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What IS Bronchopulmonary Dysplasia - (Neonatal Chronic Lung Disease)?? BPD Part 1 - Tala Talks NICU — Transcript

by Tala Talks NICU · 2,495 words · 361 segments · language en · Watch on YouTube

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0:03[Music]
0:08hello and welcome for the first time or
0:10welcome back to tala talks niku where we
0:13break down medical Concepts and make
0:15them really easy for you to understand
0:18today as many of you have already
0:20requested we are going to go over BPD or
0:23Bronco pulmonary
0:25dysplasia and because we're trying not
0:27to make these videos too long again we
0:30decided to divide this video into two
0:32different parts so today we're going to
0:34go over one what is BPD two how do you
0:39diagnose BPD and three what causes BPD
0:43in the next video we'll go over four how
0:47do we prevent BPD five how do we treat
0:50BPD and six the outcomes after BPD so as
0:55per usual just before I start remember
0:57to like this video if you want to and to
1:00subscribe to this channel if you're
1:02interested in just getting overall niku
1:04content one what is BPD BPD is another
1:09three-letter acronym that stands for
1:11Bronco pulmonary dysplasia which
1:14describes a chronic lung disease or a
1:17lung disease that babies have for a long
1:21period of time that started when they
1:23were premature BPD was first described
1:27by Northway in 1967
1:30at that time a lot of babies had really
1:34bad RDS and a lot of them died from RDS
1:37if they did survive RDS then they
1:40continued to have respiratory symptoms
1:42for a long time eventually that
1:44prolonged respiratory course after that
1:47initial odds was labeled BPD so it's
1:51that stage when the infant is over the
1:53initial RDS and the initial surfactant
1:56deficiency but they're still needing
1:59oxygen they still have respiratory
2:00symptoms they still may need may need
2:03pressure support and their x-rays don't
2:05look normal that really is BPD BPD
2:09affects about 10 to 15,000 infants a
2:12year in the United States and obviously
2:14a lot more than that internationally
2:16about 40% of extremely low birth weight
2:19babies that's babies that are born less
2:21than 1,000 grams will end up developing
2:24BPD now because more and more of these
2:27extremely low birth weight babies are
2:29actually surviving we're all doing a
2:31much better job with keeping micro pries
2:33alive then obviously we would expect
2:37that there's going to be a higher
2:38population that's susceptible to getting
2:40BPD so BPD is actually one of the few
2:43three-letter acronyms in the ncu that we
2:46really haven't been very good at
2:47decreasing the rate of so why do we care
2:51so much about BPD so what if a baby goes
2:53home on a little bit of oxygen or um
2:56just has respiratory symptoms the reason
2:59why we care care about BPD is that we
3:01know that infants with that diagnosis
3:03especially obviously with a severe BPD
3:06have a much higher chance of having
3:08issues later in life so have higher
3:10issues of having developmental problems
3:12cerebral py even decrease in academic
3:15performance decrease growth as well as a
3:18whole host of pulmer um problems as well
3:21as readmissions to Hospitals number two
3:25how do we diagnose BPD so the
3:28interesting thing about BPD is that it
3:30really is a clinical diagnosis it isn't
3:33a lab test or necessarily a chest x-ray
3:36that you can look at and say this baby
3:37definitely has BPD although there are
3:40some kind of pretty typical x-ray
3:42findings in infants with BPD and I'll
3:43get to that later really how we diagnose
3:46BPD is how much support the infant needs
3:50how much oxygen as well as how much
3:52positive pressure support obviously this
3:54is a pretty subjective diagnosis but
3:56I'll get to that in a second
3:58historically loads of different
4:00definitions have been used to diagnose a
4:03baby with BPD initially the diagnosis
4:06was based on the fact that if you needed
4:08oxygen for 28 days then you had BPD but
4:12then as more and more babies were
4:14surviving that seemed pretty unfair so
4:17for example if you're a 22 weer at 28
4:19days of life you're still 26 weeks so
4:21it's a bit harsh still calling that BPD
4:24in 1988 the clinical definition of BPD
4:28became do you still need oxygen at 36
4:32weeks correct to gestational age and I'm
4:34going to talk about other different
4:37issues with that but basically that is
4:40the definition that stands most commonly
4:43now and that is used most frequently in
4:45literature is a baby still on oxygen at
4:4836 weeks corrected gestational age the
4:51Canadian neonatal Network published a
4:53study that showed that developmental
4:56outcomes at 18 to 24 months were best
4:59predicted by whether a baby needed
5:01oxygen at 40 weeks not at 36 weeks
5:05however the problem with that definition
5:07as I'm sure you're all realizing is that
5:09there are a lot of babies that are
5:10discharged home before 40 weeks so
5:13they're discharged home at 38 weeks or
