Medicine:Bronchopulmonary dysplasia

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Bronchopulmonary dysplasia
CXR - Bronchopulmonary dysplasia.jpg
Radiograph of bronchopulmonary dysplasia
CausesLong-term high oxygen supplementation

Bronchopulmonary dysplasia (BPD; part of the spectrum of chronic lung disease of infancy) is a chronic lung disease which affects premature infants. Premature (preterm) infants who require treatment with supplemental oxygen or require long-term oxygen are at a higher risk.[1] The alveoli that are present tend to not be mature enough to function normally.[2] It is also more common in infants with low birth weight (LBW) and those who receive prolonged mechanical ventilation to treat respiratory distress syndrome. It results in significant morbidity and mortality. The definition of bronchopulmonary dysplasia has continued to evolve primarily due to changes in the population, such as more survivors at earlier gestational ages, and improved neonatal management including surfactant, antenatal glucocorticoid therapy, and less aggressive mechanical ventilation.[3]

Currently the description of bronchopulmonary dysplasia includes the grading of its severity into mild, moderate and severe. This correlates with the infant's maturity, growth and overall severity of illness.[4] The new system offers a better description of underlying pulmonary disease and its severity.[5]

"The term 'bronchopulmonary dysplasia' was first used by [William] Northway et al. in 1967 to describe a chronic form of injury to the lungs caused by barotrauma and oxygen injury in preterm infants requiring mechanical ventilation."[6]

Presentation

Complications

Feeding problems are common in infants with bronchopulmonary dysplasia, often due to prolonged intubation. Such infants often display oral-tactile hypersensitivity (also known as oral aversion).[7]


Physical findings:[citation needed]

  • hypoxemia;
  • hypercapnia;
  • crackles, wheezing, and decreased breath sounds;
  • increased bronchial secretions;
  • hyperinflation;
  • frequent lower respiratory infections;
  • delayed growth and development;
  • cor pulmonale;
  • CXR shows with hyperinflation, low diaphragm, atelectasis, cystic changes.

Cause

Prolonged high oxygen delivery in premature infants causes necrotizing bronchiolitis and alveolar septal injury, with inflammation and scarring. This results in hypoxemia. Today, with the advent of surfactant therapy and high frequency ventilation and oxygen supplementation, infants with BPD experience much milder injury without necrotizing bronchiolitis or alveolar septal fibrosis. Instead, there are usually uniformly dilated acini with thin alveolar septa and little or no interstitial fibrosis. It develops most commonly in the first four weeks after birth.[8] Bronchopulmonary dysplasia is now known to be due to abnormal wound healing in response to injury;[9] it has been linked to alterations in the Wnt/beta-catenin pathway.[10]

Diagnosis

Earlier criteria

The classic diagnosis of bronchopulmonary dysplasia may be assigned at 28 days of life if the following criteria are met:[citation needed]

  1. Positive pressure ventilation during the first two weeks of life for a minimum of three days.
  2. Clinical signs of abnormal respiratory function.
  3. Requirements for supplemental oxygen for longer than 28 days of age to maintain PaO2 above 50 mm Hg.
  4. Chest radiograph with diffuse abnormal findings characteristic of bronchopulmonary dysplasia.

Newer criteria

The 2006 National Institute of Health (US) criteria for BPD (for neonates treated with more than 21% oxygen for at least 28 days)[11] is as follows:,[12][13]

Mild
  • Breathing room air at 36 weeks' post-menstrual age or discharge (whichever comes first) for babies born before 32 weeks, or
  • breathing room air by 56 days' postnatal age, or discharge (whichever comes first) for babies born after 32 weeks' gestation.
Moderate
  • Need for <30% oxygen at 36 weeks' postmenstrual age, or discharge (whichever comes first) for babies born before 32 weeks, or
  • need for <30% oxygen to 56 days' postnatal age, or discharge (whichever comes first) for babies born after 32 weeks' gestation.
Severe
  • Need for >30% oxygen, with or without positive pressure ventilation or continuous positive pressure at 36 weeks' postmenstrual age, or discharge (whichever comes first) for babies born before 32 weeks, or
  • need for >30% oxygen with or without positive pressure ventilation or continuous positive pressure at 56 days' postnatal age, or discharge (whichever comes first) for babies born after 32 weeks' gestation.

