Bronchopulmonary dysplasia: Clinical practices in five Portuguese neonatal intensive care units

Guimarães, H.; Rocha, G.; Vasconcellos, G.; Proença, E.; Carreira, M.L.; Sossai, M.R.; Morais, B.; Martins, I.; Rodrigues, T.; Severo, M.

doi:10.1016/S2173-5115(10)70035-X

Article information

Abstract

With the advent of surfactant, prenatal corticosteroids (PNC) and advances in technology, the survival rate of extremely low birth weight (ELBW) infants has improved dramatically. Rates of bronchopulmonary dysplasia (BPD) vary widely among neonatal intensive care units (NICUs) and many studies using multiple interventions have shown some improvement in BPD rates. Implementing potentially better practices to reduce BPD has been an effort made over the last few decades.

Aim

To compare five Portuguese NICUs in terms of clinical practices in very low birth weight (VLBW) infants, in order to develop better practices to prevent BPD.

Patients and methods

256 preterm neonates, gestational age (GA)<30 weeks and/or birthweight (BW)<1250g admitted to five Portuguese NICUs (centers 1 to 5) between 1st January 2004 and 31st December 2006, were studied. VLBW infants with major malformations, grade IV intraventricular haemorrhage in the first week of life and metabolic or neuromuscular disease were excluded. BPD was defined as oxygen dependency at 36 weeks of postconceptional age. We considered a practice to be improved as clinically significant whenever a decrease greater than 10% in the prevalence of BPD adjusted for the practice, GA and BW was achieved compared to BPD prevalence adjusted only for GA and BW.

Results

The overall prevalence of BPD was 12.9%. Our results revealed that PNC use should be improved in centers 4 and 5; fluid policy in center 4; oxygen therapy and sepsis prevention in centers 1 and 2. Patent ductus arteriosus (PDA) treatment should be improved in center 2.

Conclusion

The implementation of potentially better practices to reduce lung injury in neonates in Portuguese NICUs, according to each NICU, must be addressed to increase the prescription of PNC, to use a lower FiO2, to be careful with fluid administration in the first weeks of life and to prevent PDA and sepsis. It is necessary to follow guidelines, recommendations or protocols to improve quality in the prevention of BPD.

Key-words:

Bronchopulmonary dysplasia

neonatal intensive care

preterm infants

better practices

mechanical ventilation

oxygen therapy

prenatal corticosteroids

sepsis

patent ductus arteriosus

Resumo

Com o advento do surfactante, dos corticosteróides pré-natais e dos avanços na tecnologia, a sobrevida dos recém-nascidos de extremo baixo peso tem melhorado dramaticamente. As taxas de displasia broncopulmonar (DBP) variam amplamente entre unidades, e vários estudos, avaliando resultados de múltiplas intervenções, têm mostrado alguma melhoria na prevalência da DBP. A implementação de potenciais boas práticas na DBP tem sido adoptada por muitos serviços nas últimas décadas.

Objectivo

Comparar cinco unidades portuguesas de cuidados intensivos neonatais no que se refere as práticas clínicas no tratamento dos recém-nascidos de muito baixo peso, para desenvolver e melhorar as boas práticas na prevenção da DBP.

População e métodos

Foram estudados 256 recém-nascidos com a idade gestacional inferior a 30 semanas e/ou peso ao nascer inferior a 1250g, admitidos nas cinco unidades portuguesas (centros 1 a 5) entre 1 de Janeiro de 2004 e 31 de Dezembro de 2006. Foram excluídos os recém-nascidos com malformações major, hemorragia intraventricular grau IV na primeira semana de vida e com doença metabólica ou neuromuscular. Definimos DBP como a dependência do oxigénio às 36 semanas de idade pósconcepcional. A necessidade de melhorar determinada prática foi considerada significativa sempre que se verificava uma melhoria superior a 10% na prevalência da DBP ajustada para a prática, idade gestacional e peso ao nascer, comparada com a prevalência ajustada só para a idade gestacional e peso ao nascer.

Resultados

A prevalência global da DBP foi de 12,9%. Os resultados mostram que o uso de corticosteróides pré-natais deve ser melhorado nos centros 4 e 5; a política de fluidos deve ser melhorada no centro 4; o uso de oxigénio e a prevenção da sépsis deve ser melhorada nos centros 1 e 2. O tratamento do canal arterial patente deve ser melhorado no centro 2.

