The Section of Neonatology

Care of the Bronchopulmonary Dysplasia (BPD) Patient Following Discharge

Each year, thousands of babies receive the highest level of care from neonatologists at Nationwide Childrens Hospital. As one of the largest neonatal centers in the nation, we dedicate ourselves not only to treating, but ultimately preventing all complications of prematurity, including Bronchopulmonary Dysplasia (BPD). Inside this practice tool, look for information about the ongoing care and management of patients with BPD following discharge from the hospital.

The Section of Neonatology at Nationwide Childrens Hospital

The Section of Neonatology at Nationwide Childrens Hospital is one of the largest programs in the country, and is dedicated to not only treating, but ultimately preventing all complications of prematurity. With nearly 170 beds, Nationwide Childrens provides the most comprehensive care for newborns in the region. Our Level III Newborn Intensive Care Units (NICU) and our Newborn Special Care Units (NSCU) specialize in the management of babies with complex birth defects, severe prematurity and complications of pregnancy, labor and delivery. Our neonatologists are nationally recognized for their efforts in establishing small baby guidelines and for treatments and research related to infant feeding disorders and bronchopulmonary dysplasia. Our BrONCHOPulmONAry DySPlASIA ExPErTS Alfred Gest, MD, is the Medical Director for the Comprehensive Center for Bronchopulmonary Dysplasia and an Associate Professor of Clinical Pediatrics at The Ohio State University. A board-certified neonatologist since 1984, his special interests are in the pathogenesis and treatment of BPD. Dr. Gest directs a chronic pulmonary care team to follow babies prospectively and to achieve some consistency in long-term care, utilizing a database of clinical parameters for observing the time course of development of chronic lung disease and for evaluating the response of the disease to specific therapies. Rachel Brown, MD, is an attending neonatologist at Nationwide Childrens Hospital and an Assistant Professor of Clinical Pediatrics at The Ohio State University College of Medicine. She is a board-certified neonatologist with an interest in the prevention and treatment of BPD. George Mandy, MD, is an attending neonatologist at Nationwide Childrens Hospital and an Assistant Professor of Pediatrics at The Ohio State University. With more than 10 years of experience managing BPD, his interests include the prevention, pathogenesis and treatment of BPD. Alicia Moise, MD, is the Associate Medical Director of Nationwide Childrens C4 NICU and an Associate Professor of Pediatrics at The Ohio State University. She has been a boardcertified neonatologist for nearly 20 years and has an interest in the care of extremely premature infants and in the prevention of BPD. Edward Shepherd, MD, is the Associate Medical Director of Nationwide Childrens Hospital J4 NICU and an Assistant Professor of Pediatrics at The Ohio State University. He is a board-certified neonatologist and shares a particular interest in the prevention and treatment of BPD. Stephen Welty, MD, is the Chief of the Section of Neonatology at Nationwide Childrens Hospital and an Associate Professor of Pediatrics at The Ohio State University College of Medicine. He is board certified in neonatology and has research and clinical interests in identifying the markers associated with BPD and the design of exquisitely specific therapies to prevent the development of BPD and improve outcomes in premature patients. Amy M. Knupp, RN, MSN, CNS, is the nurse coordinator for the Comprehensive Center for BPD. She received her bachelors degree in nursing from Bowling Green State University and her masters degree in nursing from Kent State University. She has worked in the neonatal intensive care unit since 1998. She has a particular interest in continual process improvement for transitioning families and infants with BPD from hospital to home. Angela Gross, RN, BSN, is the nurse clinician for the Comprehensive Center for BPD. She received her bachelors degree in nursing from Mount Carmel College of Nursing. She has worked at Nationwide Childrens Hospital since 1999, primarily working with infants with BPD and their families. She has a special interest in maintaining care and following the long-term progress of infants with BPD.

For more information about the Section of Neonatology at Nationwide Childrens Hospital, visit our web site, www.NationwideChildrens.org/Neonatology To arrange a transport, call our 24-Hour Emergency Communications Center (ECC) at 1-800-642-6666 or (614) 722-5100.

The Comprehensive Center for Bronchopulmonary Dysplasia

Care of the BPD Patient After Discharge Bronchopulmonary Dysplasia (BPD) is a multifaceted disease that affects both premature infants after the immediate neonatal period, and low birth weight babies who spend longer periods of time on ventilation. BPD encompasses all of the medical problems associated with impaired lung function, as well as the growth, development and social functioning of the child and family. The Comprehensive Center for Bronchopulmonary Dysplasia at Nationwide Childrens Hospital is comprised of an interdisciplinary team that addresses the medical, nutritional, developmental and social needs of patients in a single location. The center, available on both an inpatient and outpatient basis, is designed to minimize emergency room visits and hospital admissions. Since its inception in 2004, it has helped to decrease babies with BPD readmission rates from 33 percent to 7 percent. As part of their development plans, patients are followed beyond the usual neonatal period in order to gather data on long-term growth, nutrition and development. This information is used to guide future therapies and the direction of the overall program for prevention, treatment and follow-up of BPD.

Treating the Whole Family BPD places extreme demands on families who are often required to keep numerous and varied outpatient appointments. Education is a critical component for families so that they are well informed, have realistic expectations and understand why certain therapies are used. The center is designed to foster collaboration between pediatricians and families to address the nutritional, developmental, general medical and social services needs of each patient for long-term development. Nationwide Childrens unique approach to the management of BPD attracts families from across the country. Patients receive specialized treatment and families return home with specific treatment plans for their children. Additionally, there is a commitment to ongoing consultation between Nationwide Childrens and the patients primary care physician.

