\r\n\tAt the same time, predicting and designing smarter, sustainable, resilient and livable cities is the desire of many governments and policy makers all over the world. However, there is not enough discussion around connecting the concept of smart and the concepts of desirable future cities including ‘sustainability, resilience and livability’. The concept “smart” can address intelligent transport systems for modelling and simulation, autonomous urban mobility, smart infrastructure, urban mobility, urban farms and sponge cities concepts. This book intends to provide an overview of emerging trends such as machine learning, artificial intelligence, internet of things and automation incorporated into powerful systems including online GIS to make a smarter, more sustainable, livable and resilient city.
",isbn:"978-1-83880-200-4",printIsbn:"978-1-83880-199-1",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"37ca01618d7f291efb11a4d115b9cb63",bookSignature:"Dr. Sara Shirowzhan and Dr. Kefeng Zhang",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9431.jpg",keywords:"Digital disruption, Environmental change, Rapid population growth, Smart city, Sensing technology, Remote sensing, Advanced GIS applications, Urban growth, Urban planning&management, Computational intelligence, Human-centric services, Big data evaluation, City environment monitor, Analytics and prediction, Smart City architecture, Water sensitive city",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 28th 2019",dateEndSecondStepPublish:"May 15th 2019",dateEndThirdStepPublish:"September 15th 2019",dateEndFourthStepPublish:"November 4th 2019",dateEndFifthStepPublish:"December 30th 2019",remainingDaysToSecondStep:"7 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!0,editors:[{id:"273838",title:"Dr.",name:"Sara",middleName:null,surname:"Shirowzhan",slug:"sara-shirowzhan",fullName:"Sara Shirowzhan",profilePictureURL:"https://mts.intechopen.com/storage/users/273838/images/system/273838.jpeg",biography:"Dr Sara Shirowzhan completed her PhD in Geomatic Engineering at UNSW and her strong capability in designing and conducting high quality multi-disciplinary research has been demonstrated by solving complex problems facing digital representation and analysis of the built environment and civil engineering infrastructures. Her areas of interest for research are automation, laser scanning technologies and robotics for construction, remote sensing and advanced GIS for Smart Cities and monitoring 3D urban growth, metric development for sustainability assessment and urban infrastructures. Some of her areas of expertise include lidar technology, machine learning algorithms and app development. She has taught and supervised students in architecture, urban planning and construction departments as a lecturer, and research supervisor in several universities for over 10 years.",institutionString:"University of New South Wales",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"UNSW Sydney",institutionURL:null,country:{name:"Australia"}}}],coeditorOne:{id:"300088",title:"Dr.",name:"Kefeng",middleName:null,surname:"Zhang",slug:"kefeng-zhang",fullName:"Kefeng Zhang",profilePictureURL:"https://mts.intechopen.com/storage/users/300088/images/system/300088.jpeg",biography:"Dr. Zhang graduated from PhD in Civil Engineering at Monash University. His research areas include stormwater quality monitoring and modelling, Water Sensitive Urban Design (WSUD) green technologies (e.g. green walls and biofilters) for stormwater/greywater management, WSUD treatment validation, advanced stormwater treatment methods and integrated urban water modelling. He is the research manager of the Sino-Australia Centre on Sponge City, a large international research centre that involves partnerships between UNSW, Monash University and Dajiang Environmental Corporation, working on research areas of green technology development, urban water modelling and novel technologies for stormwater management. He is also experienced with development of integrated urban water models, e.g. UrbanBEATS (a WSUD planning support tool) and Water Sensitive Cities Toolkit (a tool to quantify the multiple benefits associated with WSUD implementations based on multidisciplinary research).",institutionString:"University of New South Wales",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"UNSW Sydney",institutionURL:null,country:{name:"Australia"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"11",title:"Engineering",slug:"engineering"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"194667",firstName:"Marijana",lastName:"Francetic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/194667/images/4752_n.jpg",email:"marijana@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"62185",title:"Nonlinear Response on External Electric Field and Nonlinear Generalization of Fluctuation-Dissipation Theorem for Levy Flights",doi:"10.5772/intechopen.78549",slug:"nonlinear-response-on-external-electric-field-and-nonlinear-generalization-of-fluctuation-dissipatio",body:'As well known, the fluctuation-dissipation theorem (FDT) establishes the relation between two different physical phenomena: the fluctuations and the dissipation. The fluctuations or the stochastic motion are determined by random stochastic forces. The dissipation or the directed motion is determined by regular forces. Nevertheless in the linear case, they are related by the fluctuation-dissipation theorem (FDT). One of the first and well-known examples of this FDT is Einstein’s relation between diffusion coefficient
Here
We first recall the well-known Einstein’s arguments [1]. Let the diffusion current be
and the particles are in the equilibrium state and are described by Boltzmann’s distribution function:
where
Boltzmann’s statistics
Fick’s law for the diffusion current:
It also means that the root-mean-square displacement depends on time in a linear way and it is characterized by diffusion coefficient
Ohm’s law, which describes a linear dependence on electric field
Consequently, if one of these above assumptions does not hold, then we expect that Einstein’s relation is broken and the new generalized relation will be appeared.
