Bronchopulmonary Dysplasia (BPD) in Preterm Neonates

• Supporting Health IV discusses people with chronic health challenges, focusing on respiratory issues.

Class Objectives

• Identify safe and effective nursing management of pharmacotherapeutic regimens for individuals across the lifespan experiencing chronic respiratory disorders.
• Identify nursing outcomes and interventions for individuals and their families.
• Prioritize nursing diagnoses, outcomes, and interventions to create a nursing care plan for a case study.
• Build a repertoire of collaborative approaches to support self-management and effective coping for individuals across the lifespan experiencing chronic disorders.
• The chronic respiratory disorders include bronchopulmonary dysplasia (BPD), cystic fibrosis, end-stage COPD, interstitial lung disease, pulmonary artery hypertension, and lung transplantation

Bronchopulmonary Dysplasia (BPD)

• BronchoPulmonary Dysplasia (BPD) is a chronic lung disease that develops in preterm neonates treated with oxygen and positive-pressure ventilation.
• BPD often leads to lung infections and chronic lung issues in the future.
• Treatment often includes antibiotics, corticosteroids, diuretics, electrolyte replacement, and bronchodilators as needed

Surfactant Therapy

• Surfactant therapy is used to prevent and treat BPD.
• Surfactant therapy involves lipoproteins to lower surface tension in the alveoli.
• It is instilled via an endotracheal tube in liquid form.

Adequate Nutrition

• Neonates with BPD need high calories for growth and healing.
• Total energy needs can exceed 130 kcal/kg/day
• Protein intake requirements are generally 3.5-4 g/kg/day.

Modest Fluid Restriction

• The feeding volume may be reduced and provided with high caloric density.

Oxygenation

• Target SpO2 between 90-95%, avoiding high (>95%) and low oxygenation.

Decompensation

• Infants with BPD experience sudden episodes of pulmonary decompensation.
• Decompensation can be identified by worsening gas exchange and respiratory distress.
• Potential causes for decompensation include bronchospasm, fluid retention, pulmonary air leak, endotracheal tube displacement, or symptomatic tracheobronchomalacia.

Cystic Fibrosis

• Early interventions for growth and development involve targeted nutrition to increase height and weight after diagnosis.
• Goals of interventions include minimizing pulmonary complications.
• Adequate nutrition is needed for growth, height, weight, and bone density.
• Additionally, appropriate physical activity and reasonable quality of life is needed for the child and family

Therapeutic Pharmacological Interventions

• CFTR modulator therapy can be used for treatment.
• Airway Clearance Therapies involve hypertonic saline DNase.
• Additional treatments consist of intermittent antibiotic therapy and glucocorticoid therapy.
• Colonization of MRSA is a critical factor requiring longer hospital stays.

Therapeutic Interventions for Pulmonary Issues

• Antibiotic therapy, airway clearance therapies, and oxygen may be needed.
• Chest physiotherapy and viscous secretions can be a growing medium for bacteria.
• Colonization of MRSA is a critical factor in recovery and longer hospital stays.

Chest Physiotherapy

• Chest physiotherapy is essential for illness prevention and treatment and involves twice daily treatments.
• Treatments should include percussion and postural drainage and positive expiratory pressure (PEEP).
• Additional treatments can include active cycle of breathing, autogenic drainage, and oscillatory PEP devices (https://youtu.be/cbXUDSj7kgl ).
• High-frequency chest compression (HFCC), exercise, and percussive vests can also be used.

Developmental Considerations

• Living with cystic Fibrosis is stressful.
• Children may respond well to gentle coaxing, positive reinforcement and Frank negotiation
• Families may need emotional support/validation
• Local, national, and international support groups offer emotional and practical support.
• Cystic Fibrosis Canada can assist:

Invasive Lines

• Invasive lines can be stressful.
• Peripherally inserted vascular access devices
• Centrally inserted vascular access devices (can be tunneled appearing as ports), or CVAD's are used for medications, fluids, and nutrition (TPN) in some instances in pediatric nursing
• Feeding Tubes: NG, NJ, G-Tube can be used.
• Oxygen and nebulizer equipment

Interventions for GI Issues

• Energy requirements typically need to be over 150% of recommended daily allowances.
• Replacement of pancreatic enzymes includes 1-5 pills per meal, to achieve a goal of 1-2 stools per day.
• Prolapse of the rectum is associated with large bulky stools.
• Patients are at risk for bowel obstruction.

