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Pediatrics and Neonatology xxx (xxxx) xxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.pediatr-neonatol.com

Original Article

Lung ultrasound score as a predictor of

ventilator use in preterm infants with
dyspnea within 24 h after dhospitalization
Lihua Zhang, Jinnan Feng, Di Jin, Zekun Yu, Yangming Qu,
Meiyu Zheng, Hui Wu*

Department of Neonatology, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun
130021, China

Received May 30, 2022; received in revised form Aug 2, 2022; accepted Sep 21, 2022
Available online - - -

Key Words Background: Selecting the correct ventilation strategy is crucial for the survival of preterm in-
dyspnea; fants with dyspnea in NICU. Lung ultrasound score (LUSsc) is a potential predictor for respira-
lung ultrasound; tory support patterns in preterm infants.
lung ultrasound score Methods: We prospectively included 857 preterm infants. LUS was performed in the first 2 h af-
ter admission, and LUSsc was determined by two specialist sonographers. Participants were
divided into two categories according to gestational age (<32þ0 weeks and 32þ0e36þ6 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 þ0 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
e0.809), the cut-off point of LUSsc was 8, and the sensitivity and specificity were 74.0% and
68.3%, respectively. In the 32þ0e36þ6 weeks group, the AUC was 0.863 (95% CI: 0.811
e0.911), with a cut-off point of 7. Sensitivity and specificity were 75.3% and 0.836%, respec-
tively. In the validation set, using the actual clinical respiratory support selection results for
verification, the validation results showed for the <32þ0 weeks group (Kappa value 0.660,
P < 0.05, McNemar test P > 0.05) for preterm 32 þ0 e36 þ6 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 pre-
term infants with dyspnea.

Abbreviations: LUS, Lung ultrasound; LUSsc, Lung ultrasound score.

* Corresponding author.
E-mail address: wuhui@jlu.edu.cn (H. Wu).

https://doi.org/10.1016/j.pedneo.2022.09.019
1875-9572/Copyright ª 2023, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: L. Zhang, J. Feng, D. Jin et al., Lung ultrasound score as a predictor of ventilator use in preterm infants with
dyspnea within 24 h after dhospitalization, Pediatrics and Neonatology, https://doi.org/10.1016/j.pedneo.2022.09.019
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L. Zhang, J. Feng, D. Jin et al.
Registered at ClinicalTrials.gov (identifier: chiCTR1900023869).
Copyright ª 2023, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
1. Introduction
Most premature infants have difficulty breathing after birth
and require respiratory support and adjuvant treatment.
Current treatments focus on lung-protective ventilation
strategies, with the option of non-invasive respiratory
support rather than invasive respiratory support.1 However,
non-invasive respiratory support is insufficient for some
hospitalized preterm infants who require invasive me-
chanical ventilation. For these patients, failure to treat in
time can delay recovery, so interventions that maximize
survival while minimizing potential adverse effects,
including Bronchopulmonary Dysplasia (BPD), are required.
In infants who receive invasive ventilation inappropriately,
overtreatment may lead to lung injury and more sedation,
as well as financial loss.2 Lung ultrasound (LUS) plays an
active role in auxiliary treatment for lung disease, including
prognosis prediction, disease diagnosis, evaluation, and
monitoring.3e5 By dividing the lungs into several lung re-
gions and scoring the ultrasound images of each lung region
according to a unified scoring standard, the total LUSsc can
be calculated.6 LUSsc is a comprehensive index that can
reflect the condition of lung ventilation and can more
accurately assess the oxygenation status.7 LUSsc can be
used to evaluate disease severity, monitor the changes in
disease, and reflect the treatment effect sensitively.6,8e14
Some correlation analyses between LUSsc and the clinical
criticality of the child revealed that the more severe the pa-
tient’s condition, the higher was the LUSsc.6,11,15,16 A study
used modified LUSsc to predict ventilation requirements in
Neonatal Respiratory Distress Syndrome (RDS) and the mode of
respiratory support on day of life 3 (DOL 3).15 However, there
have been no studies on the prediction of respiratory support
patterns within 24 h of admission in preterm infants using
LUSsc. Selection of the correct respiratory support mode in
the early admission of premature infants with dyspnea can
reduce the adverse consequences caused by delayed illness or
excessive treatment, so the early and reasonable selection of
respiratory support mode is crucial. We designed a prospec-
tive study in the Chinese population with the aim of predicting
respiratory support needs within 2 h of admission in preterm
infants. We planned to stratify premature infants by gesta-
tional age using 12-segment LUSscs and analyze other clinical
factors that affect the mode of respiratory support to further
to validate corresponding LUSscs in a validation set.
