Meta-analysis of Lung Ultrasound Scores for Early Prediction of Bronchopulmonary Dysplasia

Setting the Standards: Neonatal Lung Ultrasound in Clinical Practice

The use of lung ultrasonography in neonates is increasing at a very fast rate. Evidence-based guidelines on the use of lung ultrasound (LU) in neonates and children have been published and well received across the world. However, there remains a lack of standardized curriculum for lung ultrasound training and standards for its application at the bedside. This article focuses on providing a standardized approach to the application of lung ultrasonography in neonates for the common neonatal conditions and how it can be integrated into bedside clinical decision-making.

Lung ultrasound in early prediction of bronchopulmonary dysplasia in pre-term babies

PURPOSE

Bronchopulmonary dysplasia (BPD) is a respiratory morbidity related to prematurity. Early prediction of BPD allows the selection of patients who would benefit from new therapies. Lung ultrasound (LUS) is a non-invasive diagnostic tool that has proven to be reliable for many neonatal diseases recently. The study aimed to detect the role of LUS in predicting BPD at days 7 and 14 of life in preterm babies.

METHODS

This was a prospective cohort study that included 95 preterm babies ≤ 34 weeks. Lung ultrasounds were performed on days 7 and 14 of life.

RESULTS

The mean gestational age of the studied neonates was 30.25 ± 2.21 weeks. The mean birth weight was 1347.66 ± 432.14 gm. Patients who developed BPD had statistically significantly higher LUS scores on both days 7 and 14 of life. At first examination, a LUS score > 8 showed a sensitivity of 83.33% and a specificity of 60.87%, whereas at follow-up, a LUS score > 8 showed a sensitivity of 76.39% and a specificity of 82.61%. The multivariate logistic regression analysis shows that the most important factors associated with BPD were gestational age ≤ 30 weeks, LUS score at first examination > 8, platelets ≤ 245 × 109/L, segment neutrophils ≤ 42%, and CRP > 5 mg/l.

CONCLUSIONS

The LUS score predicts BPD at 7 and 14 days of life. LUS scores increased with increasing BPD severity. LUS score > 8 was an independent factor in the prediction of BPD.

Lung Ultrasonography Scores in Preterm Infants and Respiratory Outcomes at Age 2 Years

This cohort study examines the role of lung ultrasonography score in estimating respiratory episodes needing drugs or hospitalization in premature infants.

Measurement of lung oxygenation by near-infrared spectroscopy in preterm infants with bronchopulmonary dysplasia

INTRODUCTION

It has recently been reported that it is possible to monitor lung oxygenation (rSO2L) by near-infrared spectroscopy (NIRS) in preterm infants with respiratory distress syndrome (RDS). Thus, our aim was to assess the possibility of monitoring rSO2L in infants with evolving and established bronchopulmonary dysplasia (BPD) and to evaluate if rSO2L correlates with BPD severity and other oxygenation indices.

METHODS

We studied 40 preterm infants with gestational age ≤30 weeks at risk for BPD. Patients were continuously studied for 2 h by NIRS at 28 ± 7 days of life and 36 weeks ± 7 days of postmenstrual age.

RESULTS

rSO2L was similar at the first and second NIRS recordings (71.8 ± 7.2 vs. 71.4 ± 4.2%) in the overall population, but it was higher in infants with mild than in those with moderate-to-severe BPD at both the first (73.3 ± 3.1 vs. 71.2 ± 3.2%, p = .042) and second (72.3 ± 2.8 vs. 70.5 ± 2.8, p = .049) NIRS recording. A rSO2L cutoff value of 71.6% in the first recording was associated with a risk for moderate-to-severe BPD with a sensitivity of 66% and a specificity of 60%. Linear regression analysis demonstrated a significant positive relationship between rSO2L and SpO2/FiO2 ratio (p = .013) and a/APO2 (p = .004).

CONCLUSIONS

Monitoring of rSO2L by NIRS in preterm infants with evolving and established BPD is feasible and safe. rSO2L was found to be higher in infants with mild BPD, and predicts the risk for developing moderate-to-severe BPD and correlates with other indices of oxygenation.

ATS core curriculum 2023. Pediatric pulmonary medicine: Respiratory disorders in infants

The American Thoracic Society Core Curriculum updates clinicians annually in pediatric pulmonary disease. This is a summary of the Pediatric Pulmonary Medicine Core Curriculum presented at the 2023 American Thoracic Society International Conference. The respiratory disorders of infancy discussed in this year's review include: the care of the patient with bronchopulmonary dysplasia in the neonatal intensive care unit, clinical phenotypes and comorbidities; diffuse lung disease; pulmonary hypertension; central and obstructive sleep apnea. The care of infants with respiratory disorders often poses significant challenges to the general pediatric pulmonologist, sleep clinician, and neonatologist. This review aims to highlight the most clinically relevant aspects of the evaluation, management, and outcomes of infants with these key respiratory disorders, while emphasizing the importance of multidisciplinary care. Furthermore, this document summarizes essential aspects of genetic testing, novel imaging and treatment modalities, and includes multiple resources for clinical practice.

Diagnostic Accuracy of Lung Ultrasound in Neonatal Diseases: A Systematized Review

Background: Respiratory problems are frequent in newborns, and are mainly studied with chest X-rays, whereas CT scans are usually needed for the evaluation of rare malformations and diseases. Lung ultrasound (LUS] has been proposed as an alternative method of diagnosing a variety of respiratory conditions. In recent years, there has been a rapid increase in LUS studies, thanks to the ability of LUS to rapidly exclude complications and significantly reduce radiation exposure in this fragile population. We aimed to summarize the current knowledge about LUS. Methods: A literature search was conducted on the Medline and Cochrane databases using appropriate terms. The inclusion criteria were: English language and human species. Exclusion criteria were: non-English language, animal species, case reports, case series, non-systematic reviews, and editorials. Results: The search returned 360 results. No Cochrane reviews were found. Titles and abstracts were screened, and 37 were finally considered. Studies concerning the use of lung ultrasound for the following conditions were presented: neonatal respiratory distress syndrome, transient tachypnea of the newborn, pneumothorax, pulmonary hemorrhage, pneumonia, bronchopulmonary dysplasia, and prediction of extubation success. Conclusions: We discussed the utility of LUS for the diagnosis and treatment of neonatal diseases according to the most recent literature.