Subsequently, we consider the case, when diffusion has an anomalous power character:
These anomalous stochastic processes were intensively studied [2]. The value
In this chapter, the Levy flights diffusion in an external weak electric field is considered. The problem consists of that the diffusion coefficient for Levy flight, which is determined in a usual way, has an infinite value:
It occurs due to the possibility of diffusing particle to move for an arbitrary distances at every step. So, if we apply the usual Einstein relation (1), then we obtain the infinite value for a mobility of particle
But it is not possible to have infinite value of mobility from the physical point of view. What does it means? We believe that it means Einstein’s relation in its usual form does not apply. Furthermore, we show that instead of linear response—Ohm’s law—another new nonlinear response is appeared in the studied problem. Namely, the drift velocity depends on a weak electric field in a nonlinear way:
Here,
It is necessary to emphasize that this nonlinearity occurs in arbitrary weak fields and it was a consequence of the anomalous Levy super-diffusion. In other words, Ohm’s law (the linear response to a field) holds in the case of usual diffusion and Ohm’s law does not apply at all for case of Levy flight super-diffusion.
This chapter was organized as follows. In Section 2, the preliminary generalization of Einstein’s relation for a Levy flights was obtained. The qualitative estimations for drift velocity in two cases of super diffusion and usual diffusion were obtained too in Section 2. In Section 3, the one-dimensional discrete Levy flight diffusion was studied. The stable non-Gaussian distribution was deduced. The problem of Levy random walks in an external electric field or anisotropic Levy diffusion was studied in Section 4. The numerical simulations of Levy flights in an electric field were presented in Section 5. In Section 6, obtained new results for particle mobility were represented in the scaling form. The fluctuation-dissipation theorem for Levy flight case was rewritten in the scaling form also in Section 7. Section 8 concludes the chapter and the discussion of results was given in this section.
Let us briefly remind the Levy flights diffusion. A feature of Levy flight random walks consists of the possibility for a diffusing particle to move on arbitrary large distances at every step, so that the root-mean-square displacement appears to be infinite. The numerical simulation of Levy hops diffusion has shown that the points, visited during Levy flights diffusion, have formed spatially well-defined clusters. “For more in-depth consideration it makes easy to see that each of clusters consists of a collection of clusters, in turn, so a structure of self -similar clusters was appeared due to Levy flights” [6]. The probability distribution function
where A and μ are positive quantities,
Let us check the above three assumptions for Einstein’s relation—formulae (2–4) in the case of anomalous Levy flights super-diffusion. The first assumption about Gibbs-Boltzmann’s statistics keeps the same, because the type of statistics—Gibbs- Boltzmann’s classical statistics—was determined by the statistical properties of the system in the equilibrium and it does not depend on the kinetic properties of the system. (The kinetic phenomena as relaxation and diffusion describe the processes or ways, which lead to the equilibrium state, only.) So we use Gibbs-Boltzmann’s distribution function too. But the second assumption about Fick’s law for diffusion current is broken. The diffusion current has another form in the Levy flights case, and we write it in a general operator form:
Here,
And in the
where
where
In the case of the anomalous diffusion, we obtain
By taking a definition for the derivative of the fractional order in the form of the set [10]:
we recover that the drift velocity depends on the homogeneous electric field
It should be emphasized that this nonlinearity occurs in arbitrarily weak fields, and it was a result of the unusual anomalous character of Levy flights diffusion. The exponent of this nonlinearity relates with the critical exponent of the Levy hop diffusion as above (9):
Subsequently, we want to confirm the result (17), which was obtained from the phenomenological approach, in another way. For this aim, we consider the problem of diffusion in an electric field in more details. When we introduce the electric field into the diffusion problem, then the new “field” length, governed by external electric field, was appeared:
To understand physical sense of this new “field” length and to make necessary estimations for drift velocity, let us imagine that the medium was partitioned into the boxes of size
where
In the case of usual diffusion, this diffusion time equals to:
In the case of Levy flight, the diffusion time is proportional to powers of “field” length:
Here,
We want to stress that these preliminary generalizations of Einstein’s relation in Section 2, see formulae (17, 21), only reveal the possibility of new nonlinear behavior for drift velocity in the anomalous super-diffusion case. To prove this result in an exact way, we need to study the microscopic model.
