Bronchopulmonary Dysplasia (BPD)

Airway shaped by the NICU - Barotrauma, repeated airway manipulation, and recurrent infection leave subglottic stenosis and laryngo-, tracheo-, or bronchomalacia. Read the prior intubation and bronchoscopy records for tube size and any documented stenosis, and have smaller tubes drawn up.

Pulmonary hypertension - PH complicates 25% to 50% of infants with severe BPD. Look for the screening transthoracic echocardiogram done at 36 weeks postmenstrual age and the BNP trend; hepatomegaly and congested systemic veins point the same way. Cor pulmonale, transient systemic hypertension, and LV hypertrophy travel with it.

Keep PVR down - Hypoxia, hypercarbia, and acidosis all raise pulmonary pressure and widen right-to-left shunt. Ventilate to this child's usual gas exchange, not to textbook numbers.

Oxygen target - Titrate to SpO2 91% to 95%, avoiding below 85% and above 97%. Extra oxygen is not free here - these are the same infants at risk for retinopathy of prematurity.

Reactive airways - BPD survivors carry asthma-like physiology with reduced FEV1, FVC, and FEF50%. Treat them like an asthmatic: bronchodilator before induction, adequate depth before instrumenting.

Blunted hypoxic drive - Carotid body signaling is reduced, and the worse the BPD the flatter the ventilatory response to both hypoxia and hyperoxia. They apnea, breathe periodically, and decompensate, so plan postoperative apnea monitoring rather than same-day discharge.

Reflux - Gastroesophageal reflux is common in BPD. When the history supports it, treat the stomach as full.

Recent infection changes the plan - Ordinary respiratory infections carry real morbidity and mortality in BPD survivors, and half of these infants are readmitted in their first year. A current URI is a heavier argument for postponing here than in a healthy child.

Renal handling - Renal insufficiency, nephrocalcinosis, and hypercalciuria are described in BPD. Check the recent metabolic panel before dosing renally cleared drugs.

Bronchopulmonary dysplasia (BPD) is chronic lung disease of the preterm infant. Lung development arrests in the late canalicular and saccular stages, usually in babies born at 24 to 28 weeks who needed supplemental oxygen and positive pressure for respiratory distress. Alveolar septation stops, leaving fewer and larger alveoli and far less surface area for gas exchange, while increased collagen and elastic tissue add fixed airflow obstruction.

The pulmonary vasculature is injured at the same time. Alveolar capillaries are abnormally distributed and arteriolar smooth muscle thickens, raising pulmonary vascular resistance, and a persistent PDA or intracardiac shunt raises it further. That is why the airway problem and the right heart problem arrive together: stiff, obstructed lungs sitting on a pressure-loaded right ventricle. Severity is graded by the respiratory support the infant still needs at 36 weeks postmenstrual age.