支气管肺发育不良诊断及治疗中几个关注问题

doi:10.12372/jcp.2022.22e0333

临床儿科杂志 ›› 2022, Vol. 40 ›› Issue (6): 413-419.doi: 10.12372/jcp.2022.22e0333

支气管肺发育不良诊断及治疗中几个关注问题

李芳, 刘立婷

重庆医科大学附属儿童医院新生儿科国家儿童健康与疾病临床医学研究中心儿童发育疾病研究教育部重点实验室儿科学重庆市重点实验室（重庆 400014）

收稿日期:2022-03-08 出版日期:2022-06-15 发布日期:2022-06-07
作者简介:李芳（1979年—）,博士, ORCID：0000-0001-9038-4877, 青年编委,儿科学博士,主任医师,硕士研究生导师。重庆医科大学附属儿童医院院办公室副主任,荣获“重庆市中青年医学高端人才”称号,现任中国医师协会新生儿科医师分会生命支持专委会副主任委员,中华医学会围产医学专委会产房安全与助产学组委员,重庆医学会围产医学专委会委员兼秘书等学术任职。获得重庆医科大学优秀博士论文,先后在丹麦哥本哈根大学和美国奥古斯塔大学儿童医学中心担任访问学者,主持和主研国家自然科学基金4项,主持省市级课题4项,以第一作者或通讯作者发表SCI论文8篇,获得实用新型专利4项,执笔制定专家共识2篇,获得重庆市医学会进步二等奖1项,中国妇幼健康科学技术三等奖1项,参编专著3部,培养硕士研究生5名,参与培养博士研究生2名。
基金资助:
重庆市自然科学基金(cstc2021jcyj-msxmX0257);重庆市科卫联合项目(2021MSXM202)

Concerns about diagnosis and treatment of bronchopulmonary dysplasia

LI Fang, LIU Liting

Department of Neonatology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China

Received:2022-03-08 Published:2022-06-15 Online:2022-06-07

摘要/Abstract

摘要：

支气管肺发育不良（BPD）是早产儿尤其是极低出生体质量儿和超低出生体质量儿中最常见的慢性肺部疾病,严重影响患儿的生存和生活质量。目前,BPD发病率仍居高不下。随着对BPD认识的深入,BPD的诊断标准不断修正,治疗方法不断改进和完善,但BPD诊断标准的选择、治疗中的呼吸支持模式的选择和糖皮质激素的使用仍是临床医师存在困惑和关注的问题。本文在回顾了不同时期的BPD的诊断标准,比较它们各自的优点和不足,并针对BPD患儿的呼吸支持管理及糖皮质激素防治BPD中的关注问题进行讨论和展望。

关键词: 支气管肺发育不良, 诊断标准, 呼吸支持, 糖皮质激素

Abstract:

Bronchopulmonary dysplasia (BPD) is the commonest chronic lung disease in premature infants, especially in very and extremely low birth weight infant. BPD affects the survival rate and the quality of life of premature infants. At present, the incidence of BPD remains high. With the in-depth understanding of BPD, the diagnostic criteria of BPD are constantly revised, and the treatment methods are constantly improved and perfected. However, the selection of diagnostic criteria for BPD, the selection of respiratory support mode in treatment and the use of glucocorticoids are still problems that clinicians are confused and concerned about. This manuscript compared the different diagnostic criteria of BPD, which are all commonly used in the last decade. In addition, we discussed respiratory support management and glucocorticoid use in the prevention and treatment of BPD in neonates.

Key words: bronchopulmonary dysplasia, diagnostic criteria, respiratory support, glucocorticoids

李芳, 刘立婷. 支气管肺发育不良诊断及治疗中几个关注问题[J]. 临床儿科杂志, 2022, 40(6): 413-419.

LI Fang, LIU Liting. Concerns about diagnosis and treatment of bronchopulmonary dysplasia[J]. Journal of Clinical Pediatrics, 2022, 40(6): 413-419.