To prove the fluctuation-dissipation for Levy flights diffusion case, let us consider the one-dimensional Levy flights diffusion in more details. Briefly, we remind how the Levy stable law (10) for distribution function has been obtained. Let us denote the probability of particle to occupy
Here,
where
To simulate a Levy flight, the following Weierstrass function has been used as
Here, parameter
Let us shortly discuss the physical picture of Levy flight diffusion. Due to power distribution of hops over the lengths according to (25), the diffusing particle prefers to hop at nearest sites due to the biggest probability for nearest sites, to create the cluster from the nearest visited sites. But there is a small possibility to make a long hop from time to time. After this long hop, the new cluster of another nearest visited sites has formed at new place. So finally, the structure of self-similar clusters appears [6]. So we can say that Levy diffusion is the random walks along self-similar clusters.
Then the structural function for such random walks is equal to
Note too that the structural function of Levy flight satisfies the functional equation:
Therefore, for k → 0, it has a power behavior:
Exactly, the nonanalytic power behavior for
Let us introduce an anisotropy into the random walk on self-similar clusters, formed during Levy flights diffusion. By virtue of specific nature of Levy hops, a particle can move for an arbitrary distance
Hence, we obtain the following expressions for these probabilities:
Therefore, the structural function λ (k; E) for Levy flights diffusion in an electrical field is equal to
As well as for the usual ordinary diffusion, the second member with anisotropy for small k → 0 contains the expression for the drift velocity:
here
It is easy to see that the drift velocity satisfies the following functional equation:
It means that at weak fields
with exponent
To calculate the velocity by exact way, we used Poisson’s formula:
After calculations, we obtain the formula for the velocity:
where a power exponent is equal to γm = μ + 2π mi /ln b. It is easy to see that for arbitrary weak fields
Subsequently, the results of numerical simulations of Levy random walks were reported. Let us briefly explain the algorithm of simulations. Probabilities of left and right walks are determined as probabilities to have a random value from [0, 0.5] and [0.5, 1] correspondingly. The anisotropy of random walks is simulated by the decreasing length of [0, 0.5] for quantity W− anti-parallel field and increasing [0.5, 1] for quantity W+ in parallel field case. The simulations are made at different values of parameters a and b. As the probability
The results of random walks, Figure 1, are in accordance with the known results [2].
Typical dependence of RMS for Levy flight.
The step-like dependence of rms as a function of time is easy to understand as follows. The particle diffuses at nearest sites mainly, making the cluster from visited sites, and with a small probability hops at big distance (at next step) and again diffuses at nearest sites and so on.
The electric field leads to the particle drift. The dependence of the average displacement
Dependence of the average displacement <X(t) > on number of hops N.
These results are represented in Figure 3. The main distortion in the simulations is due to the random character of walks, and it was checked in the calculations from values of average displacement at zero fields.
Dependence of relation μexp/μtheor at different values of anisotropy.
In this section, we additionally introduce the usual diffusion on the nearest neighboring sites in the process of random Levy walks. It gives us the possibility to proceed the transition from Levy super-diffusion to the usual diffusion. For this aim, the finite hop length
Hence, the structural function for complex random walks with Levy diffusion and ordinary diffusion is equal to
In the case of complex alternative diffusion, the main contribution to the root-mean-square displacement was provided by Levy flights on long times, corresponding to big scales. Correspondingly, on small times and at small scales, the main contribution was provided by the usual diffusion. In the limit of the small lengths of hops
We consider this transition
Let us introduce the anisotropy into these complex random walks as described earlier, but now we replace the hop length
Accordingly, the velocity has been described by the following formula:
To calculate this sum in formula (42), Poisson’s method of summation has been used again.
The following results have obtained. For weak electric fields (
and in the strong fields (
Note that the particle velocity has two asymptotic regimes in accordance with the diffusion limits: Levy hops and usual ordinary diffusion. The Levy flight diffusion leads to the nonlinear response, and the usual diffusion leads to the linear Ohm’s law. So the two different power dependencies of particle mobility (43, 44) were obtained for a specific distribution of hops as (38). But before this result was obtained without any assumptions about the nature of hops, only specific form of Levy diffusion current was used as (11). And now, we consider the specific distribution of hops (38) only as microscopic model. We believe that the same nonlinear result will be correct for another hops distribution over lengths.
