Bronko Dislasia Radiologi

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1990, The British Journal of Radiology, 63, 444-447Bronchopulmonary dysplasia: a radiographic and clinicalreview of 20 patientsBy Patricia Fitzgerald, MRCPI, FRCR, Veronica Donoghue, DMRD, FRCR and *W. Gorman, MBFRCPI (Paeds)Radiology and *Paediatric Departments, National Maternity Hospital, Holies Street, Dublin 2{Received August 1989 and in revised form January 1990)

Abstract. This paper reviews the radiological features of 20 infants with bronchopulmonary dysplasia, with part icular emphasison the early radiological findings in these infants, the clinical findings and radiological progression. Of 20 infants, eight hadidiopathic respiratory distress in the first week of life, two infants had early radiological abnormalities other than idiopathicrespiratory distress and 10 infants had n orm al initial chest radiog raph s. The complicating features included lower respiratoryinfections (88% ), patent ductus a rteriosus (40% ) and areas of atelectasis (40% ). Areas of atelectasis were more comm on in infantswith an intial ly normal chest radiograph than in those with idiopathic respiratory distress syndrome (p = 0.015). Mortality fromsevere bronchopulmonary dysplasia was 70% in this series.

In 1967, Northway et al introduced the term "bronch o-pulmonary dysplasia" to describe chronic lung diseasefollowing assisted ventilation of pre-term infants withsevere idiopathic respiratory distress syndrome. Wehave found that idiopathic respiratory distress (IRDS) isnot a necessary prerequisite to the development of bron-chopulmonary dysplasia (BPD) and have found it morerelevant to define it, according to Mortensson et al(1983), as an infantile lung disorder induced duringartificial ventilation irrespective of the underlyingcondition.The purpose of our study was to review, first, theearly radiological findings of infants who develop bron-chopulmonary dysplasia, and secondly, the occurrenceof superimposed radiological abnormalities and theirlikely contribution to the occurrence of BPD.

Materials and methodsWe retrospectively reviewed all infants who developedbronchopulmonary dysplasia (Stage IV as defined byNorthway et al, 1967) during the period 1984 to 1987inclusive at the National Maternity Hospital, HoliesAddress reprint requests to Dr V. Donoghue, NationalMaternity Hospital, Holies Street, Dublin 2.

Street, Dublin. There were 20 infants in the group: ninemale and 11 female.The radiographs and clinical records of each infantwere reviewed. Particular attention was paid to birth-weight, gestational age, length of time spent on assistedventilation, m aximum oxygen pressures (percentage O2),presence of a patent ductus arteriosus and the results oftracheal aspirate cultures. The presence of atelectasis onthe chest radiograph was noted. We also noted whethera clinical diagnosis of lower respiratory tract infectionwas made during the infant's illness. The outcome foreach patient was recorded.Measurement data were evaluated by Student's /-test,and frequency data were analysed by Fisher's exact test(2-tail).

ResultsFollowing analysis of the initial chest radiographobtained on Day 1 in each child, it was possible todivide the infants into three separate groups on the basisof the radiographicfindings.Group 1 and Group 2 werecompared and a statistical analysis was performed onthe data as described. The results are summarized inTables I and II.

Table I. Compar ison of Group s 1 and 2G ro up 1 ( = 8) G ro u p 2 (n = 10) Significance levelM ean SD M ean SD

Gestational age (weeks)Birth weight (g)Ventilation (days)Maximum O 2 pressure (%)

27.63 0.75920 21534 2397 6

27.4 0.721010 29334 2937 27

Not significant (NS)N SN Sp = 0.07 (NS)

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Bronchopulmonary dysplasia

Figure 1. Idiopathic respiratory distress syndrome; underae-ration, homogeneous opacification, air bronchograms. Figure 2. Bronchopulmonary dysplasia, hyperinflated lungswith multiple, fine, lacey densities.

Group 1This group included eight infants who had initialradiographic evidence of idiopathic respiratory distresssyndrome (Fig. 1). Each infant developed Stage IVbronchopulmonary dysplasia (Fig. 2).Group 2This group included 10 patients who had no initialradiographic abnormalities (Fig. 3), and did not haveany clinical criteria of idiopathic respiratory distresssyndrome. All were subsequently ventilated because ofrepeated apnoeic episodes. Each infant developedStage IV bronchopulmonary dysplasia (Fig. 4).Group 3This group includes two low birth weight, pre-terminfants who had minor chest radiographic abnormalitiesinitially. One infant had a mild degree of excess fluidand the second infant had an interstitial pattern whichwas subsequently diagnosed as congenital pneumoniaon clinical and bacteriological grounds. Both infantsrequired assisted ventilation for an average of 3 weeks.Neither infant is alive.

