The Value of a Modified Chest-X ray Scoring System Combined with Clinical Variables in Early Prediction ofBronchopulmonary Dysplasia in Very Preterm Infants

The Value of a Modified Chest-X ray Scoring System Combined with Clinical Variables in Early Prediction ofBronchopulmonary Dysplasia in Very Preterm Infants | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Value of a Modified Chest-X ray Scoring System Combined with Clinical Variables in Early Prediction ofBronchopulmonary Dysplasia in Very Preterm Infants Liping Xu, Wenwen Chen, Shuzhen Dai, Zhenhai Zhang, Qiaoling Huang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8523476/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objective Bronchopulmonary dysplasia (BPD) is often accompanied by specific Chest-X ray patterns even in the early or evolving stages before the diagnosis is established. We aim to assess Chest-X ray's predictive value for BPD in preterm infants less than 32 weeks gestation. Method This is a retrospective, single-center study, including preterm infants born at less than 32 weeks gestation in our NICU from 2019 to 2024. We collected their clinical information during the maternal, birth and early postnatal periods. A chest X-ray scoring system was introduced based on the appearance of reduction in transparency, interstitial lesions, solid lesions and cystic vesicle. Risk factors were selected through univariable analyses. Prediction model was established through logistic regression and assessed by the AUC. The cut-off value of chest X-ray score was determined. Result A total of 747 infants was enrolled. The mean gestational age was 29.4 ± 1.6 weeks and mean birth weight was 1392 ± 313 g. The incidence of BPD was 22.4%. Univariable analysis and logistic regression showed gestational age, birth weight, mechanical ventilation mode, and chest X-ray score on day 7 postnatal age were associated with BPD, with adjusted odds ratios of 1.4 (95%CI: 1.2–1.7), 1.3 (95%CI: 1.1–1.4), 2.8 (95%CI: 2.0-3.8) and 1.8 (95%CI: 1.4–2.3), respectively. The AUC of the combination of the factors was 0.872 (95%CI: 0.843–0.902). The cut-off value of chest X-ray score was 3 with a sensitivity of 80% and specificity of 81%. Conclusion Predictive factors for the development of BPD were lower gestational age, lower birth weight, higher respiratory support mode, and higher chest X-ray score on day 7 postnatal age. A chest X-ray score ≥ 3 was a good predictor of BPD. Bronchopulmonary dysplasia chest-X ray score mechanical ventilation preterm infants Figures Figure 1 Figure 2 Introduction Bronchopulmonary dysplasia (BPD) is a chronic lung disease that poses a significant threat to the life and long-term health of preterm infants. It not only causes respiratory disorder, such as frequent respiratory tract infections, lung function impairment, asthma, and exercise intolerance, but also affects cardiovascular, neurological, and nutritional aspects, imposing a huge burden on public health and family social economy [ 1 , 2 ] . With the advancement of perinatal and neonatal medicine, NICUs achieved a declined rates of death and serious morbidities except BPD. The incidence of BPD remains high at 30%-40% [ 3 ] , and even be increasing since more immature infants survive. According to the current criteria, the diagnosis of BPD is usually made after 28 days or 36 weeks post-menstrual age (PMA). By this time, certain irreversible injuries to lung likely occur, and the optimal intervention window might be missed. It is essential to identify those at high risk for developing BPD at an early stage so that treatment strategies can be introduced to prevent disease progression. Numerous prediction models for BPD were reported, but none of them has been widely used in clinical practice. Most of the existing models usually analyzed clinical variables, failing to accurately capture the early visual changes of the disease. Searching for reliable indicators remains one of the major challenges for neonatologists. Chest-X ray imaging is a routine bedside examination for critically ill patient. It can provide crucial morphological clues of lung disease. Since first described by Northway et al in 1967, BPD was defined by radiologic features and pathologic findings when available. In 2018 NICHD diagnostic criteria, chest-X ray was incorporated [ 4 ] . Therefore, we assumed that chest-X ray has the potential for early prediction and diagnosis. The aim of this study was to discuss a scoring system of chest X-ray combined with traditional clinical indicators for improving early diagnosis of BPD in the first week after birth. Method This study was conducted in Zhangzhou Affiliated Hospital of Fujian Medical University between January 2019 and December 2024.It was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2400082145). The research protocol was approved by the institution (No.2023LWB350). Informed consents were also obtained from parents. Preterm infants born at less than 32 weeks gestational age (GA) were enrolled. Infants with major congenital malformations and those who developed spontaneous perforation in the first week after birth were excluded. All included patients underwent chest X-ray on day 7 (±1 day) of postnatal age. All images were taken in supine, antero-posterior position, using Fuji Medical X-ray Generator (ZU-L3SB-T). The chest X-ray image was calculated by 2 investigators expert in radiology within 48 hours of scan. The chest X-ray scoring system was based on the following 4 patterns: (1) reduction in transparency: 0 point for no RDS changes, 1 point for ground-glass-like changes and air bronchogram, and 2 points for white lung; (2) interstitial lesions: 0 point for no interstitial lesions, 1 point for scattered streaks, and 2 points for diffuse streaks; (3) solid lesions: 0 point for no solid lesions, 1 point for a single solid lesion, and 2 points for ≥2 solid lesions; (4) cystic vesicle appearance: 0 points for no cystic changes, 1 point for cystic present in less than 1/3 of the lung field, 2 points for 1/3 to 2/3 of the lung field, and 3 points for more than 2/3 of the lung field. This was a modification that was previously reported [5] . The scores from all 4 patterns were added for a total possible score between 0 and 8 points. To assess interobserver correlation, 20% of random and anonymized images were reassessed by other investigators and scores were compared, and intraclass correlation coefficient was calculated. Perinatal data including maternal gestational hypertension, chorioamnionitis (either clinical or histological), preterm premature rupture of membranes (p-PROM), magnesium sulfate and antenatal steroids (ANS) usage, and baseline characteristics including GA, birth weight (BW), sex, small for GA (SGA) and mode of delivery were collected. Postnatal parameters on day 7 including the mode of respiratory support (non-respiratory support, nasal cannula or