Targeted management of evolving and established chronic lung disease of prematurity assisted by cardiopulmonary ultrasound: A case report of four patients

Abstract

Bronchopulmonary dysplasia (BPD) is one of the most common complications of premature birth. The current definition of BPD is based on the duration of oxygen therapy and/or respiratory support. Among the pitfalls of all the diagnostic definitions, the lack of a proper pathophysiologic classification makes it difficult to choose an appropriate drug strategy for BPD. In this case report, we describe the clinical course of four premature infants, admitted to the neonatal intensive care unit, for whom the use of lung and cardiac ultrasound was an integral part of the diagnostic and therapeutic process. We describe, for the first time to our knowledge, four different cardiopulmonary ultrasound patterns of evolving and established chronic lung disease of prematurity and the consequent therapeutic choices. This approach, if confirmed in prospective studies, may guide the personalized management of infants suffering from evolving and established BPD, optimizing the chances of success of the therapies and at the same time reducing the risk of exposure to inadequate and potentially harmful drugs.

Keywords: bronchopulmonary dysplasia (BPD); case report; endotype; lung ultrasonography (LUS); phenotype (mesh); targeted neonatal echocardiography.

Figure 1

Sonographic patterns of bronchodysplasia (BPD). Representative pictures of Lung Ultrasound (LUS) and echocardiography of the patients at the time of the beginning of therapy. (A–C) Case 1: (A) LUS showing homogenously and gravity-related distributed B-lines with a normal pleural line; (B) color-Doppler of the pulmonary artery showing normal flow; (C) B-mode evaluation of ventricular chambers showing normal eccentricity index (EI). (D-F) Case 2: (D) LUS showing inhomogeneous B-line distribution with spared areas of normal sonographic lung appearance, surrounded by areas containing multiple B-lines. Pleural line thickened and irregular; (E) color-Doppler of the pulmonary artery showing normal flow; (F) B-mode evaluation of ventricular chambers showing normal EI. (G-I) Case 3: (G) LUS homogenously and gravity-related distributed B-lines with subpleural atelectasis of the dependent regions; (H) color-Doppler of the patent ductus arteriosus showing pulsatile flow; (I) M-mode evaluation of the left atrium (LA) to aorta (Ao) ratio, showing important dilation of the ratio atrium (LA:Ao = 2); (L-N) Case 4: (L) LUS showing confluent B-lines with sparing areas, thickened pleural line, and with subpleural atelectasis; (M) color-Doppler of the pulmonary artery showing decreased acceleration time/ejection time (AT/ET) = 0.28; (N) B-mode evaluation of ventricular chambers showing decreased EI (EI = 1.2).

Figure 2

Histological examination of the placentas. Representative pictures of the histological examination of the placenta. H & E 5×: Hematoxylin and eosin stain at 5 magnifications; H & E 10×: Hematoxylin and eosin stain at 10 magnification; IHC-CD34: Immunohistochemistry stains for cluster of differentiation. (A-C) Case 1: (A) H & E showing normal placenta for the gestational age with mild signs of chorioamnionitis; (B) H & E showing absence of vasculitis; (C) IHC showing normal distribution of CD34 in the placental vessels. (D-F) Case 2: (D) H & E stain showing severe chorioamnionitis; (E) H & E stain showing severe vasculitis; (F) IHC showing normal distribution of CD34 in the placental vessels. (G-I) Case 3: (G) H & E showing normal placenta for the gestational age with mild signs of chorioamnionitis; (H) H & E showing absence of vasculitis; (I) IHC showing normal distribution of CD34 in the placental vessels; (L-N) Case 4: (L) H & E showing severe chorioamnionitis and acute ischemic area of malperfusion; (M) H & E stain showing severe vasculitis and funisitis; (N) IHC showing severe suppression of CD34 expression.

Figure 3

Patient clinical course. Graphics representing the need for respiratory assistance of each patient. The vertical axis shows the mean fraction of inspired oxygen (FiO2) needs for each day, the horizontal axis represents the post-menstrual age (PMA). The time-point for each specific (cardiopulmonary ultrasound (CPUS) guided intervention is highlighted in each graphic.