What is the best approach for an infant with bronchopulmonary dysplasia (BPD) having difficulty weaning from mechanical ventilation?

Management of Difficult Ventilator Weaning in BPD

For an infant with bronchopulmonary dysplasia having difficulty weaning from mechanical ventilation, avoid increasing tidal volume and inspiratory pressure (which worsens lung injury), avoid long-term high-dose steroids (which cause neurodevelopmental harm), and instead optimize lung-protective ventilation strategies while addressing underlying causes of ventilator dependence. 1, 2, 3

Ventilation Strategy: Minimize Barotrauma

The priority is lung-protective ventilation, not aggressive ventilator settings:

• Minimize peak inspiratory pressures and avoid large tidal volumes to reduce ventilator-associated lung injury, which is the primary driver of ongoing BPD progression 4, 1, 2
• Increasing tidal volume and inspiratory pressure (Option A) directly contradicts evidence-based management and will worsen ventilator-induced lung injury 5, 6
• Consider permissive hypercapnia and permissive hypoxemia strategies rather than normalizing blood gases through aggressive ventilation 6

Steroid Considerations: Short-Term Low-Dose Only If Necessary

If steroids are considered for facilitating extubation, short-term low-dose approaches are preferred over long-term high-dose regimens:

• Long-term high-dose systemic corticosteroids (particularly dexamethasone) are associated with cerebral palsy, developmental delay, and abnormal neurologic examinations and should be avoided (Option B is contraindicated) 3
• Short-term low-dose steroids (Option C) may facilitate weaning from mechanical ventilation in established BPD, but this must be weighed against risks and should only be used after optimizing all other interventions 3
• Inhaled corticosteroids via metered-dose inhaler with spacer or nebulized budesonide are preferred over systemic steroids to reduce symptoms and improve lung function with lower systemic effects 2
• Early hydrocortisone therapy may be safer than dexamethasone for extremely preterm infants without the adverse neurodevelopmental effects 3

Comprehensive Evaluation for Underlying Causes

Before considering any escalation, systematically evaluate treatable causes of ventilator dependence:

• Assess for pulmonary hypertension with echocardiogram, as PH is common in BPD and associated with higher morbidity and mortality 4, 1, 2
• Evaluate for gastroesophageal reflux and aspiration using upper gastrointestinal series, pH or impedance probe, and swallow studies, as ongoing aspiration contributes to lung injury 4, 1
• Consider flexible bronchoscopy to diagnose anatomic and dynamic airway lesions such as tracheomalacia that may contribute to hypoxemia and poor responses to therapy 4, 1
• Assess for bronchoreactivity and consider bronchodilator therapy if reversible airway obstruction is present 1

Management of Pulmonary Hypertension

If pulmonary hypertension is identified, aggressive treatment is essential:

• Initiate inhaled nitric oxide (iNO) at 10-20 ppm, which can be weaned to 2-10 ppm for maintenance therapy to improve oxygenation and allow lower FiO2 4, 2
• Consider sildenafil (0.5-2 mg/kg three times daily) as part of an aggressive program to treat PH, which has been associated with improvement in 88% of patients and facilitated weaning from mechanical ventilation 4, 2
• Monitor response with serial echocardiograms every 2-4 weeks initially, then at 4-6 month intervals with stable disease 4, 1

Supportive Pharmacotherapy

Optimize medical management to reduce work of breathing and fluid overload:

• Use diuretics (furosemide, chlorothiazide, or spironolactone) cautiously for signs of right heart failure or pulmonary edema, as they improve pulmonary compliance and decrease airway resistance 4, 2
• Ensure adequate nutrition and growth, as these are essential for successful weaning 7

Long-Term Mechanical Ventilation When Necessary

For infants who fail to wean despite optimal management:

• Consider long-term mechanical ventilatory support in a long-term facility or home setting for patients with severe BPD who fail to maintain near-normal ventilation or require high FiO2 despite conservative treatment 4
• The goal is to provide normal blood gas tensions, nutrition, growth, and development rather than weaning as rapidly as possible 7
• Over 70% of infants with severe chronic respiratory failure can survive with this approach 7

Critical Pitfalls to Avoid

• Never increase tidal volumes and inspiratory pressures in an attempt to "push through" difficult weaning—this worsens ventilator-induced lung injury 5, 6
• Never use long-term high-dose systemic steroids due to severe neurodevelopmental consequences 3
• Never initiate pulmonary vasodilator therapy without first optimizing treatment of underlying lung disease and confirming persistent PH 2
• Never rely on spot oxygen checks—perform overnight oximetry or polysomnography for accurate assessment 2