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Case by Dr Nina Nouraeyan (Neonatologist at the Jewish General Hospital)
Table of Contents
Case Summary
Case Summary
This case features a female infant born at 23 weeks’ gestation following cervical insufficiency, prolonged premature rupture of membranes, candidal infection, and incomplete antenatal corticosteroid coverage. As expected for an infant born at this gestational age, respiratory management was challenging. She required immediate intubation, initially needed high-frequency ventilation, and was subsequently transitioned to an assist-control mode with improving oxygenation and ventilation by Day 7 of life.
Clinical Deterioration
Clinical Deterioration
At 10 days of life, the infant exhibited:
Increasing oxygen requirements
Increased secretions in the endotracheal tube
Normal white blood cell count
Normal C-reactive protein
Blood and endotracheal cultures were obtained, and the POCUS team was consulted to help differentiate the cause of the clinical change.
Chest X-Ray Findings: The radiograph was nonspecific, demonstrating diffuse bilateral hazy opacities and increased interstitial markings. No focal consolidation or effusion could be confidently identified. As is common in neonates, the X-ray lacked diagnostic clarity.
POCUS Examination
POCUS Examination
Given the nonspecific radiographic findings, lung ultrasound was performed.
Left Lung (L1–L3 zones)
Across all three anterior zones, A-lines were absent and coalescent B-lines were present, indicating increased interstitial and alveolar fluid.
Right Lung (R2 zone)
Ultrasound revealed:
Hepatization of the lung parenchyma
Air-fluid levels
A small pleural effusion adjacent to the diaphragm
These findings are consistent with consolidation suggestive of pneumonia.
Microbiology and Management
Microbiology and Management
The endotracheal sputum culture grew resistant Klebsiella. Blood cultures remained negative. The infant was treated with Meropenem. Notably:
WBC count increased 24 hours after treatment initiation
Repeat blood cultures continued to be negative
Follow-up lung ultrasounds showed resolution within 7 days, at which point antibiotics were discontinued.
Teaching Points
Teaching Points
1. Lung Ultrasound Outperformed Chest X-ray in this case.
This case demonstrates the diagnostic utility of POCUS in neonates:
Chest X-rays are frequently nonspecific and may miss pneumonia altogether
Lung ultrasound offers direct visualization of consolidation, effusions, and dynamic air bronchograms
In this case, the chest X-ray did not provide diagnostic guidance, whereas ultrasound clearly identified VAP
2. Challenges With Existing VAP Definitions
There is currently no gold standard for diagnosing ventilator-associated pneumonia in neonates. Three commonly referenced approaches include:
Clinician judgment
National Healthcare Safety Network (NHSN) definition
Canadian consensus definition
Each method has limitations—either overly restrictive criteria or a lack of direct visualization.
3. How Lung POCUS Enhances Diagnosis and Management
Lung ultrasound adds significant clinical value by:
Directly identifying parenchymal consolidation
Supporting timely and appropriate antimicrobial therapy
Guiding duration of treatment
Reducing unnecessary exposure to broad-spectrum antibiotics
Supporting stewardship and protection of the neonatal microbiome
4. Importance of VAP Prevention
VAP contributes to:
Increased days on mechanical ventilation
Progressive lung injury
Greater antibiotic use
Increased risk of complications
Since 2017, our site has implemented the “Zap the VAP” prevention strategy, resulting in fewer than one VAP case per year.
Conclusion
Conclusion
This case illustrates how POCUS lung ultrasound is an essential tool for evaluating neonates with respiratory deterioration. Its ability to directly visualize pulmonary pathology supports accurate diagnosis, targeted therapy, and responsible antibiotic use. Institutions are encouraged to develop local VAP diagnostic guidelines in which lung POCUS plays a central role. Our site is currently in the process of approving a VAP diagnostic guideline and will share this once completed.
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