Clinical presentation and criteria of the course
The disease has no specific starting signs. The development of BPD can be suspected when, in classical RDS with increasing diuresis by days 3–4, the expected improvement does not occur.
The criteria for an unfavorable course and the development of dysplasia are:
- Inability to extubate and wean the child off mechanical ventilation for several months.
- Persistent need for oxygen supplementation.
- Persistence of hypoxemia and hypercapnia even after episodes of initial temporary status improvement.
There are specific features of the so-called «new form» of the disease. Unlike the classical variant, a persistent need for oxygen comes to the forefront, while episodes of bronchial obstruction develop rather rarely. Regardless of the form, all patients are in the high-risk group for a complicated course of respiratory syncytial virus infection.
Physical examination findings
Objective examination reveals characteristic changes in appearance, chest shape, and breathing pattern.
- Appearance: Skin is pale, cyanosis is noted. In children receiving long-term steroid therapy, a Cushingoid appearance develops.
- Chest: Acquires a barrel-shaped, emphysematously distended configuration.
- Respiratory mechanics: Pronounced tachypnea (up to 80–100 respiratory movements per minute) and expiratory dyspnea (expiration is prolonged and labored) are observed. Accessory muscles actively participate in breathing (intercostal retractions, sternal retractions). Paradoxical breathing («seesaw» sign) is characteristic, where the sternum retracts during inspiration while the abdomen protrudes due to the action of the abdominal muscles.
Auscultatory findings include weakened breath sounds and crepitations (indicating interstitial pulmonary edema). Dry wheezes and fine crackles are also heard, which must be determined in the absence of signs of heart failure. Due to high aerodynamic resistance and airway hyperreactivity, persistent bronchial obstruction syndrome develops.
As the disease progresses, right ventricular heart failure may join. It manifests as cardiomegaly, tachycardia, gallop rhythm, hepatosplenomegaly, and the development of peripheral edema.
Complications
All typical complications of the disease can be conveniently divided into three broad groups:
- Respiratory: Chronic respiratory failure (observed in 15–60% of children) and episodes of acute respiratory failure joining it (8–65%).
- Hemodynamic: Pulmonary hypertension (21–23%), development of cor pulmonale (4%), and systemic arterial hypertension (13–43%).
- Nutritional: Growth retardation and malnutrition (25–40%).
Diagnostic program and imaging methods
The examination is divided into basic and advanced.
Mandatory minimum includes complete blood count, acid-base balance assessment, ECG, continuous blood pressure monitoring, and pulse oximetry. The main routine instrumental method is chest radiography. In intensive care units, it is performed electively 1–2 times a month. Emergency radiographs are taken in case of negative dynamics, suspicion of pneumonia, or «air leak» syndromes (pneumothorax).
Advanced examination is performed according to indications:
- Hemodynamic assessment: Echocardiography, right heart catheterization with a vascular reactivity test.
- Respiratory system assessment: High-resolution computed tomography (HRCT), polysomnography, tidal breathing flow-volume loop analysis.
HRCT is used primarily for differential diagnosis if it is necessary to exclude interstitial lung diseases, developmental anomalies, recurrent pneumothorax, or bronchiolitis obliterans.
Differential diagnosis
Respiratory symptoms require the exclusion of a wide range of pathologies, which are divided into the following groups:
- Infections: Pneumonia, neonatal sepsis, congenital tuberculosis.
- Aspirations: Meconium aspiration syndrome, microaspirations.
- Malformations: Congenital heart defects (including total anomalous pulmonary venous return), anatomical airway obstructions, tracheobronchomalacia.
- Specific pathologies: Persistent pulmonary hypertension of the newborn, pulmonary lymphangiectasia, cystic fibrosis, surfactant protein B deficiency, acute RDS.
- Background conditions: Gastroesophageal reflux, immunodeficiencies.
Groups of complications are easy to remember by the acronym RGN: Respiratory, Hemodynamic, Nutritional.
Class and exam questions
How to differentiate the onset of BPD from the usual course of RDS?
In uncomplicated RDS by days 3–4 against the background of increased diuresis, clinical improvement is noted. With the development of BPD, this does not happen; ventilation dependency and hypoxemia persist.
What are the auscultatory criteria not associated with heart failure?
These are dry wheezes and fine crackles that should be heard in the absence of signs of circulatory failure.
How often should routine radiography be performed?
In the intensive care unit, routine chest radiography is performed 1–2 times a month. As needed — in case of deterioration.
What else to study on this topic
- Pathogenesis of the development of high bronchial aerodynamic resistance
- Mechanisms of cor pulmonale development in chronic hypoxemia
- Features of the course of RSV infection in premature infants with bronchopulmonary dysplasia
- Interpretation of acid-base balance parameters during prolonged mechanical ventilation
- Genetically determined surfactant protein B deficiency: differences from BPD
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