Neonatal Lung POCUS Teaching Tools

Course Objectives

Lung Ultrasound Video

Probe Selection

Mode / Presets

Lung Landmarks and Zones

Image Acquisition

Image Interpretation

No Pneumothorax - M-Mode

References

Examples in the context of significant RDS

Neonatal Lung POCUS Teaching Tools

By Dr Nina Nouraeyan for the McGill University – Neonatal Perinatal Medicine Residency - Updated December 21st, 2025

Course Objectives

By the end of the module, learners will be able to:
- Acquire high quality images of the lung representing all 4 lung areas on both sides
- Properly interpret and grade the lung fields as per the universally accepted method
- Appropriately diagnose normal lung ultrasound findings
- Differentiate between different lung pathologies such as:
  - - Respiratory distress syndrome
    - Transient tachypnea of the newborn
    - Meconium aspiration
    - Pneumonia
    - Pleural Effusion
    - Atelectasis
    - Pneumothorax

Video on lung-ultrasound acquisition to be viewed below:

Lung Ultrasound Video

Lung POCUS - new.mp4

Thank you to the family who generously volunteered to participate in video recordings, helping us create educational content that will be shared with our community of learners.

Probe Selection

· Linear or Hockey-stick probe (preferred for most lung imaging)

· Curvilinear probe may be used when assessing for pleural fluid

Mode / Presets

Use the Lung or Neonatal Lung preset depending on the ultrasound machine.
On the GE Venue GO, ensure that in every lung zone you pick the appropriate label buy clicking on the appropriate location on the lung icon (see video below for details).
Selecting the correct preset is essential for appropriate depth, gain, and artifact visualization.

Lung Landmarks and Zones

Landmarks on the chest wall are standardized scanning zones, not anatomical lung lobes. For uniformity, each hemithorax is divided into four regions:

R1/L1: The Upper zone on either side is demarcated as R1 (right) or L1 (left).
- This area is along the midclavicular line from the apex of the lung to the nipple
R2/L2: The Lower zone on either side is demarcated as R2 (right) or L2 (left).
- This area is along the midclavicular line from the nipple line until the visualization of the diaphragm
R3/L3: The Lateral segment on either side is demarcated as R3 (right) or L3 (left).
- This area is along the mid clavicular line from the most cranial point in the axilla until the visualization of the diaphragm
R4/L4: The Subcostal segment on either side is demarcated R4 (right) or L4 (left).
- This uses the curvilinear probe and is meant to look for fluid accumulation
- Again the marker is pointing cranially and it is placed at the junction of the diaphragm and the underlying solid tissue (liver spleen) to be used as an acoustic window

Image Acquisition

For R1–R3 and L1–L3:
- Probe marker points cranially (12 o’clock);
- Images are acquired in the longitudinal axis
For R4/L4:
- Use a curvilinear probe
- Probe placed subcostally with the marker cranially
Required Images for Each Zone
- For each of the 4 regions on both sides, obtain:
  1. A still image
  2. A sweep video of the region
  3. M-mode image
- This ensures proper interpretation, documentation, and comparison over time.

Image Interpretation

It must always be recalled that when looking at lung ultrasound you are interpreting artifact. There is very little organ that is being directly visualized as the lung is air filled organ and air does not allow ultrasound penetration. Details of image interpretation is the concept of this course, however to give some background information please note the following.

There are four important components to recognize on an ultrasound:
- - Pleural movement – this is the “shimmering” white line that moves indicating both the visceral and parietal parts of the pleura sliding against each other with each breath
  - A lines – which are vertical reverberation artifacts from the pleura
  - Ribs – that show as shadows cast down as the US waves are absorbed by the bone/cartilage and show as black shadows beneath it
  - B lines – which are horizontal artifacts from fluid that shoot down like “comets”

In order to ensure that a good quality image is being attained here are some key principles:

The R1/L1 region must include the apex – therefore the curvature of the lung as it starts in the apex and flattens out must be included
The R2-R3/L2-L3 regions must include the diaphragm which is identified by a double train track line (Ensure the diaphragm is visible (double “train-track” appearance).
Each image must represent the “bat-sign” which reveals the ribs and the lung underneath with rib shadows giving a “bat” appearance which indicates that your probe is properly at a 90 degree angle with the lung. Bat-sign: two ribs & pleural line beneath, confirming correct 90° orientation.

When grading a lung ultrasound to ensure uniform language in comparing images and communicating between health care professionals, these are the scoring systems that are used.

Score 0

Score 1

Score 2

Score 3

- In M-mode there are three important image types that can be acquired. Recall that M mode is looking at one location over time
  - - The sea-shore sign which is a normal finding indicating the unmoving chest wall and muscles in contrast to the moving pleural underneath
    - The bar-code sign which indicates a separation of the visceral and parietal pleura due to a pneumothorax indicating the lack of lung sliding
    - The sinusoidal wave sign which indicates fluid and the movement of the lung as it expands in the fluid with breathing