We want to remark that above results look similar to the phase transition theory results [12, 13]. First of all, we have the analog of correlation radius for phase transition
So to clarify the obtained results, the expression for the particle mobility
where
For our model of Levy flights diffusion, this scaling exponent
At the small scales
Usually, the Einstein relation between diffusion and conductivity was considered as a simple example of fluctuation-dissipation theorem (FDT), which was connected by the different characteristics of the considered system: the dissipation, described by the relaxation time
We want to stress that this obtained nonlinearity (43) essentially differs from the usual nonlinearity, and our result means that the relation between the nonlinear mobility and the coefficient of diffusion existed in the new nonlinear form, when the mobility became as nonlinear function of the electric field
Here,
It seems that this investigated case was a first case when the fluctuation-dissipation theorem in the usual form of linear relation between two coefficients was broken. And instead of simple relation between linear coefficients, the new and more general relation between exponents of mobility and exponent of the super-diffusion appeared.
From this point of view, we believe that the case of usual diffusion or Einstein’s relation between two coefficients of diffusion and mobility is the limiting case of new generalized FDT between exponents of mobility of particle in an electric field and exponent of diffusion:
Let us discuss the results. All the above obtained both the nonanalytic behavior of structural function for small k → 0 and the nonlinear electric field dependence of the velocity in arbitrarily weak fields which were the asymptotical results. We show that the current (velocity) depends on electric field in a nonlinear way due to the anomalous character of Levy flights and possibility to fly at arbitrary distances:
Nonlinear properties of media intensively have been studied. Usually, the nonlinearity has been connected with the expansion of electric current for set in powers of the electric field and with consideration of the cubic nonlinearity [14]:
But our result essentially differs from the results, obtained by this method. We show that in the investigated case of Levy super-diffusion, the nonlinear behavior appeared due to anomalous super-diffusion character and the electric current depends on electric field in a power nonlinear way. It means that Ohm’s law or a linear term was absent in the field series expansion of the current (58) in the investigated case.
The generalization of fluctuation-dissipation theorem for a case of Levy flights diffusion was obtained. Instead of well-known Einstein’s relation between diffusion coefficient
It is interesting to note that from the above-obtained results, we understand what two results were contained in Einstein’s relation (1). Firstly, we can say that Einstein recovers or proves the existence of Ohm’s law (linear response) for any systems with usual diffusion, and secondly, he established the relation between diffusion coefficient and mobility of particle in a linear case.
As for “real” systems, the different theories with different predictions have been existed and numerical simulations have not given a clear answer yet: the non-monotonically dependence with time were founded [15, 16]. We hope that these results may be applied for real disordered systems and in particular also for the problem of hopping in the disordered systems, but we need to make further investigations for it [17].
Point-of-care ultrasound (POCUS) is an imaging modality that continues to gain acceptance in pediatric and neonatal medicine. While ultrasound initially served as a clinical tool with a consultative model with radiology and cardiology disciplines, the value of POCUS in assessment of the heart and other organs is slowly being recognized. In neonatology throughout many areas of the world, functional echocardiography performed by neonatologists has been at the forefront in the growth of POCUS compared to non-cardiac POCUS. Technological advances have pushed ultrasound (US) to have improved image quality and mobility while reducing cost and size of devices increasing the availability of ultrasound as a point-of-care bedside tool in several areas such as emergency medicine, obstetrics, and intensive care. Despite the early adoption in obstetrics and maternal-fetal medicine, the actual bedside implementation in neonatology has unfortunately been much slower. Examples in neonatology where POCUS may continue to expand include central line placement, endotracheal tube localization, diagnosis of pneumothoraces, cardiac function assessment, and bowel viability assessment just to name a few. What follows is a practical synopsis of the most active uses and opportunities for POCUS in neonatology.
The newborn brain is readily accessible for sonographic imaging by the open soft tissue windows of the anterior fontanelle and the open sutures found between the unfused cranial bones. Neonatologists are quite familiar with viewing and interpreting cranial ultrasound images as these are routinely reviewed daily on clinical rounds. The primary views are coronal (front to back), sagittal (left to right) and axial views for posterior fossa [1]. POCUS can provide excellent views of the general architecture of the brain especially the two ventricles, evaluation of hemorrhage or calcifications and early evidence of ischemic changes. The use of POCUS for brain imaging is particularly useful when suspect hemorrhage may be responsible for deterioration or hemodynamic instability, at times when sonographic support is not readily available. The detection of increased pressure, cerebral edema or stroke is not sensitive with HUS and other imaging modalities such as CT or MRI are recommended. It is important to remember that these evaluations are limited in evaluating this triangulated view of the brain and can miss events or lesions outside of this window in the parietal regions. Head ultrasound is one of the easier techniques to learn for neonatologists since the views are already very familiar to them. The imaging techniques hinge upon establishing stable upright views of the two hemispheres and axial views of the posterior fossa structures. Neonatal providers have ample experience in reviewing and interpreting head ultrasounds for common pathology such as periventricular leukomalacia, intraventricular and intracranial hemorrhages and so most of the skills are focused on imaging.