Management

Infants with bronchopulmonary dysplasia are often treated with diuretics that decrease fluid in the alveoli where gas exchange occurs and bronchodilators that relax the airway muscles to facilitate breathing.[14] To alleviate bronchopulmonary dysplasia, caffeine is another commonly used treatment that reduces inflammation and increases lung volume thereby improving extubation success and decreasing the duration of mechanical ventilation.[15] Viral immunization is important for these children who have a higher risk of infections in the respiratory tract.[16]

Corticosteroid treatment

There is evidence that steroids (systemic corticosteroid treatment) given to babies less than seven days old can prevent bronchopulmonary dysplasia.[17] This treatment increases the risk of neurodevelopmental sequelae (cerebral palsy) and gastrointestinal perforation.[17]

For babies seven days old and older, "late systemic postnatal corticosteroid treatment" may reduce the risk of death and of bronchopulmonary dysplasia.[18] There is some evidence that this treatment does not increase the risk of cerebral palsy, however, long-term studies considering the neurodevelopmental outcomes is needed to further understand the risk of this treatment option.[18] Late systemic postnatal corticosteroid treatment is therefore only recommended for babies seven days old or older who cannot be taken off of a ventilator.[18] The benefit and risks of systemic corticosteroid treatment in older babies who are not intubated (on a ventilator) is not known.[18]

Vitamin A

Vitamin A treatment in low birth weight babies may improve the 36-week mortality risk, decrease the days of mechanical ventilation, and decrease the incidence of bronchopulmonary dysplasia.[19]

Other

Oxygen therapy at home is recommended in those with significant low oxygen levels.[20]

Hypercarbia (too much carbon dioxide in the blood) may contribute to the development of bronchopulmonary dysplasia.[21] Monitoring the level of carbon dioxide in neonatal infants to ensure that the level is not too high or too low (hypocarbia) is important for improving outcomes for neonates in intensive care.[22] Carbon dioxide can be monitored by taking a blood sample (arterial blood gas), through the breath (exhalation), and it can be measured continuously through the skin by using a minimally invasive transcutaneous device.[22] The most effective and safest approach for measuring carbon dioxide in newborn infants is not clear.[22]

It is not clear if treatment with superoxide dimutase supplementation is effective at preventing bronchopulmonary dysplasia in infants born preterm or at reducing preterm infant mortality.[23]

Epidemiology

The rate of BPD varies among institutions, which may reflect neonatal risk factors, care practices (e.g., target levels for acceptable oxygen saturation), and differences in the clinical definitions of BPD.[24][25][26]

