Lung ultrasound is increasingly used in emergency departments, medical wards, and critical care units—adult, pediatric, and neonatal. In vitro and in vivo studies show that the number and type of artifacts visualized change with lung density. This has led to the idea of a quantitative lung ultrasound approach, opening up new prospects for use not only as a diagnostic but also as a monitoring tool. Consequently, the multiple scoring systems proposed in the last few years have different technical approaches and specific clinical indications, adaptable for more or less time-dependent patients. However, multiple scoring systems may generate confusion among physicians aiming at introducing lung ultrasound in their clinical practice. This review describes the various lung ultrasound scoring systems and aims to clarify their use in different settings, focusing on technical aspects, validation with reference techniques, and clinical applications.

Background Esophageal balloon calibration was proposed in acute respiratory failure patients to improve esophageal pressure assessment. In a clinical setting characterized by a high variability of abdominal load and intrathoracic pressure ( i.e. , pelvic robotic surgery), the authors hypothesized that esophageal balloon calibration could improve esophageal pressure measurements. Accordingly, the authors assessed the impact of esophageal balloon calibration compared to conventional uncalibrated approach during pelvic robotic surgery. Methods In 30 adult patients, scheduled for elective pelvic robotic surgery, calibrated end-expiratory and end-inspiratory esophageal pressure, and the associated respiratory variations were obtained at baseline, after pneumoperitoneum–Trendelenburg application, and with positive end-expiratory pressure (PEEP) administration and compared to uncalibrated values measured at 4-ml filling volume, as per manufacturer recommendation. Data are expressed as median and [25th, 75th percentile]. Results Ninety calibrations were successfully performed. Chest wall elastance worsened with pneumoperitoneum–Trendelenburg and PEEP (19.0 [15.5, 24.6] and 16.7 [11.4, 21.7] cm H 2 O/l) compared to baseline (8.8 [6.3, 9.8] cm H 2 O/l; P < 0.0001 for both comparisons). End-expiratory and end-inspiratory calibrated esophageal pressure progressively increased from baseline (3.7 [2.2, 6.0] and 7.7 [5.9, 10.2] cm H 2 O) to pneumoperitoneum–Trendelenburg (6.2 [3.8, 10.2] and 16.1 [13.1, 20.6] cm H 2 O; P = 0.014 and P < 0.001) and PEEP (8.8 [7.7, 15.6] and 18.9 [16.3, 22.0] cm H 2 O; P < 0.0001 vs . baseline for both comparison; P < 0.001 and P = 0.002 vs . pneumoperitoneum–Trendelenburg) and, at each study step, they were persistently lower than uncalibrated esophageal pressure ( P < 0.0001 for all comparisons). Overall, difference among uncalibrated and calibrated esophageal pressure was 5.1 [3.8, 8.4] cm H 2 O at end-expiration and 3.8 [3.0, 6.3] cm H 2 O at end-inspiration. Uncalibrated esophageal pressure swing was always lower than calibrated one ( P < 0.0001 for all comparisons) with a difference of −1.0 [−1.8, −0.4] cm H 2 O. Conclusions In a clinical setting with variable chest wall mechanics, uncalibrated measurements substantially overestimated absolute values and underestimated respiratory variations of esophageal pressure. Calibration could substantially improve mechanical ventilation guided by esophageal pressure. Editor’s Perspective What We Already Know about This Topic Esophageal pressure can be used as a surrogate for pleural pressure for optimizing mechanical ventilation However, surgeries such as pelvic robotic surgery involve fluctuations in abdominal load and intrathoracic pressure that may artificially influence esophageal pressure What This Article Tells Us That Is New This study enrolled patients undergoing pelvic robotic surgery and found that esophageal balloon calibration significantly improved assessment of esophageal pressure when compared with the conventional uncalibrated approach to measuring esophageal pressure