图/表 3

表1

表2

表3

参考文献 36

[1]	Stoll BJ, Hansen NI, Bell EF, et al. Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012 [J]. JAMA, 2015, 314(10): 1039-1051. doi: 10.1001/jama.2015.10244
[2]	Jobe AH, Bancalari E. Bronchopulmonary dysplasia[J]. Am J Respir Crit Care Med, 2001, 163(7): 1723-1729. doi: 10.1164/ajrccm.163.7.2011060
[3]	Higgins RD, Jobe AH, Koso-Thomas M, et al. Bronchopulmonary Dysplasia: Executive Summary of a Workshop[J]. J Pediatr, 2018, 197: 300-308. doi: 10.1016/j.jpeds.2018.01.043
[4]	Jensen EA, Dysart K, Gantz MG, et al. The Diagnosis of Bronchopulmonary Dysplasia in Very Preterm Infants. An Evidence-based Approach[J]. Am J Respir Crit Care Med, 2019, 200(6): 751-759. doi: 10.1164/rccm.201812-2348OC
[5]	Han YS, Kim SH, Sung TJ. Impact of the definition of bronchopulmonary dysplasia on neurodevelopmental outcomes[J]. Sci Rep, 2021, 11(1): 22589. doi: 10.1038/s41598-021-01219-0
[6]	王陈红, 沈晓霞, 陈鸣艳, 等. 不同诊断标准下早产儿支气管肺发育不良诊断及预后分析[J]. 中华儿科杂志, 2020, 58(5): 381-386.
[7]	Vyas-Read S, Logan JW, Cuna AC, et al. A comparison of newer classifications of bronchopulmonary dysplasia: findings from the Children's Hospitals Neonatal Consortium Severe BPD Group[J]. J Perinatol, 2022, 42(1): 58-64. doi: 10.1038/s41372-021-01178-4
[8]	Isayama T, Lee SK, Yang J, et al. Revisiting the Definition of Bronchopulmonary Dysplasia: Effect of Changing Panoply of Respiratory Support for Preterm Neonates[J]. JAMA Pediatr, 2017, 171(3): 271-279. doi: 10.1001/jamapediatrics.2016.4141
[9]	Zhang ZQ, Huang XM, Lu H. Early biomarkers as predictors for bronchopulmonary dysplasia in preterm infants: a systematic review[J]. Eur J Pediatr, 2014, 173(1): 15-23. doi: 10.1007/s00431-013-2148-7
[10]	Yang Y, Li J, Mao J. Early diagnostic value of C-reactive protein as an inflammatory marker for moderate-to-severe bronchopulmonary dysplasia in premature infants with birth weight less than 1500 g[J]. Int Immunopharmacol, 2022, 103: 108462. doi: 10.1016/j.intimp.2021.108462
[11]	Ahmed S, Odumade OA, van Zalm P, et al. Urine Proteomics for Noninvasive Monitoring of Biomarkers in Bronchopulmonary Dysplasia[J]. Neonatology, 2022, 119(2): 193-203. doi: 10.1159/000520680
[12]	Schmidt AR, Ramamoorthy C. Bronchopulmonary dysplasia[J]. Paediatr Anaesth, 2022, 32(2): 174-180. doi: 10.1111/pan.14365
[13]	杜立中, 早产儿支气管肺发育不良临床管理专家共识[J]. 中华儿科杂志, 2020(5): 358-365.
[14]	Gilfillan M, Bhandari A, Bhandari V. Diagnosis and management of bronchopulmonary dysplasia[J]. BMJ, 2021, 375: n1974.
[15]	González-Pacheco N, Sánchez-Luna M, Chimenti-Camacho P, et al. Use of very low tidal volumes during high-frequency ventilation reduces ventilator lung injury[J]. J Perinatol, 2019, 39(5): 730-736. doi: 10.1038/s41372-019-0338-5 pmid: 30770883
[16]	Ramos-Navarro C, González-Pacheco N, Rodríguez-Sánchez de la Blanca A, et al. Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates[J]. Eur J Pediat, 2020, 179(12): 1833-1842. doi: 10.1007/s00431-020-03694-5
[17]	Sánchez-Luna M, González-Pacheco N, Belik J, et al. New Ventilator Strategies: High-Frequency Oscillatory Ventilation Combined with Volume Guarantee[J]. Am J Perinatol, 2018, 35(6): 545-548. doi: 10.1055/s-0038-1637763
[18]	Enomoto M, Keszler M, Sakuma M, et al. Effect of Volume Guarantee in Preterm Infants on High-Frequency Oscillatory Ventilation: A Pilot Study[J]. Am J Perinatol, 2017, 34(1): 26-30. doi: 10.1055/s-0036-1584141
[19]	Shetty S, Hunt K, Peacock J, et al. Crossover study of assist control ventilation and neurally adjusted ventilatory assist[J]. Eur J Pediatr, 2017, 176(4): 509-513. doi: 10.1007/s00431-017-2866-3
[20]	Makker K, Cortez J, Jha K, et al. Comparison of extubation success using noninvasive positive pressure ventilation (NIPPV) versus noninvasive neurally adjusted ventilatory assist (NI-NAVA)[J]. J Perinatol, 2020, 40(8): 1202-1210. doi: 10.1038/s41372-019-0578-4
[21]	McKinney RL, Keszler M, Truog WE, et al. Bronchopulmonary Dysplasia Collaborative. Multicenter Experience with Neurally Adjusted Ventilatory Assist in Infants with Severe Bronchopulmonary Dysplasia[J]. Am J Perinatol, 2021, 38(S 01): e162-e166.
[22]	Barrington KJ. The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs[J]. BMC Pediatr, 2001, 1:1. pmid: 11248841
[23]	Doyle LW, Cheong JL, Hay S, et al. Late (≥ 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants[J]. Cochrane Database Syst Rev. 2021, 11(11): CD001145.
[24]	Doyle LW, Davis PG, Morley CJ, et al. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial[J]. Pediatrics, 2006, 117(1): 75-83. pmid: 16396863
[25]	Cuna A, Lagatta JM, Savani RC, et al. Association of time of first corticosteroid treatment with bronchopulmonary dysplasia in preterm infants[J]. Pediatr Pulmonol, 2021, 56(10): 3283-3292. doi: 10.1002/ppul.25610
[26]	Ramaswamy VV, Bandyopadhyay T, Nanda D, et al. Assessment of Postnatal Corticosteroids for the Prevention of Bronchopulmonary Dysplasia in Preterm Neonates: A Systematic Review and Network Meta-analysis[J]. JAMA Pediatr, 2021, 175(6): e206826. doi: 10.1001/jamapediatrics.2020.6826
[27]	Lemyre B, Dunn M, Thebaud B. Postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia in preterm infants[J]. Paediatr Child Health. 2020, 25(5): 322-331. doi: 10.1093/pch/pxaa073
[28]	Doyle LW, Cheong JL, Hay S, et al. Early (<7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants[J]. Cochrane Database Syst Rev, 2021, 10(10): CD001146.
[29]	Onland W, Cools F, Kroon A, et al. Effect of Hydrocortisone Therapy Initiated 7 to 14 Days After Birth on Mortality or Bronchopulmonary Dysplasia Among Very Preterm Infants Receiving Mechanical Ventilation: A Randomized Clinical Trial[J]. JAMA, 2019, 321(4): 354-363. doi: 10.1001/jama.2018.21443 pmid: 30694322
[30]	Watterberg KL, Walsh MC, Li L, et al. Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia[J]. N Engl J Med, 2022, 386(12): 1121-1131. doi: 10.1056/NEJMoa2114897
[31]	Bassler D, Shinwell ES, Hallman M, et al. Long-Term Effects of Inhaled Budesonide for Bronchopulmonary Dysplasia[J]. N Engl J Med, 2018, 378(2): 148-157. doi: 10.1056/NEJMoa1708831
[32]	Duijts L, van Meel ER, Moschino L, et al. European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia[J]. Eur Respir J, 2020, 55(1): 1900788. doi: 10.1183/13993003.00788-2019
[33]	Szabó H, Baraldi E, Colin AA. Corticosteroids in the prevention and treatment of infants with bronchopulmonary dysplasia: Part II. Inhaled corticosteroids alone or in combination with surfactants[J]. Pediatr Pulmonol, 2022, 57(4): 787-795. doi: 10.1002/ppul.25808
[34]	Volarevic V, Markovic BS, Gazdic M, et al. Ethical and Safety Issues of Stem Cell-Based Therapy[J]. Int J Med Sci, 2018, 15(1): 36-45. doi: 10.7150/ijms.21666
[35]	Tong Y, Zuo J, Yue D. Application Prospects of Mesenchymal Stem Cell Therapy for Bronchopulmonary Dysplasia and the Challenges Encountered[J]. Biomed Res Int. 2021, 2021: 9983664.
[36]	Tieu A, Hu K, Gnyra C, et al. Mesenchymal stromal cell extracellular vesicles as therapy for acute and chronic respiratory diseases: a meta-analysis[J]. J Extracell Vesicles, 2021, 10(12): e12141.

