Guideline 6.2 — Bronchopulmonary Dysplasia

BEDSIDE ACTION BOX — The Evolving/Established BPD Infant

Use the least injurious support that achieves targets: volume-targeted ventilation, permissive hypercapnia, and avoid both hyperoxia and repeated desaturation.
Target SpO₂ 91–95% up to 36 weeks' PMA; after 36 weeks, 93–97% to protect against pulmonary hypertension.
Optimise nutrition (higher calories for increased work of breathing) and avoid fluid overload.
Caffeine and vitamin A are the best-evidenced preventive drugs; postnatal steroids and diuretics are consultant-led, individualised decisions.
Screen established/severe BPD for pulmonary hypertension with echocardiography.

1. Overview & Definition

Overview

Bronchopulmonary dysplasia (BPD), also called chronic lung disease of prematurity, is the most common chronic complication of extreme prematurity. The "new BPD" reflects arrested alveolar and pulmonary vascular development in a surfactant-treated, often less severely inflamed lung, rather than the fibrotic, oxygen-and-ventilator-injured lung of the pre-surfactant era. Management is a marathon: minimise ongoing lung injury, optimise growth, treat reversible contributors, and monitor for pulmonary hypertension, while preparing the family for a prolonged course and possible home oxygen.

Why This Topic Matters

BPD is associated with prolonged hospitalisation, home oxygen, recurrent respiratory illness, pulmonary hypertension, poor growth, and adverse neurodevelopment. Prevention (antenatal steroids, gentle ventilation, caffeine, judicious oxygen) matters more than any single treatment, because established BPD has no quick cure.

Definition

BPD is defined by a persistent need for respiratory support/supplemental oxygen for at least 28 days, with severity graded by the level of support required at 36 weeks' postmenstrual age (PMA) for infants born <32 weeks (or at 56 days' postnatal age for infants ≥32 weeks).

2. Who This Guideline Applies To

Scope

Preterm infants (predominantly <30 weeks / very low birth weight) with evolving or established chronic lung disease requiring ongoing respiratory support or oxygen beyond the first weeks of life.
Infants being assessed for BPD severity at 36 weeks' PMA (or 56 days for ≥32 weeks) and those approaching discharge with an oxygen requirement.
Cross-references: acute RDS/surfactant (6.1); pulmonary hypertension (6.3); nutrition (7.3); retinopathy screening (2.3); GER (11.3).

3. Key Definitions

Core Terminology

The vocabulary needed to grade and manage chronic lung disease.

Term	Definition	Practical note
BPD / CLD	Chronic lung disease of prematurity: oxygen/support dependence ≥28 days with impaired alveolar and vascular growth.	"New BPD" is developmental arrest more than fibrosis.
PMA	Postmenstrual age = gestational age + postnatal age.	36 weeks' PMA is the key assessment point for <32-week infants.
Permissive hypercapnia	Tolerating a higher PaCO₂ (with acceptable pH) to allow lower ventilator pressures/volumes.	Reduces volutrauma; avoid hypocapnia.
Volume-targeted ventilation	Ventilation delivering a set tidal volume, adapting pressure to compliance.	Preferred mode; limits volutrauma.
BPD-associated pulmonary hypertension	Elevated pulmonary pressures complicating moderate–severe BPD.	Screen with echocardiography; see 6.3.

4. Severity Grading

BPD Severity by Support at Assessment

Graded by respiratory support at 36 weeks' PMA (born <32 weeks) or at 56 days' postnatal age/discharge (born ≥32 weeks), after ≥28 days of oxygen. Contemporary NICHD/Jensen criteria grade by mode of support (I–III).

Severity	Born <32 weeks (assess at 36 wk PMA/discharge)	Born ≥32 weeks (assess 56 days/discharge)
Mild	Breathing in air	Breathing in air
Moderate	<30% oxygen	<30% oxygen
Severe	≥30% oxygen and/or CPAP or ventilation	≥30% oxygen and/or CPAP or ventilation

Note on Definitions

Several definitions coexist (NIH 2001 consensus, the physiologic oxygen-reduction test, the 2018 NICHD workshop grades, and the 2019 NICHD/Jensen grade I–III system based on mode of support at 36 weeks). This site grades BPD with the 2019 mode-of-support system, which best predicts 2-year outcomes; the practical message — more support at 36 weeks' PMA means worse disease and higher risk of pulmonary hypertension and adverse outcomes — is the same.