high-flow nasal cannula oxygen support, non-invasive respiratory support, conventional mechanical ventilation, high-frequency ventilation), hemoglobin, early-onset sepsis (EOS), patent ductus arteriosus (PDA) were also documented. The main outcome of this study was BPD, which was diagnosed in accordance with 2018 NICHD diagnostic criteria [4] . Infants who had persistent parenchymal lung disease (radiographic confirmation of parenchymal lung disease) and required hood O 2 or nasal cannula or N-CPAP or NIPPV or invasive IPPV for ≥3 consecutive days to maintain arterial oxygen saturation in the 90%-95% range at 36 weeks PMA was diagnosed with BPD. BPD were classified into 3 severity grades (grade I, II, and III) based on respiratory parameters. Analysis was performed via SPSS version 26 software. Descriptive data were presented as means ± SD or percentages. To compare differences between two groups, chi-square tests for categorical variables and two-sample t-tests or Mann–Whitney U tests for continuous variables were applied. Analyses of the main outcome and risk factors were performed via logistic regression, with 95% CIs calculated for ORs adopting the forward entry method. A p-value of ≤0.2 was used in univariate analysis for inclusion of putative risk factors into the multivariate (adjusted) model. A p-value of <0.05 was considered to be statistically significant. To identify an optimal cut-off of chest X-ray score for BPD diagnosis, ROC curve, sensitivity, and specificity were analyzed. Result During the study period, a total of 791 infants met the eligibility criteria and 747 infants were enrolled. The study flow diagram was shown in Figure 1. Mean GA of enrolled infants was 29.4 ± 1.6 weeks and mean birth weight (BW) was 1392 ± 313 g. Of these 747 infants, 463 (62%) infants were boys, 534 (71.5%) were exposed to antenatal steroids, 425 (56.9%) were delivered by cesarean. There were 182 (24.4%) infants diagnosed with BPD according to 2018 NICHD diagnostic criteria, of whom 16.9% (n = 126) had grade I BPD; 5.4% (n = 40) had grade II BPD and 2.1% (n = 16) had grade III BPD. Infants who were diagnosed with BPD were born at lower GA, lower BW and had a lower rate of cesarean delivery. The clinical characteristics of 2 groups (BPD and non-BPD) of infants are showed in Table 1. Univariable analyses showed that delivery mode, chorioamnionitis, PDA, and chest X-ray score and respiratory support requirements on day 7 postnatal age were significantly associated with BPD (Table 1). The chest X-ray scores were significantly higher in infants diagnosed with BPD compared with infants not diagnosed with BPD (Table 1.). In addition, the level of hemoglobin on day 7 postnatal age was lower in BPD group compared with non-BPD group. Multiple logistic regression modeling demonstrated that GA, BW, chest X-ray score and respiratory support mode on day 7 postnatal age can predict BPD. For every 1 week decline in GA and every 100 g decline in BW, the risk of BPD increased by 40% and 30% respectively. For every 1 point gaining in chest X-ray score, the risk of BPD increased by 80%. For every 1 level elevation in respiratory support mode, the riks of BPD increased by 1.7 times (Table 2). The AUC of the combination of GA, BW, chest X-ray score and respiratory support mode on day 7 postnatal age to predict BPD was 0.872 (95%CI: 0.843-0.902) (Table 3 and Figure 2.). The cut-off value of chest X-ray score was 3 with a sensitivity of 80% and specificity of 81%. Table 1. Comparison of baseline characteristics and clinical parameters of included patients Characteristics Non-BPD (n = 565) BPD (n = 182) p Gestational age at birth (wk), mean (SD) 29.8 (1.3） 28.0 (1.7) ＜0.001 Birth weight (g), mean (SD) 1472 (283) 1145 (273) ＜0.001 Male sex, n (%) 349 (61.8) 114 (62.6) 0.834 Small for gestational age, n (%) 27 (4.8) 13 (7.1) 0.218 Antenatal steroids, n (%) 399 (70.6) 135 (74.2) 0.355 Antenatal magnesium sulfate, n (%) 61 (10.8) 21 (11.6) 0.774 Preterm premature rupture of membranes, n (%) 149 (26.4) 37 (20.3) 0.099 Cesarean delivery, n (%) 338 (59.8) 87 (47.8) 0.004 Chorioamnionitis, n (%) 211 (37.4) 86 (47.3) 0.018 Chest X ray score on day 7 of postnatal age, median (range) 0 (0, 4) 1 (0, 5) ＜0.001 Mechanical ventilation on day 7 of postnatal age, n (%) 31 (5.5) 74 (40.7) ＜0.001 High frequency respiratory support on day 7 of postnatal age, n (%) 11 (1.9) 21 (11.5) ＜0.001 Hemoglobin (g) on day 7 of postnatal age, mean (SD) 135 (23) 131 (22) 0.016 Early-onset sepsis, n (%) 23 (4.1) 8 (4.4) 0.848 Patent ductus arteriosus, n (%) 64 (11.3) 50 (27.5) ＜0.001 Table 2. Logistic regression with adjusted odds ratios for BPD Factors aOR 95% CI p Lower limit Upper limit Gestational age (every 1 week decline) 1.4 1.2 1.7 0.001 Birth weight (every 100 g week decline) 1.3 1.1 1.4 ＜0.001 Chest X-ray score (every 1 point elevation) 1.8 1.4 2.3 ＜0.001 Respiratory support mode (every 1 level elevation) 2.8 2.0 3.8 ＜0.001 Table 3. AUC analysis of the BPD predictive model Factors AUC (95%CI) p Gestational age 0.800 (0.761, 0.839) ＜0.001 Birth weight 0.798 (0.760, 0.835) ＜0.001 Chest X-ray score 0.734 (0.692, 0.776) ＜0.001 Respiratory support 0.723 (0.679, 0.766) ＜0.001 Combination 0.872 (0.843, 0.902) ＜0.001 Discussion The definition and classifications of BPD are evolving since its first proposal by Northway et al in 1967. The widely used 2001 NICHD criteria defined it as the use of supplemental oxygen for ≥ 28 days and classified it into 3 grades (mild, moderate and severe) according to oxygen requirements and/or respiratory support at 36 weeks PMA [ 6 ] . In previous studies, moderate or severe BPD was usually used as the main outcome because this degree of severity is associated with high respiratory morbidity and high rates of neurodevelopmental impairment [ 7 , 8 ] . The 2018 NICHD criteria revised that infants who were on room air at 36 weeks PMA, regardless of respiratory support in the first 28 days, were not classified as having BPD [ 4 ] . The updated definition of BPD showed a good predictive ability for short-term co-morbidities and mid-term respiratory outcomes [ 9 , 10 ] , which is being used in the current study. Despite there are emerging studies in BPD prediction, estimating the risk for BPD during the first several days of life remains attractive. An ideal model should incorporate objective and easy-to-acquire data. This study established an early prediction model for BPD on day 7 postnatal age and identified that lower GA, lower BW, higher respiratory support mode, higher chest X-ray scores were associated with higher risk of BPD. The results not only provide an early and accurate predictor for BPD, but also allow clinicians to take targeted interventions to combat the devastating disease. GA and BW were the most commonly incorporated indicator in BPD predictive models [ 11 ] . The negative correlated between BPD and GA or BW has been demonstrated