标准	诊断时机	影像学评估	分级评估时机	分级依据
2001 NICHD	任何氧依赖（FiO₂>21%）>28 d	无	胎龄<32周,PMA 36周或出院时;胎龄≥32周,生后56 d或出院时	FiO₂
2018 NICHD	胎龄<32周, PMA 36周时持续用氧≥3 d	肺实质病变	PMA 36周	FiO₂、呼吸支持模式
2019 Jensen	PMA 36周时持续用氧	无	PMA 36周	呼吸支持模式

标准	分级依据	无BPD	轻度/ I级	中度/ II级	重度/ III级
2001 NICHD	FiO₂及是否正压通气	-	未用氧	FiO₂<30%	FiO₂≥30%或需正压通气
2018 NICHD¹⁾	有创正压通气	-	无	FiO₂ 21%	FiO₂>21%
	NCPAP、NIPPV或流量≥3L/min的鼻导管	-	FiO₂ 21%	FiO₂ 22%~29%	FiO₂≥30%
	流量1~3L/min的鼻导管或头罩吸氧	-	FiO₂ 22%~29%	FiO₂≥30%	鼻导管及头罩吸氧均不考虑Ⅲ级
	流量<1L/min的鼻导管	-	FiO₂ 22%~70%	FiO₂>70%	鼻导管及头罩吸氧均不考虑Ⅲ级
2019 Jensen	呼吸支持模式	未吸氧	鼻导管吸氧<2L/min	鼻导管吸氧>2L/min或无创通气	有创机械通气

