What is the recommended management of bronchopulmonary dysplasia in a pre‑term infant?

Management of Bronchopulmonary Dysplasia in Preterm Infants

The cornerstone of BPD management is early CPAP at birth (5-6 cm H₂O) with selective surfactant only if CPAP fails, combined with gentle ventilation strategies that minimize lung injury, judicious oxygen targeting to maintain saturations of 92-95%, and avoidance of routine diuretic therapy. 1, 2

Initial Respiratory Support Strategy (Delivery Room and First Hours)

Start CPAP immediately at birth for all spontaneously breathing preterm infants with respiratory distress rather than routine intubation. 1, 3, 4

• This approach reduces the combined risk of BPD and death compared to prophylactic intubation and surfactant (relative risk reduction of approximately 47% for need of mechanical ventilation in infants 25-28 weeks gestation). 3
• Reserve intubation and mechanical ventilation only for infants who fail CPAP despite optimal settings. 1, 4
• If intubation becomes necessary, administer surfactant early (<2 hours of life) for infants <30 weeks gestation with severe respiratory distress syndrome. 3, 4

Common pitfall: Administering prophylactic surfactant to infants already stable on CPAP increases the risk of death or chronic lung disease (RR 1.13,95% CI 1.02-1.25). 3

Ventilation Management to Prevent Further Lung Injury

Minimize peak inspiratory pressures and avoid large tidal volumes to reduce ventilator-associated acute lung injury. 1, 5

• Use the minimal inflation pressure necessary to achieve heart rate improvement or chest expansion (typically 20-25 cm H₂O for preterm infants). 3
• Employ permissive hypercapnia and rapid ventilator rates when mechanical ventilation is required. 6
• Consider high-frequency oscillatory ventilation as an alternative when poor lung compliance and low volumes complicate the clinical course. 1

Oxygen Management and Monitoring

Target oxygen saturations between 92-95% to prevent pulmonary hypertension without causing additional oxygen toxicity. 1, 2, 5

• Perform overnight oximetry or polysomnography rather than relying on spot checks, as brief assessments are insufficient for oxygen management decisions. 2
• Titrate oxygen based on continuous pulse oximetry monitoring across all activity states including sleep. 2, 3

Critical pitfall: Avoid relying on arbitrary timelines for weaning oxygen; base decisions on documented adequate saturations (≥92-95%) during sleep and activity. 2

Pharmacologic Management

Bronchodilators and Inhaled Corticosteroids

For infants without recurrent respiratory symptoms (cough, wheeze), do not routinely prescribe short-acting bronchodilators or inhaled corticosteroids. 1

For infants with chronic cough or recurrent wheezing, initiate a trial of inhaled corticosteroids with monitoring to assess for clinical improvement. 1

• Administer via metered-dose inhaler with spacer or nebulized budesonide to reduce symptoms and improve lung function. 2
• Similarly, trial short-acting bronchodilators for symptomatic infants and monitor response. 1

Diuretic Therapy

Do not routinely use diuretics in infants with BPD, and judiciously discontinue chronic diuretic therapy for infants discharged from the NICU on these medications. 1, 2

• The evidence for diuretic efficacy is very low quality, based on small studies (largest only 43 infants) from 1983-1992 examining "old BPD" rather than the current phenotype. 2
• No trial has shown that diuretics reduce BPD incidence, shorten mechanical ventilation duration, or decrease NICU length of stay. 2
• Short-term physiological improvements (improved compliance, reduced airway resistance) do not translate to meaningful clinical outcomes. 2
• Significant risks include nephrolithiasis, metabolic bone disease, metabolic alkalosis, dehydration, ototoxicity, and impaired weight gain. 2

For infants already on chronic diuretics at discharge: Wean gradually while monitoring for signs of worsening pulmonary edema or increased work of breathing, avoiding abrupt cessation. 2

Screening and Management of Pulmonary Hypertension

Screen all infants with established BPD for pulmonary hypertension using echocardiography, as PH occurs in 25-37% of BPD cases and is associated with 47% mortality within 2 years of diagnosis. 1, 5

• Perform annual echocardiography for long-term follow-up, as PH can persist into infancy and childhood. 1
• Early detection provides prognostic information and guides more aggressive interventions. 1

When pulmonary hypertension is confirmed, aggressively optimize treatment of the underlying lung disease before initiating pulmonary vasodilator therapy. 2, 5

Pulmonary Vasodilator Therapy

For infants with established BPD and symptomatic pulmonary hypertension:

• Initiate inhaled nitric oxide at 10-20 ppm, then wean to 2-10 ppm for maintenance therapy. 2, 5
• Use iNO cautiously in infants with suspected left ventricular dysfunction. 1
• Add sildenafil at 0.5-2 mg/kg three times daily for persistent PH. 2, 5
• Monitor response with serial echocardiograms initially every 2-4 weeks, then at 4-6 month intervals with stable disease. 5

Important caveat: Inhaled nitric oxide is NOT indicated for prevention of BPD in preterm neonates ≤34 weeks gestational age, as efficacy was not established in four large trials totaling 2,600 preterm infants. 7

Nutritional Support

Provide adequate nutrition as it plays an important role in lung injury protection and recovery. 8

• Infants with severe BPD frequently have increased metabolic demands and growth failure. 8
• Optimize caloric intake while managing fluid balance carefully. 8

Evaluation for Complicating Factors

Assess for underlying conditions that may worsen respiratory status:

• Evaluate for chronic reflux and aspiration. 5
• Consider flexible bronchoscopy for diagnosis of structural airway abnormalities and dynamic airway lesions. 5
• Screen for bronchoreactivity. 5

Long-Term Management and Follow-Up

Enroll infants with BPD who have PH or are at risk for developing late PH in longitudinal care with an interdisciplinary pediatric pulmonary hypertension program. 1

• Maintain home oxygen therapy as needed based on documented hypoxemia. 8
• Ensure immunizations are up to date and provide RSV prophylaxis to prevent infections in these vulnerable patients. 8
• Address social and financial issues with families, as outpatient management requires specialized staff and equipment. 8

Therapies to Avoid

Do not use postnatal systemic corticosteroids routinely for BPD prevention or treatment. 3, 9

• While systemic glucocorticoids improve short-term lung function and accelerate weaning from oxygen and mechanical ventilation, they are associated with adverse neurodevelopmental outcomes. 9
• The risks, particularly long-term neurological effects, preclude routine use. 9

Do not use ECMO for BPD management unless severe pulmonary hypertension is present and unresponsive to medical therapy. 1