Lung Ultrasound for Neonatal Respiratory Distress in a Resource-Limited County Hospital: A pilot study

Lung Ultrasound for Neonatal Respiratory Distress in a Resource-Limited County Hospital: A pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Lung Ultrasound for Neonatal Respiratory Distress in a Resource-Limited County Hospital: A pilot study Xingyu Zhu, Yunrui Zhuang, Kaili Qian, Fengfang Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8585943/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted 13 You are reading this latest preprint version Abstract Background Lung ultrasound (LUS) is increasingly used as a radiation-free alternative to chest X-ray (CXR) for diagnosing neonatal respiratory distress syndrome (RDS). However, evidence regarding its feasibility and clinical utility in resource-limited county hospitals remains limited. Methods This prospective pilot observational study enrolled neonates with respiratory distress within 24 hours of birth in a county-level maternal and child health hospital. All infants underwent bedside LUS and CXR. LUS was performed using a standardized six-zone scanning protocol with a total score ranging from 0 to 18. Diagnostic performance of LUS for RDS was assessed using receiver operating characteristic (ROC) curve analysis. Factors associated with patient transfer were also analyzed. Results A total of 34 neonates were included, of whom 17 (50%) were diagnosed with RDS. LUS scores were significantly higher in the RDS group than in the non-RDS group (median 10.0 vs. 5.0, P < 0.001). LUS demonstrated high diagnostic accuracy for RDS, with an area under the ROC curve of 0.912. An optimal cut-off score of 9.0 yielded a sensitivity of 70.6% and a specificity of 94.1%. Notably, LUS scores were not significantly associated with patient transfer decisions (P > 0.05). Within the RDS group, 64.7% of neonates were successfully managed locally despite elevated LUS scores. Conclusions Bedside LUS is a feasible and accurate diagnostic tool for neonatal RDS in resource-limited county hospitals. Its primary clinical value lies in establishing a definitive diagnosis rather than directly guiding transfer decisions, supporting safe local management of selected neonates based on overall clinical assessment. Introduction Neonatal respiratory distress syndrome (RDS) remains a leading cause of morbidity in preterm infants [1]. While tertiary centers have widely adopted lung ultrasound (LUS) as a radiation-free alternative to chest X-ray (CXR), its implementation in grassroots institutions remains limited. In China, the management of neonates is increasingly shifting towards county-level hospitals [2]. However, these resource-limited settings often face specific challenges, including a lack of 24-hour radiology services and the risks associated with transporting unstable neonates for imaging [3]. Although LUS diagnostic features for RDS are well-validated in academic centers, evidence regarding its feasibility and clinical utility in primary care settings is scarce. Specifically, it remains unclear whether LUS serves merely as a diagnostic substitute or if it can guide triage decisions (e.g., transfer vs. local retention). This pilot study aimed to assess the diagnostic accuracy of LUS for RDS in a county-level maternal and child health hospital and to evaluate its role in clinical decision-making. Materials and Methods Study Design and Population This single-center prospective observational study was conducted in the Neonatal Intensive Care Unit (NICU) of a county-level hospital in Zhejiang Province, China. The study protocol was approved by the local ethics committee. Written informed consent was obtained from parents. A total of 34 neonates exhibiting signs of respiratory distress within 24 hours of birth were enrolled. Exclusion criteria included congenital malformations and the need for immediate cardiopulmonary resuscitation. LUS Protocol Bedside LUS was performed using a Philips EPIQ 5 system with a high-frequency linear probe (7.5–12 MHz). A standardized 6-zone scanning protocol was employed as previously described [4,5]. Each zone was scored from 0 (normal aeration) to 3 (consolidation), yielding a total score of 0–18. A score of 0 indicated normal A-lines; 1 indicated ≥3 B-lines; 2 indicated coalescent B-lines; and 3 indicated consolidation. All scans were performed by trained clinicians blinded to the CXR results. Diagnostic Criteria RDS was diagnosed based on clinical presentation, characteristic chest X-ray findings (ground-glass opacity and air bronchograms), and typical lung ultrasound features, including consolidation with air bronchograms, pleural line abnormalities, and the absence of A-lines [6]. Statistical Analysis Data were analyzed using SPSS 26.0. Continuous variables were compared using the Mann-Whitney U