What is the recommended treatment for a preterm infant (<32 weeks gestation) with bronchopulmonary dysplasia following mechanical ventilation and supplemental oxygen?

Treatment of Bronchopulmonary Dysplasia in Preterm Infants

Initial Respiratory Support Strategy

Begin continuous positive airway pressure (CPAP) at 5–6 cm H₂O immediately after birth for all spontaneously breathing preterm infants with respiratory distress, reserving intubation only for those who fail CPAP. This approach reduces the combined risk of BPD and death compared with routine intubation and prophylactic surfactant (RR 0.53; 95% CI 0.34–0.83). 1, 2

• Administer surfactant selectively—only when infants fail CPAP and require mechanical ventilation—rather than prophylactically, as prophylactic surfactant increases the risk of death or chronic lung disease (RR 1.13; 95% CI 1.02–1.25). 1, 2

• For infants <30 weeks gestation who require mechanical ventilation after initial stabilization, give surfactant within the first 2 hours of life using the INSURE technique (Intubation-Surfactant-Rapid Extubation), which reduces subsequent need for mechanical ventilation (RR 0.67; 95% CI 0.57–0.79). 1, 2

Ventilation Management to Minimize Ongoing Lung Injury

• Use the lowest peak inspiratory pressure that achieves adequate chest expansion (typically 20–25 cm H₂O for preterm infants) and avoid large tidal volumes to limit ventilator-associated acute lung injury. 3

• Maintain PEEP at 5–6 cm H₂O; avoid higher levels (8–12 cm H₂O) as they reduce pulmonary blood flow and increase pneumothorax risk. 1

• Target permissive hypercapnia and gentle ventilation strategies, though these show short-term benefits without significantly reducing BPD rates. 4

Oxygen Targeting and Monitoring

Maintain oxygen saturations between 92–95% to prevent pulmonary hypertension while avoiding oxygen toxicity. 3

• Base oxygen-weaning decisions on documented stable saturations (≥92–95%) during sleep and activity using overnight oximetry or polysomnography, not spot checks or arbitrary timelines. 3

Pharmacologic Management

Corticosteroids

• Consider a short course of low-dose systemic corticosteroids after the first or second week of life only for infants who cannot be weaned from the ventilator and are at high risk for severe BPD. 4, 5

• For infants with established BPD who have chronic cough or recurrent wheezing, initiate a monitored trial of inhaled corticosteroids (via metered-dose inhaler with spacer or nebulized budesonide) to assess clinical improvement. 3

Diuretics

Do not use diuretics routinely in BPD; discontinue chronic diuretics before NICU discharge whenever possible. The evidence supporting diuretic benefit is very low quality from small historic studies (largest trial: 43 infants), and no trial has shown that diuretics reduce BPD incidence, shorten mechanical ventilation duration, or decrease NICU length of stay. 3

• If infants are already on chronic diuretics at discharge, wean judiciously while monitoring for worsening pulmonary edema or increased work of breathing. 3

• Diuretics carry significant risks including nephrolithiasis, metabolic bone disease, metabolic alkalosis, dehydration, ototoxicity, and impaired weight gain. 3

Bronchodilators

• Do not prescribe short-acting bronchodilators routinely; reserve them for symptomatic infants with recurrent wheezing, and monitor response to guide continuation. 3

Caffeine and Vitamin A

• Administer caffeine as a preventative strategy, which has demonstrated effectiveness in reducing BPD. 6

• Consider vitamin A supplementation as part of early nutritional support. 4, 6

Screening and Management of Pulmonary Hypertension

Screen all infants with established BPD for pulmonary hypertension using echocardiography, as PH is present in 25–37% of BPD cases and carries a 47% mortality rate within two years of diagnosis. 3

• Perform annual echocardiographic follow-up because PH can persist into later childhood. 3

• When PH is confirmed, first optimize treatment of the underlying lung disease before adding pulmonary vasodilators—do not initiate vasodilator therapy without confirming persistent PH on serial echocardiograms. 3

Pulmonary Vasodilator Therapy

• Start inhaled nitric oxide (iNO) at 10–20 ppm, then wean to 2–10 ppm for maintenance; use cautiously in infants with suspected left-ventricular dysfunction. 3, 5

• Add oral sildenafil at 0.5–2 mg/kg three times daily for persistent PH after iNO optimization. 3, 5

• Consider bosentan as a second-line agent if sildenafil is insufficient. 5

Nutritional and Fluid Management

• Provide early nutritional support with fluid restriction to optimize growth while minimizing pulmonary edema. 4

Long-Term Respiratory Support

• For infants with severe BPD requiring prolonged support, provide oxygen therapy via nasal cannulae or, in refractory cases, consider tracheostomy (required in approximately 5% of severe BPD cases). 5, 7

• Median duration of mechanical ventilation in severe BPD is 37 days, with 66% requiring supplemental oxygen at discharge. 7

Critical Pitfalls to Avoid

• Do not routinely intubate and give prophylactic surfactant without first attempting CPAP in spontaneously breathing preterm infants—this increases BPD and death. 1, 2

• Do not continue diuretics indefinitely without reassessing clinical necessity—they lack long-term benefit and cause serious complications. 3

• Do not initiate pulmonary vasodilator therapy without first aggressively treating the underlying lung disease and confirming PH on echocardiogram. 3

• Do not rely on spot oxygen checks for weaning decisions—use overnight oximetry or polysomnography to capture saturations during sleep. 3

• Do not use excessive ventilation pressures or large tidal volumes—these cause ventilator-induced lung injury that worsens BPD. 3