II. Definition
- Chronic Lung Disease in Infants and Children
- Occurs secondary to Hyaline Membrane Disease associated with Prematurity
III. Epidemiology
- Incidence increases with earlier Gestational ages
-
Incidence increases with lower birth weights
- Incidence: Affects 50-80% of infants with birth weight <900 grams
- Incidence has dramatically decreased with the regular use of surfactant in Premature Infants
IV. Pathophysiology
- Chronic lung inflammation and scarring related to prolonged Mechanical Ventilation in Premature Infants
- Reults in lung remodeling
V. Risk Factors
- Very low birth weight
- Meconium Aspiration
- Congenital Heart Disease (e.g. Patent Ductus Arteriosus)
- Perinatal infections (e.g. TORCH Viruses)
- Persistent Pulmonary Hypertension
- Significant levels of Ventilatory support
VI. Signs
VII. Diagnosis
-
General BPD Criteria (all 3 required)
- Mechanical Ventilation in the neonatal period
- Continued oxygen needs (FIO2 >21%) at age 28 days
- Respiratory insufficiency
- Newborns born at <32 weeks gestation
- Mild
- Breathing room air at 36 weeks Postmenstrual age OR by time of discharge
- Moderate
- Oxygen requirements <30% FIO2 at 36 weeks Postmenstrual age OR by time of discharge
- Severe
- Requires >30% FIO2 or PPV/N-CPAP at 36 weeks Postmenstrual age OR by time of discharge
- Mild
- Newborns born at >=32 weeks gestation
- Mild
- Breathing room air at 56 days Postnatal age OR by time of discharge
- Moderate
- Oxygen requirements <30% FIO2 at 56 days Postnatal age OR by time of discharge
- Severe
- Requires >30% FIO2 or PPV/N-CPAP at 56 days Postnatal age OR by time of discharge
- Mild
- References
VIII. Imaging: Chest XRay
IX. Management: Exacerbations and general concerns
- Treat as Asthma Exacerbation initially
- See Pediatric Asthma
- Recognize that some obstruction may be fixed and unresponsive to further bronchodilation
- Trial Bronchodilators but do not over-use if poor response
- Supportive care may be mainstay of therapy (oxygen, IV hydration)
- Oxygen
- Keep Oxygen Saturation at 92% or higher
- Home oxygen may be required
- Inhaled agents
- Albuterol
- Ipratropium Bromide
- Inhaled Corticosteroids (e.g. Budesonide or Fluticasone)
- Adjunctive agents
- Diuretic indications
- Consider in sudden weight gain
- Antibiotics indications
- Immunodeficiency
- Recurrent respiratory infections
- Suspected Bacterial illness
- Diuretic indications
-
Car Seats may need adjustment (restraint may exacerbate symptoms)
- Require Car Seat test before NICU discharge
- Special prone or supine car safety device may be indicated
X. Management: Hospital admission indications
- Respiratory Rate >70-80 per minute (or significant increase from baseline)
- Hypoxia with increased oxygen requirement (or hypercarbia)
- Poor feeding secondary to respiratory condition
- Apnea
- New Pulmonary Infiltrates
XI. Complications
- Heart and lung changes
- Cor Pulmonale (or Pulmonary Hypertension)
- Right Ventricular Hypertrophy (and main pulmonary artery enlargement)
- Apparent Life-Threatening Events In Children (ALTE)
- Respiratory infections (e.g. RSV)
- Increased susceptibility
- Increased severity
- Reactive Airways
- Episodic respiratory distress and Wheezing
-
Growth Delay
- Require higher Caloric Intakes due to increased work of breathing
XII. Associated Conditions: Exacerbating factors seen in very Premature Infants
- Subglottic Stenosis (from prolonged intubation)
- Laryngomalacia
- Tracheomalacia
XIII. Course
- Lung function often normalizes by teen years
XIV. References
- Claudius and Boyer in Majoewsky (2013) EM:Rap 13(2):10
- Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, Burlington, p, 72-5
- Walsh (2006) Pediatrics 117: S52-6 [PubMed]