines may be seen in the first day of life
[4,5]. Although LUS is slowly gaining ground in neonatal intensive care
units, and despite all its advantages, with few exceptions, LUS is still not
included in the systematic diagnostic workup of neonatal respiratory
distress.
In the six patients with MAS, we observed a range of unevenly
distributed dynamic signs. The lungs showed a changing and irregular
presence of a variety of signs in the different lung areas during the
clinical course, which were easily detected by portable ultrasound
devices. The choice of ultrasound probe did not influence the result of
LUS, although a precise evaluation of the pleural line was not possible
using the phased array and the curved array probes. Both standard chest
radiographs and LUS show typical and easily interpreted findings in
MAS, but LUS has the added advantage of allowing for a three-
dimensional and serial/real time evaluation of the lungs at both the
parenchyma and the airway level, thereby describing more closely the
clinical situation.
Even though this is not shown in our cases, severe MAS with
extensive surfactant dysfunction could progress to a fully condensed
(white) lung [4], which is clearly a form of meconium-induced acute
respiratory distress syndrome through increased inflammation and
surfactant catabolism [12].
LUS in neonates and infants is usually performed using linear, high-
resolution probes [35]. Our imaging has been provided with different
probes, according to the availability in the different centres; despite this
limitation, consistent and reasonable findings were found. Our cases were
collected from several tertiary referral centers due to the fact that MAS
has become a rare disease [12] and hence one single center would not be
able to see enough cases.
S43
LUS should not be a substitute for standard chest radio-graphs [4],
which easily provide the diagnosis of MAS. However, LUS can reduce
the use of X-rays in clinical practice, with clear benefits in terms of
irradiation [13], especially if multiple serial imaging needs to be
performed. LUS allows for a three-dimensional study of different lung
areas, whilst chest X-rays describe them only in a single projection.
Finally, LUS allows for real time bedside follow-up of patients since the
observed signs change with the improving clinical picture.
Conversely, it is important to note that LUS might express all its
potential only if used by clinicians who know the patients clinical
history and, therefore, if imaging and clinical findings are correlated
[3,4,7]. A future step would be to study the potential of LUS to estimate
lung aeration and to guide mechanical ventilation at the bedside: this will
require specific clinical studies and technical improvements.
In conclusion, we provide the first formal data about US imaging of
MAS. This may be useful in clinical practice and as a future research
tool.
Conflict of interest statement
The authors have no conflicts of interest to declare.
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