Conclusão

Neste estudo, a implementação de boas práticas para reduzir a lesão pulmonar nos recém-nascidos, de acordo com cada unidade, deve ser dirigida ao aumento da prescrição de corticosteróides pré-natais, ao uso de menor FiO2, ao uso criterioso de líquidos na primeiras semanas de vida, à prevenção do canal arterial patente e da sépsis. Guidelines, recomendações ou protocolos são necessários na melhoria da qualidade na prevenção da DBP.

Palavras-chave:

Displasia broncopulmonar

cuidados intensivos neonatais

recém-nascidos de pré-termo

boas práticas

ventilação mecânica

oxigénio

corticosteróides pré-natais

sépsis

canal arterial patente

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Bibliography

[1.]

W.H. Northway Jr., R.C. Rosan, D.Y. Porter.

Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia.

N Engl J Med, 276 (1967), pp. 357-368

http://dx.doi.org/10.1056/NEJM196702162760701 | Medline

[2.]

E. Bancalari, G.E. Abdenour, R. Feller, J. Gannon.

Bronchopulmonary dysplasia: clinical presentation.

J Pediatr, 95 (1979), pp. 819-823

Medline

[3.]

A.T. Shennan, M.S. Dunn, A. Ohlsson, K. Lennox, E.M. Hoskins.

Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period.

Pediatrics, 82 (1988), pp. 527-532

Medline

[4.]

M.C. Walsh, Q. Yao, P. Gettner, E. Hale, M. Collins, A. Hensman, R. Everette, N. Peters, N. Miller, G. Muran, K. Auten, N. Newman, G. Rowan, C. Grisby, K. Arnell, L. Miller, B. Ball, G. McDavid.

National Institute of Child Health and Human Development Neonatal Research Network. Impact of a physiologic definition on bronchopulmonary dysplasia rates.

Pediatrics, 114 (2004), pp. 1305-1311

http://dx.doi.org/10.1542/peds.2004-0204 | Medline

[5.]

R.A. Ehrenkranz, M.C. Walsh, B.R. Vohr, A.H. Jobe, L.L. Wright, A.A. Fanaroff, L.A. Wrage, K. Poole.

National Institutes of Child Health and Human Development Neonatal Research Network Validation of the National Institutes of Health consensus definition of bronchopulmonary dysplasia.

Pediatrics, 116 (2005), pp. 1353-1360

http://dx.doi.org/10.1542/peds.2005-0249 | Medline

[6.]

I.R.S. Sosenko, E. Bancalari.

New developments in the presentation, pathogenesis, epidemiology and prevention of bronchopulmonary dysplasia.

The Newborn Lung Eduardo Bancalari, Richard A Polin. Saunders Elsevier, (2008),

[7.]

Crossing the Quality Chasm.

A new health system for the 21st century.

National Academy, (2001),

[8.]

N.R. Payne, M. LaCorte, P. Karna, S. Chen, M. Finkelstein, J.P. Goldsmith, J.H. Carpenter, Breathsavers Group.

Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative. Reduction of bronchopulmonary dysplasia after participation in the Breathsavers Group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative.

Pediatrics, 118 (2006), pp. S73-S77

http://dx.doi.org/10.1542/peds.2006-0913C | Medline

[9.]

N.R. Payne, M. LaCorte, S. Sun, P. Karna, M. Lewis-Hunstiger, J.P. Goldsmith, Breathsavers Group.

Evaluation and development of potentially better practices to reduce bronchopulmonary dysplasia in very low birth weight infants.

Pediatrics, 118 (2006), pp. S65-S72

http://dx.doi.org/10.1542/peds.2006-0913B | Medline

[10.]

K. Burch, W. Rhine, R. Baker, F. Litman, J.W. Kaempf, E. Schwarz, S. Sun, N.R. Payne, P.J. Sharek.

Implementing potentially better practices to reduce lung injury in neonates.

Pediatrics, 111 (2003), pp. e432-e436

Medline

[11.]

P.J. Sharek, R. Baker, F. Litman, J. Kaempf, K. Burch, E. Schwarz, S. Sun, N.R. Payne.