2. Methods
2.1. Population
This was a prospective study that included premature in-
fants with dyspnea admitted to Bethune First Hospital of
Jilin University from July 2019 to April 2021 (Fig. 1). The
2
inclusion criteria were as follows: 1) admission to the hos-
pital 4 h after birth and complete LUS examination within
2 h of admission; 2) symptoms of dyspnea after birth,
including skin cyanosis, groaning, nasal flaring, and
retraction. The exclusion criteria were as follows: 1) suf-
focation and general anesthesia for cesarean section; 2)
supplementation of PS before LUS examination; 3) chest
wall deformities or abnormal respiratory mechanics caused
by lung tumors, including severe arrhythmia caused by
congenital heart disease, and organic diseases of the liver
and kidney. Included patients were divided into two cate-
gories according to gestational age (<32þ0 weeks and
32þ0e36þ6 weeks); preterm infants from each stratum
were randomly divided into a training set and a validation
set at a 4:1 ratio. This study was approved by the Ethics
Committee of the First Hospital of Jilin University, and all
guardians of patients signed an informed consent form. The
ethical batch number is 19K053-001.
2.2. Research outcomes
The main outcomes of our study were non-invasive and
invasive respiratory support within 24 h of admission: 1) use
of continuous positive airway pressure (CPAP), non-invasive
positive airway pressure ventilation (NIPPV), and nasal
catheter oxygen inhalation were classified as non-invasive
respiratory support; 2) use of synchronized intermittent
mandatory ventilation（SIMV）and high frequency oscilla-
tory ventilation (HFOV) were classified as invasive respira-
tory support. Invasive respiratory support was selected
based on neonatal mechanical ventilation strategies17 and
specific ventilation mode combined with clinical experi-
ence. The investigator did not intervene.
2.3. Equipment
Mindray diagnostic equipment (Manufacturer: Mindray
Company, Shenzhen, China) was used for bedside ultrasonic
diagnosis; the probe model was the C1-5 Linear probe, and
the frequency was 9.0 MHz.
2.4. Calculation of lung ultrasound score
Each lung was divided into three areas (front, middle, and
back) using the anterior and posterior axillary lines as the
boundaries. Taking the midpoint of the two nipples as the
boundary, each lung was divided into upper and lower lung
fields. The left and right lungs were divided into the upper
front, lower front, upper axillary, mid-axillary, upper back,
and lower back regions, giving a total of 12 areas between
the two lungs. In LUS examination, preterm infants were
placed in the supine, lateral or prone position, and US ex-
amination was performed in a quiet state, following the
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Pediatrics and Neonatology xxx (xxxx) xxx
Figure 1 Screening flowchart for premature infants.
procedure from top to bottom, left to right, and one by one
between the intercostals. The LUS score was assigned as
follows: 0 Z normal aeration; 1 Z moderate loss of aera-
tion: interstitial syndrome (defined by multiple spaced B
lines), or localized pulmonary edema (defined by coales-
cent B lines in less than 50% of the intercostal space
examined in the transversal plane or subpleural consolida-
tions); 2 Z severe loss of aeration: alveolar edema defined
by diffused coalescent B lines occupying the whole inter-
costal space; and 3 Z complete loss of lung aeration: lung
consolidation defined as a tissue pattern with or without air
bronchogram. LUSsc was calculated as the sum of the 12
regional scores.18 The lowest score was 0 points, and the
highest was 36 points. All enrolled patients completed the
initial LUS examination within 2 h after admission and
before the use of PS. Two fixed sonographers scored
together, and the sonographers did not know the breathing
pattern of the infants.
2.5. Statistical analysis
Statistical analyses were conducted using IBM SPSS 25.0
statistical software. Data were tested for normality with
the KolmogoroveSmirnov test, then either the median and
interquartile range was calculated, or absolute numbers
and percentages to describe the variables were measured.