Current perception and barriers to implementing lung ultrasound in Canadian neonatal intensive care units: a national survey

Despite the growing body of literature supporting the use of point-of-care lung ultrasound (POC-LU) in neonates, its adoption in Canadian neonatal intensive care units (NICUs) remains limited. This study aimed to identify healthcare providers' perceptions and barriers to implementing POC-LU in Canadian NICUs. We conducted an electronic survey targeting neonatologists, neonatal fellows, neonatal nurse practitioners, and registered respiratory therapists in 20 Canadian NICUs. The survey comprised a 28-item questionnaire divided into four sections: (1) participants' demographics and availability of POC-LU equipment, (2) experience and interest in POC-LU learning, (3) perception of POC-LU as a diagnostic tool, and (4) barriers to POC-LU implementation in NICUs. A total of 194 participants completed the survey, with neonatologists comprising the majority (45%). Nearly half of the participants (48%) reported prior experience with POC-LU. The most prevalent indications for POC-LU use were diagnosis of pleural effusion (90%), pneumothorax (87%), and respiratory distress syndrome (76%). Participants identified the primary barrier to POC-LU adoption as the lack of trained providers available for both training and clinical integration. Notably, most respondents (87%) expressed keen interest in learning neonatal POC-LU. A subgroup analysis based on the responses collected from NICU-directors of 12 institutions yielded results consistent with those of the overall participant pool.     Conclusion: This survey underscores the perceived importance of POC-LU among NICU healthcare providers. A Canadian consensus is required to facilitate the development of widespread training programs as well as standardized clinical practice guideline for its implementation. What is Known: • In recent years, point-of-care lung ultrasound (POC-LU) has emerged as an important tool in neonatology, revolutionizing the assessment and management of critically ill infants. However, its adoption in Canadian Neonatal Intensive Care Units remains limited. What is New: • Most Canadian healthcare providers showed high level of interest in learning POC-LU techniques. Additionally, POC-LU was perceived as a useful tool for diagnosis and guiding intervention in various neonatal respiratory diseases. Nonetheless, the lack of expertise emerged as the primary barrier to its adoption and practice across different groups of participants regardless of their clinical experience level.

The Impact of Respiratory Therapist Performed Point-of-Care Lung Ultrasound on the Respiratory Care in Neonates, Manitoba Experience, Canada

OBJECTIVE

 We aimed to evaluate the impact of the registered respiratory therapist (RRT) performed point-of-care lung ultrasound (POC-LUS) on patient management in the neonatal intensive care unit (NICU).

STUDY DESIGN

 This is a retrospective cohort study of neonates who had RRT performed POC-LUS in two level III NICUs in Winnipeg, Manitoba, Canada. The analysis aims mainly to describe the implementation process of the POC-LUS program. The primary outcome was the prediction of the change in clinical management.

RESULTS

 A total of 136 neonates underwent 171 POC-LUS studies during the study period. POC-LUS resulted in a change in clinical management following 113 POC-LUS studies (66%), while it supported continuing the same management in 58 studies (34%). The lung ultrasound severity score (LUSsc) was significantly higher in the group with worsening hypoxemic respiratory failure and on respiratory support than infants on respiratory support and stable or not on respiratory support, p < 0.0001. LUSsc was significantly higher in infants on either noninvasive or invasive than those not on respiratory support, p-value <0.0001.

CONCLUSION

 RRT performed POC-LUS service utilization in Manitoba improved and guided the clinical management of a significant proportion of patients who received the service.

Prognostic Relevance of the Lung Ultrasound Score: A Multioutcome Study in Infants with Respiratory Distress Syndrome

OBJECTIVE

 There is growing evidence for the usefulness of the lung ultrasound score (LUS) in neonatal intensive care. We evaluated whether the LUS is predictive of outcomes in infants with respiratory distress syndrome (RDS).

STUDY DESIGN

 Neonates less than 34 weeks of gestational age were eligible for this prospective, multicenter cohort study. The outcomes of interest were the need for mechanical ventilation (MV) at <72 hours of life, the need for surfactant (SF), successful weaning from continuous positive airway pressure (CPAP), extubation readiness, and bronchopulmonary dysplasia. Lung scans were taken at 0 to 6 hours of life (Day 1), on Days 2, 3, and 7, and before CPAP withdrawal or extubation. Sonograms were scored (range 0-16) by a blinded expert sonographer. The area under the receiver operating characteristic curve (AUC) was used to estimate the prediction accuracy of the LUS.

RESULTS

 A total of 647 scans were obtained from 155 newborns with a median gestational age of 32 weeks. On Day 1, a cutoff LUS of 6 had a sensitivity (Se) of 88% and a specificity (Sp) of 79% to predict the need for SF (AUC = 0.86), while a cutoff LUS of 7 predicted the need for MV at <72 hours of life (Se = 89%, Sp = 65%, AUC = 0.80). LUS acquired prior to weaning off CPAP was an excellent predictor of successful CPAP withdrawal, with a cutoff level of 1 (Se = 67%, Sp = 100%, AUC = 0.86).

CONCLUSION

 The LUS has significant predictive ability for important outcomes in neonatal RDS.

KEY POINTS

· Lung ultrasound has significant prognostic abilities in neonatal RDS.. · Early sonograms (0-6 h of life) accurately predict the requirement for SF and ventilation.. · Weaning off CPAP is effective when the LUS (range 0-16) is less than or equal to 1..

Correlation between early postnatal body weight changes and lung ultrasound scores as predictors of bronchopulmonary dysplasia in preterm infants: A secondary analysis of a prospective study

Recent research links early weight changes (EWC) with bronchopulmonary dysplasia (BPD) in preterm neonates, while lung ultrasound score (LUS) has shown promise in predicting BPD. We aimed to explore the correlation between LUS and EWC as markers of extravascular lung edema and to investigate the correlation between LUS and EWC in preterm infants with respiratory distress syndrome regarding future BPD development. This secondary analysis of a prospective study involved infants ≤ 28 weeks gestation. Enrolled infants underwent lung ultrasound assessment on postnatal days 3, 7 and 14, measuring LUS. EWC was computed on the same time points. Infants were classified as either having BPD or not. Descriptive statistics, correlation coefficient, and area under the receiver operating characteristic (AUROC) curve analysis were utilized. Of 132 infants, 70 (53%) had BPD. Univariate analysis revealed statistically significant differences in LUS and EWC at days 3, 7, and 14 between BPD and no-BPD groups (p < 0.001). A statistically significant but weak positive correlation existed between LUS and EWC (r0.37, r0.29, r0.24, and p < 0.01) at postnatal days 3, 7, and 14, respectively. AUROC analysis indicated LUS having superior predictive capacity for the need for invasive mechanical ventilation at day 14 as well as the later BPD development compared to EWC (p < 0.0001).

CONCLUSION

In a cohort of extreme preterm infants, our study revealed a positive yet weak correlation between LUS and EWC, suggesting that EWC was not the major contributing to the evolving chronic lung disease.

WHAT IS KNOWN

• Recent evidence links Early Weight-Changes with bronchopulmonary dysplasia in preterm neonates. • Lung ultrasound score has shown promise in early prediction of the subsequent development of bronchopulmonary dysplasia in preterm infants. No studies have examined the correlation between Early Weight-Changes and Lung ultrasound score in preterm infants during first 2 weeks after birth.

WHAT IS NEW

• Our study demonstrated a positive and statistically significant correlation between early LUS and EWC, indicating their potential role as early predictors for the subsequent development of BPD in extreme preterm infants. • The weak correlation between the two parameters may stem from the possible restricted influence of EWC, given that it may not be the primary factor contributing to the evolving chronic lung disease.

