Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Abstract

Background Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.

Management of diuretics in infants with bronchopulmonary dysplasia discharged on home oxygen

“…After neonatal intensive care unit (NICU) discharge, data show that diuretic usage decrease over the first year of life 4,5 . The American Thoracic Society recently published recommendations for outpatient respiratory management which suggest against the routine use of diuretics, and recommend discontinuing them in the outpatient setting 6 . However, for infants on home oxygen therapy, it remains unclear how and when to discontinue diuretics, balancing the recommendations to wean medication against a potential logistic preference to wean from home oxygen first.…”

Management of diuretics in infants with bronchopulmonary dysplasia discharged on home oxygen.

“…18 Infants in our center are variably discharged home from the NICU on inhaled corticosteroids; in clinic we follow a guideline to prescribe inhaled corticosteroids only if the infant has recurrent coughing and wheezing, following the recent published ATS recommendations. 6 It is unlikely that the longer duration of home oxygen therapy was related to inhaled corticosteroids themselves but rather to intercurrent illness; we also noted that respiratory rehospitalizations, emergency department visits, and systemic corticosteroid bursts were associated with longer duration of home oxygen therapy. Nonetheless, our data provide reassurance that starting routine inhaled corticosteroids in infants with BPD discharged with home oxygen therapy does not appear beneficial in decreasing the length of home oxygen.…”

“…4,5 The American Thoracic Society recently published recommendations for outpatient respiratory management which suggest against the routine use of diuretics, and recommend discontinuing them in the outpatient setting. 6 However, for infants on home oxygen therapy, it remains unclear how and when to discontinue diuretics, balancing the recommendations to wean medication against a potential logistic preference to wean from home oxygen first.…”

Insurance coverage and respiratory morbidities in bronchopulmonary dysplasia

“…If insurance is only a marker of other disparities or inequities, including access to a medical home, more comprehensive studies of socioeconomic and environmental factors affecting infants with postprematurity respiratory disease are needed to identify risk factors and the complex interplay between social, economic, and medical factors. Although clinical interventions (e.g., standardization of care based on evidence‐based guidelines) 37,38 may decrease some of the disparate outcomes observed with insurance status, changes in social and economic policies are also needed 39 …”