To compare variables between groups, we used the Mann
Whitney U test or the chi-square test depending on the
specialty of the variables. Multivariate logistic regression
analysis was performed on the significant factors of single
factor analysis. The receiver operating curve (ROC) was
3
performed to find relationships between LUSsc and the
need of invasive respiratory support. Then, its sensitivity
and specificity were calculated. The cut-off value was
verified using kappa consistency and the McNemar test in
the verification set.
3. Results
Overall, 857 cases of premature infants born at 23þ0e36þ6
weeks were included. Non-invasive respiratory support
modes included CPAP (442 cases) and NIPPV (126 cases).
Invasive respiratory support modes included SIMV (182
cases) and HFOV (107 cases). The training set included 459
cases in the non-invasive respiratory support group (104
cases, <32þ0 weeks; 355 cases 32þ0e36þ6 weeks), and 228
cases in the invasive respiratory support group (147 cases,
<32þ0 weeks; 81 cases, 32þ0e36þ6 weeks). We compared
two groups of clinical data, including general patient in-
formation, perinatal factors, arterial blood gas within 2 h of
admission, and LUSsc, OI, Lung ultrasound diagnosis, etc.
Gestational age stratification was analyzed separately.
3.1. Univariate analysis of clinical data following
invasive and non-invasive respiratory support for
preterm infants (23D0e36D6 weeks) (Table 1)
The training set for preterm infants born at <32þ0 weeks
included 104 infants in the non-invasive respiratory support
group and 147 infants in the invasive respiratory support
group. There were significant differences in the weight,
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Table 1 A
Comparison of clinical factors of invasive and non-invasive respiratory support in preterm infants (<32þ0 weeks).
Basic Information non-invasive respiratory invasive respiratory X2/Z P-value
support group support group
(n Z 104) (n Z 147)
Gestational age (weeks) (IQR) 30 (28, 30) 30 (28，31) 0.252 0.801*
Weight (g) 1695 (1530, 1907) 1220 (1000, 1450) 8.846 ＜0.001 *
Male (n) 60 (57.7%) 77 (52.4%) 0.693 0.405y
cesarean section (n) 70 (67.3%) 76 (51.7%) 6.097 0.009y
Apgar score at 1min(n) 7 (7，8) 6 (5，7) 6.062 ＜0.001*
Apgar score at 5 min(n) 8 (8，9) 8 (7，8) 6.965 ＜0.001*
RDS (n) 48 (46.1%) 106 (72.1%) 20.120 ＜0.001y
TTN (n) 32 (30.8%) 27 (18.4%) 15.751 ＜0.001y
Use PS after LUS inspection (n) 9 (8.7%) 122 (82.9%) 186.094 ＜0.001y
PROM (n) 38 (36.5%) 40 (27.2%) 2.371 0.076y
Amniotic fluid fecal stain (n) 2 (1.9%) 10 (6.8%) 2.097 0.074y
Gestational diabetes (n) 16 (15.4%) 19 (12.9%) 2.306 0.354y
Gestational hypertension (n) 31 (29.8%) 32 (21.8%) 3.680 0.097y
Prenatal use of Corticosteroids (n) 46 (44.2%) 68 (65.3%) 1.073 0.425y
PH 7.32 (7.24，7.38) 7.3 (7.25，7.36) 0.765 0.444 *
PCO2 (mmHg)(IQR) 45 (36，56) 44 (37，54) 0.200 0.842*
OI (mmHg)(IQR) 326 (219，395) 200 (132，264) 7.373 ＜0.001*
BE (mmol/L)(IQR) 3.6 (-5.3，-1.7) 4.4 (-5.9，-2.6) 2.270 0.023*
lac (mmol/L)(IQR) 1.7 (1.3，2.3) 2.3 (1.7，3.4) 4.667 ＜0.001*
PEEP (cmH2O)(IQR) 6 (6，7) 7 (6，8) 6.424 ＜0.001*
PIP (cmH2O)(IQR) 16 (15.17) 17 (16.18) 3.616 ＜0.001 *
LUSsc (point)(IQR) 4 (2，8) 12 (5，18) 6.735 ＜0.001*
B
Comparison of clinical factors of invasive and non-invasive respiratory support in preterm infants (32þ0-36þ6 weeks).
