ATS Core Curriculum 2017: Part II. Pediatric Pulmonary Medicine

Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension: Basing Care on Physiology

Bronchopulmonary dysplasia (BPD) is the heterogeneous chronic lung developmental disease of prematurity, which is often accompanied by multisystem comorbidities. Pulmonary vascular disease and pulmonary hypertension (PH) contribute significantly to the pathogenesis and pathophysiology of BPD and dramatically influence the outcomes of preterm infants with BPD. When caring for those patients, clinicians should consider the multitude of phenotypic presentations that fall under the "BPD-PH umbrella," reflecting the need for matching therapies to specific physiologies to improve short- and long-term outcomes. Individualized management based on the patient's prenatal and postnatal risk factors, clinical course, and cardiopulmonary phenotype needs to be identified and prioritized to provide optimal care for infants with BPD-PH.

Clinical phenotypes and management concepts for severe, established bronchopulmonary dysplasia

With advances in care, the bronchopulmonary dysplasia phenotypes have evolved, so that infants who would have died in previous eras are now surviving with significant pulmonary and neurologic morbidities. The spectrum of bronchopulmonary dysplasia phenotypes is broad, however, ranging from very mild to very severe disease, and management strategies used in previous eras of care may not be appropriate for the most severe phenotypes. The pathophysiology depends largely on the gestational age at birth, but disease progression and long-term outcome depends on the net sum of antenatal, perinatal and postnatal exposures. There is no single management strategy for the wide spectrum of clinical presentations of BPD; care must be individualized. Regardless of the phenotype, the support apparatus should match the disease physiology. Here we describe an interdisciplinary approach to management in terms of achieving clinical stability and progress along a continuum, from diagnosis at 36 weeks of corrected gestational age to convalescence. The clinical trajectory depends on the balance of factors related to support of respiration, healing of the lungs, and return of organ growth and development. The overall treatment strategy should optimize positive influences that lead to a pro-growth state, while minimizing exposures that interfere with lung growth and development. This is best achieved by use of a multi-disciplinary team, with feedback loops that inform clinical decision-making regarding respiratory stability, tolerance for cares and activities, the clinical response to changes in the care plan, and progress in growth and development.