Background: In the past, ultrasound has not been widely used for neonatal chest imaging due to the obscuring artifact generated by normal air-filled lung. Aim of work: This study aimed to determine the value of chest ultrasonography in comparison to chest x-rays in diagnosis and follow up of neonates with respiratory distress. Methods: This prospective study has been conducted at Neonatal Intensive Care Unit (NICU), Al-Azhar Assiut University Hospital from 1 st November 2019 to October 2020. The study was conducted to 50 neonates with moderate respiratory distress, 14 of them were females (28%) and 36 of them were males (72%). All newborns included in the study admitted to neonatal intensive care unit: 13 of them stabilized on nasal oxygen, 37 of them stabilized on Nasal Continuous Positive Airway Pressure (NCPAP) for 6 hours. 8 of them need mechanical ventilation based on clinical, arterial blood gases and lung ultrasonographic findings. Lung ultrasound was performed within 2 hours and repeated after 6 hours. Chest x-ray was performed and scored. Both Lung ultrasound score and chest x-ray score were used and compared for respiratory distress in neonates. Results: Lung ultrasound has important role in diagnosis and follow up of neonates with respiratory distress and considered higher than chest X-ray regarding its ability to detect different patterns of white lung in term of pulmonary oedema (B-Lines) (40%),consolidation(62%) and pleural effusion (8%). Conclusion:Lung ultrasound is a non-invasive, bedside and reproducible method that could improve the management of neonatal respiratory distress. After 6 hours of Nasal Continuous Positive Airway Pressure (NCPAP), neonatal lung ultrasound is a useful predictor of the need for intubation over chest x-ray.Respiratory distress syndrome was the main diagnosis of respiratory distressed infants followed by transient tachypnea of newborn, pneumonia, meconium aspiration syndrome (MAS), and finally pleural effusion.