Bronchopulmonary dysplasia

Background

• Chronic lung disease that develops in premature infants who require prolonged mechanical ventilation and/or supplementary oxygen, usually due to respiratory distress syndrome
• Develops within first 4 weeks of life while infant still in NICU
• Typically lung function improves with time, but many require long term O2 supplementation or other therapy

Clinical Features

• May be asymptomatic until something (e.g. infection, respiratory irritant) triggers decompensation
• SOB
• Hypoxia
• Increased respiratory secretions
• Wheezing, crackles
• +/- pulmonary hypertension
• Poor feeding

Differential Diagnosis

Pediatric Wheezing

• Upper Airway diseases
  • Allergic rhinitis and sinusitis
• Large Airway Obstruction
  • Foreign body aspiration
  • Vascular ring or laryngeal webs
  • Laryngotracheomalacia
  • Enlarged lymph node or tumor
  • Vocal cord dysfunction
• Small Airway Obstruction
  • Asthma
  • Viral bronchiolitis
  • Cystic Fibrosis
  • Bronchopulmonary dysplasia
  • Congenital heart disease or other cardiac disease
• Other causes
  • GERD
  • Anaphylaxis

Pediatric Shortness of Breath

Pulmonary/airway

• Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspirated foreign body
  • Asthma exacerbation

• Structural
  • Bronchopulmonary dysplasia
  • Choanal atresia
  • Neoplasm
  • Subglottic stenosis
  • Tracheoesophageal fistula
  • Tracheomalacia
  • Spontaneous pneumothorax

• Infectious
  • Bacterial tracheitis
  • Bronchiolitis (peds), URI
  • Croup
  • Epiglottitis
  • Pertussis
  • Pneumonia
  • Cystic fibrosis exacerbation

• Trauma
  • Rib fractures
  • Flail chest
  • Traumatic pneumothorax
  • Pulmonary contusion

• Other
  • Inhalation exposure
  • Meconium aspiration syndrome
  • Pulmonary edema
  • Pulmonary hypertension, cor pulmonale
  • Respiratory distress syndrome

Cardiac

• Congenital heart disease
• Vascular ring
• Cardiac tamponade
• Congestive Heart Failure (peds)
• Myocarditis (peds)

Other diseases with abnormal respiration

• Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
• Brief resolved unexplained event
• Anemia
• Abdominal distension (e.g. SBO, liver failure
• Neonatal abstinence syndrome
• Decreased perfusion states
  • Pediatric shock
  • Sepsis (peds)
  • Dehydration (peds)
• Metabolic acidosis
  • Diabetic ketoacidosis (peds)
  • Inborn errors of metabolism
  • Salicylate toxicity
• CO Poisoning
• Diaphragm injury
• Renal Failure
• Electrolyte abnormalities
• Organophosphate toxicity
• Tick paralysis
• Fever (Peds)
• Panic attack
• Porphyria

Evaluation

CXR of a patient with of bronchopulmonary dysplasia.

• Typically not an ED diagnosis
• Evaluate for precipitants of decompensation (e.g. infectious workup etc.)
• CXR
  • Hyperinflation, low diaphragm, atelectasis, cystic changes

Management

• Escalate chronic home therapies
• Supplementary O2 and/or positive pressure ventilation as needed
• Bronchodilators
• Diuretics if euvolemic-hypervolemic
• Treat decompensated pulmonary hypertension

Disposition

• Low threshold to admit for acute respiratory symptoms

See Also

• Respiratory distress syndrome