Sonographic dynamic assessment of lung injury in a child with hypoplastic left heart syndrome undergoing extracorporeal membrane oxygenation

Introduction: Performed for many years in clinical settings, pleural and lung ultrasound (PLUS) has emerged to be an invaluable tool to diagnose underlying conditions of respiratory failure, to monitor disease progression and to ensure appropriate therapeutic intervention. PLUS basically relies on the analysis of two prevalent ultrasound artefacts: A-lines and B-lines. A-lines are hyperechoic reverberation artefacts of the pleural line. A-lines combined with lung sliding show that lungs are well aerated. B-lines are vertical hyperechoic reverberation artefacts arising from pleural line extending to the bottom of the screen. The prevalence of B-lines indicates a pathologic parenchyma. Since PLUS is readily available, easily affordable, and biologically non-invasive, it is especially suitable for bedside clinical care in critically ill and unstable adult patients. Several authors have recently proposed PLUS for application in critically ill neonates and children. We report a case in which PLUS was used to clinically monitor a complex lung lesion during treatment of a child with congenital heart disease suffering from severe lung injury. Case description: A 1-year-old male with hypoplastic left heart syndrome underwent bidirectional Glenn procedure and systemic-to-left pulmonary artery shunt for heart palliation. After surgery, he developed a severe acute respiratory distress syndrome (ARDS) and extra-corporeal membrane oxygenation (ECMO) treatment was started. PLUS was performed daily to monitor the disease's progression and response to treatment during lung rest. As B-lines were decreasing and A-lines were becoming visible, we were able to monitor the improving aeration of the injured lung. The ultrasound showed high consistency with traditional imaging. Discussion: Due to its non-ionizing nature, low cost, easy availability, easy repeatability and real-time results, PLUS is a feasible and beneficial bedside imaging technique for critically ill and unstable adult and pediatric patients. A reliable monitoring of ongoing treatments is certainly helpful to provide appropriate intervention, correctly schedule chest X-ray and CT-scan, and optimize ECMO weaning. The present case suggests that PLUS may be a successful and useful tool for monitoring lung diseases in children with CHD with severe post-operative complex lung injury.