Neonatal lung ultrasonography score after surfactant in preterm infants: A prospective observational study

Predicting extubation failure in preterm infants using lung ultrasound: a diagnostic accuracy study

OBJECTIVE

To determine the accuracy of pre-extubation lung ultrasound (LUS) to predict reintubation in preterm infants born <32 weeks' gestation.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Two neonatal intensive care units.

METHODS

Anterior and lateral LUS was performed pre-extubation. The primary outcome was the accuracy of LUS scores (range 0-24) to predict reintubation within 72 hours. Secondary outcomes were accuracy in predicting (1) reintubation within 7 days, (2) reintubation stratified by postnatal age and (3) accuracy of lateral imaging only (range 0-12). Pre-specified subgroup analyses were performed in extremely preterm infants born <28 weeks' gestation. Cut-off scores, sensitivities and specificities were calculated using receiver operating characteristic analysis and reported as area under the curves (AUCs).

RESULTS

One hundred preterm infants with a mean (SD) gestational age of 27.4 (2.2) weeks and birth weight of 1059 (354) g were studied. Thirteen were subsequently reintubated. The AUC (95% CI) of the pre-extubation LUS score for predicting reintubation was 0.63 (0.45-0.80). Accuracy was greater in extremely preterm infants: AUC 0.70 (0.52-0.87) and excellent in infants who were <72 hours of age at the time of extubation: AUC 0.90 (0.77-1.00). Accuracy was poor in infants who were >7 days of age. Lateral imaging alone demonstrated similar accuracy to scanning anterior and lateral regions.

CONCLUSIONS

In contrast to previous studies, LUS was not a strong predictor of reintubation in preterm infants. Accuracy is increased in extremely preterm infants. Future research should focus on infants at highest risk of extubation failure and consider simpler imaging protocols.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12621001356853.

Advanced Diagnostics of Respiratory Distress Syndrome in Premature Infants Treated with Surfactant and Budesonide through Computer-Assisted Chest X-ray Analysis

This research addresses the respiratory distress syndrome (RDS) in preterm newborns caused by insufficient surfactant synthesis, which can lead to serious complications, including pneumothorax, pulmonary hypertension, and pulmonary hemorrhage, increasing the risk of a fatal outcome. By analyzing chest radiographs and blood gases, we specifically focus on the significant contributions of these parameters to the diagnosis and analysis of the recovery of patients with RDS. The study involved 32 preterm newborns, and the analysis of gas parameters before and after the administration of surfactants and inhalation corticosteroid therapy revealed statistically significant changes in values of parameters such as FiO2, pH, pCO2, HCO3, and BE (Sig. < 0.05), while the pO2 parameter showed a potential change (Sig. = 0.061). Parallel to this, the research emphasizes the development of a lung segmentation algorithm implemented in the MATLAB programming environment. The key steps of the algorithm include preprocessing, segmentation, and visualization for a more detailed understanding of the recovery dynamics after RDS. These algorithms have achieved promising results, with a global accuracy of 0.93 ± 0.06, precision of 0.81 ± 0.16, and an F-score of 0.82 ± 0.14. These results highlight the potential application of algorithms in the analysis and monitoring of recovery in newborns with RDS, also underscoring the need for further development of software solutions in medicine, particularly in neonatology, to enhance the diagnosis and treatment of preterm newborns with respiratory distress syndrome.

Diagnostic utility of lung ultrasound in predicting the need for surfactant therapy in preterm neonates with respiratory distress

Background

Lung ultrasound is an accurate and early predictor for surfactant replacement therapy in respiratory distress syndrome (RDS) as compared to clinical parameters and chest x-ray. However, lung pathologies for respiratory distress at birth have overlapping symptomatology and low middle-income countries have a higher incidence of congenital pneumonia, in addition to RDS, making the immediate diagnosis difficult. Thus, there is a need for assessing a cutoff for lung ultrasound scores in the given setting.

Objectives

The primary objective was to determine the diagnostic accuracy of the lung ultrasound score (LUS) in predicting the need for surfactant therapy in preterm neonates with respiratory distress. Secondary objectives were to correlate LUS with corresponding oxygen saturation to the fraction of inspired oxygen ratio (SpO2/FiO2), arterial/Alveolar oxygen pressure ratio (a/A), and chest x-ray (CXR) findings.

Methodology

A prospective observational study was carried out at a tertiary-level neonatal intensive care unit in India in 2022 enrolling 100 neonates <34 weeks gestational age with respiratory distress at birth. After initial stabilization of the neonate, LUS was performed and baseline parameters were noted. Surfactant was administered as per the 2019 European Consensus guidelines and LUS was repeated after 6 h of therapy.

Results

The mean gestation of enrolled neonates was 31.06 ± 2.12 weeks and the mean birthweight was 1,412 ± 391 g. Approximately 58% were diagnosed with RDS and 30% had congenital pneumonia. Surfactant was administered to 40% of neonates. The cutoff LUS for surfactant therapy was 7 [area under the curve (AUC) 0.977; 95% CI, 0.947-1; P < 0.001; with sensitivity 92.5%, specificity 96.67%, PPV 94.87%, and NPV 95.08%] and the cutoff LUS for the second dose of surfactant was 10 (AUC 0.964; 95% CI, 0.913-1; P < 0.001). The score decreased by 3.24 (2.44-4.05) after 6 h of the first dose and correlated significantly with SpO2/FiO2 ratio (-0.750), a/A ratio (-0.650), and CXR findings (0.801).

