Aura Ioana Cristea

Objectives: Tracheobronchomalacia (TBM) is common in Grade 3 Bronchopulmonary Dysplasia (BPD), but there is wide variation in frequency and method of evaluation. Objective quantitative methods are needed for translational studies and future drug trials. This study aimed to determine whether positive end‐expiratory pressure (PEEP) and oxygen saturation index (OSI) can predict TBM in Grade 3 BPD. Methods: We retrospectively reviewed flexible bronchoscopy videos from a cohort of infants with Grade 3 BPD to determine the presence of TBM. PEEP and mean OSI in the week before the first bronchoscopy were assessed as predictors of TBM using multiple logistic regression. Subject Demographics: The study included 56 infants with Grade 3 BPD with a median gestational age (GA) of 25.3 weeks (IQR 2.8) and median post‐menstrual age (PMA) at first bronchoscopy of 40.7 weeks (IQR 6.1). Results: Thirty‐seven subjects (66%) were found to have TBM, although 13 subjects lacked evidence of TBM on the first evaluation (false negative rate 35%). PEEP and OSI had 86% sensitivity for predicting TBM, but only 30% specificity ( p = 0.02). In a post‐hoc analysis of the 13 initial bronchoscopies that “missed” TBM, 10 had a higher level of sedation in the first evaluation compared to the later assessment that revealed TBM. Conclusions: We found that PEEP and OSI are sensitive but not specific for predicting TBM in Grade 3 BPD. In addition, there are frequent false negative evaluations when bronchoscopy is performed under higher levels of sedation. We propose a more precise bronchoscopy method for quantifying TBM.

The increase in tracheostomies among infants and children, driven by medical advances and evolving family preferences, underscores the need for standardized, evidence-based guidelines. This guideline outlines management recommendations for these medically complex and resource-intensive children with tracheostomies, incorporating best evidence on diagnostic tools and streamlined care protocols. This Clinical Practice Guideline adheres to American Thoracic Society policies and procedures, utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to form clinical questions, summarize evidence, and develop recommendations with a health equity perspective. A multidisciplinary panel with expertise in pediatric tracheostomy care contributed to recommendations for ethical considerations, discharge processes, in-home caregiver requirements, and diagnostic tools (tracheal aspirate cultures, bronchoscopy, and polysomnography). The panel recommends applying ethical principles to guide shared decision-making about tracheostomy placement (strong recommendation). We also recommend a standardized discharge process involving comprehensive family caregiver training for safe transitions from hospital-to-home (conditional recommendation). A continuously awake, trained caregiver to manage emergencies is also recommended for high-risk patients (strong recommendation). The panel recommends tracheal aspirate cultures during acute respiratory episodes to guide antibiotic therapy, but not for routine surveillance (conditional recommendation), bronchoscopy for thorough airway examination before tracheostomy decannulation (strong recommendation), and polysomnography before decannulation to ensure respiratory stability (conditional recommendation). These guidelines aim to standardize and improve the management of pediatric patients with tracheostomies by providing evidence-based recommendations for ethical considerations, discharge planning, and diagnostic assessments. Implementing these guidelines aims to enhance patient safety and quality of life through a structured and patient-centered approach.

Objective To identify factors associated with the timing of ventilator liberation and tracheostomy decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who required chronic outpatient invasive ventilation. Study design Multicenter retrospective study of 154 infants with sBPD on outpatient ventilators. Factors associated with ventilator liberation and decannulation were identified using Cox regression models and multilevel survival models. Results Ventilation liberation and decannulation occurred at median ages of 27 and 49 months, respectively. Older age at transition to a portable ventilator and at discharge, higher positive end expiratory pressure, and multiple respiratory readmissions were associated with delayed ventilator liberation. Surgical management of gastroesophageal reflux was associated with later decannulation. Conclusions Ventilator liberation timing was impacted by longer initial admissions and higher ventilator pressure support needs, whereas decannulation timing was associated with more aggressive reflux management. Variation in the timing of events was primarily due to individual-level factors, rather than center-level factors.

