A modified lung ultrasound score to evaluate short-term clinical outcomes of bronchopulmonary dysplasia

Characteristics of scores used for quantitative lung ultrasound in neonates: a systematic review

BACKGROUND

Quantitative lung ultrasound is increasingly being used in neonatology. The aim of this study is to identify the lung ultrasound scores (LUS) available for use in neonates, describe their characteristics and determine which LUS are most used and validated.

METHODS

A systematic review of the literature was conducted following PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols extension for reporting literature searches in systematic reviews) guidelines. Articles describing LUS in newborn animals and human neonates, published up to March 2024, were searched in the PubMed and Embase databases.

RESULTS

Out of 757 identified studies, 121 were included. Most of the articles were published in the past 5 years, predominantly by European investigators. They described 32 different LUS. Only 10 (31.4%) of these LUS had undergone at least one validation attempt and only 15 (48.4%) used the four-step scoring scale (i.e. scored from 0 to 3) based on classical lung ultrasound patterns originally described and well established in adult critical care medicine. The most common (49 (40.5%) of all the articles) neonatal score (published by Brat et al. in 2015) was based on this classical grading system. The most commonly used score was also validated using the greatest number of techniques and applied to all major neonatal respiratory disorders. Its simplified version is used to analyse six chest areas (anterior and lateral) to guide surfactant administration, while its extended version includes 10 areas by adding four posterior ones.

CONCLUSIONS

The most commonly used and validated score, consistent with adult critical care practice, should be the standard for assessing lung aeration in neonates.

Lung ultrasound score for prediction of bronchopulmonary dysplasia in newborns: A meta-analysis

BACKGROUND

Bronchopulmonary dysplasia (BPD) ranks among preterm infants' most common and severe respiratory diseases. Lung ultrasound scores (LUS) play a vital role in predicting early BPD and guiding treatment and intervention strategies for affected patients.

OBJECTIVE

Performed a meta-analysis to assess the diagnostic LUS for newborns with BPD.

METHODS

Online electronic databases such as MEDLINE, CINAHL, the Cochrane Library, and Web of Science were used to retrieve relevant research until May 2023. A total of 117 literatures were collected, and ten eligible articles were selected for meta-analysis.

RESULTS

Meta-analysis was performed on 10 studies (1274 neonates). LUS at 7 days after birth (7 days of life, DOL 7) showed good diagnostic accuracy for any type of BPD, moderate and severe BPD. DOL 7 was more accurate in predicting all types of BPD (AUC = 0.87, sensitivity = 0.75, specificity = 0.83) than moderate and severe BPD (AUC = 0.80, sensitivity = 0.69, specificity = 0.79). There was no statistical significance between DOL 7 and DOL 14 in their accuracy for predicting all types of BPD (difference in AUC = 0.04, p= 0.068). There was no notable distinction between DOL 7 and DOL 14 in their accuracy for predicting moderate and severe BPD (difference in AUC =-0.04, p= 0.104).

CONCLUSIONS

The diagnostic efficacy of LUS on DOL 7 in predicting the occurrence of all types of BDP and moderate-severe BPD is determined. This will facilitate rapid and accurate detection and timely treatment, thereby reducing the risk of neonatal mortality and sequelae.

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.

Proportion of confluent B-Lines predicts respiratory support in term infants shortly after birth

OBJECTIVE

To develop and evaluate the predictive value of a simplified lung ultrasound (LUS) method for forecasting respiratory support in term infants.

METHODS

This observational, prospective, diagnostic accuracy study was conducted in a tertiary academic hospital between June and December 2023. A total of 361 neonates underwent LUS examination within 1 h of birth. The proportion of each LUS sign was utilized to predict their respiratory outcomes and compared with the LUS score model. After identifying the best predictive LUS sign, simplified models were created based on different scan regions. The optimal simplified model was selected by comparing its accuracy with both the full model and the LUS score model.

RESULTS

After three days of follow-up, 91 infants required respiratory support, while 270 remained healthy. The proportion of confluent B-lines demonstrated high predictive accuracy for respiratory support, with an area under the curve (AUC) of 89.1% (95% confidence interval [CI]: 84.5-93.7%). The optimal simplified model involved scanning the R/L 1-4 region, yielding an AUC of 87.5% (95% CI: 82.6-92.3%). Both the full model and the optimal simplified model exhibited higher predictive accuracy compared to the LUS score model. The optimal cut-off value for the simplified model was determined to be 15.9%, with a sensitivity of 76.9% and specificity of 91.9%.