Improving early diagnosis of bronchopulmonary dysplasia

INTRODUCTION

Bronchopulmonary disease (BPD) is associated with long-term neurodevelopmental and cardiorespiratory complications, often requiring significant use of resources. To reduce this healthcare burden, it is essential that those at high risk of BPD are identified early so that strategies are introduced to prevent disease progression. Our aim was to discuss potential methods for improving early diagnosis in the first week after birth.

AREAS COVERED

A narrative review was undertaken. The search strategy involved searching PubMed, Embase and Cochrane databases from 1967 to 2024. The results of potential biomarkers and imaging modes are discussed. Furthermore, the value of scoring systems is explored.

EXPERT OPINION

BPD occurs as a result of disruption to pulmonary vascular and alveolar development, thus abnormal levels of factors regulating those processes are promising avenues to explore with regard to early detection of high-risk infants. Data from twin studies suggests genetic factors can be attributed to 82% of the observed difference in moderate to severe BPD, but large genome-wide studies have yielded conflicting results. Comparative studies are required to determine which biomarker or imaging mode may most accurately diagnose early BPD development. Models which include the most predictive factors should be evaluated going forward.

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

OBJECTIVE

Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved.

DESIGN AND INTERVENTION

International online survey.

RESULTS

Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%-98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had <2 years of experience, and only 71 units (13%) had >5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique.

CONCLUSIONS

Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline.

Long-term pulmonary outcomes of young adults born prematurely: a Polish prospective cohort study PREMATURITAS 20

BACKGROUND

The long-term consequences of prematurity are often not sufficiently recognized. To address this gap, a prospective cohort study, which is a continuation of the multicenter Polish study PREMATURITAS, was conducted, utilizing unique clinical data from 20 years ago.

OBJECTIVE

The main goal was to evaluate lung function, detect any structural abnormalities using lung ultrasound, and assess psychological well-being in young adults born between 24 and 34 weeks of gestational age (GA). Additionally, the study aimed to investigate potential associations between perinatal risk factors and abnormalities observed in pulmonary function tests (PFTs) during adulthood.

METHODS

The young survivors underwent a comprehensive set of PFTs, a lung ultrasound, along with the quality of life assessment. Information regarding the neonatal period and respiratory complications was obtained from the baseline data collected in the PREMATURITAS study.

RESULTS

A total of 52 young adults, with a mean age of 21.6 years, underwent PFTs. They were divided into two groups based on GA: 24-28 weeks (n = 12) and 29-34 weeks (n = 40). The subgroup born more prematurely had significantly higher lung clearance index (LCI), compared to the other subgroup (p = 0.013). LCI ≥ 6.99 was more frequently observed in the more premature group (50% vs. 12.5%, p = 0.005), those who did not receive prenatal steroids (p = 0.020), with a diagnosis of Respiratory Distress Syndrome (p = 0.034), those who received surfactant (p = 0.026), and mechanically ventilated ≥ 7 days (p = 0.005). Additionally, elevated LCI was associated with the diagnosis of asthma (p = 0.010).

CONCLUSIONS

The findings suggest pulmonary effects due to prematurity persist into adulthood and their insult on small airway function. Regular follow-up evaluations of young survivors born preterm should include assessments of PFTs. Specifically, the use of LCI can provide valuable insights into long-term pulmonary impairment.

Lung ultrasound for the sick child: less harm and more information than a radiograph

In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate.  Conclusion: the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: • Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. • Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: • Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. • Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.

Prediction of bronchopulmonary dysplasia in very preterm infants: competitive risk model nomogram

Objective

To develop predictive clinical models of bronchopulmonary dysplasia (BPD) through competing risk analysis.

Methods

Retrospective observational cohort study, including preterm newborns ≤32 weeks gestational age, conducted between January 1, 2013 and September 30, 2022 in a third-level Neonatal Intensive Care Unit in Spain. A prediction study was carried out using competing risk models, where the event of interest was BPD and the competing event was death. A multivariate competing risk model was developed separately for each postnatal day (days 1, 3, 7 and 14). Nomograms to predict BPD risk were developed from the coefficients of the final models and internally validated.

Results

A total of 306 patients were included in the study, of which 73 (23.9%) developed BPD and 29 (9.5%) died. On day 1, the model with the greatest predictive capacity was that including birth weight, days since rupture of membranes, and surfactant requirement (area under the receiver operating characteristic (ROC) curve (AUC), 0.896; 95% CI, 0.792-0.999). On day 3, the final predictive model was based on the variables birth weight, surfactant requirement, and Fraction of Inspired Oxygen (FiO2) (AUC, 0.891; 95% CI, 0.792-0.989).

Conclusions

Competing risk analysis allowed accurate prediction of BPD, avoiding the potential bias resulting from the exclusion of deceased newborns or the use of combined outcomes. The resulting models are based on clinical variables measured at bedside during the first 3 days of life, can be easily implemented in clinical practice, and can enable earlier identification of patients at high risk of BPD.

Surfactant status assessment and personalized therapy for surfactant deficiency or dysfunction

Surfactant is a pivotal neonatal drug used both for respiratory distress syndrome due to surfactant deficiency and for more complex surfactant dysfunctions (such as in case of neonatal acute respiratory distress syndrome). Despite its importance, indications for surfactant therapy are often based on oversimplified criteria. Lung biology and modern monitoring provide several diagnostic tools to assess the patient surfactant status and they can be used for a personalized surfactant therapy. This is desirable to improve the efficacy of surfactant treatment and reduce associated costs and side effects. In this review we will discuss these diagnostic tools from a pathophysiological and multi-disciplinary perspective, focusing on the quantitative or qualitative surfactant assays, lung mechanics or aeration measurements, and gas exchange metrics. Their biological and technical characteristics are described with practical information for clinicians. Finally, available evidence-based data are reviewed, and the diagnostic accuracy of the different tools is compared. Lung ultrasound seems the most suitable tool for assessing the surfactant status, while some other promising tests require further research and/or development.

Accuracy of lung ultrasound in predicting extubation failure in neonates: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the diagnostic accuracy of lung ultrasound score (LUS) in predicting extubation failure in neonates.

STUDY DESIGN

MEDLINE, COCHRANE, EMBASE, CINAHL, and clinicaltrials.gov were searched up to 30 November 2022, for studies evaluating the diagnostic accuracy of LUS in predicting extubation outcome in mechanically ventilated neonates.

METHODOLOGY

Two investigators independently assessed study eligibility, extracted data, and assessed study quality using the Quality Assessment for Studies of Diagnostic Accuracy 2 tool. We conducted a meta-analysis of pooled diagnostic accuracy data using random-effect models. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated pooled sensitivity and specificity, pooled diagnostic odds ratios with 95% confidence intervals (CI), and area under the curve (AUC).

RESULTS

Eight observational studies involving 564 neonates were included, and the risk of bias was low in seven studies. The pooled sensitivity and specificity for LUS in predicting extubation failure in neonates were 0.82 (95% CI: 0.75-0.88) and 0.83 (95% CI: 0.78-0.86), respectively. The pooled diagnostic odds ratio was 21.24 (95% CI: 10.45-43.19), and the AUC for LUS predicting extubation failure was 0.87 (95% CI: 0.80-0.95). Heterogeneity among included studies was low, both graphically and by statistical criteria (I2  = 7.35%, p = 0.37).