by previous studies. Our study further confirmed the dosage effect of GA and BW that contributing to BPD. Every 1 week in GA and 100 g in BW decline increased the risk (by 30%-40%) of BPD. GA is a crucial factor that determines the maturity of the lung. The lower the GA, the earlier stage the lung goes through. Among numerous factors, GA conveyed the most predictive information for BPD risk [ 12 ] . Moreover, GA is probably an intermediate confounder variable that needs consideration in the analysis. Several variables such as delivery mode, chorioamnionitis and PDA were significant in the bivariate analysis, however, while incorporating GA simultaneously in multiple logistic regression, they showed no “net effect”. Because these variables were inherently related to GA [ 13 ] . BW reflects the growth potential of the fetus and the lung. Infants who born with lower BW birth always had significant postnatal growth impairment and increased risk of BPD [ 14 ] . Chest X-ray has been the primary tool for assessing lung disease. According to Northway et al’s original study, chest X-ray manifestations of BPD typically underwent four stages, which were consistent with the pathologic findings of the lung injury. The 2018 NICHD criteria reintroduced “radiographic confirmation of parenchymal lung disease” in the definition of BPD, emphasizing the need for chest X-ray in BPD diagnosis. Thus, chest X-ray still holds an irreplaceable role in diagnosing and assessing BPD. Over the last decades, the underlying pathophysiology of BPD has changed due to advances in perinatal and neonatal care. The typical chest X-ray manifestations also appeared earlier than expected, without distinguishable boundary. The earlier emerging chest X-ray signs can be used as means to warn and monitor the progression of the disease. Previous studies found that interstitial pneumonia pattern on chest X-ray on day 7 postnatal age had a high specificity for predicting BPD [ 15 ] . Our prior study also discovered specific chest X-ray patterns (diffuse opacities or grid shadows/interstitial opacities or mass opacities or cystic lucencies), which can be used for quickly identifying infants at higher risk of BPD [ 16 ] . In this study, we developed a scoring system based on the specific patterns as priorly described. The scoring system demonstrated excellent consistency among different operators, which was user-friendly. More importantly, we provided a specific cut-off value of ≥ 3, which added meaningful information to design a better definition of BPD. Mechanical ventilation (MV) can impede alveolar septation and angiogenesis, by imposing volutrauma, atelectotrauma and biochemical injury, which contributed to BPD [ 17 ] . Evidence has been obtained from pre-clinical studies using different animal models [ 18 ] . Prolonged MV is considered as an important postnatal risk factor of BPD [ 19 , 20 ] . Recent studies found that the need for MV on postnatal days 7 and 14 can effectively predict BPD [ 21 ] . Consistent with the previous studies, we found that the need for higher level respiratory support mode on day 7 postnatal age was a good predictor of BPD. It's worth noting that the conclusion was drawn based on a rescue high frequency ventilation (HFV) strategy. HFV was started once other conventional mechanical ventilation (CMV) modes failed to deliver adequate gas exchange. It's interesting that in infants who needed MV the first week of life and later developed BPD, better pulmonary V/Q matching at near-term age was observed in those who ventilated with high frequency oscillatory ventilation (HFOV) compared with those who ventilated with CMV [ 22 ] . In the context of selective HFV strategy, the effect needs to be reassessed. The main limitation of our study was its retrospective nature. However, a relatively large, homogeneous sample, strict design and detailed data acquisition ensured high internal validity and minimized the potential bias. Still, caution is needed when the findings of this study are generalized to patients in other clinical settings. Future studies should aim to externally validate the model using multicenter datasets. Conclusion Predictive factors for the development of BPD were lower gestational age, lower birth weight, higher respiratory support mode, and higher chest X-ray score on day 7 postnatal age. A chest X-ray score ≥ 3 can serve as a valuable indicator. Abbreviation ANS Antenatal steroids AUC Area under the receiver operating characteristic curve BPD Bronchopulmonary dysplasia BW Birth weight CI Confidence interval CMV Conventional mechanical ventilation EOS Early-onset sepsis GA Gestational age HFOV High frequency oscillatory ventilation HFV High frequency ventilation IPPV Intermittent Positive Pressure Ventilation MV Mechanical ventilation N-CPAP Nasal Continuous Positive Airway Pressure NICHD National Institute of Child Health and Human Development NICU Neonatal Intensive Care Unit NIPPV Non-Invasive Positive Pressure Ventilation OR Odds ratio PDA Patent ductus arteriosus PMA Postmenstrual age p-PROM Preterm premature rupture of membranes ROC Receiver operating characteristic RDS Respiratory distress syndrome SD Standard deviation V/Q Ventilation/Perfusion Ratio Declarations Statement of Ethics This study was conducted in accordance with the World Medical Association Declaration of Helsinki. Informed consents were obtained from the parents of the enrolled infants. The Ethics Committee of Zhangzhou Affiliated Hospital of Fujian Medical University approved this study (No.2023LWB350). Conflict of Interest Statement The authors declared no financial or conflicts of interest. Funding This study was not funded. Author Contributions XLP initiated the study and wrote the manuscript. CWW performed the data analysis and contributed to the writing of the manuscript. DSZ, ZZH, HQL, HXL and LLC collected the data. LGM revised the manuscript and supervised the study. All authors contributed to the article and approved the submitted version. Data Availability Statement The datasets generated during the current study are available from the corresponding author on reasonable request. References DOYLE L W, RANGANATHAN S, MAINZER R M, et al. Relationships of Severity of Bronchopulmonary Dysplasia with Adverse Neurodevelopmental Outcomes and Poor Respiratory Function at 7-8 Years of Age [J]. 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BROKKEN T, HüTTEN M C, OPHELDERS D, et al. Optimized lung expansion ventilation modulates ventilation-induced lung injury in preterm lambs [J]. Pediatr Pulmonol, 2024, 59(11): 2891–900. XIONG P, LI L, YU Z, et al. Risk factors for bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis [J]. PeerJ, 2025, 13: e20202. RAMOS-NAVARRO C, MADERUELO-RODRíGUEZ E, CONCHEIRO-GUISáN A, et al. Risk factors and bronchopulmonary dysplasia severity: data from the Spanish Bronchopulmonary Dysplasia Research Network [J]. Eur J Pediatr, 2022, 181(2): 789–99. SU Y H, WU T Y, WANG T T, et al. Association of early respiratory support with mortality and bronchopulmonary dysplasia in very-low-birth-weight preterm infants [J]. Pediatr Neonatol, 2025. KJELLBERG M, SANCHEZ-CRESPO A, JONSSON B. First week of life respiratory management and pulmonary ventilation/perfusion matching in infants with bronchopulmonary dysplasia: a retrospective observational study [J]. J Perinatol, 2023, 43(3): 317–23. