Overview
Definition:
Home oxygen therapy in Bronchopulmonary Dysplasia (BPD) involves providing supplemental oxygen to infants at home to maintain adequate oxygenation and support lung recovery, typically after NICU discharge
Weaning refers to the gradual reduction and eventual discontinuation of supplemental oxygen as the infant's respiratory status improves.
Epidemiology:
BPD affects approximately 20-30% of infants born before 28 weeks gestation, with a higher incidence in those requiring mechanical ventilation
Home oxygen therapy is prescribed for a significant proportion of these infants to facilitate transition to home and improve long-term outcomes.
Clinical Significance:
Effective home oxygen management and a structured weaning plan are crucial for reducing hospital readmissions, improving neurodevelopmental outcomes, and enhancing the quality of life for infants with BPD
This requires close collaboration between the medical team, parents, and home health providers.
Clinical Presentation
Symptoms:
Infants may present with tachypnea
Intermittent cyanosis
Recurrent lower respiratory tract infections
Poor weight gain
Increased work of breathing at rest or with activity
Episodes of apnea or bradycardia.
Signs:
Persistent hypoxemia (SpO2 < 90-92% on room air)
Increased respiratory rate
Retractions
Nasal flaring
Grunting
Wheezing or crackles on auscultation
Failure to thrive.
Diagnostic Criteria:
Diagnosis of BPD is typically made based on the need for supplemental oxygen or respiratory support at 36 weeks corrected gestational age
The need for home oxygen is determined by persistent hypoxemia documented by pulse oximetry or arterial blood gas measurements at rest and during activity or sleep.
Diagnostic Approach
History Taking:
Detailed birth history (gestational age, birth weight, prematurity complications)
NICU course (duration of ventilation, surfactant use, comorbidities like PDA, NEC)
Current respiratory support at home
Feeding history and growth pattern
Parental concerns and understanding of care
Previous hospitalizations or readmissions.
Physical Examination:
Complete respiratory assessment including rate, rhythm, work of breathing, breath sounds
Cardiac examination for murmurs or gallops
Nutritional assessment including weight, length, and head circumference
Neurological assessment for developmental milestones
Oximetry monitoring at rest, during feeding, and during sleep.
Investigations:
Pulse oximetry to assess oxygen saturation (SpO2) at rest, during feeding, sleep, and activity
Arterial blood gases (ABGs) if oximetry is unreliable or to assess ventilation
Chest X-ray to assess lung aeration and rule out concurrent pneumonia or other abnormalities
Echocardiogram to assess for pulmonary hypertension or a significant patent ductus arteriosus (PDA).
Differential Diagnosis:
Congenital heart disease
Persistent pulmonary hypertension of the newborn
Anemia
Sepsis
Gastroesophageal reflux with aspiration
Other chronic lung diseases (e.g., cystic fibrosis, congenital airway anomalies).
Management
Initial Management:
Establish clear oxygen goals (e.g., SpO2 90-95% at rest, 88-92% during sleep)
Determine appropriate flow rate and delivery device (nasal cannula, high-flow nasal cannula, mask)
Provide thorough education to caregivers on oxygen safety, equipment use, and monitoring.
Medical Management:
Diuretics (e.g., Furosemide, Spironolactone) to manage fluid overload and pulmonary edema
Bronchodilators (e.g., Albuterol) if bronchospasm is a significant component
Corticosteroids (e.g., Dexamethasone) may be used judiciously for severe BPD, with careful consideration of side effects
Nutritional support to promote growth and lung healing
Consider inhaled nitric oxide for pulmonary hypertension if present.
Supportive Care:
Ensure safe oxygen delivery system and backup power source
Optimize environmental factors (avoid smoke exposure, control humidity)
Implement infection control measures
Monitor for signs of respiratory distress or deterioration
Regular follow-up with pulmonology and primary care teams
Parental support and respite care resources.
Weaning Strategies:
Gradual reduction in oxygen flow rate or fraction of inspired oxygen (FiO2) based on objective assessment of SpO2 and work of breathing
Weaning can occur by reducing flow rate by 0.1-0.2 L/min or FiO2 by 1-2% every few days or weeks
Transition from continuous to intermittent oxygen use (e.g., only during sleep or activity)
Consider trial of room air for defined periods
Target oxygen independence at or beyond 40 weeks corrected gestational age if stable.
Complications
Early Complications:
Pneumothorax
Bronchopulmonary dysplasia itself (severe forms)
Respiratory failure requiring rehospitalization
Pulmonary hypertension.
Late Complications:
Failure to thrive
Neurodevelopmental delays
Pulmonary artery hypertension
Recurrent lower respiratory tract infections
Asthma-like symptoms
Increased risk of otitis media and hearing loss.
Prevention Strategies:
Minimize exposure to high oxygen concentrations and prolonged mechanical ventilation in the NICU
Use of antenatal corticosteroids
Judicious use of inhaled corticosteroids
Early and aggressive treatment of infections and PDA
Optimize nutritional support
Strict avoidance of environmental irritants.
Prognosis
Factors Affecting Prognosis:
Gestational age at birth
Severity of BPD
Presence of comorbidities (e.g., PDA, pulmonary hypertension)
Adequacy of home care and parental support
Access to follow-up medical care
Nutritional status.
Outcomes:
Most infants with mild to moderate BPD will be weaned off oxygen and achieve significant improvement in lung function by school age
Severe BPD can lead to chronic respiratory insufficiency and increased mortality
Neurodevelopmental outcomes vary widely depending on severity and comorbidities.
Follow Up:
Regular pulmonary function testing
Serial echocardiograms to monitor for pulmonary hypertension
Developmental assessments
Audiology and ophthalmology evaluations
Close monitoring of growth and respiratory status
Vaccination against respiratory syncytial virus (RSV) is often recommended.
Key Points
Exam Focus:
Key indicators for home oxygen requirement (SpO2 thresholds)
Principles of oxygen safety and caregiver education
Structured approach to oxygen weaning
Management of common comorbidities like PDA and pulmonary hypertension
Recognizing signs of respiratory deterioration requiring rehospitalization.
Clinical Pearls:
Always assess oxygen needs in different states (rest, sleep, activity, feeding)
Emphasize caregiver education on oxygen safety to prevent fires or other hazards
Individualize weaning plans based on infant's response
Consider underlying causes of persistent hypoxemia beyond BPD
Early identification and management of pulmonary hypertension are critical.
Common Mistakes:
Inadequate caregiver education leading to safety issues or non-compliance
Premature or overly aggressive weaning attempts causing decompensation
Failure to reassess oxygen needs after changes in infant's condition or environment
Neglecting to monitor for and manage associated comorbidities
Underestimating the importance of nutritional support in lung recovery.