5. Assessment at Diagnosis

Investigations

Blood gas to define the ventilation/oxygenation baseline and guide permissive targets.
Chest radiograph — evolving CLD shows hazy/homogeneous opacification developing after the first week, or coarse streaky change with cystic lucencies.
Echocardiography and ECG to screen for pulmonary hypertension and structural disease, particularly in moderate–severe BPD.
Overnight oximetry study when planning oxygen weaning or home oxygen.
Growth monitoring (weight, length, head circumference) and assessment for GER and aspiration as contributors.

6. Prevention (Highest Yield)

Evidence-Based Preventive Bundle

Antenatal corticosteroids and early CPAP with selective surfactant (see 6.1) — reduce death/BPD.
Caffeine started early — reduces BPD and improves extubation success.
Vitamin A supplementation in ELBW infants modestly reduces BPD (unit-dependent).
Lung-protective ventilation: volume-targeted ventilation, permissive hypercapnia, avoid over-distension and prolonged intubation.
Judicious oxygen: target SpO₂ 90–95%; avoid hyperoxia and wide swings.
Careful fluid balance and early optimal nutrition; treat a haemodynamically significant PDA per unit policy.

7. Management Algorithm

Confirm evolving/established BPD

Oxygen/support dependence approaching or beyond 28 days in a preterm infant; grade severity by support at 36 weeks' PMA (or 56 days).

Optimise ventilation & oxygen

Volume-targeted ventilation, lowest effective pressures, permissive hypercapnia; SpO₂ 91–95% (→ 93–97% after 36 weeks' PMA). Warm, humidified oxygen.

Optimise nutrition & fluids

Provide higher caloric intake for increased work of breathing; involve dietitian if growth is poor; avoid fluid overload.

Persistently ventilator-dependent with high/rising oxygen?

Consider a course of postnatal corticosteroids (consultant decision; consent parents). Do not combine with NSAIDs. Consider a diuretic trial.

Screen for complications

Echocardiography for pulmonary hypertension; assess GER/aspiration; monitor growth; plan ROP and immunisations (including RSV prophylaxis).

Plan weaning & discharge

Wean support/oxygen guided by targets and oximetry; stop diuretics before discharge where possible; arrange home-oxygen pathway and multidisciplinary follow-up.

⚠ Do-not-miss

New/worsening desaturations or failure to progress → exclude pulmonary hypertension, aspiration, airway disease (e.g., tracheobronchomalacia, subglottic stenosis), and intercurrent infection.

8. Step-by-Step Management

Respiratory Support

Prefer volume-targeted/volume-guarantee ventilation; if pressure-limited, use the lowest pressures that deliver appropriate tidal volumes.
Accept permissive hypercapnia with adequate pH; avoid hypocapnia (linked to injury and adverse neurodevelopment).
Wean from invasive to non-invasive support as tolerated; use caffeine to support extubation.

Nutrition & Fluids

Increase caloric intake (often to ~120% of usual) to meet the higher energy demand; consider fortification/energy-dense feeds.
Involve the dietitian early if growth falters; monitor weight, length, and head growth.
Avoid fluid overload; balance nutrition against the fluid-sensitivity of the BPD lung.

Corticosteroids & Diuretics (Consultant-Led)

Corticosteroids: consider only in ventilator-dependent infants with rising/persistently high oxygen needs, after weighing short-term benefit (earlier extubation) against risks (infection, poor growth, hyperglycaemia, hypertension, GI perforation/bleeding, and increased neurodisability). Obtain and document informed consent. Do not co-administer with NSAIDs.
Diuretics: a pre-agreed 7–10 day trial of a thiazide (chlorothiazide 20 mg/kg or hydrochlorothiazide 2 mg/kg twice daily) may improve lung mechanics in infants over 3 weeks; adding spironolactone has no proven benefit, and furosemide suits short-term use in BPD crises. Watch for electrolyte disturbance and hypochloraemic alkalosis (plus calcium loss and nephrocalcinosis with furosemide); give chloride as KCl 2–4 mEq/kg/day above usual needs. Aim to stop before discharge.

