NICU LUNG POCUS

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NORMAL V RDS

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LUS IN RDS

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PRE-EMPT DONT WAIT FOR FIO2 TO GO OVER 30%

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✅ 1. The 12 Lung Areas

Each hemithorax = 6 zones
Total = 12 zones

Anterior (2 per side)

• Upper anterior

• Lower anterior

Lateral (2 per side)

• Upper lateral

• Lower lateral

Posterior (2 per side)

(If safe to turn the infant)

• Upper posterior

• Lower posterior

→ Right lung: 6 zones
→ Left lung: 6 zones

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🟩 2. LUS SCORE PER ZONE (0–3)

Score 0 — Normal aeration

• A-lines present

• Normal lung sliding

• ≤2 isolated B-lines

Score 1 — Moderate loss of aeration

• 2 B-lines (non-confluent)

• Pleura may appear mildly irregular

Score 2 — Severe loss of aeration

• Coalescent B-lines (white lung appearance)

• No regions of normal aeration in that zone

Score 3 — Consolidation

• Subpleural consolidation

• Tissue-like echotexture

• May have air bronchograms

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🟥 3. TOTAL LUS SCORE FOR RDS SEVERITY

Add up all 12 zones:

Total Score	Interpretation
0–5	Mild / normal aeration
6–12	Moderate aeration loss
13–18	Moderate–severe aeration loss
19–36	Severe RDS (white lung + consolidations)

(Ranges vary slightly in publications, but these are widely used clinical thresholds.)

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📌 4. How It’s Used Clinically

• Diagnose RDS vs TTN

  • TTN = more B-lines, less consolidation

  • RDS = coalescent B-lines + posterior worsening + consolidations

• Guide surfactant therapy

  • LUS Score ≥ 10–12 → often correlates with need for surfactant

• Track lung improvement after CPAP, HFNC, ventilation

• Reduce X-rays in NICU

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🟦 5. Quick Summary (1 Glance)

12 zones: A2 + L2 + P2 (each side = 6)
Score 0–3 per zone → total 0–36
Higher score = worse aeration
Consolidation = 3 (worst)

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Here’s a clear, clinical explanation of the Snowflake Sign in neonatal lung ultrasound — concise and accurate.

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❄️ SNOWFLAKE SIGN – Neonatal Lung Ultrasound

✅ What It Is

The Snowflake Sign refers to hyperechoic (bright), punctate or branching “snowflake-like” air bronchograms seen within a large subpleural consolidation on lung ultrasound.

It looks like tiny white specks or flakes inside a tissue-like lung region.

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✅ What It Indicates

Typical of SEVERE RDS (Hyaline Membrane Disease), due to:

• Marked loss of lung aeration

• Surfactant deficiency

• Micro-atelectasis

• Collapse with trapped air in bronchi → “snowflakes”

It is a highly specific sign of RDS, not TTN.

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🧠 Why It Happens

In severe RDS:

• Alveoli collapse → tissue-like consolidation

• Some air remains in bronchi → appears as bright, scattered points

• These points shimmer/cluster → the “snowflake” appearance

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🩺 Diagnostic Meaning

Sign	Interpretation
Snowflake sign	Severe RDS (surfactant deficiency)
Location	Usually anterior + posterior lung zones
Associated score	LUS score in these zones = 3 (consolidation)
Clinical implication	Often correlates with surfactant requirement

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🔍 Differentiation from Other Signs

Not TTN → TTN shows B-lines but NO tissue-like consolidation.
Not pneumonia → pneumonia shows irregular, localized consolidations with dynamic air bronchograms, not snowflakes.

Snowflake sign = diffuse, homogeneous consolidation with hyperechoic micro-bronchograms.

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📌 Ultra-Short Definition

“Snowflake sign = bright micro-air-bronchograms scattered within a homogeneous consolidation → hallmark of severe neonatal RDS.”

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SNOW FLAKE ON 3-4

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GOLDEN HOUR- DEXTROSE, CAFFEINE, LINES 

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UN STEROIDED BOY - MORE AT RISK - MAY NEED 2ND DOSE AFTER 12 HRS 

cf    STEROIDED GIRL 

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INSUREC 

INSUREc is a common neonatal respiratory management acronym.

✅ INSUREc = INtubate – SURfactant – Extubate (to CPAP)

Here’s the breakdown:

• IN – Intubate the infant

• SU – Give Surfactant through the endotracheal tube

• RE – Extubate immediately

• C – to CPAP (Continuous Positive Airway Pressure)

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📌 What It Means Clinically

INSUREc is used for babies with RDS to:

• give surfactant early

• avoid mechanical ventilation

• reduce lung injury (BPD risk)

• return quickly to non-invasive support (CPAP)

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📌 Ultra-Short Definition

INSUREc = Surfactant via brief intubation → immediate extubation → CPAP support.

If you want, I can also explain:

• When to use INSURE vs LISA/MIST

• Criteria for CPAP failure

• Surfactant dose triggers using LUS score
  Just tell me!

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NOT AS SENS SPF AFTER 34 WKR 

LUNG US FOR RDS BEST BETN 24-24 WKRS 

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