CONCLUSIONS

The predictive value of LUS in neonatal extubation failure may hold promise. However, given the current level of evidence and the methodological heterogeneity observed, there is a clear need for large-scale, well-designed prospective studies that establish standardized protocols for lung ultrasound performance and scoring.

REGISTRATION

The protocol was registered in OSF (https://doi.org/10.17605/OSF.IO/ZXQUT).

Imaging of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a multifactorial disease with many associated co-morbidities, responsible for most cases of chronic lung disease in childhood. The use of imaging exams is pivotal for the clinical care of BPD and the identification of candidates for experimental therapies and a closer follow-up. Imaging is also useful to improve communication with the family and objectively evaluate the clinical evolution of the patient's disease. BPD imaging has been classically performed using only chest X-rays, but several modern techniques are currently available, such as lung ultrasound, thoracic tomography, magnetic resonance imaging and electrical impedance tomography. These techniques are more accurate and provide clinically meaningful information. We reviewed the most recent evidence published in the last five years regarding these techniques and analyzed their advantages and disadvantages.

Modified lung ultrasound score for bronchopulmonary dysplasia predicts late respiratory outcomes in preterm infants

OBJECTIVE

Lung ultrasound (LUS) is a useful and radiation-free diagnostic tool for predicting bronchopulmonary dysplasia, which is a risk factor for late respiratory disease. However, data on the relationship of LUS with late respiratory disease was scarce. This study aims to determine whether LUS is associated with late respiratory disease during early childhood.

METHODS

This prospective cohort study enrolled preterm infants born before 32 weeks of gestation. LUS was performed at 36 weeks' postmenstrual age. The predictive values of a modified lung ultrasound (mLUS) score based on eight standard sections were assessed to predict late respiratory disease, defined as a physician diagnosis of bronchopulmonary dysplasia deterioration, asthma, reactive airway disease, bronchiolitis, pneumonia, or respiratory-related hospitalization during the first 2 years of life.

RESULTS

A total of 94 infants completed follow-up, of whom 74.5% met the late respiratory disease criteria. The mLUS scores were significantly associated with late respiratory disease (adjusted odds ratio: 1.23, CI: 1.10-1.38, p < 0.001). The mLUS scores also well predicted late respiratory disease (AUC = 0.820, 95% CI: 0.733-0.907). These scores were superior to the classic lung ultrasound score (p = 0.02) and as accurate as the modified NICHD-defined bronchopulmonary dysplasia classification (p = 0.91). A mLUS score ≥14 was the optimal cutoff point for predicting late respiratory disease.

CONCLUSION

The modified lung ultrasound score correlates significantly with late respiratory disease and well predicts it in preterm infants during the first 2 years of life.

Monitoring of the Healthy Neonatal Transition Period with Serial Lung Ultrasound

Ultrasound has been used to observe lung aeration and fluid clearance during the neonatal transition period, but there is no consensus regarding the optimal timing of lung ultrasound. We aimed to monitor the trend of the serial lung ultrasound score (LUS) and extended LUS (eLUS) throughout the neonatal transition period (≤1, 2, 4, 8, 24, and 48 h after birth), assess any correlation to the clinical presentation (using the Silverman Andersen Respiratory Severity Score (RSS)), and determine the optimal time of the ultrasound. We found both LUS and eLUS decreased significantly after 2 h of life and had similar statistical differences among the serial time points. Although both scores had a positive, moderate correlation to the RSS overall (Pearson correlation 0.499 [p < 0.001] between LUS and RSS, 0.504 [p < 0.001] between eLUS and RSS), the correlation was poor within 1 h of life (Pearson correlation 0.15 [p = 0.389] between LUS and RSS, 0.099 [p = 0.573] between eLUS and RSS). For better clinical correlation, the first lung ultrasound for the neonate may be performed at 2 h of life. Further research is warranted to explore the clinical value and limitations of earlier (≤1 h of life) lung ultrasound examinations.

Cardiorespiratory Monitoring Data to Predict Respiratory Outcomes in Extremely Preterm Infants

Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (Pre-Vent) study was an observational multicenter prospective cohort study including infants born at <29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either "favorable" (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or "unfavorable" (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84-0.85 at Days 7 and 14 and 0.86-0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry <80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants.

Early prediction of pulmonary outcomes in preterm infants using electrical impedance tomography

Introduction

Electrical impedance tomography (EIT) allows assessment of ventilation and aeration homogeneity which may be associated with respiratory outcomes in preterm infants.

Methods

This was a secondary analysis to a recent randomized controlled trial in very preterm infants in the delivery room (DR). The predictive value of various EIT parameters assessed 30 min after birth on important respiratory outcomes (early intubation <24 h after birth, oxygen dependency at 28 days after birth, and moderate/severe bronchopulmonary dysplasia; BPD) was assessed.

Results

Thirty-two infants were analyzed. A lower percentage of aerated lung volume [OR (95% CI) = 0.8 (0.66-0.98), p = 0.027] as well as a higher aeration homogeneity ratio (i.e., more aeration in the non-gravity-dependent lung) predicted the need for supplemental oxygen at 28 days after birth [9.58 (5.16-17.78), p = 0.0028]. Both variables together had a similar predictive value to a model using known clinical contributors. There was no association with intubation or BPD, where numbers were small.

Discussion

In very preterm infants, EIT markers of aeration at 30 min after birth accurately predicted the need for supplemental oxygen at 28 days after birth but not BPD. EIT-guided individualized optimization of respiratory support in the DR may be possible.

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.

Prediction of respiratory distress severity and bronchopulmonary dysplasia by lung ultrasounds and transthoracic electrical bioimpedance

This study aims to evaluate whether the assessment of a lung ultrasound score (LUS) by lung ultrasonography and of thoracic fluid contents (TFC) by electrical cardiometry may predict RDS severity and the development of bronchopulmonary dysplasia (BPD) in preterm infants with respiratory distress (RDS). Infants ≤ 34 weeks' gestation admitted with RDS to two neonatal intensive care units were prospectively enrolled in this observational study. A simultaneous evaluation of LUS and TFC was performed during the first 72 h. The predictivity of LUS and TFC towards mechanical ventilation (MV) need after 24 h and BPD development was evaluated using receiver operating characteristic analysis. Sixty-four infants were included. The area under the curve (AUC) for the prediction of MV need was 0.851 (95%CI, 0.776-0.925, p < 0.001) for LUS and 0.793 (95%CI, 0.724-0.862, p < 0.001) for TFC, while an AUC of 0.876 (95%CI, 0.807-0.946, p < 0.001) was obtained for combined LUS and TFC evaluation. LUS and TFC AUC for BPD prediction were 0.769 (95%CI, 0.697-0.842, p < 0.001) and 0.836 (95%CI, 0.778-0.894, p < 0.001), respectively, whereas their combined assessment yielded an AUC of 0.867 (95%CI, 0.814-0.919, p < 0.001). LUS ≥ 11 and TFC ≥ 40 were identified as cut-off values for MV need prediction, whereas LUS ≥ 9 and TFC ≥ 41.4 best predicted BPD development.   Conclusion: A combined evaluation of LUS and TFC by lung ultrasonography and EC during the first 72 h may represent a useful predictive tool towards short- and medium-term pulmonary outcomes in preterm infants with RDS. What is Known: • Lung ultrasonography is largely used in neonatal intensive care and can contribute to RDS diagnosis in preterm infants. • Little is known on the diagnostic and predictive role of TFC, measured by transthoracic electrical bioimpedance, in neonatal RDS. What is New: • Combining lung ultrasonography and TFC evaluation during the first 72 h can improve the prediction of RDS severity and BPD development in preterm infants with RDS and may aid to establish tailored respiratory approaches to improve these outcomes.