Basic Information non-invasive respiratory Invasive respiratory X2/Z P-value
support group support group
(n Z 355) (n Z 81)
Gestational age (weeks) (IQR) 34 (33, 35) 33 (32, 34) 6.728 ＜0.001a
Weight (g) (IQR) 2150 (1790, 2490) 2000 (1570, 2330) 2.730 0.006a
Male (n) 184 (51.8%) 44 (54.3%) 0.164 0.390y
cesarean section (n) 258 (72.7%) 60 (74.0%) 0.065 0.459y
Apgar score at 1min(n) (IQR) 8 (7，8) 7 (6, 8) 5.391 ＜0.001a
Apgar score at 5 min(n) (IQR) 9 (8, 9) 8 (7.9) 5.432 ＜0.001a
RDS (n) 92 (25.9%) 66 (81.5%) 17.230 ＜0.001y
TTN (n) 95 (26.7%) 9 (11.1%) 14.351 ＜0.001y
Use PS after LUS inspection (n) 8 (2.3%) 47 (58.0%) 186.094 ＜0.001y
PROM (n) 98 (27.6%) 16 (19.8%) 0.499 2.371y
Amniotic fluid fecal stain (n) 9 (2.5%) 0 (0.0%) 0.154 2.097y
Gestational diabetes (n) 59 (16.1%) 8 (9.9%) 0.085 2.306y
Gestational hypertension (n) 103 (29.0%) 15 (18.5%) 0.035 3.680y
Prenatal use of Corticosteroids (n) 102 (28.7%) 28 (34.6%) 0.183 1.073y
PH (IQR) 7.33 (7.28，7.38) 7.31 (7.23，7.40) 1.379 0.168a
PCO2 (mmHg) (IQR) 42 (36，50) 44 (34，55) 1.147 0.251a
OI (mmHg) (IQR) 352 (276，428) 188 (123，262) 10.079 ＜0.001a
BE (mmol/L) (IQR) 3.8 (-5.4，-2.0) 4.4 (-6.7，-2.0) 1.641 0.101a
lac (mmol/L) (IQR) 1.8 (1.3，2.5) 2.1 (1.5，2.8) 2.182 0.029a
PEEP (cmH2O) (IQR) 5 (5，6) 7 (6，8) 10.879 ＜0.001a
PIP (cmH2O) (IQR) 16 (15.17) 17 (16.18) 4.407 ＜0.001a
LUSsc (point) (IQR) 2 (0，5) 14 (6.5，20) 10.463 ＜0.001a
IQR Z interquartile range; LUS: Lung Ultrasound; RDS: Respiratory Distress Syndrome; TTN: Transient Tachypnea of the New-born;
PROM: Premature Rupture of Membranes; PS: Pulmonary Surfactant; PH: Potential of Hydrogen; PCO2:Partial Pressure of Carbon Di-
oxide; OI: Oxygenation Index(PaO2/FiO2); BE: Base Excess; Lac: Lactic Acid; PEEP: Positive End Expiratory Pressure; LUSsc: Lung Ul-
trasound Score; Arterial blood gas analysis is completed within 2 h of admission; RDS and TTN diagnosis follow the standards of lung
ultrasound diagnosis of diseases; The application of PS follows the standard for supplementation of Pulmonary surfactant in premature
infants，PEEP and other ventilator parameters are based on the highest level of respiratory support required within 24 h of admission.
a
Mann-Whitney U test, yc2 test.

4
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Pediatrics and Neonatology xxx (xxxx) xxx
cesarean section, Apgar score at 1 min, Apgar score at
5 min, ultrasound indications of lung disease conforming to
RDS, Transient Tachypnea of the Newborn (TTN), the use of
PS after LUS examination, Lactic Acid (Lac), Positive End
Expiratory Pressure (PEEP), Peak Inspiratory Pressure (PIP),
LUSsc, OI (PaO2/FiO2), and BE between the two groups of
infants (P < 0.05).
Among preterm infants born at 32þ0e36þ6 weeks, 355
infants were included in the non-invasive respiratory sup-
port group and 81 infants were included in the invasive
respiratory support group. There were significant differ-
ences in the gestational age, both weight, Apgar score at
1 min, Apgar score at 5 min, ultrasound indications of lung
disease conforming to RDS, TTN, use of PS after LUS ex-
amination, Lac, PEEP, PIP, LUSsc, and OI between the two
groups (P < 0.05).