Tracheostomy and home ventilation for severe BPD (Baylor Ed. 33)

A minority of chronically ventilated infants are good candidates. The best timing is unclear. Some studies link earlier tracheostomy (<120 days) to less subglottic stenosis, less sedation and more comfort. Ventilator strategy for established BPD (larger tidal volumes, longer Ti, slower rates) is in chapter 6.7.
Outcomes to discuss honestly: 2-year readmission rates of 43–63% and frequent lower respiratory infections. After adjustment, NICHD Neonatal Research Network data show higher odds of death or neurodevelopmental impairment with tracheostomy. There may be short-term developmental gains from better growth and getting home. Long-term data are limited, so decide case by case.
Candidacy process:
- Understand the family's goals.
- Hold a multidisciplinary family meeting (neonatology, ENT, pulmonology, surgery if a gastrostomy is planned, nursing leadership, tracheostomy educator, social work).
- Weigh overall prognosis, using neuroimaging to inform the risk of neurodevelopmental impairment.
- Social work assesses home circumstances; pulmonology chooses the home ventilator mode and settings and plans in-unit trials.
- Surgery assesses the need for a gastrostomy at the same operation.
- Tracheostomy educators give hands-on training and simulation.
- Present the case at a pre-tracheostomy conference.
Around surgery: secure stable central (or midline) access for 5–7 days of sedation. Give acetaminophen 10–15 mg/kg IV every 6–8 h, plus an opioid infusion chosen by prior exposure, plus, from 44 weeks PMA, a midazolam infusion for sedation only (avoid benzodiazepines below 44 weeks, except CDH sedation — 11.7); plan anything more with the pharmacist.
Home ventilation:
- Usually requires at least 2500 g. Most home ventilators are rated for ≥5 kg (minimum Vt 50 mL), though pressure-control or pressure-support modes can serve smaller infants.
- Typical sequence: SIMV/pressure support; volume control on the conventional ventilator while recording expired Vt for several days; a paediatric circuit; then the home ventilator, readjusting Vt at each step.
- Then test SpO₂ and PCO₂ semi-upright in an infant or car seat, and trial a heat-moisture exchanger (HME) for short periods. At home, humidify with the ventilator humidifier and use the HME for outings — 1–2 hours without humidification is acceptable in a stable infant.
- Equipment: pulse oximeter, suction with spare tracheostomy tubes, portable oxygen and concentrator, tracheostomy care supplies, bag and mask.
Before discharge (AAP): train at least two family caregivers — one fully in home ventilator care, the other in infant CPR, recognizing airway emergencies and changing the tracheostomy tube — and document their skills. The home-care company, social work and discharge coordinator check the home (lighting, power, access to emergency care). Ask the electricity provider to put the infant on a priority list for power outages.

9. Medication Considerations

Drug Table (Verify All Doses Locally)

Doses are consultant-led and unit-specific — confirm against the Neonatal Formulary before use. Corticosteroid and diuretic use require individualised risk–benefit discussion.

Agent	Role	Practical dosing note	Cautions / monitoring
Caffeine citrate	Prevention; apnoea; extubation support	Load 20 mg/kg, then 5 mg/kg/day (up to 10); routine for all <1250 g.	Heart rate, tolerance; strong BPD-prevention evidence.
Vitamin A	Modest BPD reduction in ELBW	<1000 g: 5000 IU IM Monday, Wednesday and Friday for 12 doses from week 1 (if available).	Unit-dependent; injection burden.
Dexamethasone (DART / low-dose)	Facilitate extubation in ventilator-dependent BPD	DART taper: 0.075 → 0.05 → 0.025 → 0.01 mg/kg every 12 h (6, 6, 4, 4 doses; 0.89 mg/kg over 10 days) — for <30 weeks still ventilated beyond 14 days at moderate–high risk, ideally at 2–6 weeks.	Daily BP & urinary glucose; infection, growth, neurodisability risk. No NSAIDs concurrently.
Hydrocortisone	Not recommended for BPD	Early courses cause GI bleeding and perforation; late courses do not change death/BPD (section 9+).	Similar monitoring; different risk profile to dexamethasone.
Thiazide (chlorothiazide / hydrochlorothiazide)	Diuretic trial for lung mechanics	20 mg/kg or 2 mg/kg twice daily; adding spironolactone has no proven benefit.	Electrolytes, hypercalciuria/nephrocalcinosis, alkalosis. Avoid amiloride (fluid-retaining in lung). Stop if no benefit in ~1 week.
RSV prophylaxis	Prevent severe RSV disease	Per national programme (monoclonal antibody).	Eligibility per local/national policy.

