April 2026
White out lung

Case by Dr Nina Nouraeyan (Neonatologist at the Jewish General Hospital)

Monthly Case – April 2026 - Dr. Nina Nouraeyan - Posted: April 2, 2026

Case Summary

This case demonstrates why ultrasound should be used in an unstable infant to further define the cause of the acute respiratory deterioration. X Ray findings can be very vague and not give a clear diagnosis in some situations and this is a case where POCUS really made the diagnosis clear and allowed for immediate care.

Clinical Situation

This was a 25-week di/di twin, born by emergency Caesarean section following poor tracing for one twin. The mother had been betamethasone and magnesium sulfate complete. The infant stabilized quickly, was intubated and received surfactant. The neonate was extubated on day of life (DOL) 3 onto bubble CPAP and remained stable for 2 weeks with a slow wean of the CPAP. A peripheral intravenous central cathether (PICC) line was inserted on DOL 5 into the right arm and was used exclusively for total parental nutrition (TPN). On DOL 20, the patient was found to have renal losses of sodium and the sodium content of the TPN was increased to achieve sodium balance. The PICC line was found to have migrated on chest radiography but was always past mid-clavicular point and pointing down towards the SVC.

On DOL 26 was found to be profoundly hyponatremic and over the day started to have more and more work of breathing and oxygen requirement.

Chest X-Ray Findings

A chest X-ray was obtained. The radiograph demonstrated a complete white out of the right lung and left lung. From the Xray the etiology of the infant’s decompensation is unclear. Furthermore, acute hyponatremia and sudden deterioration is usually associated with necrotising enterocolitis; however, the abdominal Xray was reassuring for the abdomen.

POCUS Examination

Given the uncertainty of the diagnosis and ongoing decompensation, the POCUS team was called. A POCUS lung was done first. This is the video from the right side and of the left side.

Lung POCUS

The ultrasound demonstrates an anechoic area underneath the ribs with the pleural pushed further down then would be expected in the right lung (4R clip).

On the R4 view with the curvilinear probe you can appreciate the “jellyfish” sign of the collapsed right lung “swimming” in an effusion.

Management

The team inserted a 26G butterfly catheter into the space (5th intercostal mid axillary line) with the largest effusion identified by ultrasound. The appropriate area for insertion of the needle was identified by US with position the infant with the head of the bed elevated and rotated towards the right in order to augment the effect of cravity on the fluid collection. The infant improved drastically and returned to 30% oxygen supplementation.

After 10cc of TPN-like fluid were removed, POCUS was used to evaluate if there was more effusion residula, and it was deemed necessary to withdraw more. In the end a total of 23cc of TPN was removed. Resolution of the effusion was appreciated on POCUS after the procedure.

You can appreciate a small effusion still present in the US of R4 using the curvilinear probe but the majority of the effusion has been resolved.

On the linear probe video of R3 after the procedure you can see areas of collapse but no more effusion.

Teaching Points

POCUS complements chest X-ray by providing real-time bedside clarification of nonspecific radiographic findings—such as a “white-out”—helping differentiate between atelectasis, surfactant deficiency in a newly born neonate, or pleural effusion.

POCUS allows:

● Direct, real-time confirmation of pleural effusions

● Immediate intervention and confirmation of resolution of the effusion

● The intervention of chest tube or needle insertion for removal of the effusion can also be done under ultrasound guidance