Bronchopulmonary dysplasia (BLD) – a chronic disease of respiratory system at newborns which arises when carrying out IVL with use of high concentration of oxygen against the background of respiratory violations. The main manifestations – a syndrome of the respiratory insufficiency (RI) and bronchial obstruction, deformation of a thorax. A basis of diagnosis of a bronchopulmonary dysplasia – a X-ray analysis of OGK. Treatment at this pathology includes nonspecific therapeutic measures: balanced diet and mode, adequate respiratory support, symptomatic medicamentous medicines.
The bronchopulmonary dysplasia (BLD) is a heterogeneous pathology of the period of a neonatality which arises when carrying out IVL with high concentration of oxygen, is followed by respiratory insufficiency, a bronkhoobstruktivny syndrome and a gipoksemiya. Introduced this term for the first time, and also the American pediatrician and the radiologist Nortvey in 1967 described his radiological picture on stages. In essence BLD is not a congenital, but yatrogenny disease that contradicts its name, however other term is at the moment not offered. It arises at 16-40% of newborns with body weight less than 1500 which IVL concerning RDS is necessary. The general indicator of a lethality at a bronchopulmonary dysplasia within the first 12 months of life makes 10-25%.
Reasons of a bronchopulmonary dysplasia
The bronchopulmonary dysplasia is a polietiologichesky disease which is formed against the background of influence of several potential etiologichesky factors. Treat a barotrauma at irrational IVL those, morphological immaturity of a parenchyma of a lung, system of surfactant and antioxidant system, toxic influence of high concentration of oxygen, an infection (a mycoplasma, pnevmotsist, ureaplasmas, hlamidiya, TsMV), hypostasis of lungs of various genesis, pulmonary hypertensia, GERH, hypovitaminoses of A and E, genetic tendency.
Morphologically bronchopulmonary dysplasia passes four stages. At the I stage classical RDS develops. At the II stage there is a destruction of an epithelium of alveoluses and its subsequent regeneration, persistiruyushchy hyaline membranes are formed. Also there is hypostasis an interstition, a necrosis of bronchioles. The III stage is characterized by formation of limited emphysematous changes, atelektaz and fibrosis. At the IV stage in alveoluses retikulyarny, elastichesky and collagenic fibers collect – atelektaza, emphysema, sites of fibrosis of a lung are finally formed.
Classification of a bronchopulmonary dysplasia
According to the standard classification, there are two main forms of a bronchopulmonary dysplasia:
- Classical or "heavy" form. This option of BLD is characteristic of premature children. Develops when carrying out intensive respiratory support without introduction of medicines of surfactant. The main manifestation – existence of inflation of sites of lungs, formation of bulls and fibrosis.
- New or "easy" form of a bronchopulmonary dysplasia. It is observed at the children who were born after 32 weeks of pregnancy which for the purpose of prevention entered surfactant. Radiological it is shown by homogeneous blackout of lungs and lack of sites of swelling.
Also in domestic pediatrics and a neonatology clinically mark out three severity of a bronchopulmonary dysplasia:
- Easy BLD. At rest ChD in repartitions of physiological norm (to 40 in min.), is less often noted insignificant at loading (to 60 in min.). Signs of bronchial obstruction at respiratory infections are possible, moderate emphysema. The needs for oxygen support for gestational age are more senior than 36 weeks does not arise.
- Medium-weight bronchopulmonary dysplasia. Against the background of crying, feeding, concern develops (60-80 in min.). At rest dry or melkopuzyrchaty rattles can be listened. Bronchial obstruction against the background of infectious diseases is often observed. Radiological emphysema, a pneumosclerosis is noted. There is a need for respiratory support
- Heavy bronchopulmonary dysplasia. Expressed (80 in min. and more) at rest. Pronounced bronchial obstruction, auskultativny signs of insufficiency of respiratory system. Pulmonary heart is often formed, there is a delay of physical development. Radiological emphysema, poverty of the pulmonary drawing, a pneumosclerosis, a set of atelektaz and peribronkhialny changes comes to light. Respiratory support with use of concentration of oxygen> 30% is required.