Conclusion

The study predicted an optimal LUS cutoff of 7 and 10 for the need for the first dose of surfactant and re-treatment, respectively, in neonates <34 weeks gestational age with respiratory distress.

A Retrospective Analysis of Ultrasonic Diagnosis of Neonatal Respiratory Distress Syndrome

ABSTRACT

The aim of the study was to investigate ultrasound's diagnostic capabilities for infant respiratory distress syndrome. Retrospective analysis was performed on the clinical information of 96 newborns with respiratory distress syndrome who were treated at our hospital between July 2015 and October 2017. The patients were split into the mild group (n = 55) and the severe group based on the findings of the chest x-ray examinations (n = 41). All neonates underwent an ultrasound examination at baseline, 12 hours after treatment and 24 hours after treatment of pulmonary surfactant (PS). Between the 2 groups, ultrasonographic characteristics and imaging scores were compared between infants with and without PS treatment. When compared with the severe group, the ultrasound score in the mild group was lower ( P < 0.05). Before treatment, there was no statistically significant difference in ultrasound score between the PS treatment group and the non-PS treatment group ( P > 0.05). At each time point after treatment, the ultrasonography score of the non-PS treatment group was greater than that of the PS treatment group ( P < 0.05). Neonatal respiratory distress syndrome severity may be accurately assessed using ultrasound technology. Furthermore, the results of ultrasonography examinations may serve as a significant marker for assessing and measuring the severity of newborn respiratory distress syndrome.

Who Needs a Second Dose of Exogenous Surfactant?

OBJECTIVE

To identify prenatal and postnatal risk factors associated with surfactant redosing.

STUDY DESIGN

Retrospective, single-regional center study including all infants born from 24 + 0 to 31 + 6 weeks of gestation in the Marche Region, Italy, and admitted to a single level III regional NICU from January 1, 2004, to February 28, 2021. Clinical factors associated with surfactant redosing were identified through logistic regression analysis.

RESULTS

Of 1615 consecutive admissions, 662 infants were treated with exogenous surfactant: 462 (70%) received a single dose and 200 (30%) received more than 1 dose (25.5% two doses and 4.5% three doses). Risk of redosing was higher for infants born to mothers with hypertension in pregnancy (OR 3.95, P < .001), for small for gestational age (SGA) infants (OR 3.93, P < .001) and when the first surfactant dose was 100 mg/kg instead of 200 mg/kg (OR 4.56/4.61, P < .001). Infants with greater GA, delayed first surfactant administration, and milder respiratory distress syndrome had reduced risk of redosing. Infants who required multiple surfactant doses had a higher rate of bronchopulmonary dysplasia and mortality, as well as longer duration of respiratory support than patients that received 1 dose.

CONCLUSIONS

Hypertension in pregnancy and SGA status were found to be statistically and clinically significant predictors of surfactant redosing. Understanding the pathophysiology of these conditions requires further investigation.

The future of neonatal lung ultrasound: Validation of an artificial intelligence model for interpreting lung scans. A multicentre prospective diagnostic study

BACKGROUND

Artificial intelligence (AI) is a promising field in the neonatal field. We focused on lung ultrasound (LU), a useful tool for the neonatologist. Our aim was to train a neural network to create a model able to interpret LU.

METHODS

Our multicentric, prospective study included newborns with gestational age (GA) ≥ 33 + 0 weeks with early tachypnea/dyspnea/oxygen requirements. For each baby, three LU were performed: within 3 h of life (T0), at 4-6 h of life (T1), and in the absence of respiratory support (T2). Each scan was processed to extract the region of interest used to train a neural network to classify it according to the LU score (LUS). We assessed sensitivity, specificity, positive and negative predictive value of the AI model's scores in predicting the need for respiratory assistance with nasal continuous positive airway pressure and for surfactant, compared to an already studied and established LUS.

RESULTS

We enrolled 62 newborns (GA = 36 ± 2 weeks). In the prediction of the need for CPAP, we found a cutoff of 6 (at T0) and 5 (at T1) for both the neonatal lung ultrasound score (nLUS) and AI score (AUROC 0.88 for T0 AI model, 0.80 for T1 AI model). For the outcome "need for surfactant therapy", results in terms of area under receiver operator characteristic (AUROC) are 0.84 for T0 AI model and 0.89 for T1 AI model. In the prediction of surfactant therapy, we found a cutoff of 9 for both scores at T0, at T1 the nLUS cutoff was 6, while the AI's one was 5. Classification accuracy was good both at the image and class levels.

CONCLUSIONS

This is, to our knowledge, the first attempt to use an AI model to interpret early neonatal LUS and can be extremely useful for neonatologists in the clinical setting.

Lung ultrasound score predicts patent ductus arteriosus ligation among neonates ≤25 weeks

BACKGROUND

This prospective study aimed to investigate whether lung ultrasound score (LUSs) can predict the patent ductus arteriosus (PDA) ligation.

METHODS

Preterm infants ≤25 weeks of gestational age (GA) were enrolled. A lung ultrasound was performed on the 14th day of life. Each lung zone was given a score between 0 and 4. A receiver-operating characteristic (ROC) curve was constructed to evaluate the ability of the LUSs for predicting ligation.

