What is the DART (Dexamethasone, Vitamin A, and other supportive therapies such as Diuretics and Respiratory therapies) regime in the management of Bronchopulmonary Dysplasia (BPD)?

DART Regime in Bronchopulmonary Dysplasia (BPD)

The DART regime for bronchopulmonary dysplasia management includes dexamethasone for severe cases with careful consideration of risks, vitamin A supplementation as a preventive measure, diuretics for short-term use only with planned discontinuation, and respiratory therapies including supplemental oxygen targeting 92-95% saturation.

Dexamethasone Component

Dexamethasone use in BPD requires careful consideration of benefits versus risks:

• Indications: Reserved for infants with established severe BPD who fail to wean from mechanical ventilation despite optimization of respiratory support 1
• Dosing regimen: Short course (.5 mg/kg/d × 2 days, .25 mg/kg/d × 2 days, .1 mg/kg/d × 3 days) 2
• Risks: Significant adverse effects including hypertrophic cardiomyopathy, gastrointestinal perforation, and potential cerebral palsy 3
• Monitoring: Regular assessment of pulmonary response using ventilation parameters and oxygen requirements

Important Caution

While dexamethasone is effective for BPD prevention, the European Respiratory Society recommends against routine use of systemic corticosteroids after the neonatal period due to risk-benefit concerns 4.

Vitamin A Component

Vitamin A plays a crucial role in epithelial regeneration during recovery from lung injury:

• Dosing: Supplementation as a preventive measure (specific dosing based on institutional protocols)
• Evidence: One of only two medications (along with caffeine) shown in high-quality studies to prevent BPD without clinically important adverse effects 3
• Mechanism: Supports epithelial regeneration during recovery from lung injury 2
• Synergy: May enhance the beneficial pulmonary response to dexamethasone treatment 2

Diuretics Component

Diuretics should be used judiciously with a plan for discontinuation:

• Indications: Short-term use only for acute worsening of lung compliance with evidence of pulmonary edema 5
• Monitoring: Regular assessment for electrolyte abnormalities, nephrolithiasis, and hearing loss 5
• Discontinuation: Natural weaning by relative decrease in dose with increasing weight gain if started in the neonatal period 4
• Caution: The American Thoracic Society recommends against routine use of diuretics for infants with post-prematurity respiratory disease due to limited evidence of long-term benefits 5

Respiratory Therapies Component

Respiratory support is fundamental to BPD management:

• Oxygen therapy: Target oxygen saturations between 92-95% in patients with established BPD and pulmonary hypertension 1, 5
• Ventilation strategies: Minimize peak inspiratory pressure and avoid large tidal volumes to reduce ventilator-associated lung injury 1
• Bronchodilators: Consider for infants with asthma-like symptoms or demonstrated reversibility in lung function 4
• Inhaled nitric oxide (iNO): Can be effective for infants with established BPD and symptomatic pulmonary hypertension 1

Comprehensive Assessment and Monitoring

Regular monitoring is essential for optimal management:

• Echocardiogram: Recommended for screening for pulmonary hypertension in infants with established BPD 1
• Serial assessments: Perform echocardiograms at 4-6 month intervals depending on clinical course 1
• Lung function testing: Suggested for all children with BPD 4
• Evaluation for comorbidities: Assess for gastroesophageal reflux, aspiration, structural airway abnormalities, and bronchoreactivity 1

Pulmonary Hypertension Management

Pulmonary hypertension is a significant complication in BPD requiring specific attention:

• Screening: Echocardiogram recommended for all infants with established BPD 1
• Oxygen therapy: Maintain saturations between 92-95% 1
• Pulmonary vasodilators: Consider for infants with BPD and pulmonary hypertension after optimizing respiratory and cardiac management 1
• Cardiac catheterization: Recommended before initiating long-term pulmonary hypertension therapy to assess disease severity and contributing factors 1

Multidisciplinary Approach

A coordinated care approach improves outcomes:

• Core team: Establish a multidisciplinary group familiar with the chronicity of established BPD 6
• Discharge planning: Comprehensive planning for transition from hospital to home
• Long-term follow-up: Continued monitoring into childhood and adolescence for respiratory complications

The DART regime represents a structured approach to managing BPD, with each component addressing different aspects of this complex disease. Implementation should be guided by regular assessment of clinical response and adjustment of therapies as needed.