IN BRIEF

Best Practices in Severe BPD Treatment

April 18, 2017
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To help standardize care, the Bronchopulmonary Dysplasia Collaborative has published a comprehensive review of evidence-based approaches for treatment of patients with severe forms of the disease.

Infants with severe bronchopulmonary dysplasia (BPD) have high risks of late morbidities and mortality, but the best ways to manage these vulnerable patients are still debated. In fact, it’s not always clear how to define “severe BPD”.

The Bronchopulmonary Dysplasia Collaborative, a group of institutions led by Nationwide Children’s Hospital, has recently published a review to guide neonatologists – and to help the multidisciplinary teams that are crucial for a patient’s ongoing care.

“One of the focuses of neonatology has been on the prevention of BPD,” says Leif Nelin, MD, chief of the Division of Neonatology at Nationwide Children’s and senior author of The Journal of Pediatrics review. “That’s very important. When the disease occurs, however, patients are often taken care of as if they have an acute disease, when they actually have a chronic one. And once the neonatal intensive care unit phase is over, care can ultimately fall to a pulmonologist, a critical care specialist, a cardiologist or another physician, depending on the institution. Our goal is more uniform care to improve outcomes for patients.”

The authors begin with that broad definition of severe BPD, and then suggest dividing the category into two phenotypes. Type 1 is relatively less severe and refers to children who have an ongoing need for oxygen and/or continuous positive airway pressure (CPAP) or high flow nasal cannula at 36 weeks post menstrual age. Type 2, or relatively more severe, refers to children who are receiving mechanical ventilation at 36 weeks.

Both subsets are considered in the article, but those infants with type 2 severe BPD more often have serious complications and are most in need of a multidisciplinary team, says Dr. Nelin, who is also a professor of Pediatrics at The Ohio State University College of Medicine.

Among the most important treatment recommendations from the collaborative:

  • Change the ventilation strategy. A preterm baby in the first week of life does best with low tidal volumes and short inspiratory times. After the first week, as lung mechanics change with a severe BPD pattern, the strategy should shift dramatically to one of higher tidal volumes and longer inspiratory times. Sedation, appropriate in the brief acute phase of ventilation, should be altered as the disease becomes chronic.
  • Use fewer systemic steroids. Typically used to treat and prevent pulmonary exacerbations, chronic steroid use in a severe BPD patients can lead to hypertension, neurodevelopmental delay and other problems.
  • Have a follow-up plan after discharge. Institutions should identify specialists and primary care physicians who are comfortable with and willing to take care of severe BPD patients after they leave the hospital. Those institutions and doctors should also develop a standardized plan for managing those patients.

The authors also emphasize the importance of an interdisciplinary care team, which may include psychologists, developmental pediatricians, dieticians, social workers, pharmacists and occupational and other therapists – along with the more typical specialists in neonatology, pulmonary medicine and cardiology.

“In an intensive care unit, the attending physician changes every week or so,” says Dr. Nelin. “The nurses change every 12 hours. That’s a lot of discontinuity. So it’s important to have a core group of people who can lay out a road map for each patient and make sure care is consistent.”

Collaborative member institutions who participated in the review are Nationwide Children’s, The Children’s Hospital of Philadelphia, Children’s Hospital Colorado, Johns Hopkins Medical Institutions, Women and Infants Hospital (Rhode Island), Texas Children’s Hospital, Children’s Mercy Hospital and Clinics, Vanderbilt University School of Medicine and University of Massachusetts School of Medicine.

 

Reference:

Abman SH, Collaco JM, Shepherd EG, Keszler M, Cuevas-Guaman M, Welty SE, Truog WE, McGrath-Morrow SA, Moore PE, Rhein LM, Kirpalani H, Zhang H, Gratny LL, Lynch SK, Curtiss J, Stonestreet BS, McKinney RL, Dysart KC, Gien J, Baker CD, Donohue PK, Austin E, Fike C, Nelin LD. Interdisciplinary care of children with severe bronchopulmonary dysplasia. The Journal of Pediatrics. 2017 Feb; 181:12-28.

 

Photo credit: Nationwide Children’s