{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T04:59:49Z","timestamp":1780635589479,"version":"3.54.1"},"reference-count":84,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T00:00:00Z","timestamp":1780531200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background and Objectives: Lung ultrasound (LUS) has fundamentally transformed neonatal respiratory diagnostics, offering a radiation-free, bedside-applicable modality capable of guiding surfactant therapy, characterizing pulmonary pathology, and monitoring treatment response in real time. While surfactant replacement therapy is firmly established for neonatal respiratory distress syndrome (RDS), its role in acute complications\u2014specifically pulmonary hemorrhage (PH) and pneumothorax (PTX)\u2014remains uncertain and heterogeneous in clinical practice. This review examines how LUS-based phenotyping can improve the diagnostic precision and therapeutic sequencing of surfactant administration in these high-risk scenarios, and how comorbidities such as hemodynamically significant patent ductus arteriosus, persistent pulmonary hypertension, sepsis, and coagulopathy modulate clinical outcomes. Materials and Methods: We conducted a structured narrative review of studies published from 2020 onward, sourced from PubMed, Web of Science, Semantic Scholar, and Mendeley, using PRISMA-inspired selection principles. The search combined terms including \u201clung ultrasound,\u201d \u201cneonatal POCUS,\u201d \u201csurfactant therapy,\u201d \u201cpulmonary hemorrhage,\u201d \u201cneonatal pneumothorax,\u201d and \u201cLUS score.\u201d Studies focusing on neonatal populations, clinical LUS applications, and surfactant use in PH and PTX were prioritized. Results: Quantitative LUS scoring systems (range 0\u201318) predict surfactant need and re-dosing with AUC values of 0.85\u20130.87, outperforming clinical estimates alone. In PH, LUS reveals dense consolidation with alveolar flooding patterns, guiding the timing of rescue surfactant after hemodynamic stabilization; response monitoring via serial LUS is feasible and informative. In PTX, hallmark signs\u2014absent lung sliding, loss of B-lines, and the pathognomonic lung point\u2014allow diagnosis within seconds, guiding immediate thoracentesis and subsequent surfactant administration if underlying RDS is confirmed. Nationally implemented LUS protocols in neonatal intensive care units have demonstrated significant reductions in radiation exposure without compromising diagnostic accuracy. Conclusions: LUS-guided decision algorithms\u2014integrating ultrasonographic phenotyping, quantitative scoring, and hemodynamic assessment\u2014represent the current best framework for individualizing surfactant therapy in neonatal PH and PTX. Standardization of POCUS training and protocol implementation in neonatal units is essential. Prospective multicenter trials are urgently needed to define optimal indications, timing, and dosing in these vulnerable populations.<\/jats:p>","DOI":"10.3390\/children13060784","type":"journal-article","created":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T03:24:33Z","timestamp":1780629873000},"page":"784","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Lung Ultrasound-Guided Surfactant Therapy in Neonatal Pneumothorax and Pulmonary Hemorrhage: Pathophysiology, Diagnostic Ultrasonography, and Emerging Clinical Approaches"],"prefix":"10.3390","volume":"13","author":[{"given":"Adina Mihaela","family":"Frenti","sequence":"first","affiliation":[{"name":"Doctoral School, University of Medicine, Pharmacy, Sciences and Technology \u201cGeorge Emil Palade\u201d, 540142 Targu Mures, Romania"},{"name":"Clinical Department of Neonatology, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3210-2565","authenticated-orcid":false,"given":"Florin","family":"Filip","sequence":"additional","affiliation":[{"name":"Department of Pediatric Surgery, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"},{"name":"Faculty of Medicine and Biological Sciences, \u0218tefan cel Mare University of Suceava, 720229 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elena","family":"T\u0103t\u0103ranu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Biological Sciences, \u0218tefan cel Mare University of Suceava, 720229 Suceava, Romania"},{"name":"Clinical Department of Pediatrics, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5969-9205","authenticated-orcid":false,"given":"Vlad","family":"Dima","sequence":"additional","affiliation":[{"name":"Department of Neonatology, Filantropia Clinical Hospital, 011132 Bucharest, Romania"},{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roxana","family":"Axinte","sequence":"additional","affiliation":[{"name":"Doctoral School, University of Medicine, Pharmacy, Sciences and Technology \u201cGeorge Emil Palade\u201d, 540142 Targu Mures, Romania"},{"name":"Clinical Department of Pediatrics, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alina S\u00e2nz\u00e2iana","family":"Melinte","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Biological Sciences, \u0218tefan cel Mare University of Suceava, 720229 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirabela","family":"Dima","sequence":"additional","affiliation":[{"name":"Department of Puericulture and Neonatology, Victor Babe\u0219 University of Medicine and Pharmacy, 300041 Timisoara, Romania"},{"name":"Department of Neonatology, Clinical County Emergency Hospital No. 1 Timisoara, 300098 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iulia","family":"Ciubotariu","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"},{"name":"Doctoral School of Medicine, University of Oradea, 410073 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petronela","family":"Vicoveanu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Biological Sciences, \u0218tefan cel Mare University of Suceava, 720229 Suceava, Romania"},{"name":"Department of Obstetrics and Gynecology, Sf. Ioan cel Nou Emergency Hospital, 720224 Suceava, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Smaranda-Ileana","family":"Jurchis-Irimie","sequence":"additional","affiliation":[{"name":"Doctoral School of Medicine, University of Oradea, 410073 Oradea, Romania"},{"name":"Department of Physical and Rehabilitation Medicine, University of Oradea, 410073 Oradea, Romania"},{"name":"Department of Physical and Rehabilitation Medicine, Clinical County Emergency Hospital \u201cDr. Gavril Curteanu\u201d, 410157 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Smaranda","family":"Diaconescu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University Titu Maiorescu, 040441 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1016\/S0140-6736(23)00878-4","article-title":"National, regional, and global estimates of preterm birth in 2020, with trends from 2010: A systematic analysis","volume":"402","author":"Ohuma","year":"2023","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1016\/S2352-4642(21)00311-4","article-title":"Global, regional, and national causes of under-5 mortality in 2000\u201319: An updated systematic analysis with implications for the sustainable development goals","volume":"6","author":"Perin","year":"2022","journal-title":"Lancet Child Adolesc. 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