From the Guidelines
The management of infant chronic lung disease (CLD) should prioritize a comprehensive approach focusing on respiratory support, nutrition, and medication management, as outlined in the most recent clinical practice guideline from the American Thoracic Society 1.
Key Components of Management
- Respiratory support: Supplemental oxygen to maintain oxygen saturation between 90-95%, with careful monitoring to prevent complications from both hypoxemia and oxygen toxicity.
- Medication management: Diuretics like furosemide or chlorothiazide to manage fluid overload and pulmonary edema, bronchodilators such as albuterol for infants with reactive airway components, and inhaled corticosteroids like budesonide to reduce airway inflammation.
- Nutritional support: Higher caloric density formulas (24-30 kcal/oz) and fortified breast milk to support growth despite increased metabolic demands.
- Additional components of care: Gastroesophageal reflux management, immunoprophylaxis against RSV with palivizumab during RSV season, and developmental support.
Pathophysiology and Prevention
The underlying pathophysiology involves inflammation, oxidative stress, and abnormal lung development, often triggered by mechanical ventilation and oxygen therapy in premature infants 1. Prevention strategies like gentle ventilation and early surfactant administration are equally important in comprehensive management.
Clinical Practice Guideline
The American Thoracic Society clinical practice guideline provides an evidence-based approach to the outpatient management of infants, children, and adolescents with post-prematurity respiratory disease (PPRD) 1, which is essential for guiding clinical decision-making in the management of infant CLD.
From the Research
Management of Infant Chronic Lung Disease
- The management of infant chronic lung disease (CLD) involves various strategies to reduce lung injury and promote healing in the injured lung 2.
- Some effective strategies for reducing CLD include the administration of retinol (vitamin A), high frequency oscillatory ventilation, and administration of glucocorticoids 2.
- Avoiding assisted ventilation, lung protective ventilatory maneuvers, permissive hypercapnia, prevention of infection, early aggressive nutrition, and the treatment of a patent ductus arteriosus may also be effective in reducing lung injury and subsequent CLD 2.
- The use of inhaled glucocorticoids improves pulmonary dynamics, but long-term effects are unknown 2.
- Adequate oxygenation should be maintained to prevent hypoxic episodes, and diuretics are helpful during acute decompensation 2.
- Provision of adequate nutrition, immunization (routine and against respiratory syncytial virus), follow-up, and monitoring are key elements in the long-term management of infants with CLD 2.
Ventilatory Strategies
- Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be more effective than nasal continuous positive airway pressure (NCPAP) in reducing the risk of extubation failure and need for reintubation in preterm infants 3.
- NIPPV reduces the incidence of symptoms of extubation failure and need for reintubation within 48 hours to one week more effectively than NCPAP, but has no effect on chronic lung disease or mortality 3.
- Synchronisation of NIPPV may be important in delivering effective NIPPV, and the device used to deliver NIPPV may also be important 3.
Quality Improvement Processes
- A multifaceted strategy of avoiding intubation and excessive oxygen in the delivery room, the early use of CPAP, and the use of volume targeted ventilation may help significantly reduce the incidence of CLD 4.
- Sustained improvement in the incidence of CLD can be achieved through quality improvement processes, such as avoiding delivery room endotracheal intubation and using early nasal CPAP 4.
Characteristics and Outcomes
- Full-term infants with CLD are at increased risk for morbidity and mortality, and a severity-based classification for CLD in full-term infants has been proposed 5.
- Invasive ventilation at 28 days is independently associated with death or tracheostomy and home mechanical ventilation in full-term infants with CLD 5.
- Congenital pulmonary, airway, and cardiac anomalies, and bloodstream infections are more common among infants with CLD who die or require tracheostomy with home ventilation 5.