Paediatrics: Bronchopulmonary dysplasia
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that affects infants who have been born preterm.
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that affects infants who have been born preterm. Over the last decade advances in neonatal care, including the increasing use of antenatal steroids, and early surfactant therapy, have modified a change in the underlying pathology in many cases. ‘Old’ BPD was described as a disease of scarring, and repair. This condition was associated with long periods of mechanical ventilation, often with high PIP, and high FiO2. ‘New’ BPD is a condition of impaired alveolar development, with less destruction and scarring. Mechanical, oxidative and inflammatory factors all contribute to lung injury. The radiographic appearances of more recent cases are less dramatic (see Fig. 6.6), however, the impairment in lung function continues through childhood, and is associated with a number of other impairments.
The definition of BPD has evolved with time. The most commonly used definition is ‘Oxygen requirement at 36/40 corrected gestational age (CGA)’. This definition does not have any grading of severity and encompasses a wide spectrum of disease.
NICHD/NHLBI Definitions (2001)
- Mild: the need for supplemental O2at age 28 days, but not at 36/40 CGA
- Moderate: the need for supplemental O2<30% at age 28 days and at 36/40 CGA
- Severe: mechanical ventilation or requiring >30% O2at 36/40 CGA ‘Walsh’ test (2003)
- Test at 36±1/40 CGA. Aim to maintain SpO2> 88%
- BPD if need 30% O2to maintain SpO2 >88% (or ventilated)
- If <30% O2, then FiO2is gradually decreased to air. BPD is defined as the inability to maintain SpO2 >88% for 1hr
Incidence and risk factors
Incidence is dependent on the definition used. Wide variations between cen-tres with a range of 4–58% (mean 23%) of at-risk babies. BPD more likely with:
- Gestational immaturity.
- Low birth weight.
- Caucasian heritage.
- Family history of asthma.
- History of chorioamnionitis.
Prevention of BPD
No evidence of the effect
- Surfactant and ANC steroids (effect may be off-set by increased survival?)
- Closure of PDA
- Inhaled steroids
- Inhaled nitric oxide
- HFOV compared to conventional ventilation
- Treating Ureaplasma urealyticum(more research needed)
It may be of benefit to certain infants
- Systemic corticosteroids (clinical trials needed as increased risk of CP)
- nCPAP vs. intubation(need for surfactant, risk of pneumothorax)
Evidence of effect
- Caffeine citrate for apnoea of prematurity in infants <1250g
- Vitamin A supplementation for infants <1000g
Treatment of established BPD
No specific treatment has been demonstrated to show an improvement in the outcome of BPD. Oxygen is the most commonly used therapeutic agent, although the ‘correct’ dose and what SpO2 is acceptable has not been established. A number of large trials are ongoing and their results are awaited (Ref: NeOPrOM Collaboration).
Other treatments include; diuretics, corticosteroids, sildenafil, optimizing nutrition.
Immunization for at-risk infants with monoclonal respiratory syncytial virus (RSV) antibody has recently been recommended by the UK department of health. This involves monthly injections during the RSV season.
Increased survival of preterm infants has led to an increase in the number surviving with BPD. Mortality has improved (previously 10–20% would die from cor-pulmonale or respiratory infection). Other problems include:
- Increased risk of CP.
- Poorer cognitive functioning and academic performance.
- High risk of re-hospitalization with respiratory illness.
- Poorer lung function.
Respiratory problems seem to lessen as children get older, perhaps reflecting the lung’s continued growth and development.