BPD: Complication of prematurity
Despite advances in perinatal care and a steady decline in mortality among preterm infants, preventing bronchopulmonary dysplasia is still a challenge to care for children born prematurely.
Current strategies for prevention of and treatment for BPD include:
Decreasing the number of premature infants by advancing obstetric care will decrease the number of infants at risk for BPD. Antenatal steroids given to pregnant women from 23 to 34 weeks GA who are at risk for preterm delivery decreases the risk of respiratory distress syndrome, intraventricular hemorrhage, and overall mortality related to preterm delivery.24 However, this has not resulted in a decreased incidence of BPD. Although multifactorial, the reason is possibly that more infants are surviving and thus at increased risk for BPD.25,26
Postnatal steroids for the prevention of BPD is an area of great debate in neonatology. Although there is evidence that administration of steroids decreases the incidence of BPD, adverse effects appear to diminish any benefit. In addition to short-term adverse events such as hyperglycemia, hypertension, and increased infection risk, long-term follow-up has demonstrated poor neurodevelopment outcomes including cerebral palsy.2 There are some instances in which steroids may be beneficial, but the type of steroid and which patients to consider need to be individualized.27-29 Similarly, inhaled steroids are not routinely recommended and have not been found to prevent BPD, but may be useful in certain limited scenarios.30-33
Surfactant, as mentioned previously, has changed the pathophysiology of BPD. However, it has not decreased the incidence of BPD for reasons similar to those for antenatal steroids. A strategy called the INSURE (Intubation-Surfactant-Extubation) approach combining brief intubation after birth for administration of surfactant and followed by extubation/use of nasal continuous positive airway pressure (CPAP) has demonstrated a decreased risk of BPD.2,34
A number of different ventilation strategies have been employed to attempt to decrease rates of BPD. In addition to the INSURE approach, volume targeted strategies have decreased BPD compared with pressure-limited strategies of ventilation.35 Other ventilatory modes that demonstrate possible decreases in BPD include nasal intermittent mandatory ventilation, while permissive hypercapnia and jet ventilation have not decreased rates of BPD.36-39
Low vitamin A levels are associated with development of BPD, and vitamin A is part of the internal processes for lung development and repair. Whereas administration of vitamin A decreases risk of BPD, there has not been a decrease in neurodevelopment complications associated with BPD.2
Although this antibiotic has not decreased BPD rates overall, its administration decreases BPD in the previously mentioned group at higher risk because of Ureaplasma urealyticum infection.2
Nutrition and fluid restriction
Preterm infants at risk of BPD are often fluid restricted as volume overload in the first 10 days of life is hypothesized (and supported by retrospective research) as a risk factor for the development of BPD.40 However trials of fluid restriction have been small and produced mixed results.41,42 Given the outcomes associated with BPD, modest fluid restriction may be warranted, especially in the setting of patients with patent ductus arteriosus (PDA).
Even though the mechanism is not known, administration of caffeine for the treatment of apnea of prematurity demonstrated a decrease in BPD.43,44
Nitric oxide has not demonstrated a benefit in the prevention of BPD, unlike its use for treating persistent pulmonary hypertension. Although some studies have demonstrated a benefit, no systematic review shows advantages related to pulmonary outcomes, survival, or neurodevelopment outcomes. Neither the National Institute of Health consensus conference45 or a 2014 AAP clinical report46 recommend routine administration of nitric oxide for the prevention of BPD.