1. An interdisciplinary approach to care of infants with bronchopulmonary dysplasia. Alfred L. Gest, MD

2. Objectives: A brief historical perspective Explanation of pathophysiology Discuss the concepts of interdisciplinary care with examples of how it actually works. Discuss medical and developmental outcomes in infants with BPD.

3. BRONCHOPULMONARY DYSPLASIA A primary disorder of airways and lung parenchyma following interface of the lung with mechanical ventilation. Functional abnormalities are detectable by the third day of life and predisposing factors may be present at birth. Subsequent clinical behavior is largely related to pattern of re-growth of lung. Current care is supportive, not therapeutic.

4. BRONCHOPULMONARY DYSPLASIA Modern Diagnostic Criteria (NICHD–2001) Mild=0 2 >28 days, not 36 weeks PCA Moderate = < 30% 0 2 at 36 weeks PCA Severe = > 30% 0 2 or IMV at 36 weeks PCA (predictive of pulmonary/neurologic outcome risk) The Neonatal Period Ends at 28 days.

5. Pathophysiology Airway and interstitial inflammation and fibrosis Adjacent areas of atelectasis Inhomogeneous disease Increased airway resistance Decreased compliance Long expiratory time constants High pressure pulmonary edema Relative right ventricular dysfunction

9. BPD Incidence 501 - 750 751 - 1000 1001 - 1250 1251 - 1500 0 25 50 75 100 % BPD O 2 requirement at 36 weeks CGA Birthweight

10. Potentially Better Practices for Prevention of BPD Early administration of surfactant Early extubation to nasal CPAP Vitamin A Oxygen saturation targeting Nitric oxide ?

11. Why is there so much BPD? More at risk babies are surviving. The potentially better practices are difficult to implement or they are unattractive.  Nasal CPAP  Vitamin A  Delivery room surfactant  Oxygen saturation targeting

13. Initial Team Meeting With Parents Introduction to team members and team concept Education about BPD Approach to care Goals Expectations Address concerns

14. Division of Patients Into Subgroups (workgroups)  Attending physician  NNP/Resident  Nursing  Respiratory therapy  Social service  Neonatal feeding service  Clinical care coordinator  Nutrition  OT  PT  Pharmacy  Facilitator  Parent Representative

16. BPD is a Chronic Disease We should not expect BPD to improve in a day, in a week, or even in a month

20. Diuretics and BPD Use appropriate fluid restriction with adequate caloric intake primarily. Use chronic diuretic therapy cautiously:  One of the last therapies to add  One of the first therapies to stop

28. Discharge Planning Reality-based assessment of parents’ and the community’s abilities and expectations Stable oxygen need documented without exacerbations and with sustained growth and development Ability to feed orally or if not possible, a plan in place for improving oral feeds Involvement of the home care company Optimal use of home developmental service Involvement of primary care physician Clinic staff assessment

29. Nationwide Children’s Hospital Value Compass for BPD Functional All oral feeds (lack of tube feeds) Normal development at 24 months by Bayley III Clinical Growth along percentile Minimal use of post- natal steroids Adequate oxygenation- lack of cor pulmonale Satisfaction Positive experience with BPD care team Positive experience with home care Cost Re-admission within 1 month discharge Length of stay Parental financial concern

30. Nationwide Children’s Hospital Web Of Causation Under Utilized Community Resources ER Visits Lack of Reality Based Discharge Family Anxiety Reactive Airway Disease Remote Area Key Outcome Re-admission Rate

31. Nationwide Children’s Hospital Results: Incidence of BPD and Readmission Within 30 Days of Discharge BPD Clinic begins 2004

32. Nationwide Children’s Hospital Results Readmissions of infants (within 30 days of discharge) with BPD followed in the BPD clinic 9 (6.3%) 142 2007 Number of readmissions, n (%) Patients with BPD, n Year 77 (29%) 269 2003 Before BPD Clinic 8 (3.1%) 258 2004 After BPD Clinic 11 (6.2%) 177 2005 8 (4.7%) 170 2006 2008 119 11 (9%)

33. BRONCHOPULMONARY DYSPLASIA MORTALITY Northway 1967 66% Northway 1979 40% Myers 1986 30% Hansen 1991 10%

34. OUTCOME OF BPD If IPPV > 60 Days Mortality = 24% If IPPV > 90 Days Mortality = 40% Abnormal neurologic outcome = 80% (NICHD – 2001)

35. Mortality on Ventilator at More than 60 or 90 Days: Nationwide Children’s Hospital vs NICHD Vent and GroupMortality NoYesTotal 60< vent <90 NCH39443 NICHD28290372 Total32194415 Vent >90 NCH32840 NICHD393372 Total7141112 ------------------------------------------------------------------------------ mortality | Odds Ratio Std. Err. z P>|z| [95% Conf. Interval] -------------+---------------------------------------------------------------- group | 3.268139 1.149181 3.37 0.001 1.640556 6.510435 vent | 2.620394.6464599 3.90 0.000 1.615743 4.249725 ------------------------------------------------------------------------------ the mortality advantage at NCH is 3.3