Broncho Pulmonary Dysplasia
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Transcript of Broncho Pulmonary Dysplasia
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Bronchopulmonary Bronchopulmonary Dysplasia(BPD)Dysplasia(BPD)
Kumari Weeratunge M.D.
PL - 2
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Back groundBack ground
Develops in neonates treated with O2 & PPV . Originally described by Northway in 1967 using
clinical , radiographic & histologic criteria . Bancalari refined definition using ventilation
criteria , O2 requirement @ 28days to keep PaO2>50mmhg & abnormalities in chest x –ray .
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Back groundBack ground
Shennan proposed in 1988 criteria of O2 requirement @ 36 weeks corrected GA .
Antenatal steroids , early surfactant Rx & gentle modes of ventilation minimize severity of lung injury .
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PathophysiologyPathophysiology
Multifactorial Major organ systems - lungs & heart Alveolar stage of lung development - 36wks GA
to 18 months post conception Mechanical ventilation & O2 interferes with
alveolar & pulmonary vascular development in preterm mammals .
Severe BPD Pulmonary HT & abnormal pulmonary vascular development .
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Stages of BPDStages of BPD
Defined by Northway in 1967 Stage 1 - similar to uncomplicated RDS Stage 2 - pulmonary parenchymal opacities
with bubbly appearance of lungs Stage 3 & 4 – areas of atelectasis ,
hyperinflation & fibrous sheaths Recently CT & MRI of chest – reveals more
details of lung injury
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Frequency of BPDFrequency of BPD
Dependent on definition used in NICU . Using criteria of O2 requirement @ 28 days
frequency range from 17% - 57% . Survival of VLBW infants improved with
surfactant Actual prevalence of BPD has increased .
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Mortality/Morbidity of BPDMortality/Morbidity of BPD
Infants with severe BPDIncreased risk of pulmonary morbidity & mortality within the first 2 years of life .
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Pulmonary Complications of Pulmonary Complications of BPDBPD
Increased resistance & airway reactivity evident in early stages of BPD along with increased FRC .
Severe BPD Significant airway obstruction with expiratory flow limitations & further increased FRC secondary to air trapping & hyperinflation
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Volume trauma & Volume trauma & BarotraumaBarotrauma
Rx of RDS – surfactant replacement , O2 , CPAP & mechanical ventilation .
Increased PPV required to recruit all alveoli to Px atelectasis in immature lungsLung injuryInflammatory cascade .
Trauma secondary to PPV-Barotrauma VolumetraumaLung injury secondary to
excess TV from increased PPV .
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Volume trauma & Volume trauma & BarotraumaBarotrauma
Severity of lung immaturity & effects of surfactant deficiency determines PPV .
Severe lung immaturityAlveolar number is reducedincreased PP transmitted to distal bronchioles .
Surfactant deficiencysome alveoli collapse while others hyper inflate .
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Volume trauma & Volume trauma & BarotraumaBarotrauma
Increased PPV to recruit all alveoliCompliant alveoli & terminal bronchioles ruptureleaks air in to interstiumPIEIncrease risk of BPD
Using SIMV compared to IMV in infants <1000g showed less BPD .
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O2 & AntioxidantsO2 & Antioxidants
O2 accept electrons in it’s outer ringForm O2 free radicalsCell membrane destruction
Antioxidants(AO)Antagonise O2 free radicals
Neonates-Relatively AO deficient Major antioxidants – super oxide
dismutase , glutathione peroxidase & catalase
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O2 & AntioxidantsO2 & Antioxidants
Antioxidant enzyme level increase during last trimester .
Preterm birthIncreased risk of exposure to O2 free radicals
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InflammationInflammation
Activation of inflammatory mediatorsIn acute lung injury
Activation of leukocytes by O2 free radicals , barotrauma & infectionDestruction & abnormal lung repairAcute lung injuryBPD
Leukocytes & lipid byproducts of cell membrane destructionActivate inflammatory cascade
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InflammationInflammation
Lipoxigenase & cyclooxigenase pathways are involved in the inflammatory cascade
Inflammatory mediators are recovered in tracheal aspirate of newly ventilated preterm who later develops BPD
Metabolites of mediatorsvasodilatationincreased capillary permeabilityalbumin leakage & inhibition of surfactant functionrisk of barotrauma
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InflammationInflammation
Neutrophils – release collegenase & elastasedestroy lung tissue
Hydroxyproline & elastin recovered in urine of preterms who develops BPD
Di2ethylhexylphthalate(DEHP) degradation product of used ET tubeslung injury
A study in 1996 found that increased interleukin 6 in umbilical cord plasma
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InfectionInfection
Maternal cervical colonization/ preterm neonatal tracheal colonization of U.urealyticum associated with high risk of BPD
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NutritionNutrition
Inadequate nutrition supplementation of preterm compound the damage by barotrauma , inflammatory cascade activation & deficient AO stores
Acute stage of CLDincreased energy expenditure
New born ratsnutritionally depriveddecreased lung weight
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NutritionNutrition
Cu , Zn , Mn deficiencypredispose to lung injury
Vit A & E prevent lipid peroxidation & maintain cell integrity
Extreme prematurity – large amounts of H2O needed to compensate loss from thin skin
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NutritionNutrition
Increased fluid administration increased risk of development of PDA & pulmonary edema(PE)
High vent settings & high O2 needed to Rx PDA & PE
Early PDA Rx – improve pulmonary function but no effect on incidence of BPD
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GeneticsGenetics
Strong family history of asthma & atopy increase risk of development & severity of BPD
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CVS ChangesCVS Changes
Endothelial cell proliferation Smooth muscle cell hypertrophy Vascular obliteration Serial EKG – right ventricular hypertrophy Echocardiogram – abnormal right
ventricular systolic function & left ventricular hypertrophy
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CVS ChangesCVS Changes
Persistent right ventricular hypertrophy/ fixed pulmonary hypertension unresponsive to supplemental O2 leads to poor prognosis
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AirwayAirway
Trachea & main stem bronchi - abnormalities depend on duration & frequency of intubation & ventilation
Diffuse or focal mucosal edema , necrosis/ulceration occur
Earliest changes from light microscopyloss of cilia in columnar epithelium , dysplasia/necrosis of the cells
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AirwayAirway
Neutrophils , lymphocyte infiltrate & goblet cell hyperplasiaincreased mucus production
Granulation tissue & upper airway scarring from deep suctioning & repeated ET intubation results in laryngotracheomalacia , subglottic stenosis & vocal cord paralysis
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AirwayAirway
Necrotizing bronchiolitis – results from edema , inflammatory exudate & necrosis of epithelial cells .