test. Diagnostic performance was assessed using Receiver Operating Characteristic (ROC) curve analysis. Factors associated with patient transfer were analyzed to determine the utility of LUS in triage. A P -value < 0.05 was considered statistically significant. Results Demographic Characteristics and Diagnostic Accuracy Of the 34 neonates, 17 (50%) were diagnosed with RDS. The RDS group had significantly lower gestational age and birth weight compared to the non-RDS group (Table 1). LUS scores were significantly elevated in the RDS group compared to the non-RDS group (median 10.0 vs. 5.0, P < 0.001). ROC analysis indicated high diagnostic accuracy for RDS, with an Area Under the Curve (AUC) of 0.912. An optimal cut-off score of 9.0 provided a sensitivity of 70.6% and specificity of 94.1%. Factors Associated with Patient Transfer To evaluate the clinical utility of LUS in guiding triage, we compared transferred and recovery neonates (Table 2). Notably, despite the high diagnostic accuracy of LUS, the LUS score itself did not differ significantly between the transferred and recovery groups (median 9.0 vs. 8.0, P = 0.123). Within the RDS group specifically, 64.7% (11/17) of infants were successfully managed locally despite having elevated LUS scores consistent with consolidation. Discussion This pilot study confirms that LUS is a feasible and highly accurate imaging modality for diagnosing neonatal RDS in a resource-limited county hospital (AUC 0.912). A critical finding of our study is the dissociation between LUS severity scores and transfer decisions. Contrary to the hypothesis that higher LUS scores would independently drive patient referrals, our analysis revealed that transfer decisions were driven by multiple factors rather than the imaging score alone. This observation highlights the specific "utility" of LUS in primary care: it serves as a definitive diagnostic tool rather than a crude triage trigger. By accurately identifying RDS at the bedside, LUS eliminated diagnostic uncertainty (e.g., ruling out pneumothorax). However, clinicians correctly integrated this diagnostic information with physiological maturity to determine the level of care. Consequently, a subset of RDS patients with high LUS scores but sufficient maturity was successfully managed locally, preventing unnecessary transfers and keeping mothers and infants together. This study has limitations, including its single-center design and small sample size (n=34), which precluded multivariable regression. Additionally, while operators were blinded to CXR, they were aware of the clinical status. Nevertheless, these preliminary data support the implementation of LUS in county-level hospitals. In conclusion, bedside LUS is a robust tool for diagnosing RDS in resource-limited settings. Its application empowers grassroots clinicians to make precise diagnoses and safe management decisions, optimizing the allocation of healthcare resources. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Tongxiang Maternal and Child Health Hospital. Written informed consent was obtained from the parents or legal guardians of all participating neonates. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions FL and XZ conceptualized the study. FL, XZ, and YZ performed data curation and formal analysis. FL, XZ, YZ, and KQ contributed to the methodology. XZ was responsible for project administration and visualization. XZ drafted the initial manuscript. All authors contributed to manuscript revision and approved the final version. Acknowledgements The authors thank the nursing and medical staff of the Neonatal Intensive Care Unit for their support during data collection. References Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet 2012;379:2162-72. Li X, Wang H, Liu Y, Han T, Zhu X, Guo Y, et al. A nationwide survey on the management of neonatal respiratory distress syndrome: insights from the MUNICH survey in 394 Chinese hospitals. Ital J Pediatr 2024;50:160. Sharma D, Kumar P, Bansal A, Farahbakhsh N, Shastri S, Sharma P, et al. The role of chest X-ray in the diagnosis of neonatal respiratory distress syndrome: a systematic review concerning low-resource birth scenarios. Glob Health Action 2024;17:2338633. Brat R, Yousef N, Klifa R, Reynaud S, Shankar Aguilera S, De Luca D. Ultrasonography score to evaluate oxygenation and surfactant need in neonates treated with continuous positive airway pressure. JAMA Pediatr 2015;169:e151797. Raimondi F, Yousef N, Rodriguez-Fanjul J, De Luca D, Corsini I, Dani C, et al. Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications. Pediatr Res 2018;84:631-637. Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et al. European consensus guidelines on the management of respiratory distress syndrome: 2022 update. Neonatology 2023;120:3-23. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 04 Mar, 2026 Reviews received at journal 27 Feb, 2026 Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 21 Feb, 2026 Reviews received at journal 20 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor invited by journal 14 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8585943","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592910040,"identity":"e8185fe3-61cc-4ead-aca2-0368407e3d22","order_by":0,"name":"Xingyu Zhu","email":"","orcid":"","institution":"Tongxiang Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xingyu","middleName":"","lastName":"Zhu","suffix":""},{"id":592910041,"identity":"31dd7abf-8cb2-48c1-83cf-57895c77ca8e","order_by":1,"name":"Yunrui Zhuang","email":"","orcid":"","institution":"Tongxiang Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yunrui","middleName":"","lastName":"Zhuang","suffix":""},{"id":592910042,"identity":"45b69669-edd3-4c15-ad88-f648e70e9d70","order_by":2,"name":"Kaili Qian","email":"","orcid":"","institution":"Tongxiang Maternal and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kaili","middleName":"","lastName":"Qian","suffix":""},{"id":592910043,"identity":"3be6a022-3e74-488d-bdb7-a1455146a232","order_by":3,"name":"Fengfang Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACfvnDBx8kVNjI8bM3EKlFcgZbssGHM2nGkj0HiNRicIPHTHJm2+HEDTcSiLVldoOBNM+Zw4wNNx9vvMFQYxNNUAu/zIEEY56KdGbG2WnFFgzH0nIbCNrSkHAgmeeMNRuzdI6ZBGPDYcJaDA4kNhzmbWPmYZM8Q6yWG8mMjTPbnCV4JHiI1CLZc4yZARjIBhI8QL8kEOMXfvb+7z+AUVm///jhjTc+1NgQ1oLiSIkEUpRDtJCqYxSMglEwCkYGAACV+ULy83kfEAAAAABJRU5ErkJggg==","orcid":"","institution":"Tongxiang Maternal and Child Health Hospital","correspondingAuthor":true,"prefix":"","firstName":"Fengfang","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2026-01-13 01:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8585943/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8585943/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-026-06784-9","type":"published","date":"2026-03-26T16:10:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":105754972,"identity":"33b87026-8f73-4f09-8ee5-6ddbfc798b63","added_by":"auto","created_at":"2026-03-30 16:23:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322981,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8585943/v1/59e9e64b-3b9f-4a9d-b0c8-2c2a876a9f7b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLung Ultrasound for Neonatal Respiratory Distress in a Resource-Limited County Hospital: A pilot study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeonatal respiratory distress syndrome (RDS) remains a leading cause of morbidity in preterm infants [1]. While tertiary centers have widely adopted lung ultrasound (LUS) as a radiation-free alternative to chest X-ray (CXR), its implementation in grassroots institutions remains limited. In China, the management of neonates is increasingly shifting towards county-level hospitals [2]. However, these resource-limited settings often face specific challenges, including a lack of 24-hour radiology services and the risks associated with transporting unstable neonates for imaging [3].\u003c/p\u003e\n\u003cp\u003eAlthough LUS diagnostic features for RDS are well-validated in academic centers, evidence regarding its feasibility and clinical utility in primary care settings is scarce. Specifically, it remains unclear whether LUS serves merely as a diagnostic substitute or if it can guide triage decisions (e.g., transfer vs. local retention). This pilot study aimed to assess the diagnostic accuracy of LUS for RDS in a county-level maternal and child health hospital and to evaluate its role in clinical decision-making.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy Design and Population\u003c/p\u003e\n\u003cp\u003eThis single-center prospective observational study was conducted in the Neonatal Intensive Care Unit (NICU) of a county-level hospital in Zhejiang Province, China. The study protocol was approved by the local ethics committee. Written informed consent was obtained from parents. A total of 34 neonates exhibiting signs of respiratory distress within 24 hours of birth were enrolled. Exclusion criteria included congenital malformations and the need for immediate cardiopulmonary resuscitation.\u003c/p\u003e\n\u003cp\u003eLUS Protocol\u003c/p\u003e\n\u003cp\u003eBedside LUS was performed using a Philips EPIQ 5 system with a high-frequency linear probe (7.5–12 MHz). A standardized 6-zone scanning protocol was employed as previously described [4,5]. Each zone was scored from 0 (normal aeration) to 3 (consolidation), yielding a total score of 0–18. A score of 0 indicated normal A-lines; 1 indicated ≥3 B-lines; 2 indicated coalescent B-lines; and 3 indicated consolidation. All scans were performed by trained clinicians blinded to the CXR results.\u003c/p\u003e\n\u003cp\u003eDiagnostic Criteria\u003c/p\u003e\n\u003cp\u003eRDS was diagnosed based on clinical presentation, characteristic chest X-ray findings (ground-glass opacity and air bronchograms), and typical lung ultrasound features, including consolidation with air bronchograms, pleural line abnormalities, and the absence of A-lines [6].\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS 26.0. Continuous variables were compared using the Mann-Whitney U test. Diagnostic performance was assessed using Receiver Operating Characteristic (ROC) curve analysis. Factors associated with patient transfer were analyzed to determine the utility of LUS in triage. A \u003cem\u003eP\u003c/em\u003e-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic Characteristics and Diagnostic Accuracy\u003c/p\u003e\n\u003cp\u003eOf the 34 neonates, 17 (50%) were diagnosed with RDS. The RDS group had significantly lower gestational age and birth weight compared to the non-RDS group (Table 1). LUS scores were significantly elevated in the RDS group compared to the non-RDS group (median 10.0 vs. 5.0, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). ROC analysis indicated high diagnostic accuracy for RDS, with an Area Under the Curve (AUC) of 0.912. An optimal cut-off score of 9.0 provided a sensitivity of 70.6% and specificity of 94.1%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFactors Associated with Patient Transfer\u003c/p\u003e\n\u003cp\u003eTo evaluate the clinical utility of LUS in guiding triage, we compared transferred and recovery neonates (Table 2). Notably, despite the high diagnostic accuracy of LUS, the LUS score itself did not differ significantly between the transferred and recovery groups (median 9.0 vs. 8.0, \u003cem\u003eP\u003c/em\u003e = 0.123). Within the RDS group specifically, 64.7% (11/17) of infants were successfully managed locally despite having elevated LUS scores consistent with consolidation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis pilot study confirms that LUS is a feasible and highly accurate imaging modality for diagnosing neonatal RDS in a resource-limited county hospital (AUC 0.912).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA critical finding of our study is the dissociation between LUS severity scores and transfer decisions. Contrary to the hypothesis that higher LUS scores would independently drive patient referrals, our analysis revealed that transfer decisions were driven by multiple factors rather than the imaging score alone. This observation highlights the specific \"utility\" of LUS in primary care: it serves as a definitive diagnostic tool rather than a crude triage trigger.\u003c/p\u003e\n\u003cp\u003eBy accurately identifying RDS at the bedside, LUS eliminated diagnostic uncertainty (e.g., ruling out pneumothorax). However, clinicians correctly integrated this diagnostic information with physiological maturity to determine the level of care. Consequently, a subset of RDS patients with high LUS scores but sufficient maturity was successfully managed locally, preventing unnecessary transfers and keeping mothers and infants together.\u003c/p\u003e\n\u003cp\u003eThis study has limitations, including its single-center design and small sample size (n=34), which precluded multivariable regression. Additionally, while operators were blinded to CXR, they were aware of the clinical status. Nevertheless, these preliminary data support the implementation of LUS in county-level hospitals.\u003c/p\u003e\n\u003cp\u003eIn conclusion, bedside LUS is a robust tool for diagnosing RDS in resource-limited settings. Its application empowers grassroots clinicians to make precise diagnoses and safe management decisions, optimizing the allocation of healthcare resources.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Tongxiang Maternal and Child Health Hospital. Written informed consent was obtained from the parents or legal guardians of all participating neonates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFL and XZ conceptualized the study. FL, XZ, and YZ performed data curation and formal analysis. FL, XZ, YZ, and KQ contributed to the methodology. XZ was responsible for project administration and visualization. XZ drafted the initial manuscript. All authors contributed to manuscript revision and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the nursing and medical staff of the Neonatal Intensive Care Unit for their support during data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet 2012;379:2162-72.\u003c/li\u003e\n\u003cli\u003eLi X, Wang H, Liu Y, Han T, Zhu X, Guo Y, et al. A nationwide survey on the management of neonatal respiratory distress syndrome: insights from the MUNICH survey in 394 Chinese hospitals. Ital J Pediatr 2024;50:160.