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor invited by journal 09 Jan, 2026 Editor assigned by journal 09 Jan, 2026 Submission checks completed at journal 09 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8523476","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587768904,"identity":"55cb0cf3-f449-4e61-9b90-63c608f28a8c","order_by":0,"name":"Liping Xu","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liping","middleName":"","lastName":"Xu","suffix":""},{"id":587768905,"identity":"8eb89b00-5788-4536-bd4e-d09fe27f6808","order_by":1,"name":"Wenwen Chen","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian 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Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACPhDxgMGGh5+/gUgtbCAigSFNRnLGAdK0HLYxaEggVgv/6jSJxB3neQwYDjB++JhDjBaJt5sNEs/c5jFnbmCWnLmNKC1nNz5IbLvNY9lwgI2Zl0gtGw4ktp3jMTiQQKwW/l6QLQdI0SLBC/JLMo/kjIPNxPmFn//sNomPO+zs+fmbD374SIwWBokEBgbGBhALQhJjzQESFI+CUTAKRsHIBAD2qzasRgEuTgAAAABJRU5ErkJggg==","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian Medical University","correspondingAuthor":true,"prefix":"","firstName":"Guangmin","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2026-01-05 16:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8523476/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8523476/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102214190,"identity":"2d199686-ccac-45d5-bf18-1c6bbafdb167","added_by":"auto","created_at":"2026-02-09 12:43:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109980,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8523476/v1/5abec81498632eb497aaec3d.png"},{"id":102214298,"identity":"b29b7a5f-71bc-4fc1-970a-40767f3d0a49","added_by":"auto","created_at":"2026-02-09 12:43:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53515,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve for combination of gestational age, birth weight, chest X-ray score and respiratory support mode on day 7 postnatal age to predict BPD.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8523476/v1/0cb1aeadde7cc1ed2f936560.png"},{"id":102214390,"identity":"8ea34508-420d-4188-b968-72cea2da5f5b","added_by":"auto","created_at":"2026-02-09 12:43:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":607219,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8523476/v1/7348a9b3-c7b3-410b-9a37-07d92d92f329.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Value of a Modified Chest-X ray Scoring System Combined with Clinical Variables in Early Prediction ofBronchopulmonary Dysplasia in Very Preterm Infants","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBronchopulmonary dysplasia (BPD) is a chronic lung disease that poses a significant threat to the life and long-term health of preterm infants. It not only causes respiratory disorder, such as frequent respiratory tract infections, lung function impairment, asthma, and exercise intolerance, but also affects cardiovascular, neurological, and nutritional aspects, imposing a huge burden on public health and family social economy\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. With the advancement of perinatal and neonatal medicine, NICUs achieved a declined rates of death and serious morbidities except BPD. The incidence of BPD remains high at 30%-40%\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, and even be increasing since more immature infants survive. According to the current criteria, the diagnosis of BPD is usually made after 28 days or 36 weeks post-menstrual age (PMA). By this time, certain irreversible injuries to lung likely occur, and the optimal intervention window might be missed. It is essential to identify those at high risk for developing BPD at an early stage so that treatment strategies can be introduced to prevent disease progression.\u003c/p\u003e \u003cp\u003eNumerous prediction models for BPD were reported, but none of them has been widely used in clinical practice. Most of the existing models usually analyzed clinical variables, failing to accurately capture the early visual changes of the disease. Searching for reliable indicators remains one of the major challenges for neonatologists. Chest-X ray imaging is a routine bedside examination for critically ill patient. It can provide crucial morphological clues of lung disease. Since first described by Northway et al in 1967, BPD was defined by radiologic features and pathologic findings when available. In 2018 NICHD diagnostic criteria, chest-X ray was incorporated\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Therefore, we assumed that chest-X ray has the potential for early prediction and diagnosis. The aim of this study was to discuss a scoring system of chest X-ray combined with traditional clinical indicators for improving early diagnosis of BPD in the first week after birth.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis study was conducted in Zhangzhou Affiliated Hospital of Fujian Medical University between January 2019 and December 2024.It was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2400082145). The research protocol was approved by the institution (No.2023LWB350). Informed consents were also obtained from parents. \u003c/p\u003e\n\u003cp\u003ePreterm infants born at less than 32 weeks gestational age (GA) were enrolled. Infants with major congenital malformations and those who developed spontaneous perforation in the first week after birth were excluded. \u003c/p\u003e\n\u003cp\u003eAll included patients underwent chest X-ray on day 7 (\u0026plusmn;1 day) of postnatal age. All images were taken in supine, antero-posterior position, using Fuji Medical X-ray Generator (ZU-L3SB-T). The chest X-ray image was calculated by 2 investigators expert in radiology within 48 hours of scan.\u003c/p\u003e\n\u003cp\u003eThe chest X-ray scoring system was based on the following 4 patterns: (1) reduction in transparency: 0 point for no RDS changes, 1 point for ground-glass-like changes and air bronchogram, and 2 points for white lung; (2) interstitial lesions: 0 point for no interstitial lesions, 1 point for scattered streaks, and 2 points for diffuse streaks; (3) solid lesions: 0 point for no solid lesions, 1 point for a single solid lesion, and 2 points for \u0026ge;2 solid lesions; (4) cystic vesicle appearance: 0 points for no cystic changes, 1 point for cystic present in less than 1/3 of the lung field, 2 points for 1/3 to 2/3 of the lung field, and 3 points for more than 2/3 of the lung field. This was a modification that was previously reported\u003csup\u003e[5]\u003c/sup\u003e. The scores from all 4 patterns were added for a total possible score between 0 and 8 points. To assess interobserver correlation, 20% of random and anonymized images were reassessed by other investigators and scores were compared, and intraclass correlation coefficient was calculated.