RESULTS

A total of 81 infants were eligible with a median GA and birth weight (BW) of 25 weeks (24.1-25.2) and 710 g (645-770), respectively. The median time from birth to ligation was 35 days (32-51). Those who underwent ligation had a longer time of mechanical ventilation (34 [26-39] vs. 19 [12-30], p < 0.001), shorter time of noninvasive respiratory support (39 [32-51] vs. 50 [41.5-57], p < 0.01), higher incidence of the bronchopulmonary dysplasia (BPD) (p < 0.01), and severe BPD (p < 0.001). The LUSs had an area under the ROC of 0.96 (95% confidence interval: 0.93-0.99) for the prediction of ligation. A LUSs cutoff of 36 has a sensitivity and specificity of 96% and 86% and positive and negative predictive values of 82% and 98%, respectively.

CONCLUSIONS

LUSs at an early stage of life can predict PDA ligation in extremely preterm infants. It would be helpful to reduce morbidity by reducing the duration and magnitude of respiratory support.

Optimal timing and cutoff range of lung ultrasound in predicting surfactant administration in neonates: A meta-analysis and systematic review

OBJECTIVE

Timely application of surfactant replacement therapy is critical for neonates with respiratory distress syndrome (RDS). Presently, early clinical decision on surfactant use relies solely on ventilator parameters. However, ventilator parameters are unable to truly recapitulate the extent of surfactant deficiency. Lung ultrasound has been increasingly used in the early prediction of surfactant use in recent years, but its predictive value remains unclear. Therefore, we conducted this study to examine its predictive value in surfactant use and determine the optimal timing and cutoff value.

METHODS

Studies on neonates with respiratory distress or diagnosed with RDS were collected from PubMed, Embase, Cochrane Library, and Web of Science. Primary outcomes included sensitivity, specificity, and positive and negative predictive values of lung ultrasound.

RESULTS

Ten eligible studies with 1162 participants were included. The sensitivity and specificity of lung ultrasound in predicting surfactant use were 0.86 (95% CI: 0.81-0.90) and 0.82 (95% CI: 0.71-0.90), respectively. Lung ultrasound performed within 1-3 h after birth had a sensitivity of 0.89 (95% CI: 0.79-0.95) and a Youden's index of 0.67. Compared with a lung ultrasound score (LUS) cutoff of ≤6/7, ≤8, >5, >6/7, and >8, a LUS cutoff of ≤5 had higher Youden's index (0.73) and sensitivity (0.94, 95% CI: 0.85-0.97) in predicting surfactant use.

CONCLUSIONS

Lung ultrasound is effective for predicting surfactant use in neonates. Lung ultrasound within 1-3 h after birth and a LUS cutoff of 5 are recommended. However, the symptoms and oxygenation of the neonatal patients must also be considered.

The Predictive Value of Lung Ultrasound Score on Hemodynamically Significant Patent Ductus Arteriosus among Neonates ≤25 Weeks

Lung ultrasound (LU) is increasingly used to diagnose and monitor neonatal pulmonary disorders; however, its role in hemodynamically significant patent ductus arteriosus (hsPDA) has not been elucidated. This prospective study investigated the predictive value of the LU score (LUS) for hsPDA in preterm infants with gestational age (GA) ≤ 25 weeks. Preterm infants with GA ≤ 25 weeks were enrolled in this study. LU was conducted on the fourth day of life (DOL). Six lung regions in every lung were scanned, with each region rated as 0-4 points. The performance of the LUS in predicting hsPDA among infants aged ≤25 weeks was analyzed by plotting the receiver operating characteristic (ROC) curve. A total of 81 infants were included in this study. GA, birth weight (BW), gender, Apgar score, delivery mode, antenatal steroids, meconium-stained amniotic fluid, premature rapture of membrane, and early-onset sepsis were not significantly different, but infants in the hsPDA group had increased LUS (38.2 ± 2.8 vs. 30.3 ± 4.3, p < 0.001) compared with non-hsPDA group. The area under the ROC curve (AUC) value of the LUS on the fourth DOL was 0.94 (95% CI: 0.93-0.99) in predicting hsPDA. The LUS threshold at 33 achieved 89% sensitivity and 83% specificity, with the positive and negative predictive values (PPV and NPV) being 87 and 86%, respectively. The LUS can predict hsPDA in extremely preterm infants at an early stage.

Can lung ultrasound score accurately predict surfactant replacement? A systematic review and meta-analysis of diagnostic test studies

BACKGROUND

Clinical and radiographic criteria are traditionally used to determine the need for surfactant therapy in preterm infants. Lung ultrasound is a bedside test that offers a rapid, radiation-free, alternative to this approach.

OBJECTIVE

To conduct a systematic review and meta-analysis to determine the accuracy of a lung ultrasound score (LUS) in identifying infants who would receive at least one surfactant dose. Secondary aims were to evaluate the predictive accuracy for ≥2 doses and the accuracy of a different image classification system based on three lung ultrasound profiles.

METHODS

PubMed, SCOPUS, Biomed Central, and the Cochrane library between January 2011 and December 2021 were searched. Full articles enrolling preterm neonates who underwent lung ultrasound to predict surfactant administration were assessed and analyzed following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) and QUADAS-2 guidelines.