5:15even 37 weeks or whatever so you're not
5:18necessarily picking up all the infants
5:21and there have been a lot of other
5:23refinements since then as you can
5:24imagine a lot of researchers argued that
5:27there is going to be a huge difference
5:28in outcomes between a baby that is on a
5:31tiny bit of oxygen at 36 weeks versus a
5:34baby that's literally needing a
5:37conventional ventilator at 36 weeks
5:40because of this the BPD has been
5:43classified further into mild moderate
5:46and severe
5:47BPD remember just as an aside that in
5:50medicine when you're making a
5:52classification between different stages
5:55they all actually have to mean something
5:57so for example in cancer you're not just
5:59arbitarily saying stage 1 2 3 4 or
6:02whatever if a patient has a stage one
6:05diagnosis then their prognosis should be
6:07much better than a patient with stage
6:09two that's where the cut offs are made
6:12so obviously depending on the amount of
6:15oxygen or support that you need you
6:17should expect a worse outcome if you're
6:20making the differentiation between mild
6:22moderate and severe even that definition
6:25has had its issues and anybody that's
6:27worked at the bedside will realize this
6:30so what do you do about the baby who's
6:33on 1 liter 21% at 36 weeks but for
6:36whatever reason you take that one liter
6:38off and the baby starts desatting or the
6:41baby is on .02 L of 100% which is
6:45basically kind of 22% how do we classify
6:48that the most recent attempt at
6:51classification of BPD was made by an ND
6:54Workshop where they put BPD into three
6:57different grades basically the between
7:00grade 1 and grade two was whether you
7:02were on more or less than 3 l of oxygen
7:06flow at 36 weeks and grade three was
7:09when you needed any amount of positive
7:10pressure so CPAP or you were actually
7:13even incubated obviously like I said
7:15already the issue is is that we can't
7:17just say it's grade two that also has to
7:20be associated with a worse prognosis
7:22than a grade 1 BPD but as you all know
7:25and we've talked about many times
7:28following up niku patients is really
7:30hard they move around they get lost to
7:31followup the other super complicating
7:34thing about BPD is that there's still a
7:37lot of lung growth to be done after the
7:39baby leaves the niku so it's possible
7:42that a baby leaves has absolutely
7:45perfect nutrition and doesn't get
7:47readmitted into the hospital doesn't get
7:50any reinfections that infant is probably
7:53going to have a slightly better outcome
7:55lung wise than a kid that had the same
7:58course but isn't getting ideal nutrition
8:01and gets readmitted with RSV a couple of
8:03times in the first year of his life
8:05another complicating thing with a
8:07diagnosis a BPD is just how subjective
8:10the need for oxygen is so say you're 36
8:13weeks and a baby is kind of occasionally
8:16desatting then you decide one day that
8:18you're going to try to take the baby off
8:21the 1 liter 21% that they're on maybe
8:23somebody that night sees that the baby
8:25has a quick desat and just puts the baby
8:28back on again or maybe the baby is
8:30breathing a little bit fast so for that
8:32reason the baby is on nasal canula maybe
8:36they'd still be breathing it exactly the
8:37same speed if they were off the nasal
8:39canula so there's a lot of subjectivity
8:41in that just in the same nicku between
8:43the different providers in 2003 a paper
8:47was published by Walsh at Al that
8:50basically tried to decrease this
8:52subjectivity and they recommended that
8:55we should get a physiological definition
8:57of BPD basically what they said was that
9:00if at 36 weeks or close to 36 weeks a
9:03baby was on above 30% oxygen then that
9:06was it or on any positive pressure
9:08support then that baby was diagnosed as
9:11having BPD but if infants were on less
9:15than 30% then all infants were given a
9:18room air challenge basically these kids
9:21were slowly weaned off oxygen and then
9:24once they were on room air if their SATs
9:26stayed above 88% and this was later
9:29change to above 90% for an hour then
9:32they were considered to be stable on
9:35room a and to not have BPD they found
9:39that this decreased the rate of BPD by
9:41about 10% because effectively what
9:43you're doing is just removing the
9:46subjectivity the rumor challenge is
9:49probably something you should all be
9:50doing in your units right before 36
9:52weeks kind of 35 to 36 weeks to prove
9:55whether baby really does need oxygen or
9:57not so in summary the clinical
10:01definition of BPD is having an oxygen
10:03requirement at 36 weeks obviously
10:06there's loads more classifications but
10:08for the purposes of this discussion just
10:10remember that three what causes BPD well
10:14like all of you I'm sure have used a
10:16million times in your training we all
10:18learn different pneumonics and I agree a
10:21lot of these pneumonics kind of almost
10:23make it harder because you're trying to
10:24remember what each letter stands for but
10:27the classical one for BPD is that it is
