Bronchopulmonary Dysplasia - Extended version

Objectives:

1. Know the risk factors, pathogenesis and definitions for BPD
2. Appreciate the differences in epidemiology and pathogenesis of the “new BPD” vs. old BPD.
3. Review the antenatal and postnatal preventative measure that may be taken against BPD.
4. Know the clinical management of respiratory support in infants with BPD in the NICU and outpatient settings.
5. Describe the pharmacologic treatments for BPD.
6. Understand the risk of development of pulmonary hypertension.
7. Recognize the other comorbid respiratory and systemic conditions that are seen in infants with BPD.
8. Understand long-term outcomes of patients with BPD.
9. Recognize the differential diagnoses for BPD and other commonly coexisting diagnoses that may be present.

Articles:

• This comprehensive review of BPD (2007) highlights the history of BPD and how its definition has evolved, and touches upon the risk factors, treatments, and long-term outcomes. It includes a graphic summarizing the key morphologic differences found between “old” vs “new” BPD. [Objectives 1, 2, 5, 7, 8]
• The current diagnostic criteria for BPD depend on the level and duration of oxygen therapy, but it does not factor in contemporary neonatal respiratory care and does not predict childhood morbidity. In this article about the diagnosis of BPD in very preterm infants(2019), this group assessed infants based on 18 previously determined definitions of BPD disease severity and found that the optimal definition categorized BPD severity according to the mode of respiratory support administered at 36 weeks postmenstrual age. [Objective 1]
• Review article (2020) that discusses the classification, pathophysiology, treatment and preventative strategies for pulmonary hypertension associated with BPD. [Objective 6]
• This review (2019) covers the epidemiology, mechanisms/pathophysiology, diagnosis, screening, and prevention, short- and long-term management of BPD. It further goes into respiratory outcomes and the development of pulmonary vascular disease in these patients. It includes some really nice figures and imaging. [Objectives 1, 3, 4, 5 ]
• Pediatrics in Review article (2012) on BPD that provides information on the pathogenesis, antenatal and postnatal prevention and treatment of BPD. There is a great summary section at the end. [Objectives 1, 3, 4, 5]
• This article (2011) summarizes the long-term consequences of BPD. They looked at measures including mortality, presence of radiological abnormalities, lung function measurements, and the correlation between incidence of long-term complications (developmental delay, ADHD, neurological impairment, wheezing/asthma, hearing impairment, low vision, structural airway problems, cor pulmonale) and BPD severity. [Objectives 6, 7, 8]
• Long term outcomes of BPD (2009) - touching on academic, behavioral, neurosensory, cognitive and language outcomes as well as respiratory function and childhood rehospitalization risk. [Objective 8]
• This excellent review (2017) delves into the definition of BPD with severity, discusses appropriate ventilatory support, and when tracheostomy placement is warranted. It further discusses pulmonary hypertension in sBPD, nutritional support, and pharmacologic management of sBPD. It includes radiologic images of severe BPD, a table summarizing the interdisciplinary for management of sBPD, along with an action plan for management of the discharged patient with sBPD. [Objectives 4, 5, 6, 7, 8, 9]
• Another review on BPD (2017) with a focus on current treatment therapies and different potential therapies, including using azithromycin, anti-inflammatory agents, mitochondrial antioxidant drugs, and tissue stem cells. Explains therapies in the context of the pathophysiology of BPD. [Objectives 1, 5]
• This article (2012) dives into the predictors of BPD, including risk factors before birth, at birth, and after birth. It also touches upon the change in how BPD is defined and its current classification. [Objectives 1, 2, 3]
• This article (2019) touches upon the “old” vs “new” definition of BPD, reviews the criteria for home oxygen therapy, and what should occur prior to the infant being discharged from the NICU. It further discusses monitoring home oxygen as well as weaning of oxygen therapy. It finally describes impact on long term respiratory health, the risk for pulmonary hypertension, as well as the risk for systemic hypertension. [Objectives 2, 4, 6, 7]
• This article (2015) discusses the role of nutrition in the pathophysiology of BPD as well as the association between growth and pulmonary outcomes. Infants with a history of BPD typically have slower rates of postnatal growth compared to preterm infants without lung disease. It describes ways to optimize nutrition in these children, especially as inadequate nutrition and growth may affect neurodevelopment. [Objectives 3, 7, 8]
• The DART study (2006) aimed to determine the long-term effects of low-dose dexamethasone on neurosensory outcome, growth, and health. Although the study was underpowered, it found no strong association with long-term morbidity, and low dose dexamethasone after the first week of life in chronically ventilator-dependent infants had short-term benefits, including facilitating extubation and improving lung function. [Objective 5]
• A follow-up to the DART study (2007): Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial [Objective 8]
• Neonatal dysphagia may co-occur with BPD, especially in infants with persistent feeding difficulties. This article (2016) also reviews the other contributory factors that place an infant at higher risk of aspiration. [Objective 9]
• BPD may present clinically similar to interstitial lung disease. This article (2017) focuses on the different disorders that typically present in the newborn period and may result in hypoxemic respiratory failure. Abnormal growth may be seen in children with chromosomal disorders, congenital heart disease, and deficiency of filamin A, and should be considered if the diagnosis of BPD is not clear. [Objective 9]
• Retrospective cohort study (2017) looking at the impact of tracheobronchomalacia on the morbidity of infants with BPD. Looked at need for tracheostomy placement, need for g-tube placement, length of hospitalization stay, length of time needed on mechanical ventilation, and level of respiratory support post discharge. [Objective 9]

Additional Resources:

• The National Institute of Child Health and Human Development is a great resource with estimator tools, including one to predict the risk of BPD and one for infant mortality.
• Sociodemographic factors and racial disparities have a significant impact on NICU outcomes, and even more so on BPD outcomes as well. Gain an understanding of the data behind this through this report (2020).
• An easy to read handbook for parents that includes respiratory symptoms to watch out for, oxygen delivery systems, and nutritional requirements among other topics. 
• Overview of some of the radiologic findings in BPD.
• Peds Rad course created by the Cleveland Clinic. You have to make an account (it’s free!) but there is a whole section on neonatal chest, specifically BPD. There is a pre- and post-test.

Self-Assessment: coming soon