Use of Cardio-Pulmonary Ultrasound in the Neonatal Intensive Care Unit

Cardiopulmonary ultrasound (CPUS), the combination of lung ultrasound (LUS) and targeted neonatal echocardiography (TnECHO)AA, may offer a more appropriate approach to the challenging neonatal cardiovascular and respiratory disorders. This paper reviews the possible use of CPUS in the neonatal intensive care unit (NICU).

Prematurity and BPD: what general pediatricians should know

More and more very low birth weight (VLBW) infants around the world survive nowadays, with consequently larger numbers of children developing prematurity-related morbidities, especially bronchopulmonary dysplasia (BPD). BPD is a multifactorial disease and its rising incidence in recent years means that general pediatricians are much more likely to encounter a child born extremely preterm, possibly with BPD, in their clinical practice. Short- and long-term sequelae in VLBW patients may affect not only pulmonary function (principally characterized by an obstructive pattern), but also other aspect including the neurological (neurodevelopmental and neuropsychiatric disorders), the sensorial (earing and visual impairment), the cardiological (systemic and pulmonary hypertension, reduced exercise tolerance and ischemic heart disease in adult age), nutritional (feeding difficulties and nutritional deficits), and auxological (extrauterine growth restriction). For the most premature infants at least, a multidisciplinary follow-up is warranted after discharge from the neonatal intensive care unit in order to optimize their respiratory and neurocognitive potential, and prevent respiratory infections, nutritional deficiencies or cardiovascular impairments.  Conclusion: The aim of this review is to summarize the main characteristics of preterm and BPD infants, providing the general pediatrician with practical information regarding these patients' multidisciplinary complex follow-up. We explore the current evidence on respiratory outcomes and their management that actually does not have a definitive available option. We also discuss the available investigations, treatments, and strategies for prevention and prophylaxis to improve the non-respiratory outcomes and the quality of life for these children and their families, a critical aspect not always considered. This comprehensive approach, added to the increased needs of a VLBW subjects, is obviously related to very high health-related costs that should be beared in mind. What is Known: • Every day, a general pediatrician is more likely to encounter a former very low birth weight infant. • Very low birth weight and prematurity are frequently related not only with worse respiratory outcomes, but also with neurological, sensorial, cardiovascular, renal, and nutritional issues. What is New: • This review provides to the general pediatrician a comprehensive approach for the follow-up of former premature very low birth weight children, with information to improve the quality of life of this special population.

Comparison of lung ultrasound scores with clinical models for predicting bronchopulmonary dysplasia

Lung ultrasound scores (LUSs) have been demonstrated to accurately predict moderate-to-severe bronchopulmonary dysplasia (msBPD). This study attempted to explore the additional value of LUSs for predicting msBPD compared to clinical multivariate models in different gestational age (GA) groups. The study prospectively recruited preterm infants with GA < 32 weeks. Lung ultrasound was performed on days 3, 7, 14, and 21 after birth. A linear mixed-effects regression model was used to evaluate LUS evolution in infants born before and after 28 weeks. The receiver operating characteristic (ROC) procedure was used to analyze the reliability of LUS and clinical multivariable models for predicting msBPD. The optimal time to predict msBPD in all infants was 7 days with a cut-off point of 5 (area under the ROC (AUROC) curve: 0.78, 95% confidence interval (CI): 0.71-0.84). In infants with GA ≥ 28 weeks, LUSs provided a moderate diagnostic accuracy for all four time points (AUROC curve: 0.74-0.78), and the AUROC curve for the clinical multivariable model on day 14 was 0.91 (95% CI: 0.84-0.96), which was significantly higher than that of LUSs (AUROC curve: 0.77, 95% CI: 0.68-0.85, P < 0.05). In infants born at 23-27 weeks, LUSs showed a low diagnostic accuracy with higher cut-off points to predict msBPD, and the AUROC curve for GA to predict msBPD was 0.75 (95% CI: 0.59-0.85), providing diagnostic accuracy similar to that of LUSs.  Conclusion: The contribution of LUSs to predict msBPD in infants with different GAs remains controversial and requires further investigation. What is Known: • Lung ultrasound scores (LUSs) have been demonstrated to accurately predict moderate-to-severe bronchopulmonary dysplasia in infants with gestational age (GA)＜32 weeks. What is New: • The LUSs evolution differed between extremely preterm infants born before 28 weeks and preterm infants born at 28-32 weeks of gestation. • LUSs provided similar moderate predictive performance as GA-adjusted LUS and clinical multivariate models in infants born after 28 weeks, while LUSs seem to be less helpful in infants born before 28 weeks.

Diaphragmatic Thickness and Excursion in Preterm Infants With Bronchopulmonary Dysplasia Compared With Term or Near Term Infants: A Prospective Observational Study

BACKGROUND

Diaphragmatic atrophy associated with mechanical ventilation is reported in pediatric and adult patients, but a similar association has not been described in preterm infants with bronchopulmonary dysplasia (BPD).

RESEARCH QUESTION

Does BPD impact the diaphragm thickness (DT) and diaphragm excursion (DE) in infants born before 32 weeks' gestation compared with healthy late preterm or term infants?

STUDY DESIGN AND METHODS

In this prospective observational case-control study, DT at end of expiration (DT_exp), DT at end of inspiration (DT_ins), DT fraction (DTF), and DE (DE) were assessed using bedside ultrasound. Two groups were compared: infants with BPD (patients) and healthy, postmenstrual age-matched infants (control participants). To account for variations in body size between groups, diaphragmatic measurements were expressed as a ratio of body surface area (BSA). Statistical analyses were conducted using SAS software version 9.4 (SAS Institute, Inc.).

RESULTS

We enrolled 111 infants, including 56 preterm infants with BPD (mean ± SD study age, 37.7 ± 1.7 weeks) and 55 healthy control participants (mean ± SD study age, 38.1 ± 1.5 weeks). DT_exp and DT_exp to BSA ratio were significantly lower in the BPD group compared with the healthy control group (mean ± SD, 1.3 ± 0.4 mm vs 1.5 ± 0.4 mm [P = .01] and 7.1 ± 1.4 mm/m² vs 7.8 ± 1.8 mm/m² [P = .03]). DTF and DE were significantly higher in the BPD group vs the healthy control group (mean ± SD, 61.8 ± 26.0 vs 43.3 ± 19.7 [P < .01] and 6.0 ± 1.7 mm vs 4.4 ± 1.6 mm [P < .01], respectively).