\u003c/p\u003e\n\u003cp\u003ePerinatal data including maternal gestational hypertension, chorioamnionitis (either clinical or histological), preterm premature rupture of membranes (p-PROM), magnesium sulfate and antenatal steroids (ANS) usage, and baseline characteristics including GA, birth weight (BW), sex, small for GA (SGA) and mode of delivery were collected. Postnatal parameters on day 7 including the mode of respiratory support (non-respiratory support, nasal cannula or high-flow nasal cannula oxygen support, non-invasive respiratory support, conventional mechanical ventilation, high-frequency ventilation), hemoglobin, early-onset sepsis (EOS), patent ductus arteriosus (PDA) were also documented.\u003c/p\u003e\n\u003cp\u003eThe main outcome of this study was BPD, which was diagnosed in accordance with 2018 NICHD diagnostic criteria\u003csup\u003e[4]\u003c/sup\u003e. Infants who had persistent parenchymal lung disease (radiographic confirmation of parenchymal lung disease) and required hood O\u003csub\u003e2\u003c/sub\u003e or nasal cannula or N-CPAP or NIPPV or invasive IPPV for \u0026ge;3 consecutive days to maintain arterial oxygen saturation in the 90%-95% range at 36 weeks PMA was diagnosed with BPD. BPD were classified into 3 severity grades (grade I, II, and III) based on respiratory parameters.\u003c/p\u003e\n\u003cp\u003eAnalysis was performed via SPSS version 26 software. Descriptive data were presented as means \u0026plusmn; SD or percentages. To compare differences between two groups, chi-square tests for categorical variables and two-sample t-tests or Mann\u0026ndash;Whitney U tests for continuous variables were applied. Analyses of the main outcome and risk factors were performed via logistic regression, with 95% CIs calculated for ORs adopting the forward entry method. A p-value of \u0026le;0.2 was used in univariate analysis for inclusion of putative risk factors into the multivariate (adjusted) model. A p-value of \u0026lt;0.05 was considered to be statistically significant. To identify an optimal cut-off of chest X-ray score for BPD diagnosis, ROC curve, sensitivity, and specificity were analyzed.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eDuring the study period, a total of 791 infants met the eligibility criteria and 747 infants were enrolled. The study flow diagram was shown in Figure 1.\u003c/p\u003e\n\u003cp\u003eMean GA of enrolled infants was 29.4 \u0026plusmn; 1.6 weeks and mean birth weight (BW) was 1392 \u0026plusmn; 313 g. Of these 747 infants, 463 (62%) infants were boys, 534 (71.5%) were exposed to antenatal steroids, 425 (56.9%) were delivered by cesarean. There were 182 (24.4%) infants diagnosed with BPD according to 2018 NICHD diagnostic criteria, of whom 16.9% (n = 126) had grade I BPD; 5.4% (n = 40) had grade II BPD and 2.1% (n = 16) had grade III BPD. Infants who were diagnosed with BPD were born at lower GA, lower BW and had a lower rate of cesarean delivery. The clinical characteristics of 2 groups (BPD and non-BPD) of infants are showed in Table 1.\u003c/p\u003e\n\u003cp\u003eUnivariable analyses showed that delivery mode, chorioamnionitis, PDA, and chest X-ray score and respiratory support requirements on day 7 postnatal age were significantly associated with BPD (Table 1). The chest X-ray scores were significantly higher in infants diagnosed with BPD compared with infants not diagnosed with BPD (Table 1.). In addition, the level of hemoglobin on day 7 postnatal age was lower in BPD group compared with non-BPD group.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Multiple\u0026nbsp;logistic regression modeling demonstrated that GA, BW, chest X-ray score and respiratory support mode on day 7 postnatal age can predict BPD. For every 1 week decline in GA and every 100 g decline in BW, the risk of BPD increased by 40% and 30% respectively. For every 1 point gaining in chest X-ray score, the risk of BPD increased by 80%. For every 1 level elevation in respiratory support mode, the riks of BPD increased by 1.7 times (Table 2). The AUC of the combination of GA, BW, chest X-ray score and respiratory support mode on day 7 postnatal age to predict BPD was 0.872 (95%CI: 0.843-0.902) (Table 3 and Figure 2.). The cut-off value of chest X-ray score was 3 with a sensitivity of 80% and specificity of 81%.\u003c/p\u003e\n\u003cp\u003eTable 1. Comparison of baseline characteristics and clinical parameters of included patients\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eNon-BPD (n = 565)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eBPD (n = 182)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eGestational age at birth (wk), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e29.8 (1.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e28.0 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eBirth weight (g), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1472 (283)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1145 (273)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eMale sex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e349 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e114 (62.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eSmall for gestational age, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e27 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e13 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.218\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eAntenatal steroids, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e399 (70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e135 (74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eAntenatal magnesium sulfate, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e61 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e21 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003ePreterm premature rupture of membranes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e149 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e37 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eCesarean delivery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e338 (59.