A Team Approach to BPD The center provides superlative, consistent care that is convenient for patients and their families. At each visit, babies are seen by a: :: Physician :: Clinic nurse :: Nutritionist :: Social worker :: Physical therapist :: Occupational therapist The entire team serves the baby and family by utilizing evidencebased practice and research to continuously improve care, all while creating a physical and therapeutic environment that empowers families to actively participate in the progress of their children. In addition to board-certified neonatologists, the BPD team consists of: :: Case managers :: Advanced practice nurses neonatal and pediatric :: Pharmacists :: Physical and occupational therapists :: Respiratory therapists :: Social workers :: Speech therapists :: Staff nurses :: Nutritionists :: Pulmonologists :: Parents

Welcome Center Services Our Welcome Center Services supports families by coordinating all aspects of their visits with their clinical team, including: :: Housing and transportation For families who require longer stays, Welcome Center Services can assist with accommodations at the Ronald McDonald House, located on the hospitals main campus. Accommodations are available for families on a firstcome basis. :: Financial counseling to assist families with questions related to coverage for health care services, and specifically for out-ofnetwork coverage :: Interpreters :: Sibling care :: Pastoral care More information about the Welcome Center is available online at www.NationwideChildrens.org/WelcomeCenter To refer a patient to the Welcome Center, please call 1-800-792-8401 ext. 9861 or email at WelcomeCenter@NationwideChildrens.org

The Section of Neonatology at Nationwide Childrens Hospital

PrACTICE

TOOl

Care of the Bronchopulmonary Dysplasia (BPD) Patient Following Discharge

wHAT IS BPD?
:: A primary disorder of the airways and lung parenchyma following interface of the lung with mechanical ventilation and oxygen. :: Usually associated with prematurity :: Functional abnormalities are detectable by the third day of life and predisposing factors may be present at birth. :: BPD is classified by severity of the disease utilizing the following criteria1: Classification of BPD mild Definition Oxygen requirement at greater than or equal to 28 days of life, but not at 36 weeks post-conceptual age. less than 30% oxygen requirement at 36 weeks post-conceptual age. Greater than or equal to 30% oxygen requirement or Imv at 36 weeks post-conceptual age.

moderate Severe

Abbreviations: BPD, Bronchopulmonary dysplasia; Imv, Intermittent mandatory ventilation

Typical Care at Home This level of care is supportive, not therapeutic. :: Supplemental oxygen Maintain blood oxygen levels within a normal range Avoid hypoxia Keep saturations > 95%2 :: Diuretics Reduce the amount of fluid present in the lungs One of the last therapies to add One of the first therapies to discontinue May need supplemental electrolytes Electrolytes need to be monitored :: Inhaled bronchodilators Relax smooth muscle to ease breathing :: Inhaled and/or oral steroids Decrease swelling or inflammation that can cause wheezing and coughing :: Excellent nutrition Provides nutrients vital for growth and repair of lung tissue Increased calories for weight gain Increased calories often need to be supplied in conjunction with fluid restriction :: Home apnea or saturation monitor Provides continuous monitoring and recording of heart rate, breathing, and oxygen saturation

Other Problems Associated with BPD :: Congestive heart failure secondary to: Inadequate oxygenation Sodium imbalance Pulmonary infection :: Pulmonary hypertension secondary to: Inadequate oxygenation :: Increased blood pressure :: Feeding intolerance :: Developmental delays

rEfErENCES
1. Jobe, AH, Bancalari, E. NICHD/NHLBI/ORD workshop summary: Bronchopulmonary dysplasia. American Journal Respiratory Critical Care Medicine 2001; 163: 1723-1729. 2. American Thoracic Society Documents: Statement on the care of the child with chronic lung disease of infancy and childhood. American Journal Respiratory Critical Care Medicine 2003; 168: 356-396.

The Section of Neonatology at Nationwide Childrens Hospital

PrACTICE

TOOl

Preventing and Managing BPD Exacerbations

Prevention Measures :: Ensure a reality-based discharge from the hospital to home (Based on familys and communitys ability to care for the child.) :: Emphasize to families the importance of oxygen :: Practice proper hand hygiene :: Eliminate exposure to environmental tobacco smoke :: Limit exposure to contagious settings and individuals :: Utilize preventative medical therapies according to the most current recommendations such as: Respiratory syncytial virus (RSV) immunoprophylaxis Influenza vaccine Physical Examination The physical examination should include an evaluation of the child for the presence of the following: :: Wheezing :: Changes in breathing pattern, especially increased work of breathing :: Increased oxygen requirement :: Changes in feeding :: Retractions :: Nasal flaring :: Coughing :: Congestion :: Cyanosis :: Edema Management of Exacerbations :: The goals of treatment are to safely manage most BPD exacerbations at home and to minimize unnecessary emergency room visits and/or hospital readmissions. :: Families should be utilized as part of the care team for management at home. Contact the BPD Service at (614) 722-4509 :: If a child being followed by the BPD service presents in your office with respiratory difficulties. :: With questions regarding BPD. Neurodevelopmental Follow-up Neurodevelopmental follow-up is continued with the BPD service until the child is two years of age. If indicated, subsequent referrals are initiated to monitor development through early childhood.

THE COmPrEHENSIvE CENTEr fOr BrONCHOPulmONAry DySPlASIA AT NATIONwIDE CHIlDrENS HOSPITAl For more information on the program or to schedule a consult, please call (614) 722-4509. Staff members are available 24 hours a day, 7 days a week. For more information on our program, visit www.NationwideChildrens.org and enter keyword: BPD.

Care of the BPD Patient After Discharge

The Section of Neonatology 700 Childrens Drive Columbus, Ohio 43205 NationwideChildrens.org/Neonatology

CH715.3.09.7500