INTERPRETATION

In infants with BPD, DT_exp was significantly lower, whereas DTF and DE were significantly higher, compared with healthy, age-matched control participants. Future studies are required and should focus on describing the evolution of diaphragmatic dimensions in preterm infants with and without BPD.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04941963; URL: www.

CLINICALTRIALS

gov.

Respiratory and haemodynamic effects of 6h-pronation in neonates recovering from respiratory distress syndrome, or affected by acute respiratory distress syndrome or evolving bronchopulmonary dysplasia: a prospective, physiological, crossover, controlled cohort study

BACKGROUND

Pronation ameliorates oxygenation in adults with acute respiratory distress syndrome (ARDS); the effect in neonates with ARDS or other types of respiratory failure is unknown. We aimed to verify if pronation has similar respiratory and haemodynamic effects in three common types of neonatal respiratory failure.

METHODS

Prospective, physiologic, crossover, quasi-randomised, controlled cohort study performed in a tertiary academic neonatal intensive care unit. We enrolled neonates with: 1) recovering respiratory distress syndrome (RDS, mild restrictive pattern); 2) neonatal ARDS (NARDS, severe restrictive pattern); or 3) evolving bronchopulmonary dysplasia (BPD), that is chronic pulmonary insufficiency of prematurity (mixed restrictive/obstructive pattern). Neonates with other lung disorders, malformations or haemodynamic impairment were excluded. Patients were started prone or supine and then shifted to the alternate position for 6h; measurements were performed after 30' of "wash out" from the positioning and at the end of 6h period. Primary outcomes were respiratory (PtcCO_2, modified ventilatory index, PtcO₂/FiO₂, SpO₂/FiO₂, oxygenation index, ultrasound-assessed lung aeration) and haemodynamic (perfusion index, heart rate, arterial pressure, cardiac output) parameters.

FINDINGS

Between May 1st, 2019, and May 31st, 2021, 161 participants were enrolled in this study, and included in the final analysis. Pronation improved gas exchange and lung aeration (p always <0.01) and these effects were overturned in the alternate position, except for lung aeration in NARDS where the improvement persisted. The effects were greater in patients recovering from RDS than in those with evolving BPD than in those with NARDS, in this order (p always <0.01). Pronation produced a net recruitment as lung ultrasound score decreased in patients shifted from supine (16.9 (standard deviation: 5.8)) to prone (14.1 (standard deviation: 3.3), p < 0.01) and this reduction correlated with oxygenation improvement. Haemodynamic parameters remained within normal ranges.

INTERPRETATION

6h-pronation can be used to improve gas exchange and lung aeration in neonates with recovering RDS, evolving BPD or NARDS without relevant haemodynamic effects.

FUNDING

None.

Targeted neonatal echocardiography and lung ultrasound in preterm infants with chronic lung disease with and without pulmonary hypertension, screened using a standardized algorithm

Introduction

Increased recognition of the development of chronic pulmonary hypertension (cPH) in preterm infants with chronic lung disease (CLD) has prompted enhanced monitoring for the identification of different phenotypes.

Methods

All newborns consulted for oxygen/respiratory support dependency (CLD assessment) from January 2018 to December 2021 were included. TnECHO and LUS screening for cPH-CLD were performed at 36 weeks postmenstrual age. Cases of cPH related to increased pulmonary blood flow (cPH-IPBF) were referred to Pediatric Cardiology. The objective of the study was to identify all cases of cPH (cPH-CLD/IPBF) in the CLD patients screened and to compare outcomes. Following a standardized algorithm, cPH-CLD patients were treated with diuretics; ultrasounds taken before and after treatment were analyzed.

Results

Seventy-two patients with CLD were screened. Twenty-two (30%) had cPH-CLD, and nine (12%) had cPH-IPBF. cPH infants underwent more days of mechanical ventilation, were more likely to have retinopathy of prematurity, and showed increased mortality. The LUS pattern observed in the 72 CLD patients consisted of a thickened pleural line and a B-line interstitial heterogeneous pattern; 29% of patients were found to have lung consolidations. After diuretic therapy, step-down in respiratory support occurred in 59% of neonates with cPH-CLD. A decrease in respiratory rate (RR), right ventricular output (RVO), markers of pulmonary vascular resistance (PVR), and B-line pattern was observed. In tissue Doppler imaging, biventricular diastolic function was found to be modified after diuretics.

Conclusions

CLD infants with cPH showed increased morbidity and mortality. In cPH-CLD patients, a decrease in RR and step-down in respiratory support was observed after diuretic treatment. Follow-up ultrasound showed a decrease in RVO, markers of PVR, and B-lines.

A scoping review of echocardiographic and lung ultrasound biomarkers of bronchopulmonary dysplasia in preterm infants

Despite recent improvements in neonatal care, moderate to severe bronchopulmonary dysplasia (BPD) is still associated with high mortality and with an increased risk of developing pulmonary hypertension (PH). This scoping review provides an updated overview of echocardiographic and lung ultrasound biomarkers associated with BPD and PH, and the parameters that may prognosticate their development and severity, which could be clinically helpful to undertake preventive strategies. A literature search for published clinical studies was conducted in PubMed using MeSH terms, free-text words, and their combinations obtained through appropriate Boolean operators. It was found that the echocardiography biomarkers for BPD, and especially those assessing right ventricular function, are reflective of the high pulmonary vascular resistance and PH, indicating a strong interplay between heart and lung pathophysiology; however, early assessment (e.g., during the first 1-2 weeks of life) may not successfully predict later BPD development. Lung ultrasound indicating poor lung aeration at day 7 after birth has been reported to be highly predictive of later development of BPD at 36 weeks' postmenstrual age. Evidence of PH in BPD infants increases risk of mortality and long-term PH; hence, routine PH surveillance in all at risk preterm infants at 36 weeks, including an echocardiographic assessment, may provide useful information. Progress has been made in identifying the echocardiographic parameters on day 7 and 14 to predict later development of pulmonary hypertension. More studies on sonographic markers, and especially on echocardiographic parameters, are needed for the validation of the currently proposed parameters and the timing of assessment before recommendations can be made for the routine clinical practice.

Intravitreal Bevacizumab Is Associated With Prolonged Ventilatory Support in Preterm Infants With Bronchopulmonary Dysplasia

BACKGROUND

Intravitreal bevacizumab (IVB), an anti-vascular endothelial growth factor (VEGF) antibody, is a widely adopted treatment for retinopathy of prematurity (ROP). Although animal studies have demonstrated that IVB inhibits alveologenesis in neonatal rat lung, the clinical influence of IVB on respiratory outcomes has not been studied.

RESEARCH QUESTION

Does IVB affect the respiratory outcome in preterm infants with bronchopulmonary dysplasia?