Interventions for Endocrine Issues

• Most common complication in children is Cystic fibrosis related diabetes (DFRD).
• Insulin regime recommended; oral hypoglycemics are not effective, and ketoacidosis is rare.
• By age 30, 50% of CF pts have diabetes.
• High fat, high calorie diet still recommended.

Interventions for Sexuality

• Discussions include fertility issues.
• 95% of males have congenital absence of vas deferens, but are not impotent.
• Assisted reproductive technology is usually required for males.
• Reduced female fertility can occur due to highly viscous cervical secretions, leading to lower conception rates.
• Genetic counselling is highly recommended, and females have a higher incidence of low-birth-weight babies and spontaneous abortions.

Adult Lung Disease

• Chronic Obstructive Pulmonary Disease
• Interstitial Lung Disease

COPD Clinical Manifestations

• Dyspnea and cough with or without sputum production.
• Wheezing during prolonged expiration, as well as Hypoxia.

COPD Exacerbation Complications

• Exacerbations are marked by worsening dyspnea cough and sputum production lasting up to 14 days.
• Exacerbations may be accompanied by tachypnea and/or tachycardia, often induced by airway infection, pollution, or irritants.
• Symptoms that change acutely during an exacerbation can include coughing, more frequent and severe
• Sputum production increases in volume and appearance, as well as dyspnea becoming more intense.

Additional COPD Complications

• Potential for hospitalization, hypercapnia, and hypoxia.
• Hypoxia can cause secondary polycythemia and possible exacerbation causing respiratory failure.
• Excessive sputum/mucous production can contribute to risk for pneumonia.
• General weakness can affect ability to cough effectively, expel air from lungs effectively (air trapping disease), and use puffers effectively.
• Additional complications can include chronic anemia, fatigue, and malnutrition, which can include cachexia and sarcopenia.
• Skeletal muscle dysfunction (wasting), pulmonary hypertension, and right heart failure (Cor Pulmonale) have been reported.
• Anxiety, panic attacks, and depression can be additional complications.

COPD Pharmacological Interventions

• Short acting inhaled bronchodilators (SABAS) and (SAMAS).
• Long acting inhaled bronchodilators (LABA) and (LAMA).
• Possible inhaled Glucocorticoids and Oral/intravenous glucocorticoids, as well as Antibiotics
• Ventolin and Ipratropium are short acting
• Salmeterol and tiotropium are long acting.
• Pulmicort is considered an inhaled Glucocorticoid.

COPD Gas Exchange

• Oxygen is a medication with a drive to breathe based on arterial CO2,
• The goal of O2 therapy is to titrate the flow rate to achieve SaO2 between 88% and 92%.
• Do not administer O2 per facial mask at rates of <=6 to prevent proper CO2 clearance, causing hypercapnia.
• Administering nebs masks is needed to remove when nebulizer is attached, and used, as it is connected to O2
• Factor in Assessment for CO2 toxicity assessment and consider monitoring priorities.
• Mind situations where CO2 retention can be potentiated, like narcotics
• Smoking with O2 is dangerous, supporting combustion to people on O2 and people around them
• Provide patient education on CO2 retention and toxicity and portable oximeters that can be purchased in the community.

Air Trapping Management

• Nurses should promote and encourage purse-lipped breathing and tripoding for dyspnea
• Breathing exercises such as Huff Cough, and Top 3 Breathing Exercises for COPD

Positive Airway Pressure

• Bilevel positive airway pressure (BPAP) is used during non-invasive positive pressure ventilation (NPPV) and delivers a pre-set inspiratory (IPAP) and expiratory (EPAP) positive airway pressures
• CPAP is not the same as BiPAP.
• BiPap applies positive air pressure on inspiration and expiration, while higher pressure is only applied on inspiration.
• The mask must have a secure seal for the machine to function correctly.
• CPAP applies minimal press resolving apneas, snoring, and obstructive events in the upper airway and not for treating hypercapnia.

Non-Pharmacological Intervention Patient Education

• Smoke cessation prevents progression, and to avoid exposure of irritants.
• Educate patients on the “right education” to equip patients with the knowledge that will support their health needs.
• Assess patients for potential need to asses and/or educate on inhaler techinque
• Patients should be thought about using supplemental oxygen with caution, and self-care to avoid deconditioning
• Acess to portable SaO2 oximeters can be purchased
• Awareness of early intervention if concerns about a patient arise
• Be cautious of people sick and consider vaccines for precaution

COPD Energy Management

• Avoid meal prep prior to meals to conserve energy with eating.
• The use of a SABA (Ventolin) before sexual activity will help.
• Patients should be encouraged to discuss any questions or concerns about sexual activity.
• Sleep/frequent naps and relaxation techniques can help with stress, depression, and anxiety.