RESULTS

Seven prospective studies recruiting 697 infants met the inclusion criteria. Risk of bias was generally low. Oxygen requirement, clinical and radiographic signs of respiratory distress syndrome were used as reference standards for surfactant replacement. The summary receiver operator characteristic (sROC) curve for LUS predicting first surfactant dose showed an area under the curve (AUC) = 0.88 (95% confidence interval [CI]: 0.82-0.91); optimal specificity and sensitivity (Youden index) were 0.83 and 0.81 respectively. Pooled estimates of sensitivity, specificity, diagnostic odds ratio, negative predictive value, and positive predictive value for LUS predicting the first surfactant dose were 0.89 (0.82-0.95), 0.86 (0.78-0.95), 3.78 (3.05-4.50), 0.92 (0.87-0.97), 0.79 (0.65-0.92). The sROC curve for the accuracy of Type 1 lung profile in predicting first surfactant dose showed an AUC of 0.88; optimal specificity and sensitivity were both 0.86. Two studies addressing the predictive accuracy of LUS for ≥2 surfactant doses had high heterogeneity and were unsuitable to combine in a meta-analysis.

DISCUSSION

Despite current significant variation in LUS thresholds, lung ultrasound is highly predictive of the need for early surfactant replacement. This evidence was derived from studies with homogeneous patient characteristics and low risk of bias.

Neonatal cardiorespiratory imaging-a multimodality state-of-the-art review

Advanced cardiorespiratory imaging of the chest with ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) plays an important role in diagnosing respiratory and cardiac conditions in neonates when radiography and echocardiography alone are not sufficient. This pictorial essay highlights the particularities, clinical indications and technical aspects of applying chest US, cardiac CT and cardiorespiratory MRI techniques specifically to neonates, summarising the first session of the European Society of Paediatric Radiology's cardiothoracic task force.

Lung Ultrasound Score in Neonates with Congenital Diaphragmatic Hernia (CDH-LUS): A Cross-Sectional Study

Introduction: The use of a lung ultrasound (LUS) score has been described in the early phases of neonatal respiratory distress syndrome; however, there is still no data regarding the application of the LUS score to neonates with a congenital diaphragmatic hernia (CDH). The objective of this observational cross-sectional study was to explore, for the first time, the postnatal changes in LUS score patterns in neonates with CDH, with the creation of a new specific CDH-LUS score. Methods: We included all consecutive neonates with a prenatal diagnosis of CDH admitted to our Neonatal Intensive Care Unit (NICU) from June 2022 to December 2022 who underwent lung ultrasonography. Lung ultrasonography (LUS) was determined at scheduled time points: (T0) during the first 24 h of life; (T1) at 24-48 h of life; (T2) within 12 h of surgical repair; (T3) a week after the surgical repair. We used a modified LUS score (CDH-LUS), starting from the original 0-3 score. We assigned 4 as a score in the presence of herniated viscera in the hemithorax (liver, small bowel, stomach, or heart in the case of a mediastinal shift) in the preoperative scans or pleural effusions in the postoperative scans. Results: We included in this observational cross-sectional study 13 infants: twelve/13 had a left-sided hernia (2 severe, 3 moderate, and 7 mild cases), while one patient had a right-sided severe hernia. The median CDH-LUS score was 22 (IQR 16-28) during the first 24 h of life (T0), 21 (IQR 15-22) at 24-48 h of life (T1), 14 (IQR 12-18) within 12 h of surgical repair (T2) and 4 (IQR 2-15) a week after the surgical repair (T3). The CDH-LUS significantly dropped over time from the first 24 h of life (T0) to a week after the surgical repair (T3), according to ANOVA for repeated measures. Conclusion: We showed a significant improvement in CDH-LUS scores from the immediate postoperative period, with normal ultrasonographic evaluations a week after surgery in most patients.

Alveolar capillary dysplasia with misalignment of pulmonary veins in a premature newborn: the role of lung ultrasound

BACKGROUND

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV) is a lethal neonatal lung disorder characterized by the decrease of the alveolar units, abnormalities in the air-blood barrier of the lung, and impaired gas exchange. Typically, it affects a full-term newborn; the symptoms usually start within a few hours after birth, resulting in severe respiratory distress and pulmonary hypertension. In most of the cases, this disorder is refractory to conventional pulmonary support.

CASE PRESENTATION

We report a case of a newborn male of 29 weeks gestational age, with birth weight of 850 g and intrauterine growth restriction. Severe respiratory distress appeared a few minutes after birth; non-invasive ventilatory support was provided in the delivery room and, as a consequence of persistent respiratory failure, he was admitted to the neonatal intensive care unit (NICU) where mechanical ventilation was required. Due to the symptoms and pulmonary ultrasound pattern suggestive of respiratory distress syndrome, surfactant treatment was administered. Lung ultrasound (LU) was used for monitoring the responsiveness to surfactant; severe pulmonary hypertension ensued, followed by respiratory failure, refractory shock, and death within 48 h. Owing to the poor response to the established therapy, ACD/MPV was suspected. The diagnosis was confirmed through autopsy. The main goal of this case report is to show the role of LU for monitoring the evolution of this disorder.

CONCLUSION

LU could provide essential information to help diagnose and follow-up the underlying cause of persistent pulmonary hypertension of the newborn in an earlier and more effective way than chest X-ray. LU is suitable for routine monitoring of lung disease in the NICU.

Lung ultrasound score as a predictor of ventilator use in preterm infants with dyspnea within 24 h after dhospitalization

BACKGROUND

Selecting the correct ventilation strategy is crucial for the survival of preterm infants with dyspnea in NICU. Lung ultrasound score (LUSsc) is a potential predictor for respiratory support patterns in preterm infants.