Central vascular catheters such as umbilical arterial catheters (UAC), umbilical venous catheters (UVC), and peripherally inserted central catheters (PICC) are the most common central catheters placed in the sick neonate. Any neonate born at less than 32 weeks gestation will have at least a UVC and/or a PICC during their admission for nutrition and/or medications. In most units all of these lines are placed blind and confirmed with a single radiograph. UVC tip localization by standard radiography is imprecise. In one study approximately 30% of the radiographs were read as normal but actually had the UVC tip in the right atrium when checked with US [2]. Radiographic localization of UVC on anterior–posterior (AP) is difficult to place in ideal position because of the doming of the diaphragm. The lateral chest radiograph is better than the AP view of the chest but this view is not as convenient with the infant typically secured down for the procedure.
Ultrasound more accurately confirms the position of the catheter tip than radiographs and reduces the exposure of ionizing radiation. Ultrasound guidance results in faster placement and fewer manipulations and radiographs for both umbilical catheters and PICC as compared with conventional placement [3, 4]. POCUS can be very useful in localizing the tip of central catheters either during placement or after a catheter has been placed to follow any migration. Umbilical catheters can frequently migrate after placement in the first few days after insertion. This may be due to drying and shrinkage of a longer umbilical cord. POCUS allows for the direct visualization of the umbilical and PICC catheters and their tips and indirect visualization of the UVC in the hepatic portion of the catheter pathway where it is localized by the shadow cast by the catheter [4]. Ultrasound may be able to help guide the catheter and thereby reduce complications during UVC, UAC, or PICC insertion. Doppler ultrasound is also useful to examine the aorta and renal vessels when placing or evaluating a UAC (Figure 1).
Umbilical catheter placement (a) UVC-umbilical venous catheter, (b) UAC-umbilical arterial catheter.
Use of POCUS for vascular access for PICCs has been limited due to the greater skillset required to accessing these small veins compared to older children. Setting up dedicated PICC teams can help develop this expertise to promote this aspect of central catheter POCUS.
With US, the UVC can be placed just beyond the IVC-RA junction. This permits good visualization and eliminates any risk of extravasation of the catheter in the liver. The UAC is readily placed just behind the heart which approximates the T7–8 position. The recognition of PICC movement in the large vessels makes it particularly challenging to manage the best position to place these catheters. Movement of the arm or leg to identify the deepest position of the PICC will ensure that the catheter does not inadvertently migrate deeper after placement and cause more risk of complications. For upper PICCs the arm position in a 45 degree flexed position at the shoulder and elbow usually represents the deepest point for a PICC while the knees bent close to the chest represent the deepest point for lower PICCs. The upper PICC can be placed at least 1 cm before the SVC-RA junction while the lower PICC is placed at 1–2 cm below the IVC-RA junction (Figure 2).
PICC localization (a) upper PICC, (b) lower PICC, PICC-peripherally, inserted central catheter, RA-right atrium, SVC-superior vena cava, IVC-inferior vena cava.
Other areas of benefit from POCUS in the NICU are arterial line placement where localization of the vessel and flow identification by Doppler ultrasound can be performed. A modified Allen test with Doppler ultrasound evaluation of collateral flow is useful prior to the procedure. Real-time ultrasound can result in fewer attempts and less chance of a hematoma as compared with palpation.
The use of echocardiography has aided the evaluation of cardiac anatomy and function of the unborn fetus and the newborn. Ordering an assessment of the heart by ultrasound is a routine practice in the NICU. There has been a need to supplement the clinical assessment and current hemodynamic monitoring as they do not provide a comprehensive picture of cardiac output and organ perfusion states. The need for serial measurements is another unmet need with routine cardiac echocardiograms since transitional physiology after birth and during illness often require repeated measurements. Bedside POCUS for cardiac assessment is still an emerging practice as training to evaluate the heart is one of the hardest POCUS skills. Despite its difficulty there are probably more neonatologists worldwide with training to assess the heart through limited functional assessments than there are for non-cardiac POCUS. Cardiac POCUS is not intended to replace a cardiology assessment or structural echocardiogram. It is intended to be limited and dynamic assessment of hemodynamic of the heart to help with clinical decision making. Cardiac assessment in neonates is unique due to the dynamic changes that occur in the first few weeks of life making it challenging to order frequent dynamic assessments. The ability to help determine rapid determination of hemodynamics with serial functional assessments makes it increasingly attractive to work it into the daily workflow [5]. The focus of neonatal cardiac POCUS is to concentrate on a limited set of assessments that are helpful in determining the real-time hemodynamics. These include assessment of the patent ductus arteriosus (PDA), ventricular function, filling of the heart and volume assessment.
