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.


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%


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


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%)


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)


PDI 41.713Motor <70

20Language <70

PDI 26.19Motor <70


4Cognitive <70

Moderate BPD (n=75)

NICHD(Bayley II)

(%)


(%)

Bayley III Outcomes <70 with Moderate and Severe BPD Compared to NICHD Bayley II

Outcomes <70

Severe BPD (n=30)


PDI 41.740Motor <85

33Language <85

PDI 26.132Motor <85


16Cognitive <85

Moderate BPD (n=75)

NICHD(Bayley II)

(%)


(%)

Bayley III Outcomes < 85 with Moderate and Severe BPD Compared to NICHD Bayley II

Outcomes <70

Severe BPD (n=30)


PDI 41.740Motor <85

33Language <85

PDI 26.132Motor <85


16Cognitive <85

Moderate BPD (n=75)

NICHD(Bayley II)

(%)


(%)

Bayley III Outcomes < 85 with Moderate and Severe BPD Compared to NICHD Bayley II

Outcomes <70

Documents

An interdisciplinary approach to care of infants with bronchopulmonary dysplasia. Alfred L. Gest, MD