Newer Modalities of Treatment for Bronchopulmonary Dysplasia in Newborns
The most important newer treatment approach for BPD is early continuous positive airway pressure (CPAP) started at birth with selective surfactant administration only when needed, rather than routine intubation with prophylactic surfactant. 1
Early Respiratory Support Strategy (Birth to 72 Hours)
Primary Approach: Early CPAP
- Initiate CPAP immediately at birth for spontaneously breathing preterm infants with respiratory distress rather than intubating and providing mechanical ventilation. 1
- This strategy results in lower rates of BPD and death compared to prophylactic or early surfactant with mechanical ventilation 1
- CPAP maintains functional residual capacity while avoiding ventilator-induced lung injury that contributes to BPD development 1
Selective Surfactant Administration
- Administer surfactant only to infants who fail CPAP and require intubation, not prophylactically to all at-risk infants 1
- Consider the INSURE technique (intubation-surfactant-extubation) to minimize ventilation time while providing surfactant when needed 1
Alternative Non-Invasive Ventilation
- Nasal intermittent positive pressure ventilation (NIPPV) is equally effective as NCPAP for initial respiratory support and may reduce hospitalization duration 2
- Both NIPPV and NCPAP similarly reduce the need for mechanical ventilation and BPD occurrence 2
Ventilation Strategies to Prevent BPD
Lung-Protective Ventilation Principles
- Minimize peak inspiratory pressures and avoid large tidal volumes to reduce ventilator-associated lung injury 3, 4
- Use permissive hypercapnia and permissive hypoxemia strategies rather than targeting normal blood gases 5
- Employ rapid ventilator rates with minimal peak pressures when mechanical ventilation is unavoidable 5
- Extubate to non-invasive support as early as possible—this is the single most effective way to reduce BPD incidence 4
Volume-Targeted Ventilation
- Newer volume-targeted ventilation modes show promise in reducing lung injury compared to pressure-limited ventilation 5
Oxygen Management
Targeted Oxygen Saturation
- Maintain oxygen saturations between 92-95% in infants with BPD to prevent pulmonary hypertension without causing additional lung inflammation or oxygen toxicity 1, 3, 6
- For infants beyond retinopathy of prematurity risk, target saturations of 95% or higher 6
- Avoid both hypoxemia (which causes bronchospasm and pulmonary hypertension) and hyperoxemia (which causes lung inflammation) 1
Comprehensive Oxygenation Assessment
- Perform overnight oximetry or polysomnography rather than relying on spot checks, as brief assessments are insufficient for oxygen management decisions 1, 6
- Periods of intermittent or prolonged hypoxia are common causes of persistent pulmonary hypertension in BPD 1
Management of Pulmonary Hypertension in BPD
Diagnostic Evaluation
- Screen for pulmonary hypertension with echocardiogram, as PH complicates BPD frequently and increases morbidity and mortality 3
- Perform serial echocardiograms every 2-4 weeks when initiating therapy, then every 4-6 months with stable disease 1, 3, 7
Treatment of Underlying Lung Disease First
- Aggressively treat the underlying lung disease before initiating pulmonary vasodilator therapy 1, 3
- Evaluate for chronic reflux and aspiration using upper GI series, pH/impedance probe, or swallow studies 1, 3, 6
- Assess for structural airway abnormalities (tonsillar/adenoidal hypertrophy, vocal cord paralysis, subglottic stenosis, tracheomalacia) via flexible bronchoscopy 1, 3, 6
- Evaluate and treat bronchoreactivity, lung edema, and airway dysfunction 1
Pulmonary Vasodilator Therapy
When pulmonary hypertension persists despite optimizing lung disease management:
Inhaled nitric oxide (iNO): Start at 10-20 ppm, then wean to 2-10 ppm for maintenance therapy 1, 3, 7, 6
Calcium channel blockers have limited utility: They show poor acute response compared to iNO and may cause systemic hypotension 1
Anti-Inflammatory Therapy for Established BPD
Inhaled Corticosteroids
- Administer inhaled corticosteroids via metered-dose inhaler with spacer or nebulized budesonide to reduce symptoms, improve lung function, and decrease bronchodilator needs 1
- This is the preferred route to avoid systemic corticosteroid side effects 1
- Inhaled steroids given for 1-4 weeks facilitate extubation in intubated infants with BPD without increasing sepsis risk 1
- Monitor for potential side effects: delayed growth, hypertension, osteoporosis, adrenal suppression, cataracts (though much less frequent than with systemic steroids) 1
- Prevent oral candidiasis by timing inhaled steroid use just before tooth brushing twice daily 1
Systemic Corticosteroids
- Early systemic steroids (before 2 weeks of age) given for 4 weeks can reduce mechanical ventilation needs but have not reduced BPD incidence 1
Other Anti-Inflammatory Agents
- Cromolyn, nedocromil, and leukotriene modifiers have limited evidence but may be considered in children over 2 years with prominent asthmatic features 1
Supportive Pharmacotherapy
Caffeine
- Caffeine administration is an established preventive measure that significantly reduces BPD risk 8
Vitamin A
- Vitamin A supplementation reduces BPD development 8
Diuretics
- Use loop diuretics, thiazides, or spironolactone cautiously for signs of right heart failure 7
Emerging Therapies
Cell-Based Therapy
- Cell therapy represents the most promising new approach to address lung damage from BPD, though it remains investigational 8
- Ongoing studies are evaluating stem cell and mesenchymal stromal cell therapies for BPD treatment 8
Critical Pitfalls to Avoid
- Do not rely on arbitrary timelines for weaning oxygen; base decisions on documented adequate saturations (≥92-95%) across all activity states including sleep 6
- Do not initiate pulmonary vasodilator therapy without first optimizing treatment of underlying lung disease and confirming persistent PH on serial echocardiograms 1, 3, 6
- Do not use brief spot-check oxygen assessments to guide therapy; comprehensive evaluation including sleep studies is essential 1, 6
- Avoid routine prophylactic intubation and surfactant in favor of early CPAP with selective surfactant only when needed 1