Chronic Lung Disease of Prematurity

Question 1

What is chronic lung disease of prematurity (CLDP)?

Answer 1

Chronic lung disease of prematurity (CLDP) is also known as bronchopulmonary dysplasia. It occurs in premature babies, typically those born before 28 weeks gestation. These babies suffer with respiratory distress syndrome and require oxygen therapy or intubation and ventilation at birth.

Question 2

Briefly describe the diagnosis of CLDP

Answer 2

Diagnosis is made based on CXR changes and when the infant requires oxygen therapy after they reach 36 weeks gestational age.

Question 3

What are the clincial features of CLDP?

Answer 3

• Low oxygen saturations
• Increased work of breathing
• Poor feeding and weight gain
• Crackles and wheezes on chest auscultation
• Increased susceptibility to infection

Question 4

There are a variety of lung conditions that affect premature babies and necessitate MV and put babies at risk of developing CLD. What are these?

Answer 4

There are a variety of lung conditions that affect premature babies and necessitate MV and put babies at risk of developing CLD. These include:

• RDS (premature infants)
• Neonatal pneumonia
• Meconium aspiration
• Diaphragmatic hernia
• Pulmonary hypoplasia
• Alveolar capillary membrane dysplasia
• Interstitial lung disease
• Surfactant protein deficiency

Question 5

Briefly describe how CLDP can be prevented

Answer 5

There are several measure that can be taken to minimise the risk of CLDP. Giving corticosteroids (e.g. betamethasone) to mothers that show signs of premature labour at less than 36 weeks gestation can help speed up the development of the fetal lungs before birth and reduce the risk of CLDP.

Once the neonate is born the risk of CLDP can be reduced by:

• Using CPAP rather than intubation and ventilation when possible
• Using caffeine to stimulate the respiratory effort
• Not over-oxygenating with supplementary oxygen

Question 6

Briefly describe the interventions for nutritional support and therapy in managing CLDP

Answer 6

• Weight gain and growth
  
  • These should be monitored, and if there is a problem with inadequate intake, consult a dietician for advice
• Gastrostomy
  
  • Procedure sometimes required to enable full feeding.
• GOR
  
  • The ‘flat’ position of the diaphragm, lung hyperinflation and tachypnoea promote the development of vomiting and GOR
  • The lungs need to be protected and adequate feeding needs to be ensured
  • Initially try medical therapy such as acid suppressants
  • If these measures fail, fundoplication and gastrostomy feeds are required
• Vitamins
  
  • Appropriate vitamin supplements are used until the child is thriving well (i.e. vitamin compound drops, folic acid, iron)

Question 7

Briefly describe the antimicrobial strategy in managing CLDP

Answer 7

• Vaccination
  
  • All immunizations should be up-to-date
  • Patients should be offered the annual influenza vaccine
  • Some may be eligible for RSV vaccine
• Antibiotics
  
  • Viral or bacterial illness may result in significant deterioration in CLD and be hard to differentiate clinically
  • Take sputum, throat swab, and nasopharyngeal aspirate for viral and bacterial cultures
  • Have a low threshold for starting antibiotics

Question 8

Wheeze is a common symptom in infants with CLD. How is this treated?

Answer 8

Wheeze is a common symptom in infants with CLD. Asthma treatments are often used in these children to relieve any bronchoconstrictive element.

Question 9

How is RSV prevented in patients with CLDP?

Answer 9

This involves monthly injections of a monoclonal antibodyagainst the virus called palivizumab. This is very expensive (around £500 per injection) so is reserved for babies meeting certain criteria.

Question 10

Briefly describe the role of O2 therapy in managing CLDP

Answer 10

The aim of supervision of these patients is to withdraw O2 in a safe and timely manner. The target SpO2 in patients on nasal cannula O2 (NC-O2) is ≥92%. Withdrawal is appropriate when the infant is clinically well, and gaining weight, and has an SpO2 that is consistently ≥92%, with NC-O2 requirement ≤0.1L/min.

Children can be weaned from continuous low-flow O2 to night-time and naps only or remain on continuous O2 throughout 24h until the child has no requirement at all.

Weaning can be directed by regular SpO2 sleep studies. O2 equipment should be left in the home for at least 3mth after the child has stopped using it. If this is in winter, it is usually left until the end of winter.