DiscussionIt has been suggested by previous authors that idio-pathic respiratory distress syndrome is the mostfrequent underlying condition in bronchopulmonarydysplasia (Bancalari et al, 1979). Indeed, some authorshave discussed bronchopulmonary dysplasia and havenot mentioned other underlying disorders apart fromidiopathic respiratory distress (Heneghan, 1986). Fiftyper cent of the infants in this study had no initialradiographic abnormality, while 40% had IRDS.We feel that those infants with normal initial chestradiographs had immature lung syndrome. This entityhas been previously discussed in terms of its radio-graphic appearance, course and complications (Edwardset al, 1980). However, it has not been previously em pha-sized that these infants can form a significant proportionof those who develop bronchopulmonary dysplasia.There is still confusion with regard to the radio-graphic findings on the initial chest radiograph.Edwards et al (1980) describe a diffuse granular patternwith superimposed perihilar opacities in children withimmature lung. Mayes et al (1983) do not discuss theinitial radiographic findings in this review. In our study,we describe infants with normal initial chest radiographs

Table II. Clinical comp arison of Gro ups 1 and 2

Patent ductus arteriosusAtelectasisPositive tracheal aspirateClinical infectionCerebral haemorrhageDeaths during study period

Grou p 1 ( =Number ofpatients215434

8)%

2812.571.55037.550

Group 2 ( =Number ofpatients

5710818

10)%

5070100801080

Significance level

N Sp = 0.015 (Significant)N SN SN SN S

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P. Fitzgerald, V. Donoghue and W. Gorman

Figure 3. Immature lung syndrome: normal init ial chestradiograph.

who subsequently developed bronchopulmonarydysplasia. The patient in Group 3 with a pattern of mildexcess fluid could also be classified as imm ature lung oncriteria used by Edwards et al (1980). We feel it isimportant to emphasize that a normal chest radiographis common in infants with immature lung.There was no significant difference between Group 1and Group 2 with regard to birth weight, duration ofassisted ventilation, lower respiratory tract infection andmortality. There was a difference between the peakpercentage of oxygen delivered which, however, failed toreach significance, p robably because of the small samplesize. Atelectasis was a prominent feature radiologicallyin those infants whose early chest radiographs werenormal. This contributed to their requirements forventilation and, thus, evolution of bronchopulmonarydysplasia.Two-thirds of the infants had positive growth fromtracheal aspirate cultures and 88% had a clinical diag-nosis of lower respiratory tract infection. These resultsare in agreement with others (Mayes et al, 1983). Super-imposed infection is an important contributory factor inthe development of the disease, as infants with respira-tory infection tend to be more difficult to wean offventilation and may need higher O2 concentration. Thediagnosis of patent ductus arteriosus was made clini-cally and radiologically in nine infants. Echocardio-graphic diagnosis was not available and, thus, the trueincidence may have been higher. Although it is notpossible to evaluate the extent of its role in the develop-ment of BPD in this study, it was an important compli-cating feature.A mortality rate of 70% for the entire group isconsiderably higher than previous reports of approxi-mately 38% (Northway, 1979; Mayes et al, 1983; Shan-karan et al, 1984). This suggests tha t the pa ttern of BPDis changing, as these studies reported on data collected adecade or more ago. It may be that the more seriouslycompromised infants are surviving long enough to

Figure 4. Bronchopulmonary dysplasia; hyperexpanded lungswith fine, lacey densities throughout. This patient had ricketswith multiple rib fractures. Note the surgical ligation of patentductus arteriosus.

develop BPD, but that these infants do not ultimatelysurvive. Previously, these children would have died priorto development of bronchopulmonary dysplasia.ConclusionWe conclude that a normal early chest radiograph inthe immature infant does not preclude the developmentof bronchopulmonary dysplasia; 50% of infants in ourseries had initially normal chest radiographs which werelater complicated by atelectasis, pneumonia and patentductus arteriosus, and which ultimately evolved tosevere BPD.In contrast to Northway's original discription, IRDSis but one of many radiological and clinical entities thatprecedes BPD.Ackno wledg m entsThe authors thank Dr M. B. Cod d, University College,Dublin and Mater Misericordiae Hospital , for assistance withstatistical analysis.

ReferencesBANCALARI, E. , A B D E N O U R , G. E., FELLER, R. & G A N N O N , J.,1979. Bronchopulmonary dysplasia cl inical presentation.Journal of Pediatrics, 95, 819-822.E D W A R D S , D. K., J A C O B , J. & G L U C K , L., 1980. The immaturelung; radiographic appearances, course an d complications.American Journal of Roentgenology, 135, 659-666.H E N E G H E N , M. A., SOSULSKI, R. & BAQUERO, J. M., 1986.Persistent pulmonary abnormalit ies in newborns: th echanging picture of bronchopulmon ary dysplas ia . PediatricRadiology, 16, 180-184MA Y E S , L. , PERKETT, E. & STAHLMAN, M., 1983. Severebronchopulmonary dysplas ia: a retrospective review. ActaPaediatrica Scandinavica, 72, 225-229.

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Bronchopulmonary dysplasiaMORTENSSON, W. , LlNDROTH, M ., JONSSON, B. & SVENNINGSEN,N ., 1983. Chest radiography and pulmonary mechanics inventilator treated low birth weight infants. Ada Radiologica,24 , 71-79.NORTHWAY, W. H., 1979. Observations on bronchopulmonarydysplasia. Journal of Pediatrics, 95, 815-818.NOR THW AY, W. H., ROSEN, R. C. & PORTER, D. Y., 1967.

Pulmonary disease following respirator therapy of hyaline-membrane disease. New England Journal of Medicine, 276,357-368.SHANKARAN, S., S ZEGO, E., EIZER T, D. & SIEGEL, P., 1984.Severe bronchopulmonary dysplasia. Predictors of survivaland outcome. Chest, 86, 607-610.

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