METHODS

We prospectively included 857 preterm infants. LUS was performed in the first 2 h after admission, and LUSsc was determined by two specialist sonographers. Participants were divided into two categories according to gestational age (<32⁺⁰ weeks and 32⁺⁰-36⁺⁶ weeks) and randomly divided into a training set and a validation set. There were two main outcomes: invasive and non-invasive respiratory support. In the training set, clinical factors were analyzed to find the best cut-off value of LUSsc, and consistency was verified in the verification set. The choice of invasive respiratory support was based on neonatal mechanical ventilation strategies.

RESULTS

Preterm infants with invasive respiratory support had a higher LUSsc, greater use of Pulmonary Surfactant（PS）, and lower Oxygenation Index（OI）、birth weight than those with non-invasive support. In the <32⁺⁰ weeks group, the area under the curve (AUC) for the receiver operating characteristic curve plotted with 2-h LUSsc was 0.749 (95% CI: 0.689-0.809), the cut-off point of LUSsc was 8, and the sensitivity and specificity were 74.0% and 68.3%, respectively. In the 32⁺⁰-36⁺⁶ weeks group, the AUC was 0.863 (95% CI: 0.811-0.911), with a cut-off point of 7. Sensitivity and specificity were 75.3% and 0.836%, respectively. In the validation set, using the actual clinical respiratory support selection results for verification, the validation results showed for the <32⁺⁰ weeks group (Kappa value 0.660, P < 0.05, McNemar test P > 0.05) for preterm 32⁺⁰-36⁺⁶ weeks (Kappa value 0.779, P < 0.05, McNemar test P > 0.05).

CONCLUSION

The LUSsc showed good reliability in predicting respiratory support mode for preterm infants with dyspnea. Registered at ClinicalTrials.gov (identifier: chiCTR1900023869).

Lung ultrasound to evaluate lung recruitment in neonates with respiratory distress (RELUS study)

BACKGROUND

Lung ultrasound (LUS) is a bedside tool useful to diagnose neonatal respiratory disease and to guide surfactant therapy. LUS scores have emerged as useful tool for newborn respiratory distress but is unknown if respiratory support settings may influence it. The aim of the study was to evaluate the feasibility of LUS scores evaluating lung recruitment in term newborns with respiratory distress when noninvasive respiratory it is increased.

MATERIAL AND METHODS

Prospective study in a tertiary neonatal intensive care unit. Inclusion criteria were term neonates with respiratory distress requiring noninvasive respiratory support with nasal continuous positive airway pressure (nCPAP) within first 6 h of life with an LUS score higher than 8 were enrolled. LUS was performed three times. First LUS (LUS-1) was done in patients in nCPAP (Fabian Device) (Acutronic) (pressure of 6 cmH₂ O). Afterwards patients were placed in duo positive airway pressure (12/6 cmH₂ O), a second LUS (LUS-2) was performed immediately and a third (LUS-3) was done 2 h later on the same respiratory support. The primary outcome was to compare LUS scores in the different timelines. Second outcomes were to evaluate the level of respiratory distress and oxygenation were evaluated with SpO₂ /fraction of inspired oxygen (FiO₂ ) ratio (S/F ratio), FiO₂  ratio, respiratory rate, and blood gas analysis which were analyzed during the LUS-1 and the LUS-3. To evaluate newborn discomfort, patients were evaluated with Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale.

RESULTS

Forty neonates were enrolled. Fifty percent were female (n = 20), median gestational age was 38 + 4 (interquartile range [IQR]: 37 + 5-39 + 4) with a median weight of 3155 g (IQR: 2637-3532). Duration of non invasive ventilation support was 72 h (IQR: 54-96). None of the patients required surfactant therapy or mechanical ventilation. LUS scores were no different between LUS-1 9 (IQR: 8.3-10) and LUS-2 9 (IQR: 8.3-10) (p = 0.675) but there were differences between LUS-1 and LUS-3 7 (IQR: 6.3-8.5) (p = 0.036). There was an improvement in the oxygen parameters, respiratory rate, and CO₂ between LUS-1 and LUS-3 (p < 0.001). There were no changes in the CRIES scale.

CONCLUSIONS

There is an improvement in clinical and laboratory parameters after the increasing of respiratory support in newborns with noninvasive ventilation. We observe a correlation with an improvement in the assessment of lung aeration were evaluated with LUS score.

Early lung ultrasound score to predict noninvasive ventilation needing in neonates from 33 weeks of gestational age: A multicentric study

OBJECTIVE

To propose an early lung ultrasound (LUS) score for the prediction of the need for respiratory assistance in newborns of gestational age (GA) ≥ 33 weeks presenting respiratory distress.

STUDY DESIGN AND SETTING

Multicenter, prospective observational study in third-level neonatal intensive care units.

PATIENT SELECTION

Infants with GA ≥ 33 + 0 weeks with respiratory distress within 3 h of life.

METHODS

Three LUS for each patient were collected: within 3 h of life (T0), at 4-6 h of life (T1), and at the resolution of symptoms (T2). The primary aim was to assess the validity of the early LUS score in predicting the need for continuous positive airway pressure (CPAP). We also evaluated the validity of the score in predicting the need for surfactant, the scores' trend in our population, and any correlation with the duration of ventilation and oxygen therapy.