COPD Surgical Interventions

• Lung volume reduction surgery, as well as lung transplantation.

COPD Palliative Care

• It is important for patients and their loved ones to express their feelings/ Healthcare providers all play an important role to show support in end of life to the patient and their and loved ones
• As nurses, we work as a team, so assess MRHP, and advocate for the patient for comfort and support

Interstitial Lung Disease; Clinical Manifestations

• Progressive dyspnea with exertion and a persistent non-productive cough.

Therapeutic Interventions for Idiopathic Pulmonary Fibrosis

• Supplemental oxygen
• Education regarding the progressive and terminal nature of the disease, with provision of palliative care principles.
• Enlist patient for pulmonary rehab to manage side effects
• Prevention of infections/exacerbations: Avoid crowds, maintain respiratory vaccination schedule
• The patient may concentrate nutrition, so frequent meals that have tolerability with caloric density
• Small frequent meals might be needed, because there needs to be fat and protein to increase calories

Pharmacologic Interventions for Idiopathic Pulmonary Fibrosis

• Antifibrotic Therapy
• Nintedanib (Ofev): A receptor blocker for multiple tyrosine kinases that mediate the elaboration of fibrogenic growth factors, slows the rate of disease progression.
• Pirfenidone (Esbriet): Inhibits transforming growth factor beta (TGF-b) stimulated collagen synthesis, decreases the extracellular matrix, and blocks fibroblast proliferation in vitro.

Pulmonary Hypertension

• Common lung disorders can cause pulmonary hypertension (PH).
• Pulmonary hypertension due to obstructive lung disease (i.e., COPD) and restrictive lung disease (i.e., ILD).
• Mixed obstruction and restriction and Hypoxia can occur without lung disease.
• Developmental Lung disorders can occur (Bronchopulmonary Dysplasia).

Interventions to Treat Pulmonary Hypertension

• Address of underlying condition(s), tolerated exertion exercise, and routine vaccinations, as well as Counseling to avoid smoking.
• Additionally, Supportive measures where indicated with oxygen (confirmed hypoxemia)

Cor Pulmonale (Right Heart Failure)

• Hypertrophy of the hearts right side with possible heart failure; results from pulmonary hypertension and/or HTN.
• Address pulmonary issues.
• Long term oxygen therapy and Diruetics if indicated
• Low sodium diet, and Palliative measures used as clinic indication/

Lung Transplant; Postoperative Care

• Postoperative regime: ventilator support, bronchodilators, chest physio, DB & C, fluid and hemodynamic monitoring, immunosuppression, detection and assessment of early rejection and monitoring infection
• Monitor chest tube/trach care, and surveillance for infection,
• Initiate Anticoagulation therapy when the patient becomes hemodynamically stable
• Provide nutritional
• Wound care as needed.

Lung Transplant; Therapeutic Interventions

• Psychological screening to ensure the patient and family can cope with the postoperative regime
• Immunosuppression therapy includes triple regime of cyclosporine, azathioprine and prednisone.
• Rejection diagnosed and acute rejection can occur in 5-7 days
• Acute rejection is treated with corticosteroids, while chronic rejection bronchiolitis obliterans, treated with immuno-suppression.

Additional Respiratory Information

• Humidified High Flow Nasal Cannula
• Surgical incision into trachea
• Creates an artificial airway into the trachea
• Useful to Bypass upper airway obstruction, Facilitate removal of secretions, or For long-term ventilation.
• Trach must be cuffed to manage, and Safety: keep extra kit at bedside to avoid issues

Accidental decannulation

• Do not put trach tube, or get help immediately.
• Ensure oxygen is used over the area
• Call healthcare personal to reinsert.
• Spares trach should be available.

Long COVID Management

• Includes physical and mental symptom clusters that persist for three months after the onset of illness.
• Be sure have vaccinations and management strategies to assess underlying cardio function.
• Inpatient and outpatient programs are available for support
• Screening tools are available provide supportive measures that are individualized to the patient
• For Long COVID be sure to ask for assistance and support groups.
• Mild/ Moderate issues should be addressed, and can be treated with breathing exercises. (orthostasis, fatigue, and any psychological or emotional issues)

This lesson discusses Bronchopulmonary Dysplasia (BPD), a chronic lung disease affecting preterm neonates treated with oxygen and positive pressure ventilation. It will cover nursing management, outcomes, and interventions. Collaborative approaches to support self-management and coping will also be discussed.