CONCLUSIONS

The proportion of confluent B-lines in LUS can effectively predict the need for respiratory support in term infants shortly after birth and offers greater reliability than the LUS score model.

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.

Changes in Thymic Size and Immunity Are Associated with Bronchopulmonary Dysplasia

OBJECTIVE

Preterm infants with bronchopulmonary dysplasia (BPD) are at increased risk for dysfunctional immune responses in the postnatal period. This study aimed to verify the hypothesis that thymic function is altered in infants with BPD and changes in the expression of thymic function-related genes affect thymic development.

STUDY DESIGN

Included in the study were infants who had a gestational age ≤32 weeks and survived to a postmenstrual age of ≥36 weeks. The clinical features and thymic size were comparatively studied between infants with and without BPD. Thymic function and the expression of thymic function-related genes were determined in BPD infants at birth, week 2, and 4 of life. The thymic size was ultrasonographically assessed in terms of the thymic index (TI) and thymic weight index (TWI). T-cell receptor excision circles (TRECs) and gene expression were quantitatively determined by real-time quantitative reverse transcription polymerase chain reaction.

RESULTS

Compared to non-BPD infants, their BPD counterparts had a shorter GA, lower birth weight, lower Apgar scores at birth, and were more likely to be of the male gender. BPD infants had an elevated incidence of respiratory distress syndrome and sepsis. TI was 1.73 ± 0.68 versus 2.87 ± 0.70 cm3 and TWI was 1.38 ± 0.45 versus 1.72 ± 0.28 cm3/kg in the BPD group versus the non-BPD group (p < 0.05). In BPD infants, no significant changes were observed in thymic size, lymphocyte counts, and TREC copy numbers at the first 2 weeks (p > 0.05), but they all exhibited a significant increase at week 4 (p < 0.05). BPD infants presented a trend toward increased expression of transforming growth factor-β1 and decreased expression of forkhead box protein 3 (Foxp3) from birth to week 4 (p < 0.05). Nonetheless, no significant difference was found in IL-2 or IL-7 expression at all time points (p > 0.05).

CONCLUSION

For preterm infants with BPD, reduced thymic size at birth might be associated with impaired thymic function. Thymic function was developmentally regulated in the BPD process.

KEY POINTS

· For preterm infants with BPD, reduced thymic size at birth might be associated with impaired thymic.. · BPD infants had an elevated incidence of respiratory distress syndrome and sepsis.. · Thymic function was developmentally regulated in the BPD process..

Optimization of lung ultrasound in ultrafast-track anesthesia for non-cyanotic congenital heart disease surgery

Objective

We aimed to explore the feasibility of lung ultrasound for perioperative assessment and the optimal effect of lung ultrasound in reducing lung complications during non-cyanotic congenital heart disease (CHD) surgery using ultrafast-track anesthesia.

Methods

Sixty patients were treated at Shenzhen Children's Hospital between 2019 and 2020. Of these, 30 patients in group N had an indication for extubation and ultrafast-track anesthesia after congenital heart surgery; the tracheal catheter was removed, and the patients were sent to the cardiac intensive care unit (CICU) for further monitoring and treatment. Another 30 patients were in group L and also had an indication for extubation and ultrafast-track anesthesia; in addition we compared lung ultrasound score (LUS) before and after surgery, when we found the cases that LUS ≥ 15, for whom targeted optimization treatment would be carried out. The tracheal catheter was removed after LUS <15 days before the patients were sent to the CICU. In all cases, the LUS and PaO2/FiO2 ratios (P/F) of both groups were recorded at the time of anesthesia induction (T0), before extubation (T1), and 5 min (T2), 1 h (T3), and 24 h (T4) after extubation. The incidence of pulmonary complications, LUS, and P/F were compared between the two groups.

Results

There was great consistency between LUS and radiographic findings. Comparing the data of the two groups at T2, T3 and T4, the P/F was higher and the LUS was lower in group L than in group N. The incidence of lung complications in group L (18 cases, 60 %) was lower than that in group N (26 cases, 86.7 %, χ2 = 5.46, P = 0.02); comparing LUS between T0 and T3, LUS decreased in a greater number of cases in group L (15, 50 %) than in group N (7 cases, 23.3 %, χ2 = 4.59, P = 0.032).

Conclusion

Lung ultrasonography can effectively help assess lung conditions. Optimization guided by lung ultrasound in ultrafast track anesthesia can significantly reduce postoperative lung complications.

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.

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.