The Lung area to Head circumference Ratio (LHR),
  The Observed/expected lung-to-head ratio (o/e LHR), and
  The Quantitative Lung Index (QLI)

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The calculator below may be used to estimate the LHR  , the o/e LHR, and the  QLI

Enter: Gestational Age   weeks days 

Select: Congenital diaphragmatic hernia (CDH)  is on  the Left side Right side
Enter Parameters for Lung Area
Longest Diameter Method

Enter: Length 1    mm                       
Enter: Length 2    mm

Tracing Method

Enter: Area traced=  mm2


Enter:  Fetal Head Circumference mm

            (1 cm ^2 = 100 mm^2)


Longest Diameter Method Tracing Method
Observed LHR= Observed LHR=
Expected LHR   Expected  LHR   
O/E LHR  = % O/E LHR  = %

 The Observed Lung area to Head circumference Ratio (LHR) =Lung area / Head circumference
Where :
The lung area of the lung contralateral to the CDH  =
  Length 1  X Length 2  OR the lung area  is obtained by tracing of the limits of the lung.
  • If the LHR is 1 or less, the prognosis is poor. The prognosis is poorer still if the liver is in the thorax.  Such patients may be candidates for prenatal intervention.
  • If the LHR is between 1.0 to 1.4 , extracorporeal membranous oxygenation (ECMO) is often needed.
  • If the LHR is  greater than 1.4, the prognosis is better

o/e LHR = (Observed  LHR/ Expected LHR ) X 100

Alfaraj MA, et al found 100% survival in patients with isolated CDH when the O/E LHR on ultrasound was greater than 45%.
Whereas, there are few survivors when the O/E LHR less than 25%

Quantitative lung index (QLI)  = lung area/(HC/10)^2

The 50th percentile for the QLI is constant at ~ 1 for the geststional age between 16 - 32 weeks.  A small lung ( 1st percentile) is defined as a QLI  0.6.

The Lung area to Head circumference Ratio (LHR),

The lung-to-head circumference  ratio (LHR) is a sonographic measure that has been proposed to identify fetuses with congenital diaphragmatic hernia (CDH) that have  a poor prognosis.

The lung area contralateral to the CDH  was originally  obtained by taking  the product of the longest two perpendicular linear measurements of the lung  measured at the level of the 4-chamber view of the heart on a transverse scan of the fetal thorax.  The product is divided by the HC.

      Lung area =  Length 1  X Length 2

The Lung area to Head circumference Ratio (LHR) =
                               Lung area / Head circumference


In a cross-sectional study of 650 normal singleton pregnancies Peralta and coworkers found manual tracing of the lung  to be a more reproducible way of measuring the lung area .

Using the tracing method the lung area contralateral to the CDH  is  be obtained by tracing of the limits of the lung.

The Lung area to Head circumference Ratio (LHR) =
                               Lung area / Head circumference

Observed/expected lung-to-head ratio (o/e LHR)

Peralta CF, et al also found that the left and right LHR increased  exponentially with gestation . Because the LHR is not gestational age independent as previously assumed  Jani J, et al proposed the introduction of a new measurement, the observed to expected (o/e) LHR, to correct for gestational age.

The observed LHR  may be expressed as a percentage of the expected mean for gestational age as the  Observed/expected lung-to-head ratio  O/E LHR.

o/e LHR = (Observed  LHR/ Expected LHR ) X 100

Where the Expected LHR using Longest Diameter Method is

Expected Right LHR  in left CDH
= 3.4802 + (0.3995 X GA) - (0.0048 X GA ^2 )

Expected  Left LHR  in right CDH
=- 2.5957 + (0.3043 X GA) - ( 0.0042 X GA ^2)

GA = gestational age in weeks

Where the Expected LHR using the Tracing Method is

Expected Right LHR in left CDH
-2.3271 + (0.27 GA)−(0.0032 GA^2)

Expected Left LHR in right CDH
-1.4994 + (0.1778 GA)−(0.0021 GA2)

GA = gestational age in weeks


The Quantitative Lung Index (QLI)

Quintero RA and colleagues showed mathematically that neither the LHR nor the observed/expected LHR are gestational age independent. They derived  a new parameter to describe right lung growth expressed as the  quantitative lung index (QLI)  = lung area/(HC/10)^2. The 50th percentile of the QLI is constant at approximately 1.0 for the gestational age between 16-32 weeks. They defined a small lung (<1st percentile) as a QLI <0.6. Further studies are needed to assess the merits of this new parameter .



1. Lipshutz GS, Albanese CT, Feldstein VA, Jennings RW, Housley HT, Beech R, Farrell JA, Harrison MR. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 1997 Nov;32(11):1634-6 PMID: 9396544
2. Alfaraj MA, et al. Congenital diaphragmatic hernia: lung-to-head ratio and lung volume for prediction of outcome.Am J Obstet Gynecol. 2011 Jul;205(1):43.e1-8. PMID 21529758

3. Quintero RA, et al The quantitative lung index (QLI): a gestational age-independent sonographic predictor of fetal lung growth. Am J Obstet Gynecol. 2011 Dec;205(6):544.e1-8. Epub 2011 Jul 22.PMID: 21944224

4. Metkus AP, et al. Sonographic predictors of survival in fetal diaphragmatic hernia. J Pediatr Surg. 1996 Jan;31(1):148-51; PMID: 8632269

5. Peralta CF,et al. Assessment of lung area in normal fetuses at 12-32 weeks. Ultrasound Obstet Gynecol. 2005 Dec;26(7):718-24.PMID: 16308896

6. Jani J, et al Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Antenatal-CDH-Registry Group. Ultrasound Obstet Gynecol. 2007 Jul;30(1):67-71.PMID: 17587219

7. Peralta CF, et al. Left and right lung volumes in fetuses with diaphragmatic hernia.
Ultrasound Obstet Gynecol. 2006 May;27(5):551-4.PMID: 16586479Jani JC, et al., Lung-to-head ratio: a need to unify the technique.Ultrasound Obstet Gynecol. 2012 Jan;39(1):2-6. doi: 10.1002/uog.11065. PMID: 22213615

All calculations must be confirmed before use. The suggested results are not a substitute for clinical judgment. Neither nor any other party involved in the preparation or publication of this site shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.

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