Introduction: Despite bronchopulmonary dysplasia (BPD) being a common morbidity of preterm birth, there is no validated objective tool to assess outpatient respiratory symptom control for clinical and research purposes.Methods: Data were obtained from 1049 preterm infants and children seen in outpatient BPD clinics of 13 US tertiary care centers from 2018 to 2022. A new standardized instrument was modified from an asthma control test questionnaire and administered at the time of clinic visits. External measures of acute care use were also collected. The questionnaire for BPD control was validated in the entire population and selected subgroups using standard methodology for internal reliability, construct validity, and discriminative properties.Results: Based on the scores from BPD control questionnaire, the majority of caregivers (86.2%) felt their child's symptoms were under control, which did not differ by BPD severity (p = 0.30) or a history of pulmonary hypertension (p = 0.42). Across the entire population and selected subgroups, the BPD control questionnaire was internally reliable, suggestive of construct validity (albeit correlation coefficients were −0.2 to −0.4.), and discriminated control well. Control categories (controlled, partially controlled, and uncontrolled) were also predictive of sick visits, emergency department visits, and hospital readmissions.Conclusion: Our study provides a tool for assessing respiratory control in children with BPD for clinical care and research studies. Further work is needed to identify modifiable predictors of disease control and link scores from the BPD control questionnaire to other measures of respiratory health such as lung function testing.

Objective Bronchopulmonary dysplasia (BPD) remains the most common late morbidity for extremely premature infants. Care of infants with BPD requires a longitudinal approach from the neonatal intensive care unit to ambulatory care though interdisciplinary programs. Current approaches for the development of optimal programs vary among centers. Study Design We conducted a survey of 18 academic centers that are members of the BPD Collaborative, a consortium of institutions with an established interdisciplinary BPD program. We aimed to characterize the approach, composition, and current practices of the interdisciplinary teams in inpatient and outpatient domains. Results Variations exist among centers, including composition of the interdisciplinary team, whether the team is the primary or consult service, timing of the first team assessment of the patient, frequency and nature of rounds during the hospitalization, and the timing of ambulatory visits postdischarge. Conclusion Further studies to assess long-term outcomes are needed to optimize interdisciplinary care of infants with severe BPD. Key Points

Background: Bronchopulmonary dysplasia (BPD) remains the most common late morbidity of preterm birth. Clinical care and research have largely focused on the pathogenesis and prevention of BPD. Preterm infants who develop BPD have significant medical needs that persist throughout their hospital course and continue after discharge, including those associated with growth and nutrition. The objective of this study was to review the available literature on nutrition and growth in infants with established BPD and to identify the knowledge and research gaps to provide direction for future studies.Methods: We conducted a literature search in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines using Ovid MEDLINE, CINAHL, and Embase. Titles, abstracts, and full texts were independently reviewed by the authors and selected based on predetermined inclusion/exclusion criteria. Results were summarized qualitatively.Results: Excluding duplicates, 2315 articles were identified. Thirty articles were selected for inclusion. We identified the following key components of nutrition support and clinical care: energy expenditure, growth, and metabolism; body composition; enteral nutrition; supplements; parenteral nutrition; and respiratory outcomes.Conclusions: Despite a large body of literature describing the role of growth and nutrition in the prevention of BPD, research is lacking with respect to interventions and management in the population with established BPD. Thus, organized approaches for clinical interventions and trials with respect to growth and nutrition in infants and young children with established BPD are needed. These studies should include multiple centers because of the small numbers of patients with BPD at each site.

Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.

Bronchopulmonary dysplasia (BPD) remains the most common late morbidity of preterm birth. Ongoing clinical care and research have largely focused on the pathogenesis and prevention of BPD in preterm infants. However, preterm infants who develop BPD have significant medical needs that persist throughout their neonatal intensive care unit course and continue post‐discharge, including those associated with growth and nutrition. The objective of this manuscript was to provide a review on nutrition and growth in infants with established BPD after discharge from the hospital and to identify the knowledge and research gaps to provide direction for future studies.