Evaluation and development of potentially better practices to prevent chronic lung disease and reduce lung injury in neonates.

Pediatrics, 111 (2003), pp. e426-e431

Medline

[12.]

A.H. Jobe, E. Bancalari.

Bronchopulmonarydysplasia.

Am J Respi Crit Care Med, 163 (2001), pp. 1723-1729

[13.]

H. MacDonald.

American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal Care at the Threshold of Viability.

Pediatrics, 110 (2002), pp. 1024-1027

Medline

[14.]

J.L. Ballard, J.C. Khoury, K. Wedig, L. Wang, B.L. Eilers-Walsman, R. Lipp.

New ballard score, expanded to include extremely premature infants.

J Pediatr, 119 (1991), pp. 417-423

Medline

[15.]

A.J. Rudolph, C.A. Smith.

Idiopathic respiratory distress syndrome of the newborn.

J Pediatr, 57 (1960), pp. 905-921

[16.]

M.C. Walsh, R.M. Kliegman.

Necrotizing enterocolitis: treatment based on staging criteria.

Ped Clin N Am, 33 (1986), pp. 179-201

[17.]

An International classification of retinopathy of prematurity.

Pediatrics, 74 (1984), pp. 127-133

Medline

[18.]

The international classification of retinopathy of prematurity revisited., International Committee for the Classification of Retinopathy of Prematurity.

Arch Ophthalmol, 123 (2005), pp. 991-999

http://dx.doi.org/10.1001/archopht.123.7.991 | Medline

[19.]

L.A. Papile, J. Burstein, R. Burstein.

Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birthweights less than 1500g.

J Pediatr, 92 (1978), pp. 529-534

Medline

[20.]

L. de Vries, J.M. Rennie.

Preterm brain injury.

Textbook of neonatology, 3rd edition., pp. 1252-1270

[21.]

E. Bancalari, N. Claure, I.R. Sosenko.

Bronchopulmonary dysplasia: changes in pathogenesis, epidemiology and definition.

Semin Neonatol, 8 (2003), pp. 63-71

Medline

[22.]

M. Walsh, W. Engle, A. Laptook, S.N. Kazzi, S. Buchter, M. Rasmussen, Q. Yao.

National Institute of Child Health and Human Development Neonatal Research Network. Oxygen delivery through nasal cannulae to preterm infants: can practice be improved?.

Pediatrics, 116 (2005), pp. 857-861

http://dx.doi.org/10.1542/peds.2004-2411 | Medline

[23.]

P. Crowley.

Prophylactic corticosteroids for preterm birth.

Cochrane Database Syst Rev, 18 (2007),

[24.]

D. Roberts, S. Dalziel.

Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth.

Cochrane Database Syst Rev, 19 (2006),

[25.]

National Institutes of Health Consensus Development Panel.

Antenatal corticosteroids revisited: repeat courses – National Institutes of Health Consensus Development Conference Statement. August 17–18, 2000.

Obstet Gynecol, 98 (2001), pp. 144-150

Medline

[26.]

C.A. Crowther, J.E. Harding.

Repeat doses of prenatal corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease.

Cochrane Database Syst Rev, 18 (2007),

[27.]

Collaborative European Multicenter Study Group.

Surfactant replacement therapy for severe neonatal respiratory distress syndrome: an international randomized clinical trial.

Pediatrics, 82 (1988), pp. 683-691

Medline

[28.]

U. Chotigeat, N. Promwong, W. Kanjanapattanakul, M. Khorana, V. Sangtawesin, S. Horpaopan.

Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods.

J Med Assoc Thai, 91 (2008), pp. S109-S114

Medline

[29.]

Halliday HL, O'Neil CP. What is the evidence for drug therapy in the prevention and management of bronchopulmonary dysplasia? In: The newborn lung. Neonatal questions and controversies. Eduardo Bancalari. Ed Richard A Polin. Saunders Elsevier 2008; 208-232.

[30.]

T.P. Stevens, E.W. Harrington, M. Blennow, R.F. Soll.

Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome.

Cochrane Database Syst Rev, 17 (2007),

[31.]

R. Soll, E. Ozek.

Multiple versus single doses of exogenous surfactant for the prevention or treatment of neonatal respiratory distress syndrome.

