Background Non invasive ventilation is the treatment of choice for neonatal moderate respiratory distress (RD). Predictors of nasal ventilation failure may be helpful in preventing clinical deterioration. Work on neonatal lung ultrasound has shown that the persistence of a hyperechogenic, “white lung” image correlates with severe distress in the preterm infant. In the present study we investigate the persistent white lung ultrasound image as a marker of non invasive ventilation failure.

Methods Newborns admitted to the Neonatal Intensive Care Unit with moderate RD and stabilised on nasal continuous positive airway pressure for 120 min were enrolled. Lung ultrasound was performed and blindly classified as Type 1 (white lung), Type 2 (prevalence of B-lines), or Type 3 (prevalence of A-lines). Chest radiograph was also examined and graded by an experienced radiologist blind to the infant’s clinical condition. Main outcome of the study was the accuracy of bilateral Type 1 to predict intubation within 24 h from scanning. Secondary outcome was the performance of the highest radiographic grade within the same time interval.

Results Fifty-four preterm infants were enrolled (gestational age 32.5 ± 2.6 weeks; birthweight 1703 ± 583 grams). Type 1 lung profile showed sensitivity 88.9% (95% CI 67.2–96.8), specificity 100% (CI 94.9–100), PPV 100% (CI 80.6–100), NPV 94.7% (CI 82.7–98.5). Chest radiograph had sensitivity 38.9% (95% CI 20–61.1), specificity 77.8% (CI 61.7–88.5), PPV 46.7% (CI 24.8–69.9), NPV 71.8% (CI 56.2–83.4).

Conclusions After a 2 h nasal ventilation trial, neonatal lung ultrasound is a useful predictor of the need for intubation, largely outperforming conventional radiology. Future studies should address whether including ultrasonography in the management of neonatal moderate RD confers clinical advantages.