Inflammatory cells , exudates & cellular debris obstruct terminal airways
Activation & proliferation of fibroblastsperibronchial fibrosis & obliterative fibroproliferative bronchiolitis
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Radiologic FindingsRadiologic Findings
Decreased lung volumes Areas of atelectasis Hyperinflation Lung haziness PIE
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bpd
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Histologic FindingsHistologic Findings
In 1996 Cherukupalli & colleagues described 4 pathologic stages
Acute lung injury Exudative bronchiolitis Proliferative bronchiolitis Obliterative fibroproliferative bronchiolitis
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Medical care in BPDMedical care in BPD
Prevention Mechanical ventilation O2 therapy Nutritional support Medications
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Mechanical VentilationMechanical Ventilation
O2 & PPV life saving Aggressive weaning to NCPAP eliminate need of
PPV Intubation primarily for surfactant therapy &
quickly extubation to NCPAP decrease need for prolong PPV
If infant needs O2 & PPV gentle modes of ventilation employed to maintain pH 7.28 – 7.40 , pCo2 45 – 65 , pO2 50- 70
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Mechanical VentilationMechanical Ventilation
Pulse oximetry & transcutaneous Co2 mesurements – provide information of oxygenation & ventilation with minimal patient discomfort
SIMV – provide information on TV & minute volumes which minimize O2 toxicity & barotrauma/volumetrauma
SIMV – allow infant to set own IT & rate
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Mechanical VentilationMechanical Ventilation
When weaning from vent & O2 difficult – when adequate TV & low FiO2 achievedtrial of extubation & NCPAP
Commonly extubation failuresecondary to atrophy & fatigue of respiratory muscles
Optimization of nutrition & diuretics – contribute to successful weaning from vent
Meticulous nursing care – essential to ensure airway patency & facilitate extubation
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O2 TherapyO2 Therapy
Chronic hypoxia & airway remodelingpulmonary HT & cor pulmanale
O2stimulate production of NOsmooth muscle relaxationvasodilatation
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O2 TherapyO2 Therapy
Repeated desats secondary to hypoxia results from- decreased respiratory drive
- altered pulmonary mechanics
- excessive stimulation
- bronchospasm Hyperoxiaworsen BPD as preterms have
a relative deficiency of AO
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O2 TherapyO2 Therapy
O2 requirement increase during stressful procedures & feedingstherefore wean O2 slowly
Keep sats 88% - 92% High altitudesmay require O2 many
months PRBC transfusionincrease O2 carrying
capacity in anemic(hct<30%) preterms
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O2 TherapyO2 Therapy
Study in 1988 found increased O2 content & systemic O2 transport , decreased O2 consumption & requirement after blood Tx
Need for multiple Tx & donor exposures decreased byerythropoetin , iron supplements & decreased phlebotomy requirements
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Nutritional SupportNutritional Support
Infant with BPD- increased energy requirements
Early TPN – compensate for catabolic state of preterm
Avoid excessive non N calories increase CO2 & complicate weaning
Early insertion of central linesmaximize calories in TPN
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Nutritional SupportNutritional Support
Rapid & early administration of increased lipidsworsen hyperbillirubinemia & BPD through billirubin displacement from albumin & pulmonary vascular lipid deposition respectively .
Excessive glucose loadincrease O2 consumption , respiratory drive & glucoseuria.
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Nutritional SupportNutritional Support
Cu , Mn , & Zn essential cofactors in AO defenses
Early initiation of small enteral feeds with EBM , slow & steady increase in volumefacilitate tolerance of feeds
Needs 120 – 150 Kcal/kg/day to gain weight
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Medical TherapyMedical Therapy
Diuretics Systemic bronchodilators
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DiureticsDiuretics
Furesemide (Lasix) Rx of choice Decrease PIE & pulmonary vascular
resistance Facilitate weaning from PPV , O2 /both Adverse effects – hyponatremia ,
hypokalemia , hypercalciuria , cholelithiasis , nephrocalcinosis & ototoxicity
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DiureticsDiuretics
Careful parenteral & enteral supplements compensate adverse effects
Thiazide & spiranolactone for long term Rx
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Systemic BronchodilatorsSystemic Bronchodilators
Methylxanthines – increase respiratory drive , decrease apnea , improve diaphragmatic contractility
Smooth muscle relaxation – decrease pulmonary vascular resistance & increase lung compliance
Exhibit diuretic effects
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Systemic BronchodilatorsSystemic Bronchodilators
Theophyline – metabolized primarily to caffeine in liver
Adverse effects – increase heart rate , GER , agitation & seizures
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PrognosisPrognosis
Pulmonary function slowly improves secondary to continued lung & airway growth & healing
Northway- Airway hyperactivity , abnormal pulmonary functions , hyperinflation in chest x ray persists in to adult hood
A study in 1990 found gradual decrease in symptom frequency in children 6 – 9 yrs