Outpatient management of post-p patients

December 21, 2021─New recommendations are available to help guide physicians who need to determine when and how to treat infants, children and adolescents with post-prematurity respiratory disease (PPRD). The American Thoracic Society has published an official clinical practice guideline in which a multidisciplinary panel of experts provides 13 conditional recommendations on diagnostic testing and clinical management of these young people. The full guideline detailing these recommendations was put online ahead of print in the American Journal of Respiratory and Critical Care Medicine.

Globally, about 12 million infants, or 10% of live births, are born prematurely and
are at risk for respiratory disease, the most common of which is bronchopulmonary dysplasia (BPD). However, all premature infants, even those who do not meet the criteria for BPD, can develop poor respiratory health later in life with signs and symptoms such as cough, recurrent wheezing, exercise intolerance, withdrawal. oxygen in the blood (hypoxemia) and reduced lung function. These people are classified as having PPRD.

In 2003, ATS published the Declaration on the care of children with chronic lung disease in infancy (CLDI) and childhood, which focused on the epidemiology, pathophysiology and treatment of ICLD in term and preterm infants. Advances in therapy such as prenatal steroids, postnatal surfactant, and protective ventilation strategies have led to significant increases in the survival of premature infants born much earlier in gestation. These increases in survival have led to an urgent need for medical advice on the treatment of patients with lung disease associated with premature birth.

“There was an urgent need for updated guidelines for clinicians treating these patients,” said panel co-chairs A. Ioana Cristea, MD, MS and Christopher D. Baker, MD, pediatric pulmonologists at Riley Hospital for Children (Indianapolis , Indiana) and University of Colorado School of Medicine (Denver, Colorado), respectively. “These recommendations are intended to assist clinicians in the outpatient management of patients with PPRD, regardless of the degree of prematurity, the severity of the disease or the age of the patient at the time of presentation.. “

The panel included 26 experts in pediatric pulmonology, neonatology, sleep medicine, radiology and nursing as well as parents of children with PPRD. They used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to formulate questions, identify and summarize relevant evidence, and develop recommendations for clinical practice. They identified seven questions on the management of the PPRD. A number of recommendations address multiple issues in each question asked; in these cases, the recommendations are abbreviated and multiple recommendations for each question are combined for the sake of brevity of this press release. To read the full recommendations, please see the guideline, found here.

All recommendations are conditional and based on very low-certainty evidence. Recommendations:

1. (a) For infants, children and adolescents with PPRD who do not have recurrent respiratory symptoms, we suggest not routinely prescribing short-acting inhaled bronchodilator therapy; (b) For people with PPRD who experience recurring respiratory symptoms (such as cough or wheezing), we suggest a short-acting bronchodilator trial with monitoring to assess clinical improvement of symptoms.
2. (a) For infants, children and adolescents with PPRD who do not have a chronic cough and recurrent wheezing, we suggest that inhaled corticosteroids should not be prescribed routinely; (b) For people with chronic cough or recurrent wheezing, we suggest a trial of inhaled corticosteroids with monitoring to assess clinical improvement in symptoms.
3. (a) For infants, children and adolescents with PPRD, we do not recommend the routine use of diuretics; (b) For infants with PPRD who are discharged from the NICU on chronic diuretic therapy, we suggest discontinuing wisely.
4. (a) For infants with PPRD who are otherwise ready to exit the NICU, we suggest the use of PSG for patients with persistent apnea, intermittent desaturation, or bradycardia beyond 40 weeks of PAM; (b) For infants, children and adolescents with PPRD, we suggest the use of PSG and / or sleep medications for those who have symptoms of sleep breathing disturbances including persistent snoring, growth retardation, or sleep disorders. persistent need for supplemental oxygen at age two.; (vs) When PSG is indicated but not available, we recommend obtaining overnight or 24 hour oximetry to screen for SDB, followed by referral to PSG and / or sleeping pills if necessary.
5. For infants, children and adolescents with PPRD, we suggest a swallowing assessment (videofluoroscopic swallowing study) for those who eat by mouth and have a cough or persistent oxygen desaturation during feeding, a suspected or confirmed vocal cord paralysis or other airway abnormalities, weaning failure resulting from oxygen therapy or ventilator support as expected, persistent or worsening pulmonary hypertension, delay chronic lung growth or symptoms disproportionate to viral respiratory infections.
6. For infants, children and adolescents with PPRD, we suggest airway endoscopy for those with unexplained symptoms such as chronic cough, wheezing, ventilator dependence, persistent hypoxemia, or a history of PDA ligation with stridor and weak cry.
7. (a) For infants, children and adolescents with PPRD who do not have symptoms suggestive of airway malacia, we suggest that dynamic airway imaging (CT or MRI) not be used as a screening test for routine diagnosis of TBM; (b) We suggest that dynamic airway imaging (CT or MRI) without sedation be used for the diagnosis or reassessment of TBM in patients with PPRD who present with recurrent symptoms suggesting airway malacia as an alternative to bronchoscopy. when the risk of anesthesia for bronchoscopy is judged to be more than the risks of radiation or if bronchoscopy is not feasible or available.

ATS has published more than 20 clinical practice guidelines on a variety of conditions, ranging from allergy and asthma to tuberculosis and other lung infections. For tools for implementing the ATS directives and their derivatives, go to here.

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