PACULit Daily Literature Update: A Simplified Regional Lung Ultrasound Score for Surfactant Administration in Neonatal RDS A Prospective Observational Study
Daily Literature Update
A Simplified Regional Lung Ultrasound Score for Surfactant Administration in Neonatal RDS A Prospective Observational Study
Raimondi F, Dolce P, Veropalumbo C, et al. Pediatr Pulmonol. 2025;60(7):e71206. doi:10.1002/ppul.71206.
Introduction
Neonatal Respiratory Distress Syndrome (RDS) remains a leading cause of morbidity in preterm infants, primarily driven by surfactant deficiency and resultant alveolar collapse. Early and accurate identification of neonates requiring surfactant therapy is critical to improving respiratory outcomes while minimizing invasive interventions. Lung ultrasound scoring (LUS), particularly the total lung ultrasound score (tLUS), has been validated as a noninvasive, bedside tool to assess lung aeration and guide surfactant administration.
The current study builds upon this foundation by investigating whether a simplified regional lung ultrasound score (rLUS), specifically focusing on midclavicular (MC) lung zones, can offer rapid, accurate prediction of surfactant need among preterm neonates stabilized on non-invasive continuous positive airway pressure (nCPAP). This approach seeks to streamline clinical workflows and reduce neonatal stress in the critical early hours of life.
Study Overview
Study Design & Methodology
Study Type: Secondary analysis of a multicenter, prospective observational study
Population: 175 preterm infants with Respiratory Distress Syndrome on nCPAP within first 2 hours of life
Intervention: Lung ultrasound to calculate regional lung scores (rLUS) and total lung ultrasound score (tLUS, 0-18 scale)
Outcome: Need for surfactant administration determined by blinded clinicians
Additional Parameters: Oxygen saturation/inspired oxygen fraction ratio (SatO2/FiO2) measured and incorporated into predictive modeling.
Key Findings
- A midclavicular (MC) regional lung ultrasound score 60; 2 served as an early marker of aeration heterogeneity in neonatal RDS.
- Left MC score alone demonstrated strong prognostic ability for surfactant need with an AUC of 0.86, sensitivity 79%, and specificity 90%.
- Right MC score yielded similar accuracy (AUC 0.87; sensitivity 74%; specificity 93%).
- Combining left and right MC scores improved prediction further (AUC 0.90; sensitivity 82%; specificity 89%; optimal cutoff = 3).
- A comprehensive predictive model integrating gestational age, SatO2/FiO2 ratio, and combined MC score achieved an AUC of 0.95.
- The study highlights the heterogeneity of lung aeration in early RDS and validates a simplified regional ultrasound score as a rapid and reliable surfactant guidance tool.
Evidence Synthesis & Clinical Context
The evolution of lung ultrasound scoring systems has been catalyzed by a strong evidence base supporting ultrasounds utility in neonatal RDS surfactant management. This study refines prior methodologies by focusing on simplified regional scores, improving clinical applicability without sacrificing accuracy.
Guideline Foundations
- Sweet et al., 2023: European Consensus Guidelines emphasize early and selective surfactant administration in RDS to optimize outcomes and minimize ventilator-induced lung injury (PMID: 36863329).
- Brat et al., 2015: First demonstrated that a comprehensive six-zone lung ultrasound score robustly predicts surfactant need in preterm infants on CPAP, underscoring ultrasound as a reliable bedside tool (PMID: 26237465).
- Capasso et al., 2023: Systematic review and meta-analysis confirmed excellent overall predictive accuracy of LUS scores for surfactant replacement, reinforcing broad clinical acceptance (PMID: 36717970).
Comparative Advantages of Simplified Regional Scoring
The source studys focus on midclavicular lung regions condenses the ultrasound assessment, enabling quicker evaluations during critical stabilization periods. This simplification could reduce procedural time and minimize neonatal disturbance while maintaining or improving predictive accuracy.
Summary Table: Key Published Studies on Lung Ultrasound Scoring in Neonatal RDS
| Study | Design | Population | Key Findings |
|---|---|---|---|
| Brat et al., 2015 | Prospective observational | 98 preterm infants on CPAP | Six-zone LUS score predicted surfactant need with high accuracy (AUC > 0.85) |
| Capasso et al., 2023 | Systematic review & meta-analysis | Multiple RCTs and cohorts | Confirmed excellent prognostic performance of LUS scores across studies |
| Raimondi et al., 2025 (Source Study) | Prospective observational secondary analysis | 175 preterm infants on nCPAP | Simplified midclavicular regional scores accurately predicted surfactant need (AUC 0.90 combined; 0.95 integrated model) |
Remaining Evidence Gaps
- Need for randomized controlled trials directly comparing total versus simplified regional lung ultrasound scores across neonatal centers.
- Validation of simplified scores in diverse neonatal populations including extreme prematurity and differing ethnicity/geography.
- Assessment of impact of ultrasound-guided surfactant therapy on long-term respiratory and neurodevelopmental outcomes.
Clinical Implications
- Utilize simplified midclavicular lung ultrasound scoring as a rapid bedside tool to identify preterm neonates needing surfactant, reducing procedure time and distress.
- Incorporate combined MC scores with gestational age and oxygenation parameters (SatO2/FiO2) for enhanced predictive accuracy.
- Employ lung ultrasound as a noninvasive guide to optimize timing and selection for surfactant therapy, potentially improving neonatal respiratory outcomes.
Strengths & Limitations
| Strengths | Limitations |
|---|---|
| Multicenter prospective design strengthens generalizability | Secondary analysis; not originally powered for simplified score validation |
| Blinded surfactant administration decisions reduce bias | Relatively small sample size for subgroup analyses |
| Integration of ultrasound with clinical variables (gestational age, SatO2/FiO2) | No long-term outcome data reported |
Future Directions
Prospective multicenter randomized controlled trials comparing total and simplified regional lung ultrasound scoring systems are warranted. Expanding validation across diverse neonatal populations and evaluating the impact on long-term respiratory and neurodevelopmental outcomes remains critical.
Conclusion
The combined midclavicular regional lung ultrasound score provides a simplified, rapid, and highly accurate bedside predictor for surfactant administration in neonatal RDS, offering an important tool to optimize early respiratory management and reduce neonatal stress during critical care.
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References
- Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi:10.1159/000528914. PMID:36863329.
- Brat R, Yousef N, Klifa R, Reynaud S, Shankar-Aguilera S, De Luca D. Lung Ultrasonography Score to Evaluate Oxygenation and Surfactant Need in Neonates Treated With Continuous Positive Airway Pressure. JAMA Pediatr. 2015;169(8):e151797. doi:10.1001/jamapediatrics.2015.1797. PMID:26237465.
- Capasso L, Pacella D, Migliaro F, et al. Can lung ultrasound score accurately predict surfactant replacement? A systematic review and meta-analysis of diagnostic test studies. Pediatr Pulmonol. 2023;58(5):1427-1437. doi:10.1002/ppul.26337. PMID:36717970.