3.2. Multivariate analysis of clinical predictors of
invasive respiratory support（Table 2）
Multiple logistic regression analysis was performed by
selecting indicators with clinical predictive value from the
factors with statistical differences in single factor analysis;
among the factors included, for preterm infants born at
<32þ0 weeks with dyspnea, infants with high LUSsc, low
oxygenation index, low birth weight, low Apgar score at
5 min, and a more negative BE were more likely to receive
invasive respiratory support. For preterm infants born at
32þ0e36þ6 weeks with dyspnea, infants with high LUSsc,
low oxygenation index, and low birth weight were more
likely to receive invasive respiratory support.
3.3. ROC curve (Fig. 2)
For early preterm infants born at <32þ0 weeks, the area
under the ROC curve was 0.749 (95% CI: 0.689e0.809,
P < 0.05). The best cut-off value was 8 points; the sensi-
tivity and specificity were 74.0% and 68.3%, respectively.
Table 2 A Logistic regression analysis of influencing factors between non-invasive respiratory support group and invasive
respiratory support group for ＜32þ0 weeks preterm.
Influencing factors b OR（95%CI）
Use PS after LUS inspection 3.478
OI 1.060
LUSsc 0.113
Birth weight 0.004
Apgar score at 5 min 0.595
BE 0.111
Constant 6.013
B
Logistic regression analysis of influencing factors between non-invasive respiratory support group and invasive respiratory
support group for 32þ0-36þ6 weeks preterm.
Influencing factors b OR（95%CI）
Use PS after LUS inspection 4.500
OI 0.900
LUSsc 0.107
Birth weight 0.002
Constant 1.245
5
For late preterm infants born within 32þ0e36þ6 weeks, the
area under the ROC curve was 0.863 (95% CI: 0811e0.915,
P < 0.05). The best cut-off value was 7 points. These
findings indicate that LUSsc has predictive value in the
early respiratory support mode of premature infants with
dyspnea.
3.4. Verification（Table 3）
Sixty-two early preterm infants (<32þ0 weeks) were
included in the randomly selected validation set. The pre-
diction results were verified with the clinical respiratory
support model; the coincidence rate of two results was
83.9%, and the non-conformity rate was 16.1%. The LUSsc
prediction results were in good agreement with the clinical
results (Kappa value, 0.660; P < 0.05, McNemar test
P > 0.05). The late preterm infant (32þ0e36þ6 weeks)
group included 108 infants. The prediction results were
verified with the clinical respiratory support model. The
conformity rate of the two results was 92.6%, and the non-
conformity rate of the two results was 7.4%. The LUSsc
prediction results were very consistent with the clinical
results (Kappa value, 0.779; P < 0.05, McNemar test
P > 0.05).
4. Discussion
With the development of LUS technology in the field of
neonatal medicine, we can diagnose lung diseases following
the “Guidelines for the Ultrasonic Diagnosis of Newborn
Lungs”.19 Additionally, using LUS to guide the use of me-
chanical ventilation and the timing of weaning,20 we can
predict disease occurrence, establish a differential diag-
nosis, assess the severity of the disease, and guide the use
of PS. Research has shown that LUS can be used as a pre-
dictor of invasive respiratory support with high accuracy;
the sensitivity of 95% and specificity of 82.5% are highly
consistent with those of X-ray examinations (k Z 0.9; 95%
P
32.401（10.457e100.397） ＜0.001
1.346（1.208e1.578） ＜0.001
1.119（1.037e1.209） 0.004
0.996（0.995e0.998） ＜0.001
0.552（0.312e0.976） 0.041
0.896 (0.778e1.030) 0.008
408.717 0.105
P-value
89.988（8.796e920.686） ＜0.001
2.304（1.409e3.768） <0.001
1.112（1.038e1.192） ＜0.001
1.002（1.001e1.003） 0.017
0.288 0.787
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L. Zhang, J. Feng, D. Jin et al.
Figure 2 a ROC curve of Lung ultrasound scores in preterm
with dyspnea less than 32þ0weeks b ROC curve of Lung ultra-
sound scores in preterm with dyspnea within 32þ0-36þ6 weeks.
CI: 0.83e1).15,21,22 However, there are few studies on using
LUSsc to predict the use of ventilator mode in preterm in-
fants. A study using modified LUSsc predicted ventilation
requirements and the mode of respiratory support on DOL
3.15 In a clinical setting, it is particularly important to
select the respiratory support mode quickly, accurately,
and reasonably after admission; however, previous studies
have not addressed the prediction of respiratory support
mode within 24 h of admission. Our study aimed to establish
this.