Cochrane Database Syst Rev, 21 (2009),

[32.]

R.J. Ramanathan.

Surfactant therapy in preterm infants with respiratory distress syndrome and in nearterm or term newborns with acute RDS.

Perinatol, 26 (2006), pp. S63-S64

[33.]

VLBW infants in Portugal. National Multicenter Study, 1996–2000.

Portuguese Neonatal Network.

Bial Award of Clinical Medicine, (2002),

[34.]

R. Ramanathan.

Choosing a right surfactant for respiratory distress syndrome treatment.

Neonatology, 95 (2009), pp. 1-5

http://dx.doi.org/10.1159/000151749 | Medline

[35.]

W. Oh, B.B. Poindexter, R. Perritt, J.A. Lemons, C.R. Bauer, R.A. Ehrenkranz, B.J. Stoll, K. Poole, L.L. Wright, Neonatal Research Network.

Association between fluid intake and weight loss during the first ten days of life and risk of bronchopulmonary dysplasia in extremely low birth weight infants.

J Pediatr, 147 (2005), pp. 786-790

http://dx.doi.org/10.1016/j.jpeds.2005.06.039 | Medline

[36.]

B.E Stephens, M.J. Gargus, R.V. Walden, N. Mance, J. Nye, L. McKinley, R. Tucker, B.R. Vohr.

Fluid regimens in the first week of life may increase risk of patent ductus arteriosus in extremely low birth weight infants.

J Perinatol, 28 (2008), pp. 123-128

http://dx.doi.org/10.1038/sj.jp.7211895 | Medline

[37.]

E.F. Bell, M.J. Acarregui.

Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants.

Cochrane Database Syst Rev, (2008),

[38.]

R. Ramanathan.

Optimal ventilatory strategies and surfactant to protect the preterm lungs.

Neonatology, 93 (2008), pp. 302-308

http://dx.doi.org/10.1159/000121456 | Medline

[39.]

K. Bohlin, B. Jonsson, A.S. Gustafsson, M. Blennow.

Continuous positive airway pressure and surfactant.

Neonatology, 93 (2008), pp. 309-315

http://dx.doi.org/10.1159/000121457 | Medline

[40.]

R. Ramanathan, S. Sardesai.

Lung protective ventilatory strategies in very low birth weight infants.

J Perinatol, 28 (2008), pp. S41-S46

http://dx.doi.org/10.1038/jp.2008.49 | Medline

[41.]

D. Patel, A. Greenough.

Does nasal CPAP reduce bronchopulmonary dysplasia (BPD)?.

Acta Paediatr, 97 (2008), pp. 1314-1317

http://dx.doi.org/10.1111/j.1651-2227.2008.00931.x | Medline

[42.]

O.D. Saugstad.

Take a breath – but do not add oxygen (if not needed).

Acta Paediatr, 96 (2007), pp. 798-800

http://dx.doi.org/10.1111/j.1651-2227.2006.00348.x | Medline

[43.]

O.D. Saugstad, S. Ramji, R.F. Soll, M. Vento.

Resuscitation of newborn infants with 21% or 100% oxygen: an updated systematic review and meta-analysis.

Neonatology, 94 (2008), pp. 176-182

http://dx.doi.org/10.1159/000143397 | Medline

[44.]

W. Tin, S. Gupta.

Optimum oxygen therapy in preterm babies.

Arch Dis Child Fetal Neonatal., 92 (2007), pp. F143-F147

[45.]

A. Sola.

Oxygen in neonatal anesthesia: friend or foe?.

Curr Opin Anaesthesiol, 21 (2008), pp. 332-339

http://dx.doi.org/10.1097/ACO.0b013e3282f8ad8d | Medline

[46.]

STOP-ROP Multicenter Study Group.

Supplemental therapeutic oxygen for pretreshold retinopathy of prematurity (STOP-ROP), a randomized controlled trial. I: Primary outcomes.

Pediatrics, 105 (2000), pp. 295-310

Medline

[47.]

W. Tin, T.E. Wiswell.

Adjunctive therapies in chronic lung disease: examining the evidence.

Semin Fetal Neonatal Med, 13 (2008), pp. 44-52

http://dx.doi.org/10.1016/j.siny.2007.09.008Article | Medline

[48.]

