Bronchopulmonary Dysplasia (BPD)

Definition & Risk Factors

• Definition: Requirement of supplemental oxygen for > 28 days of life
• Severity graded at 36 weeks PMA (Mild: Room air, Moderate: FiO2 < 30%, Severe: FiO2 >= 30% or positive pressure)
• Risk factors: Extreme prematurity (<28 weeks), prolonged mechanical ventilation, high peak inspiratory pressures, hyperoxia, sepsis, PDA

Prevention Strategies (First 2 weeks)

• Early prophylactic or rescue surfactant administration
• Volume-targeted ventilation (VTV) and early extubation to early CPAP/NIPPV
• Permissive hypercapnia (target PaCO2 45-55 mmHg to minimize ventilator pressures)
• Caffeine citrate administered early (within first 24-48 hours)
• Target oxygen saturations (SpO2 90-95%) to avoid hyperoxia toxicity

Chronic Management (Post 28 days)

• Optimize nutrition (120-150 kcal/kg/day with fortified breastmilk/preterm formula) for lung growth
• Fluid restriction or diuretics (e.g., chlorothiazide/spironolactone) if pulmonary edema is present
• Post-natal corticosteroids (DART protocol dexamethasone) ONLY if severe ventilator dependence and failing to extubate
• Pulmonary hypertension screening via echocardiogram at 36 weeks PMA for moderate/severe cases
• Synagis (Palivizumab) prophylaxis prior to discharge for RSV season

Advanced Respiratory & Ventilator Protocol

• Surfactant dosing (Poractant alfa): 2.5 mL/kg (200 mg/kg) initial dose, administer via INSURE or LISA method to minimize mechanical trauma.
• High-Frequency Oscillatory Ventilation (HFOV) starting parameters: MAP 1-2 cmH2O above conventional ventilation, Amplitude adjusted to achieve visible chest wiggle.
• Target SpO2 explicitly strictly to 90-95% for infants < 32 weeks to prevent Retinopathy of Prematurity.
• Provide aggressive tracheobronchial suctioning ONLY when clinically indicated by coarse breath sounds or desaturations, not routinely.
• Permissive hypercapnia: Allow PaCO2 up to 55-60 mmHg if pH remains > 7.25 to prevent barotrauma.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• BPD Ventilator Weaning: [START] Diagnosed BPD -> [ACTION] Maximize nutrition & diuretics -> [DECISION] PIP > 20? -> [YES] Slow wean / consideration of DART protocol -> [GOAL] Extubate to CPAP

References

1. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med.
2. Higgins RD, Jobe AH, Koso-Thomas M, et al. Bronchopulmonary dysplasia: executive summary of a workshop. J Pediatr.