9+. Baylor Ed. 33 BPD Management: Definitions, Phenotypes, Drugs, Steroids and Airway Disease

Severity (Baylor Table 16-11a, NIH 2001 with a split "severe")	After ≥28 days of oxygen*, at 36 weeks PMA or discharge
None	Oxygen <28 days and in room air
Mild	Room air
Moderate	<30% oxygen
Severe, type 1	>30% oxygen, or CPAP/high flow
Severe, type 2	Mechanical ventilation

*A day of oxygen means >21% for more than 12 hours. Infants given oxygen or positive pressure only for non-respiratory reasons (central apnoea, diaphragm paralysis) do not have BPD unless parenchymal disease with respiratory distress develops. Severity is graded on this site with the 2019 Neonatal Research Network definition — by mode of respiratory support at 36 weeks PMA (section 3) — which predicts 2-year outcomes better than the NIH 2001 and 2018 NICHD workshop definitions.

Course, phenotypes and goals

Causes: prenatal (placental dysfunction, growth restriction, chorioamnionitis, genetics) and postnatal (surfactant deficiency, ventilation, oxygen, infection, dysbiosis, a significant PDA), acting through volutrauma, barotrauma, inflammation, impaired vasculogenesis and arrested alveolarization. "New" BPD is impaired alveolar and vascular growth with hazy lungs. "Classic" BPD in the most immature infants brings uneven airway obstruction, bronchomalacia and hyperinflation.
Three overlapping phenotypes — parenchymal, pulmonary vascular and airway disease — so avoid one-size-fits-all management.
Course: initial improvement over 1–2 weeks, then rising oxygen need, re-opacifying lungs and wide SpO₂ swings. Early chronic ventilation is unstable with acute deteriorations. After 6–8 weeks the picture becomes more static (fibrosis, hyperinflation, oedema, emerging tracheobronchomalacia), and function improves gradually over 3–9 months.
Goals: optimize respiratory support and nutrition; support neurodevelopment, including treating opioid or sedative habituation; prevent cor pulmonale; prevent infection by extubating as early as possible.
Oxygen: chronic or recurrent hypoxia worsens pulmonary hypertension and raises mortality. Target SpO₂ 90–95% until the retina is mature; with severe BPD or echo evidence of PH, review oxygenation daily. The effect of an FiO₂ reduction on PVR or oedema may take several days to appear.
Fluids and growth: modest restriction to about 150 mL/kg/day using fortified milk or mineral-enhanced preterm formula; 110–130 mL/kg/day only for severely impaired lung mechanics. Weigh every 3–7 days, measure length and head circumference weekly, and review with a dietitian.
Development: a play-oriented environment with controlled light and noise, a consistent multidisciplinary plan led by neonatology and pulmonology, and an AABR hearing screen once eligible. Weaning support too fast shows up as fatigue during therapy sessions and can set back development.

Pulmonary hypertension in BPD

Echo: TR jet velocity, gradient and direction across a restrictive PDA or VSD, PAAT/RVET, LV eccentricity index, and septal motion. Consider cardiac catheterization before long-term therapy to look for LV diastolic dysfunction, shunts, pulmonary vein stenosis and systemic collaterals.
If PH is present: treat lung disease, aspiration and structural heart lesions. Keep SpO₂ 92–95%, PCO₂ <65 with normal pH, and ventilate near FRC, since both hyperinflation and atelectasis raise PVR.
Sildenafil if iNO cannot be weaned completely: 0.25 mg/kg/dose NG/PO every 6 h under 12 months (every 8 h over 12 months), titrated up to 1 mg/kg/dose. Watch for desaturation from worsening V/Q mismatch, systemic hypotension and feed intolerance. Pulmonary oedema on starting it → look for pulmonary vein obstruction or shunts. If echo concerns persist, involve a PH specialist (further imaging, an endothelin receptor antagonist or prostacyclin, catheterization). Follow with serial echoes. LV hypertrophy, systemic hypertension and collaterals can coexist and may overestimate PH.

