Rib-indexed posterior approach POCUS is a reliable, radiation-free modality for real-time lung recruitment assessment in neonates with NARDS, demonstrating noninferiority to CXR. Notably, our study is the first to propose the innovative use of Doppler ultrasound-guided vascular landmark identification to assist in first rib localization in neonates.

This protocol addresses critical limitations of conventional imaging, offering a safer alternative for dynamic monitoring in neonatal critical care.

Future multicenter studies integrating CT validation are warranted to confirm broader applicability.

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