It is widely accepted that LUSsc is a comprehensive
index that can reflect the oxygen content and ventilation of
the lungs. In studies where LUS images were quantified, it
was shown that the more critically ill the infant, the higher
Table 3 A Comparison of lung ultrasound scores in the validation set for preterm less than 32þ0 weeks predicted respiratory
support mode and clinical actual respiratory support (Kappa value 0.660, P < 0.05, McNemar test P > 0.05).
Lung ultrasound score predicts respiratory support
Total
B
Comparison of lung ultrasound scores in the validation set for preterm 32þ0-36þ6 weeks predicted respiratory support
mode and clinical actual respiratory support. (Kappa value 0.779, P < 0.05, McNemar test P > 0.05).
Lung ultrasound score predicts respiratory support
Total
was the LUSsc score.8,16,23 In our study, we demonstrated
the significant predictive ability of the 2 h LUSsc in pre-
dicting need for mechanical ventilation within 24 h of
admission. Thus, our findings may have significant practical
implications. Preterm infants born at <32þ0 weeks have a
LUSsc greater than 8, and preterm infants born at
32þ0e36þ6 weeks have a LUSsc greater than 7. This allows
for early identification of the most vulnerable infants,
which may lead to earlier decisions regarding invasive
mechanical ventilation.
In our study, the 12-segment score was chosen instead
of the commonly used 6-segment score.6 Although some
studies have found that the use of complex LUSscs is of
little significance,24 other studies that affirmed that the
12-zone score is superior to the simple score in diagnosing
certain diseases; the 12-segment score takes into account
the posterior part of the lung and it can be used to eval-
uate the lung condition more comprehensively than the
simple and more commonly used 6-segment score.4,15,18
However, complex LUS scoring means more operations
are required. We were careful about the implementation
process and kept the examination time short (approxi-
mately 30 s); the procedure did not cause problems or
destabilize the patient’s condition. All neonates with
dyspnea in our clinical center undergo comprehensive
bedside LUS examinations in a timely manner. The study
did not cause additional harm to the patients and there
was no delay in rescue treatment.
Early preterm infants have a higher cut-off value for
invasive respiratory support than late preterm infants. This
may be related to the immature lung development in pre-
mature infants and the atypical clinical manifestations.
Therefore, when there are clinical manifestations and
laboratory examination results of the same severity, pre-
term infants with a low gestational age often have more
severe lung changes, so the cut-off value corresponding to
invasive respiratory support is higher.6
However some researchers still believe that the LUSsc has
some definite shortcomings and that it may not be able to
assess the severity of certain pulmonary diseases in neonates
accurately. For example, in cases of pulmonary Langerhans
cell histiocytosis, lung interstitial syndrome, diffuse
Actual respiratory support
Non-invasive Invasive Total
Non-invasive 19 5 24
Invasive 5 33 38
24 38 62
Actual respiratory support
Non-invasive Invasive Total
Non-invasive 81 4 85
Invasive 4 19 23
85 23 108
6
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Pediatrics and Neonatology xxx (xxxx) xxx
parenchymal lung disease, lymphangioleiomyomatosis etc,
high-resolution CT examination is better than LUS, and pul-
monary hemorrhage and pneumothorax LUSsc cannot be
used to judge the severity of the disease accurately.25,26
Therefore, we excluded cases with these diseases as much
as possible. The main clinical diagnosis of mechanically
ventilated infants in our study was performed using ultra-
sound RDS and TTN. LUSsc can be used to effectively assess
disease severity.27
In our study, we also explored clinical factors affecting
mechanical ventilation. In both gestational age categories,
LUSsc, birth weight, OI, and use of PS after LUS inspection
were predictors of mechanical ventilation. Body weight was
an indicator of fetal growth and development. The lower
birth weight, the greater the probability was that infants
required invasive respiratory support. In a research report
on mechanical ventilation after congenital heart disease,
children with lower body weight had longer mechanical
ventilation times than children with higher body weight.28
Our research also shows that low body weight is a risk
factor for invasive respiratory support. OI was calculated as
the PtcO2 to FiO2 ratio, referring to the oxygen exchange
efficiency of the lungs. The normal range is
400e500 mmHg; OI below 300 mmHg indicates a risk of lung
respiratory dysfunction, so OI can be used an effective
predictor of invasive respiratory support. Research has
shown that the LUSsc was significantly correlated with the
OI and that the correlation remained significant after
adjustment for GA.11 Since OI is greatly affected by the
inspired oxygen concentration at the time of blood gas
analysis, the time when LUS should be performed and time
when OI should be measured are not completely consistent.