To start, cardiac POCUS can provide a rapid qualitative assessment of contractility: normal, hyperactive, reduced contractility (mild, moderate, or severe). Fractional shortening measurements are relatively easy to obtain and provide quantitative information. Cardiac filling as a measure of volume assessment can also be determined quickly. The PDA represents an important shunt to assess to facilitate clinical management to determine if the PDA is contributing to cardiorespiratory compromise or systemic hypoperfusion. The PDA can be determined to be open or closed (Figure 3). The presence of a patent ductus arteriosus can lead to an overestimate of cardiac output using usual left ventricular output measurements. An alternative measure of cardiac output using superior vena caval flow (SVC) measurements as a surrogate measure has been proposed [6, 7, 8, 9]. Unfortunately, SVC flow has not become widely used as it has proven to be difficult to minimize inter-operator variability in this measurement. While several examples of benefit of neonatal cardiac POCUS have been published, there remains a paucity of neonatal clinical studies to validate each of the functional assessments and their ability to improve diagnostic or management of the sick neonate [10, 11]. As more neonatologists become comfortable with the skillset of cardiac echocardiography, there is a need for improved standardization and quality assurance [12, 13]. There have been some attempt to standardize the practice but many feel that the standards set are excessive and restrict early adoption [14, 15]. The anatomic assessment of the heart for the most part should be left to the cardiologist but it is equally important to recognize patterns of normal structure to know when there is suspicion of a congenital heart lesion.
PDA (a) large PDA, (b) no PDA, LPA-left pulmonary artery, DA-descending aorta.
Nevertheless, despite a number of hurdles, there remains tremendous promise that neonatal cardiac POCUS can provide a focused assessment to provide hemodynamic information to the bedside clinician.
The evaluation of lung by POCUS in neonates is increasingly practiced as the imaging technique is relatively simple and the lung is readily accessible for interrogation through the chest wall. Several recent articles have noted lung ultrasound to be as good if not better than X-ray as a diagnostic modality. Reduction in cost of image acquisition and exposure to ionizing radiation improves quality of care as well as patient safety [16]. Neonatal lung POCUS is similar to pediatric lung POCUS except that the neonate has very thin soft tissue in the chest with thin ribs and a cartilaginous sternum that enables larger windows of viewing. From a technical perspective, we need a high frequency transducer like a 7–15 MHz hockey stick or equivalent linear array transducer. The detection of common respiratory conditions has been documented making it potentially possible to define the parenchymal lung disease by characteristic patterns to the common respiratory conditions such as pneumonia (PNA), transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS). The ability to make an urgent diagnosis is where the greatest utility of lung POCUS may lie as acute respiratory compromise often requires rapid diagnostics. The presence of air or fluid such as blood, transudate or exudate in the pleural space is readily discernable by US.
The complication of spontaneous pneumothorax (PTX) at birth is one such condition that may be aided by lung POCUS. PTX will display several differing US patterns compared to normal lung. The characteristic findings on US of PTX in neonates are similar to adults and children (Figure 4). Normal lung appears homogeneous in texture with the occasional presence of hyperechoic linear A (horizontal) and B (vertical) lines. Movement of the parietal and visceral pleura against each other during respiration creates a “shimmering effect” or an “ants marching effect” which is termed lung sliding. The presence of the sliding lung sign rules out a pneumothorax on B mode [17]. Further confirmation of a PTX can be achieved with M mode which displays the data from a single line in an image mapped against time on the x-axis. The appearance of moving lung tissue results in a granular appearance similar to a sandy “seashore” with the “waves” at the top representing the static soft tissue above the lungs. Some data suggests that US may not be as sensitive for PTX in neonates [18].
Pneumothorax (a) normal lung, (b) pneumothorax.
The underlying changes in RDS involve loss of the smallest airspaces (alveoli or saccules). This generates denser tissue that gives the appearance of “white lung” using lung POCUS. Some have proposed a scoring system to categorize lung disease in RDS to assist in increasing specificity for diagnosing RDS [19]. This score can reliably predict the need for surfactant treatment in preterm babies less than 34 weeks gestation treated with nasal CPAP from birth. Several studies have validated the ability to distinguish between RDS and transient tachypnea of the newborn (TTN) [20, 21]. In TTN ultrasound changes include abnormalities of pleural lines, absence of A-lines, and interstitial syndrome or pulmonary edema. Pneumonia has been described to have A-lines, interstitial syndrome and possible lung consolidation. Lung POCUS has been able to differentiate meconium aspiration syndrome from other respiratory conditions since it is also associated with absent A-lines, lung consolidation, and interstitial syndrome.
