PACUPod is your trusted source for evidence-based insights tailored to advanced clinical pharmacists and physicians. Each episode dives into the latest primary literature, covering medication-focused studies across pediatric emergency medicine, internal medicine, ambulatory care, critical care, specialty pharmacy, and many more. We break down study designs, highlight key findings, and objectively discuss clinical implications—without the hype—so you stay informed and ready to apply new evidence in practice. Whether you’re preparing for board certification or striving for excellence in patient care, PACUPod helps you make sense of the data, one study at a time.
Britany: Welcome back to PACULit, your go-to literature update for clinical research. Today, we’re discussing a study on neonatal respiratory distress syndrome (RDS) and how lung ultrasound might guide surfactant administration. Seth, your thoughts?
Seth: Excited, Britany. Neonatal RDS is critical in preterm infants, and timing surfactant therapy is key. Using lung ultrasound as a bedside tool is promising given current method limitations.
Britany: The study by Raimondi et al., published in Pediatric Pulmonology 2025, is a prospective observational study proposing a simplified regional lung ultrasound score—rLUS—to predict surfactant need in preterm neonates stabilized on nasal CPAP within two hours of life.
Seth: Early identification of infants needing surfactant can prevent unnecessary invasive ventilation and improve outcomes. Current reliance on clinical criteria and oxygenation indices like SatO2/FiO2 can delay surfactant or misclassify patients.
Britany: Chest X-rays expose neonates to radiation and may miss early lung aeration heterogeneity. Lung ultrasound is radiation-free and bedside, but prior scoring systems were complex and time-consuming.
Seth: This study aimed to develop a simplified, rapid, reliable rLUS focusing on midclavicular lung regions bilaterally to capture regional aeration differences early.
Britany: Preterm infants on nasal CPAP are a large group where early surfactant decisions are critical. Optimizing timing reduces invasive ventilation, improves respiratory outcomes, and shortens NICU stays.
Seth: To summarize: Neonatal RDS causes morbidity and mortality due to surfactant deficiency and lung immaturity. Timely surfactant is crucial but hard to determine early and accurately.
Britany: The knowledge gap was the lack of a simple, rapid ultrasound score predicting surfactant need based on regional lung aeration heterogeneity within two hours of life.
Seth: The study was a secondary analysis of a multicenter prospective cohort of 175 preterm neonates with RDS stabilized on nasal CPAP within two hours after birth.
Britany: Inclusion: preterm infants with clinical and radiographic RDS diagnosis on noninvasive support. Excluded: intubated at enrollment, major anomalies, or hemodynamic instability.
Seth: The intervention was rLUS performed within two hours, focusing on midclavicular lung regions bilaterally—a novel simplification.
Britany: They also measured SatO2/FiO2 concurrently. The comparator was standard clinical decision-making without ultrasound guidance.
Seth: Primary outcome: predictive accuracy of rLUS for surfactant need, assessed by AUC, sensitivity, specificity. Secondary: models combining gestational age and SatO2/FiO2.
Britany: Ultrasound was done within two hours; surfactant administration tracked during stabilization. ROC curve analysis evaluated performance.
Seth: Results: A midclavicular rLUS cutoff of 2 identified early aeration heterogeneity indicating surfactant need. Left midclavicular score AUC 0.86, sensitivity 79%, specificity 90%.
Britany: Right midclavicular score AUC 0.87, sensitivity 74%, specificity 93%. Combining left and right scores improved accuracy: AUC 0.90, sensitivity 82%, specificity 89% at cutoff 3.
Seth: Incorporating gestational age and SatO2/FiO2 with combined score raised AUC to 0.95, showing very high predictive accuracy.
Britany: This suggests a simple, rapid ultrasound plus clinical variables can precisely identify neonates needing surfactant early, improving outcomes and reducing unnecessary interventions.
Seth: The study highlights regional variability in lung aeration in early RDS, effectively captured by this simplified regional scoring.
Britany: This contrasts with prior complex scoring systems assessing multiple lung zones, which are time-consuming and operator-dependent.
Seth: Operator variability is a limitation; training and standardization are important for clinical use.
Britany: Also, as a secondary analysis of observational data, causation isn’t established. The population was limited to infants on nasal CPAP, so findings may not apply to intubated neonates.
Seth: Strengths include a large multicenter cohort and blinded surfactant assessment, enhancing validity.
Britany: Other studies support lung ultrasound in surfactant decisions. Llamas-Álvarez et al.’s meta-analysis of seven studies (~700 neonates) showed LUS had high predictive accuracy with AUC 0.88.
Seth: Brat et al. (2020) found a LUS cutoff of 4 predicted surfactant need with 96% sensitivity and 100% specificity, aligning with Raimondi’s approach.
Britany: De Martino et al. showed early LUS within three hours using cutoff 5 optimized surfactant prediction.
Seth: Alonso-Ojembarrena and Vento demonstrated LUS-guided surfactant reduced intubation rates and improved outcomes.
Britany: Honey et al. emphasized regional lung ultrasound enhances precision in neonatal respiratory decisions, supporting regional scores like midclavicular zones.
Seth: From a clinical pharmacy view, integrating rLUS with gestational age and oxygenation helps pharmacists support timely surfactant, reducing invasive procedures and optimizing care.
Britany: It highlights multidisciplinary NICU collaboration—pharmacists, physicians, respiratory therapists—using ultrasound data to tailor interventions.
Seth: A clinical pearl: the simplified midclavicular rLUS can be done rapidly bedside, feasible in busy NICUs without extensive ultrasound expertise.
Britany: Also, early surfactant guided by accurate prediction may reduce prolonged mechanical ventilation, limiting sedative or paralytic exposure with their interaction risks.
Seth: Minimizing invasive ventilation decreases exposure to opioids or benzodiazepines, which affect neurodevelopment and drug metabolism in preterms.
Britany: Future research could explore applicability in extremely low birth weight infants or those with comorbidities like patent ductus arteriosus.
Seth: Also, whether this scoring guides surfactant timing in evolving bronchopulmonary dysplasia or with other noninvasive ventilation modes.
Britany: To conclude, Raimondi et al. provide a practical, evidence-based tool to improve early surfactant decisions in neonatal RDS. The combined midclavicular rLUS score plus clinical variables achieves excellent predictive accuracy.
Seth: It’s a significant advance in neonatal respiratory care, potentially reducing invasive ventilation and improving outcomes. Implementation needs training and validation, but the promise is clear.
Britany: Thanks for the discussion, Seth. Listeners, review the full study and consider how regional lung ultrasound might fit your NICU protocols.
Seth: Absolutely, Britany. Staying current helps us provide the best care for our tiniest patients. Looking forward to our next PACULit update!
Britany: Same here. Until next time, keep reading, questioning, and improving patient care. Thanks for tuning in!