Drug (Baylor Ed. 33)	Dose	What the evidence and cautions say
Furosemide	1 mg/kg IV once daily; PO 2 mg/kg (1:2 ratio). Twice-daily dosing, used in term infants, needs caution in preterm infants — half-life can exceed 24 h below 31 weeks PMA	Most widely used. Short-term gains in oxygenation and compliance in infants >3 weeks, without proven long-term benefit (Cochrane 2011). A multicentre analysis (2019) found each 10% longer exposure linked to 4.6% less BPD. Best for short-term use in BPD crises. Causes hyponatraemia, hypokalaemia, hypochloraemic alkalosis and Ca/Mg loss → nephrocalcinosis, osteopenia; check electrolytes weekly or twice weekly on chronic use.
Hydrochlorothiazide	2 mg/kg/dose twice daily	Evidence mostly predates antenatal steroids and surfactant; pulmonary mechanics improve in infants >3 weeks. Decide a 7–10 day trial and success criteria in advance, then stop to reassess. Thiazides do not increase urinary Ca or Mg loss. Watch for hyponatraemia, hypokalaemia, hypochloraemic alkalosis, hypercalcaemia, osteopenia (phosphaturia) and volume depletion.
Chlorothiazide	20 mg/kg/dose twice daily
Spironolactone	—	No evidence that adding it reduces electrolyte supplements or improves lung outcomes.
Chloride supplement	2–4 mEq/kg/day above usual needs, as KCl; NaCl only if Na <130	Chronic diuretics cause hypochloraemic alkalosis with potassium depletion, linked to poor weight and head growth. Keep serum chloride >90 and never <85 (printed "mg/dL" — read as mEq/L). Potassium salts reduce urinary calcium loss more than sodium salts. Arginine chloride is an alternative (needs hepatic activation). If total KCl + NaCl exceeds 5 mEq/kg/day, reconsider the diuretic.
Albuterol / levalbuterol	MDI with spacer (90 or 45 mcg/puff): 2 puffs every 4–6 h for 24–48 h, then wean. Severe episodes: 2–4 puffs every 20 min × 3	No routine or maintenance use — no benefit on mortality, ventilation or oxygen, and true bronchospasm is uncommon before 2–3 months. Allow a 48-hour trial (or an inhaled steroid for 5–7 days) in unstable infants with rising CO₂ or oxygen need. Needing it more than 1–2 times a week → evaluate for bronchomalacia.
Vitamin A (prevention)	<1000 g: 5000 IU IM Monday, Wednesday and Friday for 12 doses, starting in week 1 (if available)	Modest reduction in chronic lung disease at 36 weeks (meta-analysis of 10 RCTs); strong recommendation, moderate-quality evidence.

Postnatal steroids (Table 16-12)

Not recommended: early (<7 days) dexamethasone (GI perforation, cerebral palsy); early hydrocortisone (GI bleeding and perforation despite less death/BPD); late hydrocortisone (no difference in death/BPD or impairment); early inhaled budesonide (increased mortality); late inhaled steroids (no benefit).
Consider late low-dose dexamethasone — which reduces death/BPD, extubation failure, cerebral palsy and impairment, at the cost of transient hyperglycaemia and hypertension — after discussion with parents, for infants <30 weeks still ventilated beyond 14 days at moderate to high risk of grade 2–3 BPD or death on the NICHD BPD outcome estimator. Best timing is 2–6 weeks of age. (Weak recommendation, moderate-quality evidence.)
Baylor schedule (DART and Canadian Paediatric Society): 0.075 mg/kg every 12 h × 6 → 0.05 mg/kg × 6 → 0.025 mg/kg × 4 → 0.01 mg/kg × 4, a cumulative 0.89 mg/kg over 10 days. Follow gases closely, wean aggressively, and aim to extubate by day 3–4. Early steroids for ELGANs are covered in chapter 2.2.
Acute exacerbation in a previously stable older infant: consider infection, worsening PH, cor pulmonale, oedema or renewed inflammation. Treat with more oxygen and support, fluid restriction and diuretics, and occasionally a short course of inhaled steroids or albuterol. Beyond 44–48 weeks PMA, a severe exacerbation may justify a prednisone or methylprednisolone burst of 1–2 mg/kg/day for 3–10 days (NIH asthma panel 2007).

