Elsevier

Seminars in Perinatology

Volume 30, Issue 4, August 2006, Pages 192-199
Seminars in Perinatology

Ventilatory Strategies in the Prevention and Management of Bronchopulmonary Dysplasia

https://doi.org/10.1053/j.semperi.2006.05.006Get rights and content

Bronchopulmonary dysplasia (BPD) leads to considerable mortality and morbidity in premature infants. Although mechanical ventilation is lifesaving in infants with respiratory distress syndrome (RDS), it may contribute to lung injury and subsequently to BPD. Appropriate ventilatory strategies for reducing BPD include redefining the goals for “adequate gas exchange,” using less mechanical ventilation support, refining the methods of mechanical ventilation, and using alternative techniques. Permissive hypercapnia, permissive hypoxemia, minimal peak pressures, rapid rates, early therapeutic continuous positive airway pressure (CPAP), and rapid extubation may help reduce mechanical ventilation-induced lung injury and possibly reduce BPD. Newer techniques of ventilation such as volume-targeted ventilation are also promising. High frequency ventilation has not been proven to reduce BPD. There is a lack of evidence-based guidelines on management of infants with established BPD. Optimization of clinical care practices and ancillary therapies need to be combined with ventilatory strategies to prevent and manage BPD.

Section snippets

Targeting a Higher PaCO2 (Permissive Hypercapnia)

Retrospective studies by Kraybill and coworkers8 and Garland and coworkers9 initially suggested that hypocapnia soon after birth was an independent risk factor for BPD. Subsequently, a prospective randomized trial showed that ventilatory strategies that maintained mild hypercapnia (PaCO2 45-55 mm Hg) were safe and reduced the need for assisted ventilation in the first 96 hours after randomization.10 A larger, multicenter, randomized trial reported that “minimal ventilation” (target PaCO2 > 52

Lower Pressures, Faster Rates, Shorter Inspiratory Times (Ti)

For a given minute ventilation, a faster ventilator rate with a lower tidal volume (TV) is preferred to a slower ventilator rate with a larger TV to reduce volutrauma that is more likely with larger TV. At very rapid ventilator rates, minute ventilation plateaus and later falls21 if the Ti decreases below 3 to 5 time constants and TV delivery is impaired. However, infants with RDS generally have short time constants and thus rapid (>60/min) ventilatory rates are acceptable as both inspiratory

Prophylactic CPAP

Prophylactic CPAP refers to the administration of CPAP soon after birth regardless of the respiratory status of the infant. A recent meta-analysis found no evidence that prophylactic nasal CPAP in infants <32 weeks gestation and/or <1500 g at birth was effective in reduction of BPD, and found there were trends toward an increased incidence of IVH in the infants who received prophylactic CPAP.37 Therefore, prophylactic nasal CPAP is not recommended currently in larger infants. In more immature

Defining What Is Meant by “BPD”

The incidence of BPD has varied from center to center not only due to variations in patient population, disease severity, and characteristics of care, but also because the definition of BPD as “oxygen requirement at 36 corrected weeks’ of age” is often not clear. Physicians may use varying criteria for defining “oxygen requirement.” Walsh and coworkers recently reported on the use of a physiologic definition of BPD in which the definition of BPD was standardized between sites by using a timed

Management of Established BPD

The transition from RDS to BPD is gradual, as the effects of chronic injury and inhibition of alveolar and vascular development overlap with and gradually replace the effects of surfactant deficiency and acute lung injury. As in RDS, the major goal of mechanical ventilation should be to maintain adequate gas exchange while minimizing ventilator-associated lung injury. There are extremely limited data from clinical trials on which to base optimal ventilatory management in established BPD, and

Summary of Overall Strategy to Minimize BPD

Strategies to reduce BPD should involve optimal obstetric care including antenatal steroids, delivery room care to avoid over-aggressive ventilation during resuscitation, and postnatal care with early therapeutic CPAP and avoidance of mechanical ventilation whenever possible. Surfactant may be administered prophylactically in the most immature infants or early in more mature infants with RDS. Larger preterm infants (>1 kg) may be extubated to NCPAP or SNIPPV promptly after surfactant

References (55)

  • A.H. Jobe et al.

    Bronchopulmonary dysplasia

    Am J Respir Crit Care Med

    (2001)
  • J.A. Lemons et al.

    Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 through December 1996

    NICHD Neonatal Res Network Pediatr

    (2001)
  • A. Artigas et al.

    The American-European Consensus Conference on ARDS. II. Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome

    Am J Respir Crit Care Med

    (1998)
  • J.S. Garland et al.

    Hypocarbia before surfactant therapy appears to increase bronchopulmonary dysplasia risk in infants with respiratory distress syndrome

    Arch Pediatr Adolesc Med

    (1995)
  • G. Mariani et al.

    Randomized trial of permissive hypercapnia in preterm infants

    Pediatrics

    (1999)
  • W.A. Carlo et al.

    Minimal ventilation to prevent bronchopulmonary dysplasia in extremely-low-birth-weight infants

    J Pediatr

    (2002)
  • L.M. Askie et al.

    Restricted versus liberal oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants

    Cochrane Database Syst Rev

    (2001)
  • L.M. Askie et al.

    Oxygen-saturation targets and outcomes in extremely preterm infants

    N Engl J Med

    (2003)
  • Supplemental Therapeutic Oxygen for Prethreshold Retinopathy Of Prematurity (STOP-ROP), a randomized, controlled trial. I. primary outcomes

    Pediatrics

    (2000)
  • W. Tin et al.

    Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation

    Arch Dis Child Fetal Neonatal Ed

    (2001)
  • J. Hagadorn et al.

    Actual vs intended pulse oxygen saturation (SpO2) in infants <28 weeks gestation

    (2004)
  • S.J. Boros et al.

    Using conventional infant ventilators at unconventional rates

    Pediatrics

    (1984)
  • C.O. Kamlin et al.

    Long versus short inspiratory times in neonates receiving mechanical ventilation

    Cochrane Database Syst Rev

    (2004)
  • A. Greenough et al.

    Synchronized mechanical ventilation for respiratory support in newborn infants

    Cochrane Database Syst Rev

    (2004)
  • N. McCallion et al.

    Volume-targeted versus pressure-limited ventilation in the neonate

    Cochrane Database Syst Rev

    (2005)
  • M. Keszler

    Volume-targeted ventilation

    J Perinatol

    (2005)
  • L.C. Chow et al.

    Are tidal volume measurements in neonatal pressure-controlled ventilation accurate?

    Pediatr Pulmonol

    (2002)
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