Prevention of bronchopulmonary dysplasia in extremely low gestational age neonates: current evidence

Abstract

Bronchopulmonary dysplasia (BPD) is one of the most frequent complications in extremely low gestational age neonates, but has remained largely unchanged in rate. We reviewed data on BPD prevention focusing on recent meta-analyses. Interventions with proven effectiveness in reducing BPD include the primary use of non-invasive respiratory support, the application of surfactant without endotracheal ventilation and the use of volume-targeted ventilation in infants requiring endotracheal intubation. Following extubation, synchronised nasal ventilation is more effective than continuous positive airway pressure in reducing BPD. Pharmacologically, commencing caffeine citrate on postnatal day 1 or 2 seems more effective than a later start. Applying intramuscular vitamin A for the first 4 weeks reduces BPD, but is expensive and painful and thus not widely used. Low-dose hydrocortisone for the first 10 days prevents BPD, but was associated with almost twice as many cases of late-onset sepsis in infants born at 24-25 weeks' gestation. Inhaled corticosteroids, despite reducing BPD, were associated with a higher mortality rate. Administering dexamethasone to infants still requiring mechanical ventilation around postnatal weeks 2-3 may represent the best trade-off between restricting steroids to infants at risk of BPD while still affording high efficacy. Finally, identifying infants colonised with ureaplasma and treating those requiring intubation and mechanical ventilation with azithromycin is another promising approach to BPD prevention. Further interventions yet only backed by cohort studies include exclusive breastmilk feeding and a better prevention of nosocomial infections.

Survey of less Invasive Surfactant Administration in England, slow adoption and variable practice

“…Respiratory distress syndrome (RDS) is a common entity in preterm infants, estimated at 95% in infants at 24 weeks of gestation, and 80% of babies at 28 weeks (VON Network 2015) caused by surfactant deficiency resulting in pulmonary insufficiency shortly after birth. Established strategies such as the use of antenatal steroids and the use of surfactant improve respiratory outcomes and reduce the incidence of bronchopulmonary dysplasia (BPD) . Despite multiple interventions to prevent BPD, the rate of this disease has remained unchanged, likely due to an increased survival of more extreme preterm infants.…”

“…Established strategies such as the use of antenatal steroids and the use of surfactant improve respiratory outcomes and reduce the incidence of bronchopulmonary dysplasia (BPD) . Despite multiple interventions to prevent BPD, the rate of this disease has remained unchanged, likely due to an increased survival of more extreme preterm infants. The standard method to administer rescue surfactant is via an endotracheal tube.…”

Early high‐dose caffeine citrate for extremely preterm infants: Neonatal and neurodevelopmental outcomes

“…Meta‐analyses of high‐ versus standard‐dose caffeine showed a significant decrease in the incidence of BPD with high‐dose caffeine, which was not demonstrated in the current study. This may relate to the fact that the high‐dose group was of lower birthweight and required more respiratory intervention, which are risk factors for BPD . Thus, the potential benefits of high‐dose caffeine citrate may have been masked by the fact that this group of infants was smaller and sicker than the group that received standard‐dose caffeine citrate.…”

“…The lungs of extremely preterm infants are susceptible to lung injury, with the subsequent development of BPD. There is some evidence that, by avoiding mechanical ventilation with an endotracheal tube, the incidence of BPD may be reduced . One way to achieve this may be the use of nasal continuous positive airways pressure (NCPAP) with or without the use of minimally invasive surfactant therapy .…”

Human milk is perhaps the single most under-rated strategy to prevent bronchopulmonary dysplasia

“…We commend Poets and Lorenz1 for their thorough review on strategies likely to reduce bronchopulmonary dysplasia (BPD). They present an overview of the effectiveness and safety of interventions backed by randomised controlled trials (RCT) and aimed at preventing BPD.…”