糖皮质激素	使用方式	剂量	使用时机
糖皮质激素	使用方式	剂量	<7 d	7~14 d	15~21 d	>21 d
地塞米松	静脉	小剂量	不推荐	机械通气1~2周仍不能撤机的BPD高风险早产儿可选择短疗程低剂量DART方案,早期使用效果更佳,1个疗程DART方案效果欠佳的可使用第2疗程		晚期使用DART方案早产儿发生II级或III级BPD的风险可能更高
地塞米松	静脉	大剂量	不推荐	不推荐	不推荐	不推荐
氢化可的松	静脉	小剂量	小于28周和/或有绒毛膜羊膜炎病史BPD高风险早产儿可选择10 d低剂量疗程用以预防BPD	不推荐	不推荐	不推荐
氢化可的松	静脉	大剂量	不推荐	不推荐	不推荐	不推荐
糖皮质激素	吸入	不推荐

支气管肺发育不良诊断及治疗中几个关注问题

Concerns about diagnosis and treatment of bronchopulmonary dysplasia

RichHTML

PDF (PC)

赞

可视化

被引次数

摘要/Abstract

引用本文

使用本文

图/表 3

参考文献 36

相关文章 15

Metrics

本文评价

推荐阅读 0

[1]	张睿洁, 郤冠楠, 王雪峰, 林昕奥, 戴家乐, 樊晓波, 汪吉梅. 简化肺脏超声在预测晚期早产儿和足月儿生后早期呼吸支持中的应用[J]. 临床儿科杂志, 2024, 42(8): 714-721.
[2]	庄亚飞, 程巾, 吴琛, 关凤军. 儿童原发性肾病综合征SOCS3表达与糖皮质激素耐药的相关性研究[J]. 临床儿科杂志, 2024, 42(5): 414-418.
[3]	林娇, 徐鑫星, 王传凯, 蒋丽琼, 王春林. Bardet Biedl综合征的诊治进展[J]. 临床儿科杂志, 2024, 42(2): 157-163.
[4]	王丽平, 尤优, 殷张华, 王依闻, 陈笋, 夏红萍. 支气管肺发育不良极早产儿合并肺静脉狭窄2例报告[J]. 临床儿科杂志, 2023, 41(4): 289-293.
[5]	朱兴旺, 史源. 无创高频振荡通气在早产儿呼吸支持中的临床应用[J]. 临床儿科杂志, 2023, 41(10): 641-645.
[6]	任淑英, 张勤. 呼吸道微生态的影响因素及其在支气管肺发育不良中的意义[J]. 临床儿科杂志, 2023, 41(10): 715-720.
[7]	夏红萍, 张拥军. 重度支气管肺发育不良的表型特征和治疗策略[J]. 临床儿科杂志, 2022, 40(6): 401-406.
[8]	丁瑛雪. 早产儿支气管肺发育不良的表型演变[J]. 临床儿科杂志, 2022, 40(6): 407-412.
[9]	徐儒政, 姜旭, 孙斌. 胎龄<32周早产儿支气管肺发育不良临床特点[J]. 临床儿科杂志, 2022, 40(6): 420-424.
[10]	孙艳茹, 刘力. 幼年皮肌炎的药物治疗进展[J]. 临床儿科杂志, 2022, 40(5): 395-400.
[11]	张猛，吴成，戴晴，等. 儿童急性荨麻疹伴消化性溃疡大出血2 例报告[J]. 临床儿科杂志, 2021, 39(7): 498-.
[12]	王慧,曹丽芳,张雪峰. 产前糖皮质激素对晚期早产儿呼吸系统疾病的影响[J]. 临床儿科杂志, 2021, 39(6): 410-.
[13]	刘晓,陈平洋,谭鑫，等. 非Magill 钳辅助LISA 技术的回顾性研究[J]. 临床儿科杂志, 2021, 39(6): 415-.
[14]	涂娟,陈朝英,夏华，等. 表现为肾病范畴蛋白尿的儿童链球菌感染后肾小球肾炎临床病理特点[J]. 临床儿科杂志, 2021, 39(6): 429-.
[15]	李睿雯. 支气管肺发育不良诊断标准的研究进展[J]. 临床儿科杂志, 2021, 39(4): 308-.