Radiographic findings in severe bronchopulmonary dysplasia (BPD)To the editor,A 460g infant was born via cesarian-section at 26 weeks and 4 days gestation. The mother’s prenatal labs were unremarkable. The mother received magnesium phosphate for five doses prior to delivery. The infant was intubated at delivery and started on assist control volume guarantee (AC/VG) mode of ventilation. He received two doses of surfactant.Chest x-ray obtained on day of life (DOL) 1 showed granular airspace opacities throughout both lungs, suggestive of surfactant deficiency (Figure 1.). Serial radiographs throughout his neonatal intensive care unit stay re-demonstrated diffuse pulmonary opacities. He was intubated until DOL 47. He required a protracted course of mechanical ventilation. Echocardiogram demonstrated pulmonary hypertension, requiring initiation of inhaled nitric oxide. Echocardiogram showed right ventricular dilation with increased wall thickness. His right ventricular systolic pressure to be 60mmHg plus the right atrial pressure with interventricular septal flattening.Given his requirement for invasive ventilation at greater than 36 weeks post-menstrual age, he met criteria for severe bronchopulmonary dysplasia (BPD)1. A non-contrasted computed tomography (CT) scan was performed on DOL 180 to further characterize his lung disease. It showed diffuse bilateral coarse interlobular septal thickening and coarse band-shaped opacities likely representing areas of intermittent discoid atelectasis. In addition, it showed intermittent cystic lucencies suggestive of BPD (Figures 2-4). These findings are consistent with a profoundly severe case of BPD in an extremely preterm infant. He underwent a tracheostomy and continued synchronized intermittent mandatory ventilation/pressure regulated volume control plus pressure support (SIMV/PRVC + PS) using established BPD ventilator strategies. His ventilator settings have been progressively weaned to final discharge settings of PEEP of 10, TV of 10mL/kg, and PS of 30.BPD is a chronic lung disease of prematurity due to arrest of alveolarization in normal lung development, leading to the development of fewer, larger alveoli with less capacity for gas exchange2. While not standard in all cases, imaging can be useful in the characterization of certain severe cases of BPD. Chest x-ray is typically the first modality used. CT can be used in more complex cases. CT often demonstrates regions of decreased attenuation, emphysema-like change, linear and subpleural opacities, and bronchial wall thickening3.