Milky Lungs: Ultrasonographic Findings in Pediatric Acute Respiratory Distress Syndrome

Naumovski Filip,Toleska Marija,Trposka Angela,Kartalov Andrijan,Kuzmanovska Biljana

doi:10.35995/ceacr2010005

Abstract

Diagnosis and following up the dynamics of Pediatric Acute Respiratory Distress Syndrome demand a more feasible, non-invasive and bedside tool, such as lung ultrasound, for monitoring the damaged lungs. We report on a 6-month-old child admitted in our Pediatric Surgical Intensive Care Unit with a clinical presentation of ileus and concomitant community acquired pneumonia. Lung ultrasound (LUS) examinations according to the BLUE Protocol were done several times during the hospital stay. A-lines were seen at admission in the upper segments, but 2–3 B-lines were present in the posterolateral segments bilaterally. Later on, separated and coalescent B-lines were seen. White lung parenchyma or milky lungs with a thickened pleural line were seen, while the worst gas exchange according to the results of Arterial Blood Gases (ABGs) has been detected. According to the findings, as many B-lines will be detected, as the severeness of lung damage and gas exchange impairement. The improvement of the gas exchange with the disappearance of the coalescent B-lines was seen later on, after ventilating the child in a prone position. Bedsides, LUS is a feasible and non-invasive point of care method that could be used for diagnosing Pediatric Acute Respiratory Distress Syndrome (PARDS) but in guiding therapy of the damaged lungs, also. The finding of diffuse, coalescent and homogenous B-lines interpreted as “Milky lungs” is consistent with the diagnosis of PARDS.

Highlights

According to the Berlin Definition made by the American–European Consensus Conference, any condition manifested with severe hypoxemia and PaO2/FiO2 ≤300 mmHg should be considered as Acute Respiratory Distress Syndrome (ARDS) in adults [1]
On the 7th day of admission, we made a new chest X-ray where we found the existence of bilaterally present consolidated white lungs, while the child was still on mechanical ventilation using Bilevel Mode with a Positive End Expiratory Pressure (PEEP) of 10 cmH20, an Respiratory Rate (RR) of 50 breaths per minute, driving pressure of 16 mBar and a Vt of 7 mL/kg
The child that we presented above had bilateral infiltrates on the chest X-ray, suggesting pulmonary infection, an Oxygenation Index (OI) of 9 and an Oxygenation Saturation Index (OSI) of 5.8, which means that the above-mentioned criteria for Pediatric Acute Respiratory Distress Syndrome (PARDS) were fulfilled

Summary

Introduction

According to the Berlin Definition made by the American–European Consensus Conference, any condition manifested with severe hypoxemia and PaO2/FiO2 ≤300 mmHg should be considered as Acute Respiratory Distress Syndrome (ARDS) in adults [1]. On the 7th day of admission, we made a new chest X-ray where we found the existence of bilaterally present consolidated white lungs, while the child was still on mechanical ventilation using Bilevel Mode with a PEEP of 10 cmH20, an Respiratory Rate (RR) of 50 breaths per minute, driving pressure of 16 mBar and a Vt of 7 mL/kg. The findings of the ABGs with pO2 of 62 mmHg and pCO2 of 87 mmHg correlated with the chest X-ray finding of PARDS, while OI was 19.1 and OSI was 11.5 We made another bedside ultrasound examination where multiple B-lines were seen bilaterally that were becoming coalescent in the lower postolateral segments (LUS score of 18). Because of persistence of the pneumomediastinum, jugulotomy was considered for a suitable surgical intervention but the child developed a new hemodynamical instability and died on the 30th day of hospital admission

Findings

Discussion

Conclusions