The role of lung ultrasound may not replace chest radiographs but may offer more time sensitive information and reduce the total number of radiographs taken. The evaluation of lung by POCUS in neonates is increasingly being studied and practiced. The most promising application may be during resuscitation where early detection and management of conditions like pneumothoraces and pleural effusions are life-saving.
Neonatal intubation remains a difficult high level skill. Although there are much less intubations taking place compared to a decade ago, the need to establish a secure airway remains ever important. This is particularly true for resuscitation of neonates <28 weeks gestation. The current standard of practice to confirm the placement of the endotracheal tube (ETT) is with chest x-ray (CXR).The passage of the ETT into the trachea or esophagus can be discerned readily using a transverse probe position in adults and pediatric subjects [22, 23, 24, 25]. POCUS can be used to rapidly and accurately visualize the anatomic position of the ETT position in preterm and term infants [26] (Figure 5). Unlike in pediatric or adult patients, evaluating the ETT in the newborn through the chest is possible due to the cartilaginous sternum. Although there is air inside and around the ETT and the entry is at a steep angle to the ultrasound probe, the tip of the probe can be identified with a white or hyperechoic line. The ideal location for the tip of the ETT is midway between the thoracic inlet and the carina. Identifying the distance of the tip of the ETT from the carina can be accurately measured. In a recent publication of an extensive database literature search on studies relating to US use for ETT position confirmation found nine studies which collectively reported a > 80% visualization of the ETT tip by US [22]. Also, US interpretation of the ETT position correlated with the XR position in 73–100% of cases. US appears comparable to XR determining ETT position in this population. As US is more easily available and is safer than CXR, it may be a better modality for confirming proper placement of ETT in neonates when time is critical. There are no current data yet on identifying tip location during placement of the ETT and so more clinical data may be required before widespread adoption.
Endotracheal tube placement ETT-endotracheal tube, RPA-right pulmonary artery.
The assessment of bowel by POCUS in neonates remains an emerging practice despite the availability of clinical data in neonates for more than a decade. POCUS can show dynamic intestinal peristalsis as well as characterize the physical nature and perfusion of bowel that can be used to assess bowel integrity and viability. The newborn can be affected by a variety of congenital and acquired bowel conditions that may lead to significant bowel dysfunction or even death. Early recognition of the signs of impending bowel injury or the progression of bowel damage is essential. Intestinal peristalsis can be quantified by counting cumulative motility events over time to give an objective assessment of bowel movement [27]. Identifying peristalsis can assist in the routine management of neonatal feeding or bowel assessment but more studies are required to validate its utility for clinical outcomes (Figure 6). Some other studies have demonstrated that gastroesophageal reflux can be evaluated by POCUS both identifying anatomic risk factors as well as visualizing the bolus but this has not gained traction in clinical practice yet [28, 29].
Normal bowel appearance.
Recent data suggest that dedicated abdominal ultrasound examination may be of utility in the diagnosis and management of infants with necrotizing enterocolitis (NEC). Advantages of ultrasound include assessment of peristalsis, vascular perfusion, bowel-wall thickening, and abdominal fluid. Absence of ionizing radiation is an added benefit. A recent meta-analysis showed that bowel ultrasound is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail over plain abdominal radiographs [30]. There are still only few studies with small case series and heterogeneous gestational age population that have investigated the comparison between plain radiographs and abdominal ultrasound in predicting the outcomes of patients with NEC.
NEC is one of the most severe gastrointestinal conditions affecting neonates. The risk increases with degree of prematurity and in those with low birth weight [31, 32, 33, 34, 35]. Although risk factors have been identified, the etiology is still not well recognized. Despite significant advances in neonatal care, mortality in NEC remains high (between 20 and 60% in a group of most immature neonates) and maintained at the same level. Therefore, in cases of clinically suspected NEC quick diagnostics and implementation of appropriate treatment are crucial [34, 35, 36]. Diagnosis is based on clinical presentation, laboratory testing and imaging. Traditionally, the gold standard for imaging evaluation of the neonatal intestine is the intestinal gas pattern on plain abdominal radiographs; however interpretation can be challenging with intestinal gas pattern being nonspecific [37, 38, 39], and significant overlap between radiographic signs of NEC and other intestinal pathology [40].