Symptoms of a bronchopulmonary dysplasia
Specific displays of a bronchopulmonary dysplasia do not exist. The disease is characterized by the expressed respiratory insufficiency against the background of high concentration of oxygen at IVL. The general state depends on severity, however, in most cases it medium-weight or heavy. The thorax takes a form, characteristic of emphysematous diseases: "a barrel-shaped form" and the horizontal course of edges, increase in the size in the perednezadny direction, protrusion of intercostal intervals and their retraction at an exhalation breath. Also at a bronchopulmonary dysplasia arises to 90-100 in 1 min., it is observed akro-or diffusion cyanosis. In attempts to transfer IVL to more sparing mode sharp insufficiency of respiratory system which is followed by the expressed giperkapniya and a gipoksemiya develops. At the termination of respiratory support against the background of spontaneous breath signs of bronchial obstruction remain.
At children with a bronchopulmonary dysplasia , emphysema and pheumothorax, bradycardia and attacks , the recuring bronchitis and pneumonia, scarce states (deficiency of vitamins D, And, E, anemia), frequent vomiting, a gastroezofagealny reflux and aspiration of food masses is also noted. Neurologic disorders, damages of a retina are quite often observed. The right ventricular insufficiency and "pulmonary heart", limited or share atelektaza of lungs recuring bronchitis, bronkhiolita and pneumonias, chronic respiratory insufficiency, atopic bronchial asthma, arterial hypertension, anemia, a delay of psychophysical development belong to the main complications of a bronchopulmonary dysplasia.
Diagnosis of a bronchopulmonary dysplasia
Diagnosis of a bronchopulmonary dysplasia includes collecting anamnestichesky data, objective survey, laboratory and tool methods of a research. When collecting the anamnesis or the pediatrician pays attention to terms in which there was childbirth, existence of the possible etiologichesky and promoting factors. At objective inspection characteristic clinical displays of a bronchopulmonary dysplasia come to light: respiratory insufficiency, deformation of a thorax etc. In OAK normokhromny hyporegenerative anemia, increase in number of neutrophils and eosinophils is defined. In biochemical blood test the gipokaliyemiya, a giponatriyemiya, a gipokhloremiya, reduction , increase in creatinine and urea can be found. One of characteristic symptoms of a bronchopulmonary dysplasia is the low partial pressure of oxygen in blood (Rao2) – 40-55 mm Hg.
Among tool methods of diagnostics at a bronchopulmonary dysplasia the X-ray analysis of OGK, a computer and magnetic and resonant tomography are considered as the most informative. Radiological method of a research which allows to reveal characteristic signs of BLD, to define severity and a stage of morphological changes of lungs is most often used. KT and MRT give the chance to reveal similar manifestations and in details to estimate structure of a parenchyma of lungs. However they are applied not so often due to the lack of the expressed advantages before a X-ray analysis and high cost.
Treatment of a bronchopulmonary dysplasia
Specific treatment of a bronchopulmonary dysplasia does not exist. The fixed therapeutic assets at this disease include oxygen support, a balanced diet, the mode, symptomatic medicamentous medicines. In spite of the fact that IVL is a main reason for development of BLD, it is one of the most important aspects of treatment. Its main objective – maintenance of indicators of blood in admissible limits: blood at the level of 7,25, a saturation – 90% and more, the partial pressure of blood – 55-70 mm Hg.
Also important role in treatment of a bronchopulmonary dysplasia is played by the child's food. At sick children a high metabolic need against the background of need of adequate growth of lungs is had. In such conditions daily caloric content within 115-150 kcal/kg/day is considered optimum. Daily regime of the child has to include the maximum rest, reusable feeding, maintenance of body temperature at the level of 36,5 °C. Among medicamentous medicines which can be applied at BLD bronchial spasmolytics, mukolitichesky and diuretichesky means, glucocorticosteroids, β2-, antibiotics and vitamins A, E are most often used.
Forecast and prevention of a bronchopulmonary dysplasia
The forecast at a bronchopulmonary dysplasia always serious. The mortality indicator in the first 3 months of life fluctuates within 15-35%, in 12 months – 10-25%. Survivors have a restoration of function of lungs with age, however morphological changes remain in 50-75% of cases. At such children already at preschool age the increased resistance of a bronchial tree is noted, after 7 years tendency to hyperreactivity appears. Adequately carried out treatment significantly reduces lethality level in the first 1-2 years, allows to achieve clinical recovery to four-year age.
Prevention of a bronchopulmonary dysplasia means antenatalny protection of a fruit, prevention of premature birth, use of the sparing IVL modes and data of duration of its carrying out to a minimum, vitamin therapy, use of medicines of surfactant. At threat of the premature birth of the child introduction of mother of glucocorticosteroids for the purpose of prevention of SDR and BLD is shown further.