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 The
Front Line
Multidisciplinary
Care of Bronchopulmonary Dysplasia
by
James M. Adams, MD
The
advent of surfactant replacement therapy and antepartum corticosteroids
for prevention of hyaline membrane disease (HMD) has produced
a striking reduction in low birth weight mortality. Many low birth
weight babies still require mechanical ventilation, however, and
bronchopulmonary dysplasia (BPD) has emerged as the dominant pulmonary
disease of the newborn. The incidence of this chronic lung disease
increases with decreasing gestation. Approximately 35% of infants
<1500 grams at birth require oxygen or mechanical ventilation
at 28 days of life, and 16% of these continue to need supplemental
oxygen at 36 weeks post conception. BPD is an inflammatory airway
injury triggered by the initial interface between mechanical ventilation
and a vulnerable infant. Early on, BPD is marked by uneven airway
obstruction, pulmonary edema, impaired lung mechanics, and increased
oxygen needs.
Obliteration
and abnormal muscularization of the pulmonary vascular bed increases
cardiac work. With time, the active process subsides and recovery
occurs by slow growth and remodeling of the lung over a period
of weeks to months. Given enough time and adequate growth, even
an infant with severe chronic lung disease and widespread fibrosis
can survive and recover significant function. Although outcomes
vary among tertiary centers with reported mortality ranging from
25% to 40%, risk of death is closely related to duration of mechanical
ventilation. Chronic ventilator-dependent infants require highly
specialized care if they are to realize full recovery potential.
Growth requires close attention to full nutrition despite severe
fluid restriction. Mechanical ventilation, supplemental oxygen,
and other ancillary measures such as bronchodilators primarily
minimize pulmonary vascular resistance and prevent cardiac failure,
buying time for long-term lung growth.
For
a ventilator-dependent infant hospitalized for months, the care
environment becomes crucial. Not only must the complex physiology
of BPD be managed, but the adverse effects of intensive care on
the daily life and development of a growing child also must be
blunted. In 1994, a multidisciplinary team was formed for the
care of chronic ventilator-dependent infants at The Newborn Center,
Texas Children’s Hospital (TCH). This team combines the expertise
of board-certified neonatologists from Baylor College of Medicine
with numerous specialists in newborn care from TCH. The Chronic
Pulmonary Care Team includes primary care nurses and practitioners,
respiratory therapists, a unit-based pharmacist, a dietitian,
and a physician-directed nutrition support team. There also are
two social workers, a child life specialist, a case resource manager,
and physical and occupational therapists. Patients receive care
in a unit designed to optimize control of noise and light, as
well as provide a family-centered environment. The team meets
biweekly to evaluate and discuss with primary care providers the
pulmonary, nutritional, and developmental needs of each patient.
The advice and recommendations of the team lead to specific goals
and consistency in the long-term care of each patient. The team
also serves as an important educational resource for health care
professionals caring for these patients.
The
severity of BPD has decreased in recent years and current evidence
suggests mortality rates are falling. At TCH, only 10% of babies
born at 1500 grams or less require mechanical ventilation for
more than 28 days. Among those requiring respirator support for
more than 3 months, more than two-thirds survive. These infants
continue to have further lung growth and improvement in lung function
after discharge and during the second year of life.
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