The usefulness of abdominal ultrasound in the diagnosis of NEC has been known since 1984 as evidenced in a number of studies [41, 42, 43]. Studies have looked at ultrasound being an adjunct to diagnose and manage infants with NEC. It allows for an earlier detection of typical signs of NEC, with more rapid disease management. When compared with abdominal radiographs in predicting NEC, studies showed that they can depict bowel distension, to some extent bowel-wall thickness, pneumatosis intestinalis, portal venous air and free abdominal air which ultrasound could easily depict as well. More importantly, abdominal ultrasound provides important additional information regarding viability of bowel wall viability and free fluid, which might aid in diagnosis and management of NEC [44, 45]. With color Doppler specific suspicious loops of bowel can be interrogated to reveal if they are perfused or not which enables the identification of non-viable bowel with a high degree of certainty. The gradual progression of NEC can be identified by POCUS from the initial hyperemia and swelling of bowel wall to the dilatation with increased disease and then thinning of bowel wall with loss of perfusion or blood flow. Therefore, nonviable bowel will no longer have any blood flow present (Figure 7Epelman diagram). The detection of portal venous gas is much easier by POCUS than by radiographs [46].
Sonographic appearance of NEC progression (figure from Epelman et al. 38 need permission).
For performing bowel ultrasound a linear probe of 8–15 MHz probe (higher frequency for higher resolution and lower depth targeting superficial structures). Features that are key include: (a) bowel wall thickening >2.6 mm, (b) increase in bowel wall echogenicity, (c) portal venous air, (d) pneumatosis Intestinalis and free air and (e) intra-abdominal fluid.
Some limitations of ultrasound include that it is operator or skill dependent and this is a real time diagnosis which might create an obstacle for radiologists to evaluate the ultrasounds retrospectively and in turn underlines the need for neonatologists to be more familiar with this tool. Currently most of the available literature are single center trials, retrospective observational cohorts. We still need more prospective studies doing head to head trials with abdominal radiograph to understand the true value and usefulness of abdominal US. More studies are required to fully validate these assessments in clinical care. Training of radiologist and their sonographers as well as other providers such as neonatologists and surgeons is required before broad adoption of bowel POCUS occurs.
Bladder aspiration through suprapubic urine collection is ideal to perform under ultrasound guidance over landmark techniques. Ultrasound of the bladder can help determine the size and location of the bladder and the volume of urine in the bladder. Portable ultrasound can significantly improve the diagnostic yield; a minimum volume on ultrasound of 10 mL is associated with a 90% successful bladder aspiration. If the cephalocaudal diameter of the bladder (sagittal view) is >20 mm and the anteroposterior diameter is >15 mm, the success rate approaches 100%.
Lumbar puncture (LP) is a relatively common procedure performed in emergency department and the NICU as part of a complete sepsis evaluation. The LP is typically performed using the “blind” surface landmark guidance. Anecdotally, this technique is reported to be have a high percentage of success. However successful identification of landmarks has been shown to be accurate only 30% of the time [47]. Traumatic or unsuccessful LPs in this group have been documented in the pediatric literature in 30–50% of patients [48, 49]. This translates to increased difficulty in obtaining CSF and higher rate of complications such as local/subdural/epidural hematoma, bloody tap and incomplete sepsis evaluation to name a few. Fluoroscopy guided LP is an alternative but challenges include limited availability, radiation exposure, need to transport critical patients for the procedure.
Use of POCUS for identification of key landmarks is a safe and easy alternative to the blind method [50, 51, 52]. In adults, using ultrasound for LP has been associated with a reduction in the number of attempts and interspaces accessed [51, 52, 53, 54, 55]. In neonates, the incompletely ossified spinous processes, minimal fat aids in interrogation of the space by ultrasound compared to older kids and adults. The good resolution of image, lack of ionizing radiation and potential for real time guidance makes ultrasound a valuable tool for performing LP in neonates [48, 56].
LP can be performed in the neonate without general anesthesia or sedation, using oral sucrose and local anesthesia. Patient can be in lateral decubitus position or sitting up. Using ultrasound to measure the interspinous space at L3-L4 and L4-L5 in varying positions, the lumbar spine is found to be maximally positioned in both neonates and children in the seated position with flexed hips versus the lateral decubitus position [57, 58]. The probe used is the 7–15 MHz hockey stick or equivalent linear array transducer. There is still very limited knowledge on ultrasound guided LP in neonates. There are two techniques described in literature, the transverse approach and longitudinal approach based on how the probe is held.
The first skill is to define the landmarks for the LP procedure. Using a surgical marker or pen one can delineate the location of midline and the position of the conus, the point where the spinal cord ends. There are no studies validating the guidance of the needle into the interspace and so this will require more studies before guidance by US is a routine procedure.
Existing and emerging POCUS applications are numerous and promising but more validation for clinical value is required in addition to larger scale training of individuals to learn and become competent in these techniques. Emphasis should be on training all incoming and existing fellows to learn POCUS.
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