10:30caused by the seven PS so the seven PS
10:34are one prematurity two positive
10:37pressure ventilation three prolonged
10:40oxygen exposure or just having a lot of
10:42free oxygen radicals four protracted use
10:46of ET tubes this one's weak basically it
10:49means that the baby's intubated for a
10:51long period of time five pulmonary edema
10:55so the baby could have that from PDA or
10:58overhydration
10:59or just um has delayed diuresis six
11:03pulmonary air leaks so for example you
11:05have a numo thorax or you have really
11:07bad pie and seven really bad
11:10pro-inflammatory Cascades so if a baby
11:13has many episodes of sepsis or has many
11:15surgeries then they're more likely to
11:17have worse BPD really though you can
11:20break all of these down into three main
11:23subgroups the first one is prematurity
11:26or just having really immature lungs
11:28number two two is just injury to the
11:30lungs whether it's from being intubated
11:33whether it's having a pneumothorax
11:34whatever it is and number three is just
11:37inflammation so for example like we were
11:39saying a pneumonia or a sepsis or
11:41whatever the two strongest risk factors
11:44for BPD are prematurity and low birth
11:47weight as you know if a baby is born
11:50very prematurely then by definition
11:52they're going to need some form of
11:54respiratory support even if it is just
11:56CPAP being on any ventilator causes
11:59injury to the lungs and our body's
12:01response to any injury is to get some
12:05sort of inflammation which in itself can
12:08be even more damaging to the lungs
12:11critical development of the lungs is
12:13happening throughout pregnancy obviously
12:16and really the last trimester the third
12:19trimester is when a lot of the alveoli
12:21are actually forming so you can imagine
12:24that if these babies are constantly
12:27getting injury to their lungs whether
12:28it's sepad or or the uh ventilator or
12:31whether it's just still needing a high
12:33oxygen and they've got the inflammatory
12:35response then just the combination of
12:38those two may affect the actual
12:41development of the lungs so those
12:43alvioli may not develop as well just
12:46because of what they are being exposed
12:48to this is an important point because
12:51it's really very different from an adult
12:53who is on the ventilator for a long
12:55period of time yes the ventilator will
12:59injure the lungs and they'll still get
13:00the swelling and everything but it won't
13:03affect the growth and development of the
13:05lungs themselves when it was first
13:07described in
13:091967 the focus of BPD was really on the
13:12injury that happens in the lungs and
13:15kind of the scarring from the
13:16non-compliant lungs and the oxygen that
13:18the lungs are being exposed to and
13:21Northway described the progression of
13:23BPD by using pathological slides so
13:25babies who had passed away as well as
13:28x-rays that showed all the scarring and
13:30the fibrosis in the lungs because of the
13:34injury that the lungs were exposed to
13:36obviously the younger and the smaller
13:38the baby the higher the chance of
13:40developing BPD and severe BPD but now
13:43it's thought that it's not really just
13:44because of the injury and the
13:46inflammation and the oxygen that the
13:48baby's being exposed to but by
13:50definition the younger that the baby is
13:53then the more that the lungs have to
13:55grow and develop outside the mother so
13:58the higher the chance that just the
14:00development of the lungs is going to be
14:02abnormal and this has been shown in
14:05specimens that infants with BPD have
14:09decreased number of alvioli and those
14:11alvioli themselves are made abnormally
14:14as compared to infants without BPD and
14:17then just generally the more injury that
14:19the lungs suffered then the worse their
14:21BPD is going to be so the longer that
14:24they need to be on the ventilator the
14:26more oxygen the higher the
14:27concentrations of oxygen they're Expos
14:29to whether they had a chest tube if that
14:31infant had several bouts of pneumonia
14:33obviously that's really going to
14:34increase the inflammation in the lungs
14:37all of those will contribute to a
14:39worsening BPD Remember by the way in
14:42utro the infants are getting their
14:45oxygen from the mother's Venus blood so
14:47basically they're exposed to saturations
14:50of kind of 50 60% so after an infant is
14:54born we now want the baby to have SATs
14:57in the 80s and '90s
14:59so you can imagine that for a baby
15:01that's technically still supposed to be
15:03in utro that really could provide a lot
15:06of free radicals and could be very
15:08damaging for the lungs and the rest of
15:10the body and that's the end of the first
15:13part of BPD please look out for the next
15:16part where we'll kind of go into a
15:18little bit more detail in the meantime
15:20please remember to like and to subscribe
15:22this video and let us know what you'd
15:24like us to talk about next thank you so
15:26much for being here
15:29oh
15:30[Music]

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