Tracheobronchomalacia and lung-injury prevention

15–34% of ventilator-dependent BPD infants have tracheo- or bronchomalacia. Episodes bring sudden work of breathing, cyanosis and poor air entry. Below 6 months it is far commoner than reactive airway disease, and bronchodilators can make it worse. PEEP is the mainstay until the airways grow. Bronchoscopy identifies it and the PEEP that holds the airway open. Dynamic CT (≥50% collapsibility) correlates with bronchoscopy in older children, but is unstudied in preterm neonates and carries radiation, so order it with great caution.
Prevention bundle:
- Early CPAP with selective surfactant; a failed CPAP trial should not stop repeated weaning attempts.
- Volume guarantee as the default mode for VLBW infants.
- Extubate as soon as criteria are met, not at a convenient time, onto CPAP or NIPPV with optimized caffeine.
- Caffeine for all infants <1250 g (CAP trial; strong recommendation).
- Vitamin A as above.
- SpO₂ targets per Table 16-13.

SpO₂ targets (Baylor Table 16-13)	Target	Strength
Preterm, birth to 36 weeks PMA	90–95%	Strong; moderate quality
BPD without pulmonary hypertension	90–95%	Strong; low quality
BPD with pulmonary hypertension	92–95%, avoiding intermittent and prolonged hypoxia	Strong; moderate quality
PPHN (pre-ductal)	91–95%	Strong; low quality
CDH (pre-ductal)	>70% for the first 10 min, >80% to 2 h, then >85%	Strong; low quality

10. Monitoring

Monitoring Table

Ongoing surveillance for the BPD infant through to discharge.

Parameter	Frequency	Target	Action if abnormal
SpO₂	Continuous	91–95% to 36 wk PMA; 93–97% after	Adjust oxygen; higher targets after 36 wk protect against pulmonary hypertension.
Growth (wt/length/HC)	Regular	Steady centile tracking	Dietitian input; increase calories.
Echocardiography	At diagnosis of mod–severe BPD, then per findings	No pulmonary hypertension	If PH, see 6.3; optimise oxygenation.
Electrolytes (if on diuretics)	Per protocol	Normal Na/K/Ca	Correct; reconsider diuretic.
BP & urinary glucose (if on steroids)	Daily	Normal	Manage hypertension/hyperglycaemia; review steroid.
Overnight oximetry	Before oxygen weaning/discharge	Adequate saturation profile	Adjust home-oxygen plan.

11. Contraindications & Precautions

Safety Cautions

Do not start systemic corticosteroids routinely or early without a clear risk–benefit discussion and consent — they carry a neurodevelopmental risk.
Do not combine dexamethasone with NSAIDs (risk of gastrointestinal perforation).
Avoid hyperoxia and large saturation swings — both worsen lung and retinal injury.
Avoid hypocapnia and over-distension during ventilation.
Avoid amiloride as the diuretic of choice (promotes lung fluid retention); watch nephrocalcinosis with loop/thiazide use.
Do not overlook pulmonary hypertension, airway malacia/stenosis, aspiration, or infection when an infant fails to progress.

12. Escalation & Follow-Up

Escalate When…

Rising oxygen/support requirement, new desaturations, or failure to wean as expected.
Echocardiographic pulmonary hypertension, right-heart strain, or unexplained cyanotic episodes.
Poor growth despite nutritional optimisation, or suspected airway disease/aspiration.
Consideration of postnatal steroids, tracheostomy, or transfer for advanced respiratory care.

Discharge & Follow-Up

Establish a home-oxygen plan when appropriate (overnight oximetry, parent training, equipment).
Aim to stop diuretics before discharge (consultant decision); reconcile all medications.
Arrange neonatal/respiratory follow-up, neurodevelopmental surveillance, ROP and hearing follow-up, immunisations, and RSV prophylaxis per policy.

