Chapter 127: Bronchopulmonary Dysplasia (BPD)

Chronic lung disease of prematurity · Definition (NICHD 2018) · Pathophysiology (new BPD) · Prevention (CPAP, caffeine, gentle ventilation) · Treatment (diuretics, bronchodilators, steroids, pulmonary hypertension)
🫁 Key fact: ~60% of infants ≤28 wk develop BPD; severity correlates with neurodevelopmental impairment and long-term respiratory morbidity.

🫁 Bronchopulmonary Dysplasia: Core Concepts

📊 Incidence & definition
~60% at ≤28 wk. NICHD 2018: mild (room air), moderate (<30% O2), severe (≥30% O2 or PPV) at 36 wk PMA. Grade III(A) for lethal BPD.
🧬 Pathophysiology (new BPD)
Arrested alveolarization + dysregulated microvascular development. Inflammation, volutrauma, oxygen toxicity, PDA, infection.
🛡️ Prevention strategies
Early CPAP, INSURE/LISA, caffeine, gentle ventilation (volume-targeted), avoid hyperoxia, treat PDA, optimal nutrition.
💊 Treatment (supportive)
Diuretics (furosemide, chlorothiazide) for pulmonary edema. Bronchodilators (albuterol) for airway reactivity. Pulmonary hypertension therapy (iNO, sildenafil).
⚠️ Systemic corticosteroids
Dexamethasone improves extubation but increases CP risk; reserve for severe ventilator-dependent infants after 7-14 days with high BPD risk.
📈 Prognosis
BPD → neurodevelopmental impairment, asthma-like symptoms, pulmonary hypertension, rehospitalizations. Lung function improves slowly over childhood.
⚡ Major complications: Pulmonary hypertension (15-40% severe BPD), subglottic stenosis, tracheomalacia, vocal cord paralysis, cor pulmonale, growth failure, ROP.

🔍 Approach to the preterm infant at risk for BPD

1
Identify high-risk infants – GA <28 wk, birthweight <1000 g, prolonged mechanical ventilation, severe RDS, PDA, sepsis, NEC.
2
Monitor respiratory status – Persistent oxygen requirement beyond 28 days, tachypnea, retractions, crackles, hypercapnia, need for PPV or CPAP at 36 wk PMA.
3
Assess for pulmonary hypertension – Echocardiogram in all moderate-severe BPD to evaluate RV pressure, septal flattening, and right heart function.
4
Rule out other causes – Airway anomalies (subglottic stenosis, tracheomalacia, vocal cord paralysis), gastroesophageal reflux, aspiration, CHD.
5
Grade severity at 36 wk PMA – Mild (room air), moderate (<30% O2), severe (≥30% O2 and/or PPV). Use for prognosis and management planning.

📋 Stepwise management of established BPD

1
Optimize lung growth & nutrition – Aggressive nutrition (120-130 kcal/kg/day), human milk fortification, monitor growth (weight, length, head circumference). Vitamin A may reduce BPD.
2
Respiratory support weaning – Gradual reduction of FiO2, CPAP (or noninvasive ventilation) to maintain FRC. Caffeine continued until stable off respiratory support.
3
Diuretics for pulmonary edema – Furosemide (1 mg/kg IV/PO) or chlorothiazide. Short-term improvement but long-term risks (nephrocalcinosis, electrolyte disturbances).
4
Bronchodilators for reactive airways – Inhaled albuterol (2.5 mg nebulized) for wheezing/BPD spells. Ipratropium bromide may be added.
5
Pulmonary hypertension management – Maintain SpO2 92-96%, avoid hypoxia. Inhaled nitric oxide (iNO) for acute exacerbations. Sildenafil (1 mg/kg q8h) for chronic PH; consider prostacyclin analogs.
6
Systemic corticosteroids (limited use) – Low-dose dexamethasone (0.89 mg/kg cumulative over 10 days) for ventilator-dependent infants at high risk of death/severe BPD after 7-14 days. Monitor for hyperglycemia, hypertension, cardiomyopathy.
📌 BPD spells: Acute hypoxemia/bradycardia due to airway obstruction (mucus plug, bronchospasm) or pulmonary hypertension. Manage with suction, bronchodilators, sedation, optimize PEEP.

🧠 Rapid reflex prompts – Bronchopulmonary Dysplasia

📌 Definition of severe BPD (NICHD 2018)?
At 36 wk PMA: need for ≥30% oxygen and/or positive pressure ventilation.
📌 Most effective prevention for BPD?
Early CPAP + selective surfactant (INSURE/LISA) + caffeine + gentle ventilation.
📌 When to consider systemic steroids for BPD?
Ventilator-dependent after 7-14 days with high risk of death/severe BPD; low cumulative dose dexamethasone.
📌 Which medication reduces BPD and improves neurodevelopment?
Caffeine citrate (started for apnea of prematurity).
📌 Complication of long-term furosemide in BPD?
Nephrocalcinosis, cholelithiasis, ototoxicity, electrolyte disturbances.
📌 Pulmonary hypertension in BPD: treatment?
Oxygen (SpO2 92-96%), sildenafil, iNO for acute, treat underlying lung disease.