RESULTS

Sixty-two patients were enrolled in the study. The mean GA was 36 weeks. The receiver operating characteristic analysis for the LUS T0 and T1 yielded area under the curves of 0.91 and 0.82 in predicting the need for CPAP, respectively. LUS score cut off of 6 (sensitivity 84.8%, specificity 86.2%) and 5 (sensitivity 66.7%, specificity 100%) were calculated at T0 and T1, respectively. We found significant correlations between LUS score and respiratory assistance, surfactant administration, and SpO₂ /FiO₂ ratio.

CONCLUSION

An early LUS score is a good noninvasive predictor of the need for respiratory assistance with CPAP and surfactant administration in newborns with GA ≥ 33 weeks.

Lung Ultrasound for Predicting the Respiratory Outcome in Patients with Bronchopulmonary Dysplasia

OBJECTIVE

This study aimed to investigate the utility of lung ultrasound (LUS) with whole chest scanning for predicting respiratory outcomes in patients with bronchopulmonary dysplasia (BPD).

STUDY DESIGN

We performed a prospective observational study. Preterm infants of less than 32 weeks' gestational age requiring oxygen therapy at 28 days of life were included. LUS was performed on day 28, at 36 weeks' postmenstrual age, and at the time of discharge. Each lung was divided into three regions by the anterior and posterior axillary lines and received an LUS score of 0 to 3 points; the total score was obtained by adding the six regional scores. The classification of BPD was determined based on the National Institute of Child and Human Development. The outcomes of this study were the development of moderate-to-severe BPD and the need for home oxygen therapy (HOT).

RESULTS

We enrolled 87 patients; 39, 33, and 15 infants had mild, moderate, and severe BPD, respectively. The LUS score correlated with BPD severity and exhibited an improvement trend with time toward the point of discharge. LUS at 28 days of life predicted moderate-to-severe BPD with an area under the curve of 0.95 (95% confidence interval: 0.91-0.99) and HOT with an area under the curve of 0.95 (95% confidence interval: 0.81-1.0).

CONCLUSION

LUS with whole chest scanning is useful for predicting respiratory outcomes in patients with BPD, as well as for understanding BPD severity or clinical improvement trends.

KEY POINTS

· LUS predicts respiratory outcomes in patients with BPD.. · LUS indicates BPD severity.. · LUS can show clinical improvement with time..

The Value of Lung Ultrasound Score in Neonatology

Point-of-care lung ultrasound (LUS) is increasingly applied in the neonatal intensive care unit (NICU). Diagnostic applications for LUS in the NICU contain the diagnosis of many common neonatal pulmonary diseases (such as Respiratory distress syndrome, Transient tachypnea of the newborn, Meconium aspiration syndrome, Pneumonia, Pneumothorax, and Pleural effusion) which have been validated. In addition to being employed as a diagnostic tool in the classical sense of the term, recent studies have shown that the number and type of artifacts are associated with lung aeration. Based on this theory, over the last few years, LUS has also been used as a semi-quantitative method or as a "functional" tool. Scores have been proposed to monitor the progress of neonatal lung diseases and to decide whether or not to perform a specific treatment. The semi-quantitative LUS scores (LUSs) have been developed to predict the demand for surfactant therapy, the need of respiratory support and the progress of bronchopulmonary dysplasia. Given their ease of use, accuracy and lack of invasiveness, the use of LUSs is increasing in clinical practice. Therefore, this manuscript will review the application of LUSs in neonatal lung diseases.

Application of ultrasonography in neonatal lung disease: An updated review

Lung disease is often life-threatening for both preterm and term newborns. Therefore, an accurate and rapid diagnosis of lung diseases in newborns is crucial, as management strategies differ with different etiologies. To reduce the risk of radiation exposure derived from the conventionally used chest x-ray as well as computed tomography scans, lung ultrasonography (LUS) has been introduced in clinical practice to identify and differentiate neonatal lung diseases because of its radiation-free characteristic, convenience, high accuracy, and low cost. In recent years, it has been proved that LUS exhibits high sensitivity and specificity for identifying various neonatal lung diseases. Here, we offer an updated review of the applications of LUS in neonatal lung diseases based on the reports published in recent years (2017 to present).

Gravity-induced loss of aeration and atelectasis development in the preterm lung: a serial sonographic assessment

OBJECTIVE

To assess the impact of gravity and time on the changes in the distribution patterns of loss of aeration and atelectasis development in very preterm infants.

STUDY DESIGN

Preterm infants less than 32 weeks gestation were included in this prospective, observational study. Infants were assessed via serial lung ultrasound (LUS) score in four lung zones, performed on days 7, 14, 21, and 28 after birth.

RESULT

Eighty-eight patients were enrolled. There was a significant main effect of gravity (P < 0.001) and time (P = 0.01) on the LUS score between gravity-dependent lungs and non-dependent lungs. Moreover, there was a significant main effect of gravity (P = 0.003) on atelectasis development between the lungs.

CONCLUSION

Gravity and time have an impact on the changes in the distribution patterns of gravity-induced lung injuries in preterm infants.

2020 year in review: Neonatal pulmonology

Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. This review summarizes the past year's publications in the topic area of neonatal pulmonology, in the context of selected literature from other journals relevant to the discipline.

The Role of Lung Ultrasound as an Early Diagnostic Tool for Need of Surfactant Therapy in Preterm Infants with Respiratory Distress Syndrome

OBJECTIVE

This study aimed to determine the accuracy of neonatal lung ultrasound (LUS) in predicting the need for surfactant therapy compared with chest X-ray (CXR) in preterm infants.