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e87 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eChorioamnionitis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e211 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e86 (47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eChest X ray score on day 7 of postnatal age, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0, 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1 (0, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eMechanical ventilation on day 7 of postnatal age, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e31 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e74 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eHigh frequency respiratory support on day 7 of postnatal age, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e21 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eHemoglobin (g) on day 7 of postnatal age, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e135 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e131 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eEarly-onset sepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e23 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e8 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003ePatent ductus arteriosus, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e64 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e50 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Logistic regression with adjusted odds ratios for BPD\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"556\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 277px;\"\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003eaOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 143px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003eLower limit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eUpper limit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eGestational age (every 1 week decline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eBirth weight (every 100 g week decline)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eChest X-ray score (every 1 point elevation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 277px;\"\u003e\n \u003cp\u003eRespiratory support mode (every 1 level elevation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. AUC analysis of the BPD predictive model\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"493\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eAUC (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eGestational age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.800 (0.761, 0.839)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eBirth weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.798 (0.760, 0.835)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eChest X-ray score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.734 (0.692, 0.776)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eRespiratory support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.723 (0.679, 0.766)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003eCombination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e0.872 (0.843, 0.902)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe definition and classifications of BPD are evolving since its first proposal by Northway et al in 1967. The widely used 2001 NICHD criteria defined it as the use of supplemental oxygen for \u0026ge;\u0026thinsp;28 days and classified it into 3 grades (mild, moderate and severe) according to oxygen requirements and/or respiratory support at 36 weeks PMA\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In previous studies, moderate or severe BPD was usually used as the main outcome because this degree of severity is associated with high respiratory morbidity and high rates of neurodevelopmental impairment\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The 2018 NICHD criteria revised that infants who were on room air at 36 weeks PMA, regardless of respiratory support in the first 28 days, were not classified as having BPD\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The updated definition of BPD showed a good predictive ability for short-term co-morbidities and mid-term respiratory outcomes\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, which is being used in the current study.\u003c/p\u003e \u003cp\u003eDespite there are emerging studies in BPD prediction, estimating the risk for BPD during the first several days of life remains attractive. An ideal model should incorporate objective and easy-to-acquire data. This study established an early prediction model for BPD on day 7 postnatal age and identified that lower GA, lower BW, higher respiratory support mode, higher chest X-ray scores were associated with higher risk of BPD. The results not only provide an early and accurate predictor for BPD, but also allow clinicians to take targeted interventions to combat the devastating disease.\u003c/p\u003e \u003cp\u003eGA and BW were the most commonly incorporated indicator in BPD predictive models\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The negative correlated between BPD and GA or BW has been demonstrated by previous studies. Our study further confirmed the dosage effect of GA and BW that contributing to BPD. Every 1 week in GA and 100 g in BW decline increased the risk (by 30%-40%) of BPD. GA is a crucial factor that determines the maturity of the lung. The lower the GA, the earlier stage the lung goes through. Among numerous factors, GA conveyed the most predictive information for BPD risk\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Moreover, GA is probably an intermediate confounder variable that needs consideration in the analysis. Several variables such as delivery mode, chorioamnionitis and PDA were significant in the bivariate analysis, however, while incorporating GA simultaneously in multiple logistic regression, they showed no \u0026ldquo;net effect\u0026rdquo;. Because these variables were inherently related to GA\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. BW reflects the growth potential of the fetus and the lung. Infants who born with lower BW birth always had significant postnatal growth impairment and increased risk of BPD\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eChest X-ray has been the primary tool for assessing lung disease. According to Northway et al\u0026rsquo;s original study, chest X-ray manifestations of BPD typically underwent four stages, which were consistent with the pathologic findings of the lung injury. The 2018 NICHD criteria reintroduced \u0026ldquo;radiographic confirmation of parenchymal lung disease\u0026rdquo; in the definition of BPD, emphasizing the need for chest X-ray in BPD diagnosis. Thus, chest X-ray still holds an irreplaceable role in diagnosing and assessing BPD. Over the last decades, the underlying pathophysiology of BPD has changed due to advances in perinatal and neonatal care. The typical chest X-ray manifestations also appeared earlier than expected, without distinguishable boundary. The earlier emerging chest X-ray signs can be used as means to warn and monitor the progression of the disease. Previous studies found that interstitial pneumonia pattern on chest X-ray on day 7 postnatal age had a high specificity for predicting BPD\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Our prior study also discovered specific chest X-ray patterns (diffuse opacities or grid shadows/interstitial opacities or mass opacities or cystic lucencies), which can be used for quickly identifying infants at higher risk of BPD\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. In this study, we developed a scoring system based on the specific patterns as priorly described. The scoring system demonstrated excellent consistency among different operators, which was user-friendly. More importantly, we provided a specific cut-off value of \u0026ge;\u0026thinsp;3, which added meaningful information to design a better definition of BPD.