Integrated echocardiography and lung ultrasound assessment of lung recruitment in preterm infants using high frequency ventilation: A prospective,single-arm,protocol-driven cohort study

Abstract

Background

Lung recruitment maneuvers (LRM) during high-frequency oscillatory ventilation (HFOV) lack bedside standardized monitoring.

Aim

To evaluate the efficacy and safety of FiO₂-guided LRM in preterm infants with moderate-to-severe respiratory-distress syndrome (RDS) using integrated functional echocardiography (FE) and lung ultrasound (LUS). Also, we hypothesized that a standardized LUS score can accurately guide successful recruitment.

Methods

This a prospective, single-arm, protocol-driven cohort study that was conducted at a tertiary NICU (Alexandria University), and 70 preterm infants (GA 32–37 weeks) requiring HFOV within 24 h of life were included. Integrated LUS and FE were performed at three phases: pre-initiation, maintenance pressure (opening), and pre-weaning. Lung aeration was quantified using a standardized 12-zone LUS protocol (0–3 points per zone) based on international consensus. Hemodynamics were assessed via tricuspid regurgitation (TR) gradient, superior vena cava (SVC) flow, and right ventricular myocardial performance index (RV-MPI).

Results

LRM led to significant improvements in oxygenation and lung aeration. Mean LUS scores decreased significantly from 23.13 ± 1.33 (pre-initiation) to 19.94 ± 1.67 (maintenance) and 3.70 ± 2.49 (pre-weaning) (p < 0.001). FE demonstrated a significant reduction in TR gradient (p < 0.001), while SVC flow and RV-MPI remained stable, indicating preserved myocardial function. Pre-weaning LUS scores were significantly associated with weaning success from HFOV.

Conclusions

FiO₂-guided LRM is effective and safe in late-preterm infants with RDS. Integrated bedside imaging confirms that recruitment improves lung aeration without compromising hemodynamics. A standardized LUS score is a reliable tool for identifying optimal lung opening and guiding the weaning process.

Keywords

lung recruitment high frequency oscillatory ventilation lung ultrasound superior vena cava flow functional echocardiography

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