BPD is chronic lung disease of preterm child. All other diseases are decreasing in preterm child except BPD

1. Broncho Pulmonary Dysplasia
(Chronic Lung Disease)
Dr. Ashutosh Aggarwal
Team Motivation Medical Academy
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

2. Broncho Pulmonary Dysplasia (Chronic Lung Disease)
- Seen in preterm infants who require mechanical ventilation and / or oxygen therapy for a
primary lung disorder
- Most common form of chronic lung disease in neonate.
- BPD is the only major complication of prematurity that continues to increase in
frequency.
- Incidence increases as the gestational age decreases.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

3. Old Definition
- In preterm child there is need for oxygen for > 28 days and severity is judged by
requirement of oxygen at 36 weeks post menstrual age (PMA)
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

4. New Definition
- Diagnosis is made when in a preterm neonate (< 32 weeks gestational age) has
persistent parenchymal lung disease, radiographic confirmation of parenchymal lung
disease and at 36 weeks postmenstrual age requires oxygen for at least 3 consecutive
days to maintain arterial oxygen saturation in the 90% - 95% range.
- Oxygen requirement can be by Invasive IPPV, Nasal – CPAP, Nasal IPPV, Hood O2 or by
Nasal Cannula.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

5. NICHD Workshop Definition of Bronchopulmonary Dysplasia
Invasive IPPV N-CPAP,
NIPPV or NC
≥ 3 L/min
NC Flow 1-<3
L/min
Hood O2 NC Flow < 1
L/min
Grade I 21% 22%-29% 22%-29% 22%-70%
Grade II 21% 22% - 29% ≥30% ≥30% ≥70%
Grade III >21% ≥30%
Grade III(A) Early death (between 14d of postnatal age and 36 weeks of PMA) due to
persistent parenchymal lung disease and respiratory failure that cannot be
attributable to other neonatal morbidities
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

6. Pathogenesis
- Strongest risk factors are prematurity and low birth weight.
- Postnatal Risk Factors
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

7. BAROTRAUMA / VOLUTRAUMA
Due to ventilator induced injury
Surfactant deficiency and immature
epithelium
High pressure is needed to distend the
terminal bronchioles and alveolar ducts
Pulmonary interstitial emphysema &
Pneumothorax
HYPEROXIA
Reactive oxygen species causes more
damage as adequate more damage as
adequate enzymes are reduced in
preterm child
Inflammation in the lung
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

8. Nutrition
In preterm child increased nutritional
requirement because of increased
metabolic needs
Inadequate nutrition interferes with
Normal growth and maturation of lung.
In very Preterm infants there is decrease in
concentration of vitamin A
Deficiency is associated with changes in the
Ciliated epithelium of the tracheobronchial
tree.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

9. Increased fluid administration
Development of patent ductus arteriosus causing pulmonary edema
Increase in oxygen and ventilation requirement
Increase in risk of BPD
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

10. Antenatal Risk Factors
1) Infection
- Ureaplasma urealyticum colonization in pregnant female is the pathogenesis of
preterm labor, premature rupture of membranes and preterm delivery.
- In high-risk neonates developing BPD, the organism has been detected in tracheal
aspirates. So UU is important in pathogenesis of BPD
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

11. Genetics
Family history of Atopy or asthma increases the incidence of BPD
In new BPD, there is role of
Growth factors – such as thyroid transcription factor 1 & VEGF in sacculation,
alveolorization and vasculogenesis of peripheral lung
Epigenetics – such as SP-Bi4 deletion, polymorphism in genes coding pro and inflammatory
cytokines
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

12. 1) Volume loss due to atelectasis and alveolar septal fibrosis alternating with overdistension
or emphysematous region.
2) In later stages there is “alveolar simplification”. This decreased alveolarization is due to
impaired septation.
3) There is also impaired vascular growth.
4) These results in significant decreases in surface area for gas exchange and blood flow.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

13. Change in Pulmonary Mechanics
1) Initially as BPD evolves, due to atelectasis there is reduced FRC.
2) Over the first 1 to 2 years of life due to hyperinflation FRC rises to above normal.
3) There is increased airway resistance. Due to collapse of the small airways, there is
expiratory flow limitation including reduced forced expiration flow.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

14. Pulmonary Vascular Diseases
1) Pulmonary HT is associated with BPD.
2) Screening for PHT should be done at 36 weeks PMA for neonates with moderate to SBPD
or unexplained desaturation episodes.
3) Echocardiography is the most common tool used to detect PH in preterm neonates.
4) Cardiac catheterization remains the gold standard for the definitive diagnosis and
assessment of PH in preterm neonates.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

15. Clinical Signs
- Tachypnoea
- Intercostal and subcostal retractions
- Use of accessory muscles
- Poor growth despite adequate calorie intake
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

16. Radiographic Changes
i) Chest X-Ray
Atlectasis, edema and emphysematous changes. There can also be presence of
cardiomegaly and fibrosis present.
i) MRI Imaging
- Heterogenous pulmonary pathology including regions of decreased alveolarization, cystic
emphysema and fibrosis.
- Also useful in evaluation of cardiac morphology.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

17. Management
- Use of antenatal steroids does not reduce the incidence of chronic lung disease
Establishment
of functional
residual
capacity (FRC)
Improving
pulmonary
blood flow
Ensuring
adequate tissue
oxygenation
Minimal lung
injury
Principles of
management
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