STUDY DESIGN AND METHODS

We retrospectively assessed very low birth weight (VLBW) preterm infants admitted to our neonatal ICU between January 2016 and June 2021. Furthermore, we evaluated the short-term respiratory outcomes after IVB therapy in VLBW preterm infants requiring ventilatory support at 36 weeks' postmenstrual age (PMA).

RESULTS

One hundred seventy-four VLBW preterm infants with bronchopulmonary dysplasia were recruited. Eighty-eight infants showed ROP onset before being ventilator free, and 78 infants received a diagnosis of the most severe ROP before being ventilator free. Among them, 32 received a diagnosis with type 1 ROP and received IVB treatment. After adjusting for gestational age, birth body weight, and baseline respiratory status, we discovered that IVB is associated significantly with prolonged ventilatory support and a lower likelihood of becoming ventilator free (hazard ratio, 0.53; P = .03).

INTERPRETATION

IVB may have a short-term respiratory adverse effect in patients requiring ventilatory support at 36 weeks' PMA. Therefore, long-term follow-up for respiratory outcomes may be considered in VLBW infants who receive IVB treatment.

Lung ultrasound score follows the chronic pulmonary insufficiency of prematurity trajectory in early infancy

Extremely preterm birth is associated with a high risk of chronic pulmonary insufficiency of prematurity (CPIP). Lung ultrasound score (LUS) proved capable to characterise CPIP progression beyond the acute setting, but still, post-discharge data remain lacking. We hypothesised a priori that LUS in both BPD and no-BPD infants declines with postnatal age from birth through early infancy. This observational retrospective cohort study included preterm infants < 32 gestational weeks, who underwent the follow-up for CPIP. LUS was assessed from birth to 8 months postnatal age, over antero-lateral (LUS) and posterior (pLUS) pulmonary areas, placing the transducer longitudinally over the midclavicular and midaxillary lines and medial to the scapular line respectively. Extended LUS (eLUS) including LUS and pLUS was calculated. The primary outcome was LUS time course. Secondary outcomes included the correlation between LUS and pLUS. Sixty-two infants were included: 22 (35.5%) in the BPD group and 40 (64.5%) in the no-BPD group. BPD group infants were smaller (weight 841 g (± 228) vs 1226 (± 328), p < 0.001) and younger (26.8 weeks (± 2.0) vs 28.9 (± 1.9), p < 0.001). LUS declined over time in the entire population (ß =  - 1.75, p < 0.001) and in both no-BPD and BPD groups (ß =  - 1.64, p < 0.001 and ß =  - 1.93, p < 0.001, respectively). eLUS declined correspondingly (p < 0.001). LUS and likewise eLUS were significantly different between BPD and no-BPD groups over time (p < 0.001).  Conclusion: LUS trajectory progressively decreased from birth to early infancy. BPD cohort tracked higher, implying a worse respiratory status. pLUS had a similar timepoint course, adding no further information to LUS. To the best of our knowledge, this is the first study that describes preterm LUS time course after discharge. LUS may help track the CPIP progression. What is Known: • Extremely preterm birth is associated with high risk of chronic pulmonary insufficiency of prematurity (CPIP). • Several studies investigated the ability of lung ultrasound score (LUS) to characterize CPIP progression beyond the acute setting, still post-discharge data remain lacking. What is New: • LUS trajectory progressively decreases from birth to early infancy; BPD cohort tracks higher, implying a worse respiratory status. pLUS has similar timepoint course, adding no further information to LUS. • The use of LUS may contribute to better characterising and monitoring CPIP in BPD and no-BPD infants.

Quantitative lung ultrasound detects dynamic changes in lung recruitment in the preterm lamb

BACKGROUND

Lung ultrasound (LUS) may not detect small, dynamic changes in lung volume. Mean greyscale measurement using computer-assisted image analysis (Q-LUS_MGV) may improve the precision of these measurements.

METHODS

Preterm lambs (n = 40) underwent LUS of the dependent or non-dependent lung during static pressure-volume curve mapping. Total and regional lung volumes were determined using the super-syringe technique and electrical impedance tomography. Q-LUS_MGV and gold standard measurements of lung volume were compared in 520 images.

RESULTS

Dependent Q-LUS_MGV moderately correlated with total lung volume (rho = 0.60, 95% CI 0.51-0.67) and fairly with right whole (rho = 0.39, 0.27-0.49), central (rho = 0.38, 0.27-0.48), ventral (rho = 0.41, 0.31-0.51) and dorsal regional lung volumes (rho = 0.32, 0.21-0.43). Non-dependent Q-LUS_MGV moderately correlated with total lung volume (rho = 0.57, 0.48-0.65) and fairly with right whole (rho = 0.43, 0.32-0.52), central (rho = 0.46, 0.35-0.55), ventral (rho = 0.36, 0.25-0.47) and dorsal lung volumes (rho = 0.36, 0.25-0.47). All correlation coefficients were statistically significant. Distinct inflation and deflation limbs, and sonographic pulmonary hysteresis occurred in 95% of lambs. The greatest changes in Q-LUS_MGV occurred at the opening and closing pressures.

CONCLUSION

Q-LUS_MGV detected changes in total and regional lung volume and offers objective quantification of LUS images, and may improve bedside discrimination of real-time changes in lung volume.

IMPACT

Lung ultrasound (LUS) offers continuous, radiation-free imaging that may play a role in assessing lung recruitment but may not detect small changes in lung volume. Mean greyscale image analysis using computer-assisted quantitative LUS (Q-LUS_MGV) moderately correlated with changes in total and regional lung volume. Q-LUS_MGV identified opening and closing pressure and pulmonary hysteresis in 95% of lambs. Computer-assisted image analysis may enhance LUS estimation of lung recruitment at the bedside. Future research should focus on improving precision prior to clinical translation.

Semi-quantitative lung ultrasound score during ground transportation of outborn neonates with respiratory failure

Lung ultrasound score (LUS) is increasingly diffused in neonatal critical care but scanty data are available about its use during transfer of severely ill neonates. We aimed to clarify the effect of ground transportation on LUS evolution, conformity of interpretation, and relationships with oxygenation and clinical severity. This is a single-center, blinded, observational, cross-sectional study. Neonates of any gestational age with respiratory distress appearing within 24 h from birth were transferred by a mobile unit towards neonatal intensive care unit (NICU) of a tertiary referral center. Calculation of LUS prior to the transportation (T1), in the mobile unit (T2), at the end of transportation (T3), and finally upon NICU admission. LUS in the mobile unit and in the NICU was performed by different physicians blinded to each other's results. LUS did not change overtime (T1: 6.3 (3.5), T2: 6.1 (3.5), T3: 5.8 (3.4); p = 0.479; adjusted for gestational or postnatal age or transport duration: p = 0.951, p = 0.424, and 0.266, respectively) but reliably predicted surfactant need (AUC at T1: 0.833 (95%CI: 0.72-0.92); AUC at T2: 0.82 (95%CI: 0.70-0.91); AUC at T3: 0.82 (95%CI: 0.70-0.90); p always < 0.0001). There were significant agreement (ICC = 0.912 (95%CI: 0.83-0.95); p < 0.001) and correlation (r = 0.905, p < 0.001) between LUS calculated during transportation and in the NICU. LUS during transportation was also significantly correlated with oxygenation index (r = 0.321, p = 0.026; standardized B = 0.397 (95%CI: 0.03-0.76), p = 0.048) and TRIPS-II score (r = 0.302, p = 0.008; standardized B = 0.568 (95%CI: 0.04-1.1), p = 0.037).

CONCLUSION

LUS during ground transportation of neonates with respiratory failure is suitable and not influenced by the transportation itself. It has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity.

WHAT IS KNOWN

• Lung ultrasound is a part of the point-of-care ultrasound, which is becoming an essential tool, to manage critically ill neonates and children in an accurate, non-invasive and quick way.

WHAT IS NEW

• Lung ultrasound score (LUS) is suitable during transportation of critically ill neonates with respiratory failure and is not influenced by the transportation itself. • LUS has a high agreement with that calculated in the NICU and correlates with patients' oxygenation and severity of respiratory failure.

Lung ultrasound score has better diagnostic ability than NT-proBNP to predict moderate-severe bronchopulmonary dysplasia

The N-terminal end of B-type natriuretic peptide (NT-proBNP) and lung ultrasound (LUS) score have been proven to be adequate early biomarkers of bronchopulmonary dysplasia (BPD) in preterm infants. Our aim was to study if the predictive capacity of each one is increased by analyzing them together. We included infants born before 32 weeks with NT-proBNP and LUS scores on the first day of life (DOL) and on the 3rd, 7th, and 14th DOL and compared the diagnostic ability for moderate-severe BPD (msBPD) of each biomarker and in combination. We also compared them with a multivariate model of msBPD using only clinical variables. The sample size was 133 patients, and twenty-seven (20%) developed msBPD. The LUS score on the 7th DOL had better performance than NT-proBNP at the same moment: area under the receiver operating characteristic curve (AUC) 0.83 (0.75-0.89) versus 0.66 (0.56-0.75), p = 0.003, without differences in the rest of the times studied. These values did not increase when using the combination of both. A multivariate regression model that included only clinical variables (birth weight and invasive mechanical ventilation (IMV) at the 7th DOL) predicted msBPD with the same AUC as after the addition of any of these biomarkers, neither together.

CONCLUSION

The LUS score is a better predictor of msBPD on the 7th DOL than NT-proBNP in preterm infants born before 32 weeks, although they have similar diagnostic accuracy on the 1st, 3rd, and 14th DOL. Neither of them, nor together, have a better AUC for msBPD than a clinical model with birthweight and the need for IMV at the 7th DOL.

WHAT IS KNOWN

• NT-proBNP and LUS score are early predictors of moderate-severe bronchopulmonary dysplasia (msBPD).

WHAT IS NEW

• The combination of both NT-proBNP and LUS score does not increase the predictive ability of each separately.

Lung ultrasound scores in neonatal clinical practice: A narrative review of the literature

Lung ultrasound (LU) has in recent years increasingly been used as a point-of-care method. Initially, LU was used as a so-called descriptive diagnostic method for neonatal respiratory diseases. Instead, this review article focuses on the use of LU as a "functional" tool using classification of findings in patterns or using semiquantitative scores. We review and describe the evidence that led to the implementation of LU in predicting the need for surfactant replacement therapy in preterm infants and in the identification of newborns at risk of developing bronchopulmonary dysplasia. LU appears to be a very promising method for the future of clinical management of newborns in both acute and chronic phases of pulmonary pathologies related to prematurity. However, further studies are needed to define its role before full implementation.

Sonographic Evaluation of the Endotracheal Tube Position in the Neonatal Population: A Comprehensive Review and Meta-Analysis

BACKGROUND

Endotracheal intubation in neonates is challenging and requires a high level of precision, due to narrow and short airways, especially in preterm newborns. The current gold standard for endotracheal tube (ETT) verification is chest X-ray (CXR); however, this method presents some limitations, such as ionizing radiation exposure and delayed in obtaining the radiographic images, that point of care ultrasound (POCUS) could overcome.

PRIMARY OBJECTIVE

To evaluate ultrasound efficacy in determining ETT placement adequacy in preterm and term newborns.

SECONDARY OBJECTIVE

To compare the time required for ultrasound confirmation vs. time needed for other standard of care methods.

SEARCH METHODS

A search in Medline, PubMed, Google Scholar and in the Cochrane Central Register of Controlled Trials (CENTRAL) was performed. Our most recent search was conducted in September 2021 including the following keywords: "newborn", "infant", "neonate", "endotracheal intubation", "endotracheal tube", "ultrasonography", "ultrasound".

SELECTION CRITERIA

We considered randomized and non-randomized controlled trials, prospective, retrospective and cross-sectional studies published after 2012, involving neonatal intensive care unit (NICU) patients needing intubation/intubated infants and evaluating POCUS efficacy and/or accuracy in detecting ETT position vs. a defined gold-standard method. Three review authors independently assessed the studies' quality and extracted data.

MAIN RESULTS

We identified 14 eligible studies including a total of 602 ETT evaluations in NICU or in the delivery room. In about 80% of cases the gold standard for ETT position verification was CXR. Ultrasound was able to identify the presence of ETT in 96.8% of the evaluations, with a pooled POCUS sensitivity of 93.44% (95% CI: 90.4-95.75%) in detecting an appropriately positioned ETT as assessed by CXR. Bedside ultrasound confirmation was also found to be significantly faster compared to obtaining a CXR.

CONCLUSION

POCUS appears to be a fast and effective technique to identify correct endotracheal intubation in newborns. This review could add value and importance to the use of this promising technique.

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.

Prediction Models for Bronchopulmonary Dysplasia in Preterm Infants: A Systematic Review

OBJECTIVE

To provide an overview and critical appraisal of prediction models for bronchopulmonary dysplasia (BPD) in preterm infants.

METHODS

We searched PubMed, Embase, and the Cochrane Library to identify relevant studies (up to November 2021). We included studies that reported prediction model development and/or validation of BPD in preterm infants born at ≤32 weeks and/or ≤1,500 g birth weight. We extracted the data independently based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS). We assessed risk of bias and applicability independently using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

Twenty-one prediction models from 13 studies reporting on model development and 21 models from 10 studies reporting on external validation were included. Oxygen dependency at 36 weeks' postmenstrual age was the most frequently reported outcome in both development studies (71%) and validation studies (81%). The most frequently used predictors in the models were birth weight (67%), gestational age (62%), and sex (52%). Nearly all included studies had high risk of bias, most often due to inadequate analysis. Small sample sizes and insufficient event patients were common in both study types. Missing data were often not reported or were discarded. Most studies reported on the models' discrimination, while calibration was seldom assessed (development, 19%; validation, 10%). Internal validation was lacking in 69% of development studies.

CONCLUSION

The included studies had many methodological shortcomings. Future work should focus on following the recommended approaches for developing and validating BPD prediction models.

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).