Management of bronchopulmonary dysplasia
- Ann R Stark, MD
Ann R Stark, MD
- Professor of Pediatrics
- Vanderbilt University School of Medicine
- Eric C Eichenwald, MD
Eric C Eichenwald, MD
- Professor of Pediatrics
- Perelman School of Medicine, University of Pennsylvania
Bronchopulmonary dysplasia (BPD), also known as neonatal chronic lung disease (CLD), is an important cause of respiratory morbidity in preterm newborns. Day-to-day care is mostly directed towards improving symptoms, with many common interventions having little impact on long-term outcome. Most patients with BPD gradually improve as healing occurs and lung growth continues, but the time required for improvement varies widely. Management is also directed at minimizing further injury, providing an optimal environment to support growth and recovery, and detecting complications associated with BPD.
The management of BPD is reviewed here. Pathogenesis and clinical features, prognosis, and potential strategies to prevent BPD are discussed separately. (See "Pathogenesis and clinical features of bronchopulmonary dysplasia" and "Outcome of infants with bronchopulmonary dysplasia" and "Prevention of bronchopulmonary dysplasia".)
Respiratory care is supportive and should minimize additional injury.
Mechanical ventilation — In patients with established bronchopulmonary dysplasia (BPD) who require mechanical ventilation, small tidal volumes are preferable to avoid additional mechanical injury. However, airway dilation and dead space to tidal volume ratio increase with chronic mechanical ventilation in extremely low birth weight (ELBW) infants , and infants with severe BPD may require higher tidal volumes to maintain effective ventilation. In particular, infants with bronchomalacia may require prolonged use, as well as higher levels of positive end-expiratory pressure (PEEP) to splint open large airways. In general, based on our clinical experience, maintaining a PEEP of 5 to 7 cm H2O minimizes atelectasis, and counters the development of pulmonary edema in infants with BPD. A slightly prolonged inspiratory duration of 0.4 to 0.5 seconds sometimes is needed to promote uniform lung inflation in patients who develop uneven airway obstruction. (See "Pathogenesis and clinical features of bronchopulmonary dysplasia", section on 'Mechanical ventilation'.)
Ongoing assessment of ventilator-dependent infants includes continuous pulse oximetry to monitor oxygenation, and intermittent blood gas sampling to monitor pH and PaCO2. The frequency of monitoring depends on the clinical condition of the patient. PaCO2 levels between 55 and 65 mmHg are tolerated as long as pH remains in the normal range (7.3 to 7.4). In patients with severe disease, PaCO2 values up to 70 mmHg may be tolerated on occasion to avoid further escalation of ventilator support.
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- RESPIRATORY SUPPORT
- Mechanical ventilation
- - Prolonged ventilation and tracheostomy
- FLUID RESTRICTION
- Our approach
- ACUTE EXACERBATIONS
- CHRONIC COMPLICATIONS
- Pulmonary artery hypertension
- Systemic blood pressure
- Vision and hearing
- Left ventricular hypertrophy
- COMPREHENSIVE MANAGEMENT APPROACH
- In-hospital care
- - Growth
- - Respiratory care
- - Surgery
- - Detection of complications
- - Planning
- - Care
- Pulmonary care
- Prevention of RSV infection
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS