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Diaphragm Function in Very Preterm Infants at 36 Weeks' Postmenstrual Age

Benjamin Stoecklin^1,2, Zeena Al-Obaidi³, Jenny Svedenkrans^4,5

¹School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia.

Pediatric Pulmonology

|May 12, 2025

Insights

Diaphragmatic function in very preterm infants with bronchopulmonary dysplasia (BPD) appears improved, contrary to initial hypotheses. Antenatal and postnatal factors explain little of this diaphragmatic effectiveness.

Area of Science:

Neonatal physiology
Respiratory medicine
Pediatric pulmonology

Background:

Bronchopulmonary dysplasia (BPD) is a chronic lung disease affecting very preterm infants.
Diaphragmatic function is crucial for respiratory support in neonates.
Understanding factors influencing diaphragmatic effectiveness is vital for infant respiratory health.

Purpose of the Study:

To investigate the influence of BPD and antenatal/postnatal factors on diaphragmatic functional effectiveness in very preterm infants.
To assess diaphragmatic pressure, work of breathing, and ventilation during spontaneous breathing.
To identify predictors of diaphragmatic functional outcomes.

Main Methods:

Prospective observational study of 182 very preterm infants at 36 weeks' postmenstrual age.
Measurement of transdiaphragmatic pressure (Pdi) normalized to tidal volume (Pdi/V_T) and diaphragmatic work of breathing (PTIdi·min^-1).
Multivariable linear regression used to identify predictive factors for diaphragmatic outcomes.

Main Results:

Infants with BPD showed lower Pdi/V_T and PTIdi·min^-1 but higher minute ventilation compared to those without BPD.
Lower birthweight Z-score and presence of BPD were negative predictors for Pdi/V_T.
Higher gestational age and better early postnatal energy intake positively predicted PTIdi·min^-1.

Conclusions:

Diaphragmatic functional effectiveness appears unexpectedly improved in infants with BPD.
This may represent an adaptive response or increased accessory muscle recruitment.
Antenatal and postnatal factors explained only a minor part of the variance in diaphragmatic effectiveness.

Read full analysis

Abstract

Objectives:

Understand how bronchopulmonary dysplasia (BPD) and antenatal and postnatal factors influence diaphragmatic functional effectiveness in very preterm infants.

Working Hypothesis:

Diaphragmatic functional effectiveness during spontaneous breathing is impaired in infants with BPD. Moreover, diaphragmatic functional effectiveness is influenced by adverse antenatal and postnatal factors.

Methodology:

Diaphragmatic functional effectiveness was assessed in a single-centre, prospective observational study in preterm infants. Transdiaphragmatic pressure (Pdi) and respiratory flow were measured during quiet sleep at 36 weeks' postmenstrual age (PMA). Pdi was normalized to tidal volume (Pdi/V_T). Diaphragmatic work of breathing per minute was calculated from the inspiratory pressure time integral (PTIdi) and respiratory rate. Factors predictive for each outcome were identified from multivariable linear regression.

Results:

Very preterm infants (n = 182) were measured at a median (IQR) 35.6 (1.3) weeks' PMA. Infants with BPD had a lower Pdi/V_T (p = 0.007) and lower PTIdi·min^-1 (p = 0.022) but higher minute ventilation (p = 0.032) and similar respiratory rates (p = 0.419) compared to infants without BPD. Birthweight Z score (R² = 0.08, p < 0.001) and BPD (R² = 0.04, p = 0.022) were independent negative predictors for Pdi/V_T while gestational age (R² = 0.04, p = 0.01) and average early postnatal energy intake (R² = 0.03, p = 0.026) were independent positive predictors for PTIdi·min^-1 on multivariable analysis. Chorioamnionitis and duration of mechanical ventilation did not contribute to the final model.

Conclusions:

Contrary to our hypothesis, diaphragm functional effectiveness appears improved in infants with BPD. We speculate this finding may reflect an adaptive process, or alternatively indicate an increased recruitment of accessory muscles to achieve required ventilation in BPD infants. Adverse antenatal and postnatal factors only explain a small proportion of variance in diaphragm effectiveness.

Keywords:

bronchopulmonary dysplasia prematurity respiratory muscle function

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