\u003c/p\u003e \u003cp\u003eMechanical ventilation (MV) can impede alveolar septation and angiogenesis, by imposing volutrauma, atelectotrauma and biochemical injury, which contributed to BPD\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Evidence has been obtained from pre-clinical studies using different animal models\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Prolonged MV is considered as an important postnatal risk factor of BPD\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Recent studies found that the need for MV on postnatal days 7 and 14 can effectively predict BPD\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Consistent with the previous studies, we found that the need for higher level respiratory support mode on day 7 postnatal age was a good predictor of BPD. It's worth noting that the conclusion was drawn based on a rescue high frequency ventilation (HFV) strategy. HFV was started once other conventional mechanical ventilation (CMV) modes failed to deliver adequate gas exchange. It's interesting that in infants who needed MV the first week of life and later developed BPD, better pulmonary V/Q matching at near-term age was observed in those who ventilated with high frequency oscillatory ventilation (HFOV) compared with those who ventilated with CMV\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. In the context of selective HFV strategy, the effect needs to be reassessed.\u003c/p\u003e \u003cp\u003eThe main limitation of our study was its retrospective nature. However, a relatively large, homogeneous sample, strict design and detailed data acquisition ensured high internal validity and minimized the potential bias. Still, caution is needed when the findings of this study are generalized to patients in other clinical settings. Future studies should aim to externally validate the model using multicenter datasets.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePredictive factors for the development of BPD were lower gestational age, lower birth weight, higher respiratory support mode, and higher chest X-ray score on day 7 postnatal age. A chest X-ray score\u0026thinsp;\u0026ge;\u0026thinsp;3 can serve as a valuable indicator.\u003c/p\u003e"},{"header":"Abbreviation","content":"\u003cp\u003eANS Antenatal steroids\u003c/p\u003e\n\u003cp\u003eAUC Area under the receiver operating characteristic curve\u003c/p\u003e\n\u003cp\u003eBPD Bronchopulmonary dysplasia\u003c/p\u003e\n\u003cp\u003eBW Birth weight\u003c/p\u003e\n\u003cp\u003eCI Confidence interval\u003c/p\u003e\n\u003cp\u003eCMV Conventional mechanical ventilation\u003c/p\u003e\n\u003cp\u003eEOS Early-onset sepsis\u003c/p\u003e\n\u003cp\u003eGA Gestational age\u003c/p\u003e\n\u003cp\u003eHFOV High frequency oscillatory ventilation\u003c/p\u003e\n\u003cp\u003eHFV\u0026nbsp;High frequency ventilation\u003c/p\u003e\n\u003cp\u003eIPPV Intermittent Positive Pressure Ventilation\u003c/p\u003e\n\u003cp\u003eMV Mechanical ventilation\u003c/p\u003e\n\u003cp\u003eN-CPAP Nasal Continuous Positive Airway Pressure\u003c/p\u003e\n\u003cp\u003eNICHD National Institute of Child Health and Human Development\u003c/p\u003e\n\u003cp\u003eNICU Neonatal Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eNIPPV Non-Invasive Positive Pressure Ventilation\u003c/p\u003e\n\u003cp\u003eOR Odds ratio\u003c/p\u003e\n\u003cp\u003ePDA Patent ductus arteriosus\u003c/p\u003e\n\u003cp\u003ePMA Postmenstrual age\u003c/p\u003e\n\u003cp\u003ep-PROM Preterm\u0026nbsp;premature rupture of membranes\u003c/p\u003e\n\u003cp\u003eROC Receiver operating characteristic\u003c/p\u003e\n\u003cp\u003eRDS Respiratory distress syndrome\u003c/p\u003e\n\u003cp\u003eSD Standard deviation\u003c/p\u003e\n\u003cp\u003eV/Q Ventilation/Perfusion Ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the World Medical Association Declaration of Helsinki. Informed consents were obtained from the parents of the enrolled infants. The Ethics Committee of Zhangzhou Affiliated Hospital of Fujian Medical University approved this study (No.2023LWB350).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no financial or conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXLP initiated the study and wrote the manuscript. CWW performed the data analysis and contributed to the writing of the manuscript. DSZ, ZZH, HQL, HXL and LLC collected the data. LGM revised the manuscript and supervised the study. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDOYLE L W, RANGANATHAN S, MAINZER R M, et al. Relationships of Severity of Bronchopulmonary Dysplasia with Adverse Neurodevelopmental Outcomes and Poor Respiratory Function at 7-8 Years of Age [J]. J Pediatr, 2024, 269: 114005.\u003c/li\u003e\n \u003cli\u003eKIM C, UFKES S, GUO T, et al. Associations of Bronchopulmonary Dysplasia and Infection with School-Age Brain Development in Children Born Preterm [J]. J Pediatr, 2025, 281: 114524.\u003c/li\u003e\n \u003cli\u003eHORBAR J D, EDWARDS E M, GREENBERG L T, et al. Variation in Performance of Neonatal Intensive Care Units in the United States [J]. JAMA Pediatr, 2017, 171(3): e164396.\u003c/li\u003e\n \u003cli\u003eHIGGINS R D, JOBE A H, KOSO-THOMAS M, et al. Bronchopulmonary Dysplasia: Executive Summary of a Workshop [J]. J Pediatr, 2018, 197: 300\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eTOCE S S, FARRELL P M, LEAVITT L A, et al. Clinical and roentgenographic scoring systems for assessing bronchopulmonary dysplasia [J]. Am J Dis Child, 1984, 138(6): 581\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eJOBE A H, BANCALARI E. Bronchopulmonary dysplasia [J]. Am J Respir Crit Care Med, 2001, 163(7): 1723\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eTORCHIN H, LORTHE E, GOFFINET F, et al. Histologic Chorioamnionitis and Bronchopulmonary Dysplasia in Preterm Infants: The Epidemiologic Study on Low Gestational Ages 2 Cohort [J]. J Pediatr, 2017, 187: 98\u0026ndash;104.e3.\u003c/li\u003e\n \u003cli\u003eRITE S, MART\u0026iacute;N DE VICENTE C, GARC\u0026iacute;A-I\u0026ntilde;IGUEZ J P, et al. The Consensus Definition of Bronchopulmonary Dysplasia Is an Adequate Predictor of Lung Function at Preschool Age [J]. Front Pediatr, 2022, 10: 830035.