See also

References

  1. ↑ Merck Manual, Professional Edition, Bronchopulmonary Dysplasia.
  2. ↑ "Bronchopulmonary Dysplasia" (in en). https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/bronchopulmonary-dysplasia/. 
  3. ↑ Northway Jr, WH; Rosan, RC; Porter, DY (Feb 16, 1967). "Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia.". The New England Journal of Medicine 276 (7): 357–68. doi:10.1056/NEJM196702162760701. PMID 5334613. 
  4. ↑ Sahni, R; Ammari, A; Suri, MS; Milisavljevic, V; Ohira-Kist, K; Wung, JT; Polin, RA (Jan 2005). "Is the new definition of bronchopulmonary dysplasia more useful?". Journal of Perinatology 25 (1): 41–6. doi:10.1038/sj.jp.7211210. PMID 15538399. 
  5. ↑ Ehrenkranz, RA; Walsh, MC; Vohr, BR; Jobe, AH; Wright, LL; Fanaroff, AA; Wrage, LA; Poole, K et al. (Dec 2005). "Validation of the National Institutes of Health consensus definition of bronchopulmonary dysplasia". Pediatrics 116 (6): 1353–60. doi:10.1542/peds.2005-0249. PMID 16322158. 
  6. ↑ Sahni, Mitali; Mowes, Anja K. (2023), "Bronchopulmonary Dysplasia", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 30969701, http://www.ncbi.nlm.nih.gov/books/NBK539879/, retrieved 2023-09-18 
  7. ↑ Gaining & Growing. "Bronchopulmonary dysplasia", Gaining & Growing, March 20, 2007. (Retrieved June 12, 2008.)
  8. ↑ National Heart, Lung, and Blood Institute (1998). Bronchopulmonary Dysplasia. National Institutes of Health. pp. 2. https://books.google.com/books?id=rCezygKtHWUC&pg=PA2. 
  9. ↑ Thébaud, Bernard; Goss, Kara N.; Laughon, Matthew; Whitsett, Jeffrey A.; Abman, Steven H.; Steinhorn, Robin H.; Aschner, Judy L.; Davis, Peter G. et al. (2019-11-14). "Bronchopulmonary dysplasia". Nature Reviews Disease Primers 5 (1): 78. doi:10.1038/s41572-019-0127-7. ISSN 2056-676X. PMID 31727986. 
  10. ↑ Liu, Jiaqi; Xiao, Qing; Xiao, Jiani; Niu, Chenxi; Li, Yuanyuan; Zhang, Xiaojun; Zhou, Zhengwei; Shu, Guang et al. (2022-01-03). "Wnt/β-catenin signalling: function, biological mechanisms, and therapeutic opportunities". Signal Transduction and Targeted Therapy 7 (1): 3. doi:10.1038/s41392-021-00762-6. ISSN 2059-3635. PMID 34980884. 
  11. ↑ Kinsella, JP; Greenough, A; Abman, SH (Apr 29, 2006). "Bronchopulmonary dysplasia". Lancet 367 (9520): 1421–31. doi:10.1016/S0140-6736(06)68615-7. PMID 16650652. 
  12. ↑ "Bronchopulmonary Dysplasia". Patient.info. http://patient.info/doctor/bronchopulmonary-dysplasia. 
  13. ↑ Jobe, AH; Bancalari, E (June 2001). "Bronchopulmonary dysplasia". Am J Respir Crit Care Med 163 (7): 1723–9. doi:10.1164/ajrccm.163.7.2011060. PMID 11401896. 
  14. ↑ American Lung Association Scientific; Medical Editorial Review Panel. "Diagnosing and Treating Bronchopulmonary Dysplasia". https://www.lung.org/lung-health-diseases/lung-disease-lookup/bronchopulmonary-dysplasia/treating-and-managing. 
  15. ↑ Yuan, Yuan; Yang, Yang; Lei, Xiaoping; Dong, Wenbin (June 2022). "Caffeine and bronchopulmonary dysplasia: Clinical benefits and the mechanisms involved". Pediatric Pulmonology 57 (6): 1392–1400. doi:10.1002/ppul.25898. PMID 35318830. https://doi.org/10.1002/ppul.25898. 
  16. ↑ American Lung Association Scientific; Medical Editorial Review Panel. "Diagnosing and Treating Bronchopulmonary Dysplasia". https://www.lung.org/lung-health-diseases/lung-disease-lookup/bronchopulmonary-dysplasia/treating-and-managing. 
  17. ↑ 17.0 17.1 Doyle, Lex W.; Cheong, Jeanie L.; Hay, Susanne; Manley, Brett J.; Halliday, Henry L. (2021-10-21). "Early (< 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants". The Cochrane Database of Systematic Reviews 10 (5): CD001146. doi:10.1002/14651858.CD001146.pub6. ISSN 1469-493X. PMID 34674229. 
  18. ↑ 18.0 18.1 18.2 18.3 Doyle, Lex W.; Cheong, Jeanie L.; Hay, Susanne; Manley, Brett J.; Halliday, Henry L. (2021-11-11). "Late (≥ 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants". The Cochrane Database of Systematic Reviews 2021 (11): CD001145. doi:10.1002/14651858.CD001145.pub5. ISSN 1469-493X. PMID 34758507. 
  19. ↑ Huang, Li; Zhu, Diqing; Pang, Gaofeng (2021). "The effects of early vitamin A supplementation on the prevention and treatment of bronchopulmonary dysplasia in premature infants: a systematic review and meta-analysis". Translational Pediatrics 10 (12): 3218–3229. doi:10.21037/tp-21-496. ISSN 2224-4344. PMID 35070836. 
  20. ↑ Hayes D, Jr; Wilson, KC; Krivchenia, K; Hawkins, SMM; Balfour-Lynn, IM; Gozal, D; Panitch, HB; Splaingard, ML et al. (1 February 2019). "Home Oxygen Therapy for Children. An Official American Thoracic Society Clinical Practice Guideline.". American Journal of Respiratory and Critical Care Medicine 199 (3): e5–e23. doi:10.1164/rccm.201812-2276ST. PMID 30707039. 
  21. ↑ Hochwald, Ori; Borenstein-Levin, Liron; Dinur, Gil; Jubran, Huda; Ben-David, Shlomit; Kugelman, Amir (July 2019). "Continuous Noninvasive Carbon Dioxide Monitoring in Neonates: From Theory to Standard of Care". Pediatrics 144 (1). doi:10.1542/peds.2018-3640. ISSN 1098-4275. PMID 31248940. 
  22. ↑ 22.0 22.1 22.2 Bruschettini, Matteo; Romantsik, Olga; Zappettini, Simona; Ramenghi, Luca Antonio; Calevo, Maria Grazia (2016-02-13). "Transcutaneous carbon dioxide monitoring for the prevention of neonatal morbidity and mortality". The Cochrane Database of Systematic Reviews 2016 (2): CD011494. doi:10.1002/14651858.CD011494.pub2. ISSN 1469-493X. PMID 26874180. 
  23. ↑ Albertella, Martina; Gentyala, Rahul R; Paraskevas, Themistoklis; Ehret, Danielle; Bruschettini, Matteo; Soll, Roger (2023-10-09). Cochrane Neonatal Group. ed. "Superoxide dismutase for bronchopulmonary dysplasia in preterm infants" (in en). Cochrane Database of Systematic Reviews 2023 (10): CD013232. doi:10.1002/14651858.CD013232.pub2. PMID 37811631. 
  24. ↑ "Trends in neonatal morbidity and mortality for very low birthweight infants". Am J Obstet Gynecol 196 (2): 147.e1–8. 2007. doi:10.1016/j.ajog.2006.09.014. PMID 17306659. 
  25. ↑ "Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network". Pediatrics 105 (6): 1194–201. 2000. doi:10.1542/peds.105.6.1194. PMID 10835057. 
  26. ↑ "Controversy surrounding the use of home oxygen for premature infants with bronchopulmonary dysplasia". J Perinatol 24 (1): 36–40. 2004. doi:10.1038/sj.jp.7211012. PMID 14726936. 

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