The Utility of Lung Ultrasound Scoring in Predicting Post‐Extubation Respiratory Support After Congenital Heart Surgery

We read with great interest the article by Georgiev et al1 titled “The Utility of Lung Ultrasound Scoring in Predicting Post-Extubation Respiratory Support After Congenital Heart Surgery” published in the Journal of Ultrasound in Medicine. The authors are to be commended for addressing an important and clinically relevant topic, exploring the potential of lung ultrasound (LU) as a non-invasive, bedside tool to guide respiratory management in infants following congenital heart surgery—a population where timely intervention is critical. Their work adds valuable insight into the evolving role of LU in pediatric critical care and ventilator weaning strategies. However, despite these notable contributions, the study presents several additional limitations that warrant consideration and discussion. First, posterior lung regions were excluded from scanning, possibly missing dependent lung pathology. Excluding posterior lung zones—where dependent atelectasis and effusions are most prevalent—likely led to underestimation of lung aeration abnormalities, reducing sensitivity of LU scores in detecting pulmonary congestion or early respiratory compromise. For instance, Rouby et al2 emphasized that including posterior lung regions significantly enhances sensitivity and reproducibility of LU scoring in detecting loss of aeration, recommending a comprehensive anterior–lateral–posterior approach for accurate scoring. Second, the study did not integrate physiological or biochemical measures to validate LU findings. The study relies solely on LU and clinical observation without correlating findings with biomarkers (BNP, lactate) or invasive measures (EVLW index). This limits understanding of pathophysiological drivers behind LU changes and their specificity for pulmonary versus cardiac congestion. For instance, Kaskinen et al3 demonstrated a significant correlation between lung ultrasound scores and extravascular lung water, emphasizing the importance of integrating physiological or hemodynamic data to validate LU interpretations. Third, performing LU only once (≤4 h pre-extubation) may miss dynamic pulmonary changes occurring during the weaning period or after extubation, thus impairing predictive modeling of evolving lung conditions. For instance, Soummer et al4 demonstrated that serial lung ultrasound during weaning trials provides superior prediction of post-extubation distress compared to single measurements. Fourth, follow-up was limited to 48 h, missing delayed respiratory complications and recovery trends. Restricting follow-up to 48 h post-extubation omits late respiratory events, prolonged weaning, or readmission data—thereby limiting clinical relevance for outcome prediction. For instance, El Amrousy et al5 found predictive accuracy improves when LU is linked with long-term extubation success rates. Future studies should include posterior lung zones to capture dependent pathology more accurately. They should integrate biochemical and hemodynamic parameters to validate LU findings physiologically. Performing serial LU assessments before and after extubation is advised to monitor dynamic aeration changes. Additionally, studies should extend follow-up beyond 48 h to assess long-term respiratory outcomes and the durability of weaning success. In conclusion, while Georgiev et al1 highlight the promising role of lung ultrasound in predicting post-extubation outcomes, the omission of posterior lung assessment, lack of physiological validation, single pre-extubation imaging, and limited short-term follow-up restrict the study's interpretability. Addressing these aspects in future research will enhance the accuracy, clinical relevance, and long-term applicability of lung ultrasound in postoperative respiratory management for infants after congenital heart surgery. Data sharing does not apply to this article as no datasets were generated during the current study; all data were sourced from published literature.