\u003c/li\u003e\n \u003cli\u003eMUKERJI A, READ B, SU Y C, et al. Severity of Bronchopulmonary Dysplasia Using a Contemporary Canadian Definition and Early Childhood Outcomes: A Population-Based Cohort Study [J]. J Pediatr, 2025, 287: 114763.\u003c/li\u003e\n \u003cli\u003eKIM F, BATEMAN D A, GOLDSHTROM N, et al. Revisiting the definition of bronchopulmonary dysplasia in premature infants at a single center quaternary neonatal intensive care unit [J]. J Perinatol, 2021, 41(4): 756\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eKICIŃSKI P, KĘSIAK M, NOWICZEWSKI M, et al. Bronchopulmonary dysplasia in very and extremely low birth weight infants - analysis of selected risk factors [J]. Pol Merkur Lekarski, 2017, 42(248): 71\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eLAUGHON M M, LANGER J C, BOSE C L, et al. Prediction of bronchopulmonary dysplasia by postnatal age in extremely premature infants [J]. Am J Respir Crit Care Med, 2011, 183(12): 1715\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eYUM S K, KIM M S, KWUN Y, et al. Impact of histologic chorioamnionitis on pulmonary hypertension and respiratory outcomes in preterm infants [J]. Pulm Circ, 2018, 8(2): 2045894018760166.\u003c/li\u003e\n \u003cli\u003eNYP M F, TAYLOR J B, NORBERG M, et al. Impaired growth at birth and bronchopulmonary dysplasia classification: beyond small for gestational age [J]. Am J Perinatol, 2015, 32(1): 75\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eKIM H R, KIM J Y, YUN B, et al. Interstitial pneumonia pattern on day 7 chest radiograph predicts bronchopulmonary dysplasia in preterm infants [J]. BMC Pediatr, 2017, 17(1): 125.\u003c/li\u003e\n \u003cli\u003eCHEN W, ZHANG Z, XU L, et al. The Most Valuable Predictive Factors for Bronchopulmonary Dysplasia in Very Preterm Infants [J]. Children (Basel), 2023, 10(8).\u003c/li\u003e\n \u003cli\u003eVAN KAAM A H. Optimal Strategies of Mechanical Ventilation: Can We Avoid or Reduce Lung Injury? [J]. Neonatology, 2024, 121(5): 570\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eBROKKEN T, H\u0026uuml;TTEN M C, OPHELDERS D, et al. Optimized lung expansion ventilation modulates ventilation-induced lung injury in preterm lambs [J]. Pediatr Pulmonol, 2024, 59(11): 2891\u0026ndash;900.\u003c/li\u003e\n \u003cli\u003eXIONG P, LI L, YU Z, et al. Risk factors for bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis [J]. PeerJ, 2025, 13: e20202.\u003c/li\u003e\n \u003cli\u003eRAMOS-NAVARRO C, MADERUELO-RODR\u0026iacute;GUEZ E, CONCHEIRO-GUIS\u0026aacute;N A, et al. Risk factors and bronchopulmonary dysplasia severity: data from the Spanish Bronchopulmonary Dysplasia Research Network [J]. Eur J Pediatr, 2022, 181(2): 789\u0026ndash;99.\u003c/li\u003e\n \u003cli\u003eSU Y H, WU T Y, WANG T T, et al. Association of early respiratory support with mortality and bronchopulmonary dysplasia in very-low-birth-weight preterm infants [J]. Pediatr Neonatol, 2025.\u003c/li\u003e\n \u003cli\u003eKJELLBERG M, SANCHEZ-CRESPO A, JONSSON B. First week of life respiratory management and pulmonary ventilation/perfusion matching in infants with bronchopulmonary dysplasia: a retrospective observational study [J]. J Perinatol, 2023, 43(3): 317\u0026ndash;23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bronchopulmonary dysplasia, chest-X ray score, mechanical ventilation, preterm infants","lastPublishedDoi":"10.21203/rs.3.rs-8523476/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8523476/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eBronchopulmonary dysplasia (BPD) is often accompanied by specific Chest-X ray patterns even in the early or evolving stages before the diagnosis is established. We aim to assess Chest-X ray's predictive value for BPD in preterm infants less than 32 weeks gestation.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis is a retrospective, single-center study, including preterm infants born at less than 32 weeks gestation in our NICU from 2019 to 2024. We collected their clinical information during the maternal, birth and early postnatal periods. A chest X-ray scoring system was introduced based on the appearance of reduction in transparency, interstitial lesions, solid lesions and cystic vesicle. Risk factors were selected through univariable analyses. Prediction model was established through logistic regression and assessed by the AUC. The cut-off value of chest X-ray score was determined.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eA total of 747 infants was enrolled. The mean gestational age was 29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 weeks and mean birth weight was 1392\u0026thinsp;\u0026plusmn;\u0026thinsp;313 g. The incidence of BPD was 22.4%. Univariable analysis and logistic regression showed gestational age, birth weight, mechanical ventilation mode, and chest X-ray score on day 7 postnatal age were associated with BPD, with adjusted odds ratios of 1.4 (95%CI: 1.2\u0026ndash;1.7), 1.3 (95%CI: 1.1\u0026ndash;1.4), 2.8 (95%CI: 2.0-3.8) and 1.8 (95%CI: 1.4\u0026ndash;2.3), respectively. The AUC of the combination of the factors was 0.872 (95%CI: 0.843\u0026ndash;0.902). The cut-off value of chest X-ray score was 3 with a sensitivity of 80% and specificity of 81%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePredictive factors for the development of BPD were lower gestational age, lower birth weight, higher respiratory support mode, and higher chest X-ray score on day 7 postnatal age. A chest X-ray score\u0026thinsp;\u0026ge;\u0026thinsp;3 was a good predictor of BPD.\u003c/p\u003e","manuscriptTitle":"The Value of a Modified Chest-X ray Scoring System Combined with Clinical Variables in Early Prediction ofBronchopulmonary Dysplasia in Very Preterm Infants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 12:38:32","doi":"10.21203/rs.3.rs-8523476/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"252609674988534482648754599020705452548","date":"2026-02-14T22:43:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T16:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28060311282519140574271494574480745139","date":"2026-02-05T04:23:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T04:12:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T19:13:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-09T11:59:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-09T11:54:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2026-01-05T16:22:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cad3fc8e-6083-44a1-b887-72251d6914a6","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T12:38:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 12:38:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8523476","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8523476","identity":"rs-8523476","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}