What is the management approach for bronchopulmonary dysplasia (BPD)?

Management of Bronchopulmonary Dysplasia (BPD)

The management of bronchopulmonary dysplasia requires aggressive treatment of the underlying lung disease, optimization of oxygen therapy targeting 92-95% saturation, and careful consideration of pulmonary hypertension treatment in affected infants. 1, 2

Respiratory Management

Oxygen Therapy

• Target oxygen saturations of 92-95% to prevent adverse effects of hypoxia while minimizing risk of additional lung inflammation 1, 2
• Brief "spot checks" of oxygenation are insufficient; continuous monitoring may be necessary 1
• Consider sleep study to determine presence of significant hypoxic episodes and whether hypoxemia has obstructive, central, or mixed causes 1

Ventilation Strategies

• Use non-aggressive ventilation measures to minimize lung injury 2
• For patients with severe BPD and pulmonary hypertension who fail to maintain near-normal ventilation despite conservative treatment, consider long-term mechanical ventilatory support 1

Evaluation of Contributing Factors

• Perform comprehensive evaluation for:
  • Chronic reflux and aspiration (upper GI series, pH/impedance probe, swallow studies) 1
  • Structural airway abnormalities (flexible bronchoscopy) including:
    • Tonsillar and adenoidal hypertrophy
    • Vocal cord paralysis
    • Subglottic stenosis
    • Tracheomalacia and other lesions 1
  • Bronchoreactivity 1, 2
  • Pulmonary edema 1

Pulmonary Hypertension Management

• Screen for pulmonary hypertension with echocardiogram in all infants with established BPD 2
• Follow infants with BPD and pulmonary hypertension with serial echocardiograms every 2-4 weeks initially 1
• Consider cardiac catheterization before initiating long-term pulmonary hypertension therapy 2

Pharmacologic Treatment for Pulmonary Hypertension

1. Inhaled Nitric Oxide (iNO)

   • Can improve oxygenation in infants with established BPD 1
   • Typically initiated at 10-20 ppm with subsequent weaning to 2-10 ppm 1
   • Lower doses may enhance ventilation-perfusion matching 1

2. Sildenafil

   • Consider at doses of 0.5-2 mg/kg three times daily 1
   • Associated with improvement in pulmonary hypertension in 88% of patients 1
   • May facilitate weaning from mechanical ventilator support and other pulmonary hypertension therapies 1

3. Calcium Channel Blockers (CCBs)

   • Short-term benefits reported but effects may not differ from supplemental oxygen alone 1
   • Risk of systemic hypotension limits use 1
   • Poor acute response compared to iNO 1

4. Prostacyclin Analogs

   • Limited use due to concerns about worsening gas exchange and systemic hypotension 1
   • Inhaled iloprost requires frequent treatments (6-8 times daily) and may cause bronchospasm 1

Bronchodilator Therapy

• Consider bronchodilator therapy for infants with symptoms of wheezing, cough, or tachypnea 1
• Delivery via metered-dose inhaler (MDI) with spacer is preferable to nebulization:
  • Shorter administration time
  • No ventilator flow adjustment required
  • No cooling of gases
  • Avoids paradoxical deterioration in airway resistance seen with nebulization 1
• Response to bronchodilators is variable; consider infant lung function testing to identify responders 1

Diuretic Therapy

• The American Thoracic Society recommends against routine use of diuretics (conditional recommendation) 2
• Consider short-term diuretic use only for acute worsening of lung compliance with evidence of pulmonary edema 2
• Monitor for significant adverse effects:
  • Electrolyte imbalances
  • Sensorineural hearing deficits
  • Nephrolithiasis 2
• Plan for discontinuation rather than indefinite use for infants discharged on diuretics 2

Corticosteroid Use

• Reserve systemic corticosteroids (specifically dexamethasone) for infants with severe BPD who fail to wean from mechanical ventilation despite optimization of respiratory support 2
• Carefully weigh benefits versus risks, including potential adverse neurologic outcomes 1
• Consider inhaled corticosteroids for symptomatic infants, though evidence for long-term benefit is limited 2

Follow-up and Monitoring

• Implement regular monitoring with serial assessments including echocardiograms at 4-6 month intervals depending on clinical course 2
• Consider lung imaging for children with more severe BPD, using dose-reduction techniques 1
• Follow in an interdisciplinary pediatric pulmonary hypertension program for infants with BPD who have pulmonary hypertension 1

By implementing this comprehensive management approach with particular attention to optimizing oxygenation, treating pulmonary hypertension when present, and minimizing further lung injury, outcomes for infants with BPD can be improved.