STUDY DESIGN

A prospective double-blind study was conducted in infants with a gestational age <34 weeks with respiratory distress syndrome (RDS) by evaluation with LUS and CXR on admission.

RESULTS

Among 45 preterm infants, the median (interquartile range [IQR]) LUS score was 4 (2-8) in the mild RDS group, whereas it was 10 (IQR: 9-12) in the severe RDS group (p < 0.01). The LUS score showed a significant correlation with the need for total surfactant doses (ρ = 0.855; 95% confidence interval [CI]: 0.801-0.902; p < 0.001). A cut-off LUS score of four predicted the need for surfactant with 96% sensitivity and 100% specificity (area under the curve [AUC]: 1.00; 95% CI: 0.97-1.00; p < 0.01). LUS scores predicted continuous positive airway pressure (CPAP) failure accurately (AUC: 0.804; 95% CI: 0.673-0.935; p = 0.001). A significant correlation was observed between LUS scores and positive end-expiratory pressure levels (ρ = 0.782; p < 0.001). During the study period, the CXR number per infant with RDS decreased significantly when compared with preceding months (p < 0.001). The LUS score in the first day of life did not predict the development of bronchopulmonary dysplasia (AUC: 0.274; 95% CI: 0.053-0.495; p = 0.065).

CONCLUSION

The LUS score in preterm infants accurately predicts the severity of RDS, the need for surfactant and CPAP failure. The routine use of LUS can decrease the frequency of CXRs in the neonatal intensive care units.

KEY POINTS

· LUS is a nonhazardous bedside technique.. · LUS predicts the need for surfactant in preterm infants.. · LUS predicts the severity of RDS better than CXR..

Usefulness of Lung Ultrasound in Paediatric Respiratory Diseases

Respiratory infection diseases are among the major causes of morbidity and mortality in children. Diagnosis is focused on clinical presentation, yet signs and symptoms are not specific and there is a need for new non-radiating diagnostic tools. Among these, lung ultrasound (LUS) has recently been included in point-of-care protocols showing interesting results. In comparison to other imaging techniques, such as chest X-ray and computed tomography, ultrasonography does not use ionizing radiations. Therefore, it is particularly suitable for clinical follow-up of paediatric patients. LUS requires only 5-10 min and allows physicians to make quick decisions about the patient's management. Nowadays, LUS has become an early diagnostic tool to detect pneumonia during the COVID-19 pandemic. In this narrative review, we show the most recent scientific literature about advantages and limits of LUS performance in children. Furthermore, we discuss the major paediatric indications separately, with a paragraph fully dedicated to COVID-19. Finally, we mention potential future perspectives about LUS application in paediatric respiratory diseases.

Neonatal Lung Ultrasound and Surfactant Administration: A Pragmatic, Multicenter Study

BACKGROUND

Previous research shows that a lung ultrasound score (LUS) can anticipate CPAP failure in neonatal respiratory distress syndrome.

RESEARCH QUESTION

Can LUS also predict the need for surfactant replacement?

STUDY DESIGN AND METHODS

Multicenter, pragmatic study of preterm neonates who underwent lung ultrasound at birth and those given surfactant by masked physicians, who also were scanned within 24 h from administration. Clinical data and respiratory support variables were recorded. Accuracy of LUS, oxygen saturation to Fio₂ ratio, Fio₂, and Silverman score for surfactant administration were evaluated using receiver operating characteristic curves. The simultaneous prognostic values of LUS and oxygen saturation to Fio₂ ratio for surfactant administration, adjusting for gestational age (GA), were analyzed through a logistic regression model.

RESULTS

Two hundred forty infants were enrolled. One hundred eight received at least one dose of surfactant. LUS predicted the first surfactant administration with an area under the receiver operating characteristic curve (AUC) of 0.86 (95% CI, 0.81-0.91), cut off of 9, sensitivity of 0.79 (95% CI, 0.70-0.86), specificity of 0.83 (95% CI, 0.76-0.89), positive predictive value of 0.79 (95% CI, 0.71-0.87), negative predictive value of 0.82 (95% CI, 0.75-0.89), positive likelihood ratio of 4.65 (95% CI, 3.14-6.89), and negative likelihood ratio of 0.26 (95% CI, 0.18-0.37). No significant difference was shown among different GA groups: 25 to 27 weeks' GA (AUC, 0.91; 95% CI, 0.84-0.99), 28 to 30 weeks' GA (AUC, 0.81; 95% CI, 0.72-0.91), and 31 to 33 weeks' GA (AUC, 0.88; 95% CI, 0.79-0.95), respectively. LUS declined significantly within 24 h in infants receiving one surfactant dose. When comparing Fio₂, oxygen saturation to Fio₂ ratio, LUS, and Silverman scores as criteria for surfactant administration, only the latter showed a significantly poorer performance. The combination of oxygen saturation to Fio₂ ratio and LUS showed the highest predictive power, with an AUC of 0.93 (95% CI, 0.89-0.97), regardless of the GA interval.

INTERPRETATION

LUS is a reliable criterion to administer the first surfactant dose regardless of GA. Its association with oxygen saturation to Fio₂ ratio significantly improves the prediction power for surfactant need.