Parent Counselling Points

"Because your baby was born early, the lungs need longer to grow and may need extra oxygen or support for weeks to months. This is called chronic lung disease."
"Our focus is gentle support, good nutrition for lung growth, and avoiding setbacks. Some babies go home on oxygen and are gradually weaned as they grow."
"We will watch for related problems such as high blood pressure in the lungs, and arrange follow-up, vaccinations, and protection against the RSV winter virus."

13. Key Pearls

High-Value Clinical Pearls

Prevention beats treatment: antenatal steroids, CPAP, caffeine, gentle ventilation, and judicious oxygen do more than any drug for established BPD.
Grade severity by the support needed at 36 weeks' PMA — it predicts pulmonary hypertension and long-term outcome.
After 36 weeks' PMA, nudge saturation targets up (93–97%) to protect the pulmonary vasculature.
Feed the lungs: higher calories drive alveolar growth; avoid fluid overload.
Steroids can buy extubation but at a neurodevelopmental cost — reserve for the ventilator-dependent infant, individualise, and consent.
An infant who won't progress has a reason — look for pulmonary hypertension, airway malacia/stenosis, aspiration, or infection.

14. Common Mistakes to Avoid

Pitfalls & Better Practice

The recurring errors in chronic lung disease management.

Mistake	Why it harms	Better practice
Early, routine, or high-dose systemic steroids.	Increases neurodisability risk.	Reserve for ventilator-dependent infants; individualise, consent, use lowest effective course.
Chasing high saturations.	Hyperoxia worsens lung and retinal injury.	Target 91–95% (→93–97% after 36 wk PMA).
Under-feeding the BPD infant.	Poor alveolar growth, worse outcomes.	Increase calories; involve dietitian.
Prolonged diuretics without benefit.	Electrolyte disturbance, nephrocalcinosis.	Time-limited trial; stop at ~1 week if no gain.
Missing BPD-associated pulmonary hypertension.	Right-heart failure, sudden deterioration.	Echo-screen moderate–severe BPD.
High ventilator pressures/volumes.	Ongoing volutrauma perpetuates BPD.	Volume-targeted ventilation, permissive hypercapnia.

15. Board-Style High-Yield Summary

Key Takeaways

BPD = oxygen/support dependence ≥28 days; severity set by support at 36 weeks' PMA (<32 wk) or 56 days (≥32 wk).
Prevention bundle: antenatal steroids, CPAP + selective surfactant, caffeine, vitamin A, gentle volume-targeted ventilation, judicious oxygen.
SpO₂ 91–95% to 36 weeks' PMA, then 93–97% to protect against pulmonary hypertension.
Nutrition: higher calories for work of breathing; avoid fluid overload.
Postnatal steroids and diuretics are consultant-led, individualised; steroids carry neurodevelopmental risk and must not be combined with NSAIDs.
Screen moderate–severe BPD for pulmonary hypertension; plan home oxygen and multidisciplinary follow-up.

16. References

1.Bedside Clinical Guidelines Partnership / West Midlands Neonatal ODN. Chronic Lung Disease; Postnatal Dexamethasone; Oxygen Saturation. Neonatal Guidelines 2025–28.
2.Jensen EA, et al. The diagnosis of bronchopulmonary dysplasia in very preterm infants: an evidence-based approach (NICHD 2019 severity grades). Am J Respir Crit Care Med. 2019;200(6):751–759.
3.Higgins RD, et al. Bronchopulmonary dysplasia: executive summary of an NHLBI/NICHD workshop. J Pediatr. 2018;197:300–308.
4.Baylor College of Medicine, Division of Neonatology. Guidelines for Acute Care of the Neonate, Edition 33, 2025–2026.
5.Doyle LW, et al. Late (≥7 days) vs early systemic postnatal corticosteroids for BPD. Cochrane Database Syst Rev.
6.American Academy of Pediatrics. Respiratory care and BPD prevention guidance. https://publications.aap.org/

Back to Clinical Guideline Hubs

Chapter 6.2 — Bronchopulmonary Dysplasia (Chronic Lung Disease)