\u003c/li\u003e\n\u003cli\u003eSharma D, Kumar P, Bansal A, Farahbakhsh N, Shastri S, Sharma P, et al. The role of chest X-ray in the diagnosis of neonatal respiratory distress syndrome: a systematic review concerning low-resource birth scenarios. Glob Health Action 2024;17:2338633.\u003c/li\u003e\n\u003cli\u003eBrat R, Yousef N, Klifa R, Reynaud S, Shankar Aguilera S, De Luca D. Ultrasonography score to evaluate oxygenation and surfactant need in neonates treated with continuous positive airway pressure. JAMA Pediatr 2015;169:e151797.\u003c/li\u003e\n\u003cli\u003eRaimondi F, Yousef N, Rodriguez-Fanjul J, De Luca D, Corsini I, Dani C, et al. Point-of-care lung ultrasound in neonatology: classification into descriptive and functional applications. Pediatr Res 2018;84:631-637.\u003c/li\u003e\n\u003cli\u003eSweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et al. European consensus guidelines on the management of respiratory distress syndrome: 2022 update. Neonatology 2023;120:3-23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8585943/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8585943/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLung ultrasound (LUS) is increasingly used as a radiation-free alternative to chest X-ray (CXR) for diagnosing neonatal respiratory distress syndrome (RDS). However, evidence regarding its feasibility and clinical utility in resource-limited county hospitals remains limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective pilot observational study enrolled neonates with respiratory distress within 24 hours of birth in a county-level maternal and child health hospital. All infants underwent bedside LUS and CXR. LUS was performed using a standardized six-zone scanning protocol with a total score ranging from 0 to 18. Diagnostic performance of LUS for RDS was assessed using receiver operating characteristic (ROC) curve analysis. Factors associated with patient transfer were also analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 34 neonates were included, of whom 17 (50%) were diagnosed with RDS. LUS scores were significantly higher in the RDS group than in the non-RDS group (median 10.0 vs. 5.0, P \u0026lt; 0.001). LUS demonstrated high diagnostic accuracy for RDS, with an area under the ROC curve of 0.912. An optimal cut-off score of 9.0 yielded a sensitivity of 70.6% and a specificity of 94.1%. Notably, LUS scores were not significantly associated with patient transfer decisions (P \u0026gt; 0.05). Within the RDS group, 64.7% of neonates were successfully managed locally despite elevated LUS scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBedside LUS is a feasible and accurate diagnostic tool for neonatal RDS in resource-limited county hospitals. Its primary clinical value lies in establishing a definitive diagnosis rather than directly guiding transfer decisions, supporting safe local management of selected neonates based on overall clinical assessment.\u003c/p\u003e","manuscriptTitle":"Lung Ultrasound for Neonatal Respiratory Distress in a Resource-Limited County Hospital: A pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 18:31:29","doi":"10.21203/rs.3.rs-8585943/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-04T05:44:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T16:41:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T06:40:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106130336607687796624751864499956753751","date":"2026-02-21T10:59:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T15:00:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282498259267471508561589217262517849711","date":"2026-02-20T14:21:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330021630648614328956813515714962260544","date":"2026-02-17T18:04:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120450896668016184823186280131963219203","date":"2026-02-13T10:59:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T09:38:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-14T09:20:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-14T02:19:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-14T02:18:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-01-13T00:50:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"720a2c96-bdad-487c-b415-480a363ff04d","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:17:46+00:00","versionOfRecord":{"articleIdentity":"rs-8585943","link":"https://doi.org/10.1186/s12887-026-06784-9","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-03-26 16:10:41","publishedOnDateReadable":"March 26th, 2026"},"versionCreatedAt":"2026-02-18 18:31:29","video":"","vorDoi":"10.1186/s12887-026-06784-9","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06784-9","workflowStages":[]},"version":"v1","identity":"rs-8585943","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8585943","identity":"rs-8585943","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}