Our study did not combine the LUSsc with the OI to quantify
the predictive value of respiratory support. Follow-up
research should be carried out in this direction on the
basis of rational design, resulting in more reasonable and
scientific predictions.
When PS is lacking due to congenital or pulmonary dis-
ease, the patient may experience alveolar collapse and
exudation with progressively worsening dyspnea. Treat-
ment requires PS to be supplemented in time. After use of
PS, most infants with RDS are immediately relieved of their
dyspnea, the parameters of the ventilator are lowered, and
some infants are moved from the invasive respiratory sup-
port mode to the non-invasive respiratory support mode. In
the experimental data inclusion criteria, the infants who
received PS before the initial LUS examination were
excluded. The results showed that the use of PS was
significantly related to invasive respiratory support. The
application of clinical PS is often based on FIO2 and the
clinical situation of the infants; PS is used only in premature
infants with obvious dyspnea, and such patients often
require early invasive respiratory support to survive the
dangerous period.
In summary, we obtained the prediction scores using
LUSsc for use of early ventilator mode in premature infants
with dyspnea. The LUSsc prediction score had high sensi-
tivity and specificity, and the consistency of verification
results was good, so it can be used for clinical reference.
The results are also useful in predicting the factors of the
choice of ventilator mode; and birth weight, OI, and use of
PS also had predictive value. Clinicians should consider
7
LUSsc as an important reference method and judge by
integrating other influencing factors to choose respiratory
support appropriately.
Regarding limitations and prospects, our research
included samples from a single source, and clinicians in a
single center have a limited choice of ventilator modes.
Therefore, multi-center and large-sample studies are
required to further verify and modify the LUSsc. Besides the
LUSsc, there are other indicators that can predict the res-
piratory support pattern of premature infants, but our
experiment did not include all such indicators. Further
research should be conducted to establish a complete
prediction system for assisting in the selection of ventilator
modes in premature infants with dyspnea after birth. Non-
invasive and invasive respiratory support modes include a
variety of options such as CPAP, NIPPV, SIMV, and HFOV. In
the future, we can expand the data and use the LUSsc to
guide the selection of specific ventilator modes appropri-
ately. The method of oxygen supply, such as mechanical
ventilator or CPAP, may have influenced scores because we
did not exclude patients who were receiving any kind of
respiratory support. The variation trend of LUSsc may be
explored at different time points after respiratory support
in the future research. This study focused on premature
infants. In the future, we can conduct relevant research on
full-term infants who have difficulty breathing and need
respiratory support after admission. The large size and low
frequency of the linear array 9.0-MHz high-frequency probe
may affect the accuracy of readings from each lung area.
For each lung area and each probe, an appropriate LUSsc
cut off value should be initially calculated. Future studies
should try to use different probes to verify the consistency
of the results.
5. Conclusion
LUSsc is an independent predictor of the respiratory sup-
port pattern in premature infants with dyspnea within 24 h
after admission. For preterm infants born at <32þ0 weeks,
an LUSsc greater than 8 indicated that invasive mechanical
ventilation was suitable; for preterm infants born at
32þ0e36þ6 weeks, LUSsc greater than 7 shows infants
require invasive ventilation. This technique had high
sensitivity and specificity, and the validation results were
good.
Funding
The study was supported by grants from the Scientific
Research Foundation of the department of science and
technology of Jilin Province, China (Grant Number:
20190701050 GH).
Ethics approval
This study was approved by the Ethics Committee of the
First Hospital of Jilin University. The ethical batch number
is 19K053-001.
 + MODEL
L. Zhang, J. Feng, D. Jin et al.
Consent for publication
Patients’ parents signed informed consent regarding pub-
lishing their data.
Conflict of interest
The authors declare no competing interests.
Acknowledgements
The authors are grateful to 2 senior sonographers Shuyu Si
and Yiyi Guo for their analysis of the images and to the
patients who participated in this study.
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