18. General Guidelines
i. Delaying the clamping of cord
Increases the blood volume
Improved capillary perfusion
ii. Establishment of FRC at birth
Provision of adequate PEEP to infants with respiratory distress (Prevents atlectotrauma)
iii. Provision of early CPAP followed by selective use of surfactant is associated with lower
rates of BPD and death as compared to prophylactic surfactant therapy
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

19. Management in the NICU
I. Fluids and nutrition
II.Ventilator strategies
III.Pharmacological strategies
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

20. I. Fluids and nutrition
a. Fluid restriction
b. Adequate Nutrition
- Early aggressive parental nutrition and an early transition to enteral feeding should be
done
- Parenteral nutrition is continued till oral intake of at least 130ml/kg/day is reached
- Increase daily calorie intake to 120 to 150Kcal/kg/day
- Give expressed breast milk fortified with HMF
- Give multivitamin supplements to meet RDA
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

21. II. Ventilator strategies
Evolving BPD (2-4 week age) Established BPD (> week age)
Ventilator
strategies
 Minimizing ventilator support (eg.
Using nCPAP whenever possible)
 Tolerating slightly higher PaCO2 (45-55
mm Hg provided pH>7.25)
 Target SpO2 90-93%
 If on IMV
- Use PTV, if possible
- Slow rates (25-40/min)
- Moderate PEEP (4-5 cm, H2O)
- Moderate Ti (0.35-0.45 sec)
- Low tidal volume (3-6mL/kg)
- Early extubation to CPAP
 Minimizing ventilator
support
 Tolerating higher PaCO2, (55-
60 mmHg provided pH>7.25)
 Target SpO2 – 90-95%
 If on IMV:
- Use PTV if possible
- Slow rates (20-40/min)
- Longer Ti (0.4-0.7 sec)
- Larger tidal volume (5-
8mL/kg)
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

22. I. Pharmacological strategies
a. Exogenous surfactant
- Surfactant should be used selectively after establishment of adequate FRC by the use of
CPAP
- Administration of surfactant by MIST method or LISA technique decreases the incidence
of BPD
b. Vitamin A
- Large dose of vitamin A – intramuscular 5000 units three times a week for 4 weeks from
birth – decrease the risk of BPD
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

23. c. Methylxanthines – such as caffeine and aminophylline
- Used for treatment of apnea of prematurity and after extubation in all preterm VLBW
Infants
- They cause reduction in incidence of BPD as there is reduced duration of mechanical
ventilation
- Caffeine Citate Loading dose 20 mg / kg
Maintenance dose
5 – 10 mg / kg /dose IV or PO every 24 hour
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

24. d. Postnatal steroids
- Because of risk of side effects only used in extremely low birth weight who continue to
be on mechanical ventilation even after 10-14 days of age
e. Inhale Nitric oxide – No Proven benefit
f. Diuretic therapy – are used if there are clinical / radiographic features of pulmonary
edema in an infant with evolving or established BPD
- Use furosemide 0.5 – 1 mg/kg/day in infants with features suggestive of excess lung
fluid. If no improvement in 24-48 hours we stop them
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

25. Emerging Therapies
- Macrolide antibiotics
- Inositol
- Leukotriene receptor antagonists
- Intratracheal steroids
- Antioxidants – such as CuZnSOD
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

26. Flow Chart for management of BPD
At Birth
 If resuscitation required then avoid excessive pressure
 Delay cord clamping
 Ensure optimal FRC
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

27. Birth to 24 hours
 Early CPAP (try to avoid intubation)
 Fluids 60 to 80ml/kg/day
 If on ventilator then moderate PEEP (4-6cmH2O)
 Use methylxanthines to facilitate extubation
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

28. 24 hours to 1 week
 Fluid daily increment of 15-20ml/kg/day to reach maximum of 140-150ml/kg/day by day
7
 Nutrition
- Parenteral: TPN for ELBW infants till enteral feeds are achieved
- Enteral: gradually increase feed volume by 20-30ml/kg/day if accepting well, give only
breast milk
- Fortify with HMF after reaching 100ml/kg/day
 For ELBW infants on oxygen or ventilator support at 24 hours: Inj. vitamin A 5000 units
IM thrice weekly for 4 weeks
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

29. 2 to 4 weeks
 Fluids – 150 to 160 ml/kg/day
 Nutrition – fortify breast milk with HMF, Increase calorie intake to 120 to 150
Kcal/kg/day
 Steroids – consider in ELBW infants on ventilator support even after 10-14 days of age
 Diuretics for features of pulmonary edema
 Bronchodilators for bronchospasm
 Diagnose & treat pulmonary hypertension, gastroesophageal reflux
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

30. >4 weeks
 Nutrition: fortify breast milk with HMF
 Bronchodilators for bronchospasm
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

31. PREVENTION STRATEGIES
1. Avoidance of Mechanical Ventilation
• In extremely preterm neonates, non-invasive respiratory support should be used if
possible.
• Giving surfactant by less invasive technique
• Less invasive surfactant administration (LISA)
• Minimally invasive surfactant therapy (MIST)
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy

32. 2. Caffeine
• Most effective and saftest treatment for reducing the risk of CPAP.
• Caffeine administration reduces the risk of BPD and shortens the duration of
mechanical ventilation and exposure to supplemental oxygen.
3. Vitamin A
Intramuscular injection of vitamin A, resulted in reduction of BPD in extremely preterm
neonates.
4. Corticosteroids
• Antenatal steroids do not decrease the risk of BPD.
• Postnatal steroids decrease the risk of BPD but also increases the neurodevelopment
impairment.
Dr. Ashutosh Aggarwal - Team Motivation Medical Academy