C.P. Speer.

Inflammation and bronchopulmonary dysplasia: a continuing story.

Semin Fetal Neonatal Med, 11 (2006), pp. 354-362

http://dx.doi.org/10.1016/j.siny.2006.03.004 | Medline

[49.]

C.L. Bose, C.E. Dammann, M.M. Laughon.

Bronchopulmonary dysplasia and inflammatory biomarkers in the premature neonate.

Arch Dis Child Fetal Neonatal, 93 (2008), pp. F455-F461

[50.]

P. Groneck, J. Schmale, V. Soditt, H. Stützer, B. Götze-Speer, C.P. Speer.

Bronchoalveolar inflammation following airway infection in preterm infants with chronic lung disease.

Pediatr Pulmonol, 31 (2001), pp. 331-338

Medline

[51.]

G. Rocha, E. Proença, C. Quintas, T. Rodrigues, H. Guimarães.

Chorioamnionitis and lung damage in the extremely low birth weight infant.

Rev Port Pneumol, 3 (2007), pp. 745-754

[52.]

A. Gonzalez, I.R. Sosenko, J. Chandar, H. Hummler, N. Claure, E. Bancalari.

Influence of infection on patent ductus arteriosus and chronic lung disease in premature infants weighing 1000 grams or less.

J Pediatr, 128 (1996), pp. 470-478

Medline

[53.]

M. Liljedahl, L. Bodin, J. Schollin.

Coagulase-negative staphylococcal sepsis as a predictor of bronchopulmonary dysplasia.

Acta Paediatr, 93 (2004), pp. 211-215

Medline

[54.]

M. Moro, J. Pérez-Rodriguez, J. Figueras-Aloy, C. Fernández, E. Doménech, R. Jiménez, V. Pérez-Sheriff, J. Quero, V. Roques.

Predischarge morbidities in extremely and very low-birth-weight infants in spanish neonatal units.

Am J Perinatol, (2008), pp. 17

[55.]

S.G. Golombek, A. Sola, H. Baquero, D. Borbonet, F. Cabañas, C. Fajardo, G. Goldsmit, L. Lemus, E. Miura, A. Pellicer, J.M. Pérez, M. Rogido, G. Zambosco, B. van Overmeire, S.G. Golombek, A. Sola, R. Clyman, B. van Overmeire, G. Goldsmit, D. Natta, G. Zambosco, E. Miura, J.M. Péerez, C. Weissheimer, H. Baquero, J. García Harker, A.N. Oviedo Barrantes, M. Morgues, J.L. Tapia, F. Domínguez, M. Majano, F. Cabañas, Pellicer A., H. Cruz, C. Fajardo, M. Rogido, L. Lemus, A.V. Origel, Lacarruba J.M., M. Lee, J. Tresierra, H. Guimarães, R. Bustos, D. Borbonet, J.L. Perales.

First SIBEN clinical consensus: diagnostic and therapeutic approach to patent ductus arteriosus in premature newborns.

An Pediatr, 69 (2008), pp. 454-481

[56.]

A. Ohlsson, R. Walia, S. Shah.

Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants.

Cochrane Database Syst Rev, 23 (2008),

[57.]

R. Mosalli, K. Alfaleh.

Prophylactic surgical ligation of patent ductus arteriosus for prevention of mortality and morbidity in extremely low birth weight infants.

Cochrane Database Syst Rev, 23 (2008),

[58.]

D. McCurnin, S. Seidner, L.Y. Chang, N. Waleh, M. Ikegami, J. Petershack, B. Yoder, L. Giavedoni, K.H. Albertine, M.J. Dahl, Z.M. Wang, R.I. Clyman.

Ibuprofen-induced patent ductus arteriosus closure: physiologic, histologic, and biochemical effects on the premature lung.

Pediatrics, 121 (2008), pp. 945-956

http://dx.doi.org/10.1542/peds.2007-2051 | Medline

[59.]

P. Lundqvist, K. Källén, I. Hallström, L.H. Westas.

Trends in outcomes for very preterm infants in the southern region of Sweden over a 10-year period.

Acta Paediatr, 98 (2009), pp. 648-653

http://dx.doi.org/10.1111/j.1651-2227.2008.01155.x | Medline

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