What are the management strategies for bronchopulmonary dysplasia (BPD) in premature infants?

Management Strategies for Bronchopulmonary Dysplasia in Premature Infants

The management of bronchopulmonary dysplasia (BPD) requires a comprehensive approach targeting oxygen therapy with saturations of 92-95%, careful respiratory support, selective use of medications including bronchodilators and limited corticosteroids, and monitoring for complications such as pulmonary hypertension. 1

Oxygen Therapy and Respiratory Support

• Target oxygen saturations of 92-95% to prevent adverse effects of hypoxia while minimizing risk of additional lung inflammation 1
• Continuous oxygen monitoring is essential; brief "spot checks" are insufficient 1
• Implement ventilatory strategies that minimize "volutrauma" and oxygen toxicity 2
• Consider early lung recruitment with nasal respiratory support:
  • Nasal continuous positive airway pressure (NCPAP)
  • Nasal intermittent positive pressure ventilation (NIPPV) 3
• For intubated infants, use gentle ventilation strategies with permissive hypercapnia 3

Pharmacological Management

Bronchodilators

• 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 1
• Response to bronchodilators is variable; consider infant lung function testing to identify responders 1
• Be aware that children with tracheobronchomalacia can have paradoxical response to bronchodilator therapy 4

Corticosteroids

• Avoid high daily doses of dexamethasone (approximately 0.5 mg/kg per day) due to association with adverse outcomes including neurodevelopmental impairment 4
• Consider low-dose dexamethasone therapy (<0.2 mg/kg per day) to facilitate extubation in ventilator-dependent infants 4
• Reserve corticosteroid use for infants with established severe BPD who fail to wean from mechanical ventilation despite optimization of respiratory support 1
• Low-dose hydrocortisone therapy (1 mg/kg per day) given for the first 2 weeks of life may increase rates of survival without BPD, particularly for infants delivered in a setting of prenatal inflammation 4
• When considering corticosteroid therapy, balance the risks of BPD with potential adverse effects for each individual patient 4

Diuretics

• The American Thoracic Society recommends against routine use of diuretics for infants with post-prematurity respiratory disease (conditional recommendation, very-low-certainty evidence) 1
• For acute worsening of lung compliance with evidence of pulmonary edema, a short trial of diuretics may be justified 1
• Monitor for significant risks including sensorineural hearing deficits, nephrolithiasis, and electrolyte imbalances 1
• Avoid long-term diuretic use when possible, and plan for discontinuation rather than indefinite use for infants discharged on diuretics 1

Pulmonary Hypertension Management

• Screen all infants with established BPD for pulmonary hypertension using echocardiogram 1
• Follow infants with BPD and pulmonary hypertension with serial echocardiograms every 2-4 weeks initially 1
• Consider pulmonary vasodilators for infants with BPD and pulmonary hypertension after optimizing respiratory and cardiac management:
  • Inhaled Nitric Oxide (iNO) can improve oxygenation, typically initiated at 10-20 ppm with subsequent weaning to 2-10 ppm 1
  • Sildenafil may be considered at doses of 0.5-2 mg/kg three times daily 1
• Cardiac catheterization is recommended before initiating long-term pulmonary hypertension therapy 1

Diagnostic Evaluation and Monitoring

• Consider sleep study to determine presence of significant hypoxic episodes 1
• Perform comprehensive evaluation for:
  • Chronic reflux and aspiration
  • Structural airway abnormalities
  • Bronchoreactivity
  • Pulmonary edema 1
• For infants with unexplained symptoms concerning for malacia (hypoxemia, desaturation episodes, recurrent cough, dyspnea, wheezing, inability to wean from positive pressure ventilation), consider bronchoscopy and/or imaging 4
• Implement regular monitoring with serial assessments, including echocardiograms at 4-6 month intervals depending on clinical course 1

Nutritional Support

• Implement early nutritional support with fluid restriction 3
• Consider vitamin A supplementation as a preventive measure 1, 3

Prevention Strategies

• Prevention of prematurity is the most effective strategy for reducing BPD 2
• Single-course therapy with antenatal glucocorticoids in women at risk for delivering premature infants 2
• Surfactant replacement therapy in intubated infants with respiratory distress syndrome 2
• Closure of clinically significant patent ductus arteriosus 2
• Caffeine therapy 3

Long-term Follow-up

• Follow in an interdisciplinary pediatric pulmonary hypertension program for infants with BPD who have pulmonary hypertension 1
• Consider lung imaging for children with more severe BPD using dose-reduction techniques 1
• Ensure vaccination against respiratory pathogens 2

The management of BPD requires vigilant monitoring and a carefully balanced approach to respiratory support and pharmacological interventions, with particular attention to preventing complications and optimizing long-term outcomes.