Respiratory support strategies in the management of severe, longstanding bronchopulmonary dysplasia

Measurement of lung oxygenation by near-infrared spectroscopy in preterm infants with bronchopulmonary dysplasia

INTRODUCTION

It has recently been reported that it is possible to monitor lung oxygenation (rSO2L) by near-infrared spectroscopy (NIRS) in preterm infants with respiratory distress syndrome (RDS). Thus, our aim was to assess the possibility of monitoring rSO2L in infants with evolving and established bronchopulmonary dysplasia (BPD) and to evaluate if rSO2L correlates with BPD severity and other oxygenation indices.

METHODS

We studied 40 preterm infants with gestational age ≤30 weeks at risk for BPD. Patients were continuously studied for 2 h by NIRS at 28 ± 7 days of life and 36 weeks ± 7 days of postmenstrual age.

RESULTS

rSO2L was similar at the first and second NIRS recordings (71.8 ± 7.2 vs. 71.4 ± 4.2%) in the overall population, but it was higher in infants with mild than in those with moderate-to-severe BPD at both the first (73.3 ± 3.1 vs. 71.2 ± 3.2%, p = .042) and second (72.3 ± 2.8 vs. 70.5 ± 2.8, p = .049) NIRS recording. A rSO2L cutoff value of 71.6% in the first recording was associated with a risk for moderate-to-severe BPD with a sensitivity of 66% and a specificity of 60%. Linear regression analysis demonstrated a significant positive relationship between rSO2L and SpO2/FiO2 ratio (p = .013) and a/APO2 (p = .004).

CONCLUSIONS

Monitoring of rSO2L by NIRS in preterm infants with evolving and established BPD is feasible and safe. rSO2L was found to be higher in infants with mild BPD, and predicts the risk for developing moderate-to-severe BPD and correlates with other indices of oxygenation.

Types of home respiratory support in children with bronchopulmonary dysplasia and factors determining its duration: A scoping review

Bronchopulmonary dysplasia also known as chronic lung disease of prematurity has changed as a disease entity over the last five decades and children with "new bronchopulmonary dysplasia (BPD)" have better survival rates. This necessitates strategies to prevent severe BPD and provide organized home support. Home respiratory support in these children varies from home oxygen to noninvasive ventilation and tracheostomy ventilation. This review was conducted utilizing Joanna Briggs Institute publications on evidence synthesis and presentation of results for a scoping review. The Preferred Reporting Items for Systematic Review and Meta-Analyses were used to report the results. The risk of bias assessment was done using "The Cochrane Handbook for Systematic Reviews tool for interventional studies." After screening for the duplication of results and applying inclusion and exclusion criteria, twenty-seven studies were assessed by reading the full texts. Out of these, eleven were finally included in this systematic review. The total sample size from all studies was 4794, including 2705 males. The 4/11 studies home oxygen, one study reported continuous positive airway pressure/bilevel positive airway pressure and seven studies used tracheostomy or tracheostomy ventilation. The median duration of post-natal invasive ventilation was higher in those discharged on home oxygen compared to those who did not need oxygen at discharge. There is a significant proportion of children who are tracheostomy ventilated (8.65%) at home. In the absence of established guidelines, these children are vulnerable when it comes to care at home and the timing of decannulation. For home oxygen alone, guidelines by ERS, ATS and BTS have streamlined weaning protocols and the need for having a multi-disciplinary team to care for these children.

Respiratory management of established severe bronchopulmonary dysplasia

Respiratory management of infants with established severe BPD is difficult and there is little evidence upon which to base decisions. Nonetheless, the physiology of severe BPD is well described with a predominantly obstructive pattern. This pulmonary dysfunction results in prolonged exhalatory time constants and thus ventilator management must be focused on maintaining adequate oxygenation and ventilation through achieving full exhalation. This approach is often difficult to maintain in acute care settings and a culture of chronic care focused on slow change and steady progress is imperative. Once respiratory stability is achieved, the focus should shift to growth and development and avoidance of care practices and medications that impair neurodevelopment.

Respiratory management in the premature neonate

INTRODUCTION

Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes.

AREAS COVERED

Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed.

EXPERT OPINION

Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.