Outcome of Very Premature Newborn Receiving an Early Second Dose of Surfactant for Persistent Respiratory Distress Syndrome

Background: Infants presenting respiratory distress syndrome (RDS) not responding to surfactant often receive a second instillation. Few studies evaluated the consequences of this second administration. This study aimed at determining the outcome of infants presenting persistent RDS and receiving an early second dose of surfactant. Methods: Infants below 32 weeks' gestation who received a second dose of 100mg/kg of surfactant within the first 72 h of life, were retrospectively involved in this 42 months' study. They were matched to two controls receiving a single dose of 200mg/Kg based upon gender and gestational age. Results: 52/156 infants receiving two doses (Group 2-doses) were significantly more often SGA [22 (42%) vs. 21 (20%) p = 0.04] and outborn [29 (56%) vs. 13 (12%) p = 0.001]. They had received antenatal corticos teroid therapy less often [26 (50%) vs. 89 (86%) p = 0.001] and presented more severe RDS based upon FiO2 level, oxygenation index and radiography. Group 2-doses survival was lower (65.4% vs. 79.6 % p < 0.1) but surviving infants did not have different morbidity than controls. Discussion: Premature newborn receiving a second dose of surfactant had adverse antenatal characteristics, presented more severe RDS and only partially responded to the first dose. Outcomes of surviving infants who received 2 doses of surfactant were comparable to others.

LISA/MIST: Complex clinical problems almost never have easy solutions

Over the last 10 years, new techniques to administer surfactant have been promoted, based on their presumed lesser invasiveness and they have been generally called LISA (less invasive surfactant administration). We believe that the clinical potential of LISA techniques is currently overestimated. LISA lacks biological and pathophysiological background justifying its potential benefits. Moreover, LISA has been investigated in clinical trials without previous translational data and these trials are affected by significant flaws. The available data from these trials only allow to conclude that LISA is better than prolonged, unrestricted invasive ventilation with loosely described parameters, a mode of respiratory support that should be anyway avoided in preterm infants. We urge the conduction of high-quality studies to understand how to choose and titrate analgesia/sedation and optimize surfactant administration in preterm neonates. We offer a comprehensive, evidence-based review of the clinical data on LISA, their biases and the lack of physiopathology background.

Modified lung ultrasound score predicts ventilation requirements in neonatal respiratory distress syndrome

Background

We propose a modified lung ultrasound (LUS) score in neonates with respiratory distress syndrome (RDS), which includes posterior instead of lateral lung fields, and a 5-grade rating scale instead of a 4-grade rating scale. The purpose of this study was to evaluate the reproducibility of the rating scale and its correlation with blood oxygenation and to assess the ability of early post-birth scans to predict the mode of respiratory support on day of life 3 (DOL 3). As a secondary objective, the weight of posterior scans in the overall LUS score was assessed.

Methods

We analyzed 619 serial lung scans performed in 70 preterm infants < 32 weeks gestation and birth weight < 1500 g. Assessments were performed within 24 h of birth (LUS₀) and on days 2, 3, 5, 7, 10, 14, 21 and 28. LUS scores were correlated with oxygen saturation over fraction of inspired oxygen (S/F) and mode of respiratory support. Interrater agreement was determined with the intraclass correlation coefficient (ICC) and Cronbach’s alpha. Probabilities of the need for various respiratory support modes on DOL 3 were assessed with ordinal logistic regression. Least square (ls) means of the posterior and anterior pulmonary field scores were compared.

Results

The LUS score correlated significantly with S/F (Spearman rho = −0.635; p < 0.0001) and had excellent interrater agreement (ICC = 0.94, 95% CI 0.93–0.95; Cronbach’s alpha = 0.99). Significant predictors of ventilation requirements on DOL 3 were LUS₀ (p < 0.016) and birth weight (BW) (p < 0.001). In the ROC analysis, LUS₀ had high reliability in prognosing invasive ventilation on DOL 3 (AUC = 0.845 (95% DeLong CI: 0.738–0.951; p < 0.001)). Invasive ventilation was the most likely mode of respiratory support for LUS₀ scores: ≥7 (in infants with BW 900 g), ≥ 10 (in infants with BW 1050 g) and ≥ 15 (in infants with BW 1280 g). Posterior fields exhibited significantly higher average scores than anterior fields. Respective ls means (confidence levels) were 4.0 (3.8–4.1) vs. 2.2 (2.0–2.4); p < 0.001.

Conclusions

Post-birth LUS predicts ventilation requirements on DOL 3. Scores of posterior pulmonary fields have a predominant weight in the overall LUS score.

Lung ultrasound in the neonatal intensive care unit: Review of the literature and future perspectives

Lung ultrasound (LU) has been increasingly used as a point-of-care method in recent years. LU has numerous advantages compared to traditional imaging tools such as chest X-ray (radiography) (CXR): it is faster and portable, does not use ionizing radiation, is performed by the same physician who cares for the patient, and can be repeated to follow the progress of the disease and the response to treatment. There is a large body of evidence that LU has an excellent diagnostic effectiveness compared to CXR, not only in adults and children, but also in neonates. This review article describes how to perform LU, how to interpret findings, and how to use LU to diagnose and differentiate common neonatal pulmonary diseases. Strengths but also limits of the technique are highlighted. Finally, we describe the recent revolutionary role of LU. The development of scoring methods in neonates with respiratory distress syndrome allowed to quantify the severity of the disease and to assist the physician in the clinical management and follow-up.