An interdisciplinary approach to care of infants with bronchopulmonary dysplasia. Alfred L. Gest, MD
An interdisciplinary approach to care of infants with bronchopulmonary dysplasia.
Alfred L. Gest, MD
Objectives:
A brief historical perspective Explanation of pathophysiology Discuss the concepts of interdisciplinary
care with examples of how it actually works.
Discuss medical and developmental outcomes in infants with BPD.
BRONCHOPULMONARY DYSPLASIA
•A primary disorder of airways and lung parenchyma following interface of the lung with mechanical ventilation.
•Functional abnormalities are detectable by the third day of life and predisposing factors may be present at birth.
• Subsequent clinical behavior is largely related to pattern of re-growth of lung.
•Current care is supportive, not therapeutic.
BRONCHOPULMONARY DYSPLASIA
Modern Diagnostic Criteria (NICHD–2001)
Mild=02 >28 days, not 36 weeks PCA Moderate = < 30% 02 at 36 weeks PCA
Severe = > 30% 02 or IMV at 36 weeks PCA
(predictive of pulmonary/neurologic outcome risk)
The Neonatal Period Ends at 28 days.
Pathophysiology
•Airway and interstitial inflammation and fibrosis •Adjacent areas of atelectasis•Inhomogeneous disease •Increased airway resistance•Decreased compliance •Long expiratory time constants•High pressure pulmonary edema •Relative right ventricular dysfunction
Respiratory Failure Immature Lung
Pulmonary OxygenToxicity
"Volutrauma""Atelectotrauma"
BPD
GeneticPredispositionInflammation
antenatalpostnatal
BPD Incidence
501
- 750
751
- 100
0
1001
- 12
50
1251
- 15
00 0
25
50
75
100%
BPD
O
2 r
eq
uir
em
en
t at
36
weeks
CG
A
Birthweight
Potentially Better Practices for Prevention of BPD
Early administration of surfactant Early extubation to nasal CPAP Vitamin A Oxygen saturation targeting Nitric oxide ?
Why is there so much BPD? More at risk babies are surviving. The potentially better practices are
difficult to implement or they are unattractive.Nasal CPAPVitamin ADelivery room surfactantOxygen saturation targeting
Phase of BPDR ela tiv e s ta b i li ty / ins ta b i li ty
N utr i tionS o cia l
Intake inform ation
Outpatient M anagem ent
Discharge P lanning
Ongoing Hospital Care
M onthly Meeting
BPD EducationT e am A p pro ach to ca re
G o a lsE xp ec ta tio ns
M eet w ith parents
W eekly WorkM e d ica l s ta ff, R T , P T , O TS o cia l S erv ice , N u tr it ion
F a ci li ta to r
Subgroup form ation
Identify Patients
Initial Team Meeting With Parents
Introduction to team members and team concept
Education about BPD Approach to care Goals Expectations Address concerns
Division of Patients Into Subgroups (workgroups)
Attending physician NNP/Resident Nursing Respiratory
therapy Social service Neonatal feeding
service
Clinical care coordinator Nutrition OT PT Pharmacy Facilitator Parent Representative
First month
Early BPDTime of Instability
1 to 3 months
Airway InjuryRelative Stability
Growth and Remodeling
3 to 9 months
Home Plans
Two subsets:a) oxygen and NCPAPb) chronic ventilator dependence
Time Course for BPD(development, stabilization and resolution)
BPD is a Chronic Disease
We should not expect BPD to improvein a day, in a week,
or even in a month
Successful Treatment of BPD isSynonymous With Good Supportive Care
Prevention of Infection Prevention of Right Heart Failure Excellent Nutrition for Growth and Repair Developmental Assistance
Minimal Impact Respiratory Support
Prevention of Infection
Limit ports of entry Good Infection Control Policy Appropriate, Cautious Antibiotic Use
Prevention of Right Heart Failure(Cor Pulmonale)
Avoid hypoxia Keep O2 Saturations Above 95% Maintain Adequate FRC
Diuretics and BPD
Use appropriate fluid restriction with adequate caloric intake primarily.
Use chronic diuretic therapy cautiously:One of the last therapies to addOne of the first therapies to stop
Excellent Nutrition for Growth and Repair
120 Calories/kg/day Minimum Enteral 100 Calories/kg/day Minimum Parenteral These Calories Need to be Supplied in
the Face of Fluid Restriction (110–150ml/kg/day)
Developmental Assistance
Individualized Developmental Care Primary Care Nursing Multidisciplinary Approach to Care Parental Involvement Adequate Ventilatory Support
Minimal Impact Respiratory Support
Maintenance of FRC Prevention of Hypoxia Adequate Support With Minimal Damage Management of Pulmonary Edema
Suggested Ventilatory Management for BPD
IMV
PIP
PEEP
Ti
FiO2
12-20 breaths per minute
Sufficient for Chest Rise (25-45 cm H2O)
5-8 cm H2O
0.4-0.8 sec
To Maintain O2 Saturation 95-99%
Suggested Ventilatory Management for BPD
Weaning Protocol
< 50% O2 and weight gain of at least 10g / day
Pressure Support Trials Starting at 30 min / day
Once up to 12 hours / day, Wean PS
After on 8-10 PS for 12 hrs / day, go to 24 hrs
Extubate to Nasal Cannula
This Process Takes at Least 6 Weeks
Suggested Ventilatory Management for BPD
The response of the baby dictates the rapidityof progress through this weaning regimen.
If weaning is not tolerated, it is better toretreat than forge ahead.
Phase of BPDR ela tiv e s ta b i li ty / ins ta b i li ty
N utr i tionS o cia l
Intake inform ation
Outpatient M anagem ent
Discharge P lanning
Ongoing Hospital Care
M onthly Meeting
BPD EducationT e am A p pro ach to ca re
G o a lsE xp ec ta tio ns
M eet w ith parents
W eekly WorkM e d ica l s ta ff, R T , P T , O TS o cia l S erv ice , N u tr it ion
F a ci li ta to r
Subgroup form ation
Identify Patients
Discharge Planning Reality-based assessment of parents’ and
the community’s abilities and expectations Stable oxygen need documented without
exacerbations and with sustained growth and development
Ability to feed orally or if not possible, a plan in place for improving oral feeds
Involvement of the home care company Optimal use of home developmental service Involvement of primary care physician Clinic staff assessment
Nationwide Children’s HospitalValue Compass for BPD
Functional•All oral feeds (lack of tube feeds)
•Normal development at 24 months by Bayley III
Clinical•Growth along percentile•Minimal use of post-natal steroids
•Adequate oxygenation-lack of cor pulmonale
Satisfaction•Positive experience with BPD care team
•Positive experience with home careCost
•Re-admission within 1 month discharge•Length of stay•Parental financial concern
Nationwide Children’s HospitalWeb Of Causation
Under Utilized Community Resources
ER Visits
Lack of Reality Based Discharge
Family Anxiety
Reactive AirwayDisease
Remote Area
Key Outcome
Re-admission Rate
Nationwide Children’s Hospital Results: Incidence of BPD and Readmission Within 30 Days of Discharge
0
50
100
150
200
250
300
Patients withBPD
Readmissions
BPD Clinic begins 2004
Nationwide Children’s Hospital ResultsReadmissions of infants (within 30 days of discharge) with BPD followed in the BPD clinic
9 (6.3%)
142
2007
Number of readmissions, n (%)
Patients with BPD, n
Year
77 (29%)
269
2003
Before BPD Clinic
8 (3.1%)
258
2004
After BPD Clinic
11 (6.2%)
177
2005
8 (4.7%)
170
2006 2008
119
11 (9%)
BRONCHOPULMONARY DYSPLASIA
MORTALITY
Northway 1967 66%
Northway 1979 40%
Myers 1986 30%
Hansen 1991 10%
OUTCOME OF BPD
If IPPV > 60 DaysMortality = 24%
If IPPV > 90 Days Mortality = 40%
Abnormal neurologic outcome = 80%(NICHD – 2001)
Mortality on Ventilator at More than 60 or 90 Days:
Nationwide Children’s Hospital vs NICHD
Vent and Group Mortality
No Yes Total
60< vent <90
NCH 39 4 43
NICHD 282 90 372
Total 321 94 415
Vent >90
NCH 32 8 40
NICHD 39 33 72
Total 71 41 112------------------------------------------------------------------------------ mortality | Odds Ratio Std. Err. z P>|z| [95% Conf. Interval]-------------+---------------------------------------------------------------- group | 3.268139 1.149181 3.37 0.001 1.640556 6.510435 vent | 2.620394 .6464599 3.90 0.000 1.615743 4.249725------------------------------------------------------------------------------
the mortality advantage at NCH is 3.3
Severe BPD (n=30)
MDI 49.87Cognitive <70
PDI 41.713Motor <70
20Language <70
PDI 26.19Motor <70
11Language <70MDI 35.1
4Cognitive <70
Moderate BPD (n=75)
NICHD(Bayley II)
(%)
Nationwide Children’sOutcomes (Bayley III)
(%)
Bayley III Outcomes <70 with Moderate and Severe BPD Compared to NICHD Bayley II
Outcomes <70
Severe BPD (n=30)
MDI 49.87Cognitive <70
PDI 41.713Motor <70
20Language <70
PDI 26.19Motor <70
11Language <70MDI 35.1
4Cognitive <70
Moderate BPD (n=75)
NICHD(Bayley II)
(%)
Nationwide Children’sOutcomes (Bayley III)
(%)
Bayley III Outcomes <70 with Moderate and Severe BPD Compared to NICHD Bayley II
Outcomes <70
Severe BPD (n=30)
MDI 49.830Cognitive <85
PDI 41.740Motor <85
33Language <85
PDI 26.132Motor <85
37Language <85MDI 35.1
16Cognitive <85
Moderate BPD (n=75)
NICHD(Bayley II)
(%)
Nationwide Children’sOutcomes (Bayley III)
(%)
Bayley III Outcomes < 85 with Moderate and Severe BPD Compared to NICHD Bayley II
Outcomes <70
Severe BPD (n=30)
MDI 49.830Cognitive <85
PDI 41.740Motor <85
33Language <85
PDI 26.132Motor <85
37Language <85MDI 35.1
16Cognitive <85
Moderate BPD (n=75)
NICHD(Bayley II)
(%)
Nationwide Children’sOutcomes (Bayley III)
(%)
Bayley III Outcomes < 85 with Moderate and Severe BPD Compared to NICHD Bayley II
Outcomes <70