7 Bronchopulmonary Dysplasia (BPD) Nursing Care Plans

Impaired Gas Exchange

Premature birth and subsequent events such as exposure to oxygen, mechanical ventilation, inflammatory agents, and infection, likely shifts the balance from lung development consisting of lung alveolar and vascular growth to one of premature maturation, which is associated with an arrest in development and a loss of future gas exchange area; however, alveolar maturation might facilitate gas exchange in the short-term (Ambalavanan & Aslam, 2020).

Nursing Diagnosis

• Impaired Gas Exchange

May be related to

• Tissue damage
• Alveolar septation
• Premature lung development

Possibly evidenced by

• Tachypnea
• Hypoxemia
• Hypercapnia
• Restlessness
• Confusion
• Irritability
• Somnolence
• Inability to move secretions

Desired Outcomes

• The client will maintain clear lung fields and remains free of signs of respiratory distress.
• The parents will understand and participate in the treatment regimen of the client within their level of ability and situation.

Nursing Assessment and Rationales

1. Assess respiratory rate, depth, and effort, including rapid breathing, use of accessory muscles, grunting sounds, and flaring of the nostrils.
An infant with bronchopulmonary dysplasia display signs and symptoms of respiratory distress syndrome, such as tachypnea, labored breathing, nasal flaring, grunting sounds, and chest retractions. These signs are useful in evaluating the degree of respiratory distress and the chronicity of the disease process.

2. Assess for any alterations in the behavior.
The client’s level of consciousness and mental status must be observed closely. Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes, such as somnolence and irritability.

3. Observe for nail beds, and cyanosis in the skin; especially note the color of the lips, tongue, and oral mucous membranes.
Bluish discoloration of the skin around the lips and nails occurs when there is a low oxygen concentration in the blood. This is referred to as cyanosis, and can be peripheral (noted in nailbeds) or central (seen around lips or earlobes). Duskiness and central cyanosis may indicate advancing hypoxemia.

4. Monitor arterial blood gases (ABGs) and note changes.
ABG assessment may reveal the occurrence of hypoxia, acidosis, and hypercarbia as the requirement for oxygen increases. PaO2 generally decreases, indicating that hypoxia is present to a greater or lesser degree.

5. Assess the lungs for areas of decreased ventilation and auscultate the presence of adventitious sounds.
A soft, tight whistling sound (wheezing) may be heard with each breath which may indicate narrowed airways or inflammation. Auscultation may also reveal decreased air movement. The breath sounds may be faint because of decreased air movement in areas of consolidation.

6. Assess oxygen saturation using pulse oximetry during feeding, sleeping, and crying.
Balancing the risks and benefits of oxygen therapy has been a long-term, unrealized goal of neonatal intensive care. Pulse oximetry is a useful tool to detect changes in oxygenation. Continuous monitoring of oxygenation detects frequent desaturations. O2 saturation should be maintained at 90% or greater (Thebaud et al., 2019).

7. Monitor the client’s vital signs and weight.
Tachycardia can reflect the effects of systemic hypoxemia on cardiac function. Physical examination may further reveal tachypnea, increased work of breathing,  frequent desaturations, and significant weight loss during the first 10 days of life (Ambalavanan & Aslam, 2020). Daily measurement of body weight, without clothes and with the same scales, is required in order to determine weight changes (Pasha et al., 2018).

Nursing Interventions and Rationales

1. Encourage frequent position changes or elevate the head of the bed.
Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Two studies investigated the effect of prone positioning on pulmonary mechanics in mechanically ventilated neonates. While one found an improvement in resistance and work of breathing in a prone versus supine position during the breaths supported by the ventilator, the other did not find any difference in terms of resistance but reported a significant improvement in static compliance and work of breathing in the prone versus the supine position during unsupported breaths (Vendettuoli et al., 2015).

2. Suction the nose and mouth with a bulb syringe as needed. Perform chest physiotherapy as indicated.
Chest physiotherapy is required every four hours as tolerated and suction should be performed four times per day as and when required and when oxygen should be administered as necessary. Chest physiotherapy and suctioning help remove mucus from the airway and lungs (Pasha et al., 2018).

3. Provide a calm, quiet environment. Cluster all care and procedures performed.
During respiratory distress, the client experiences dyspnea and hypoxemia, making the infant irritable and fussy. An irritable and frequently crying infant further increases their own oxygen demand, which is already restricted. Keeping the infant’s environment quiet and soothing and scheduling all procedures after enough rest helps the client to become less stimulated and calm, thus decreasing oxygen demand.

4. Restrict fluids as indicated.
Based on the severity of their lung disease, infants are restricted to a total fluid volume of 120 to 150 ml/kg/day. Restriction of fluid intake allows for improved pulmonary function by preventing pulmonary edema and improving gas exchange (Sahni, 2022).

5. Administer medications for bronchopulmonary dysplasia (BPD), as prescribed: 

• 5.1. Bronchodilators (albuterol, caffeine citrate, ipratropium bromide)
  Administration of beta-2 agonists can decrease airway resistance and improve compliance. However, their routine use is not recommended in BPD as it has not been shown to improve long-term outcomes. Their use is restricted to managing acute episodes of bronchoconstriction in older infants who remain ventilator-dependent (Sahni, 2022). 
• 5.2. Corticosteroids (hydrocortisone, dexamethasone)
  Systemic corticosteroids have been used in BPD to improve lung function, reduce inflammation, and reduce the need for mechanical ventilation (Sahni, 2022). Corticosteroids are powerful down regulators of inflammation and have been widely used to prevent and treat BPD. In a small randomized controlled trial, a short course of dexamethasone delivering a lower initial and total dosage than used previously led to a reduction in the duration of ventilation and was not associated with long-term neurodevelopmental impairment (Thebaud et al., 2019).
• 5.3. Diuretics (Lasix)
  Thiazides and loop diuretics are the most commonly used diuretics in the setting to improve short-term pulmonary mechanics of BPD. These agents are most commonly used in infants who are ventilator dependent with increasing requirements of positive-end-expiratory pressure despite fluid restriction (Sahni, 2022).
• 5.4. Inhaled nitric oxide
  Inhaled nitric oxide (iNO) is a short-acting gas that relaxes the pulmonary vasculature. It may also act as an anti-inflammatory agent at low concentrations. Although certain selected subgroups may benefit, whether the sickest and smallest infants at greatest risk of BPD benefit from iNO remains unclear (Ambalavanan & Aslam, 2020).
• 5.5. Caffeine
  Treatment with respiratory stimulants, such as caffeine, is the best-evaluated treatment for reducing BPD risk. The Caffeine for Apnea of Prematurity (CAP) trial demonstrated that caffeine administration reduces the risk of BPD and shortens the duration of ventilation with an endotracheal tube and exposure to supplemental oxygen. Importantly, these short-term benefits are followed by an improvement in cognitive and motor outcomes in infants at 18 months of age (Thebaud et al., 2019).

6. Inform parents that the infant may be prescribed a surfactant-replacement therapy.
New, less invasive techniques have emerged to administer exogenous pulmonary surfactant at birth that does not require intratracheal intubation. Exogenous pulmonary surfactant has drastically improved the survival of preterm infants by facilitating the transition to air breathing of premature infants. A new therapy under investigation, surfactant protein-D (SP-D), accomplishes a critical role in the innate immune function of the lungs where it promotes phagocytosis and clearance of invading infectious pathogens. SP-D also regulates inflammatory responses and influences pulmonary surfactant lipids homeostasis by decreasing the surfactant pool sizes in newborns (Arroyo & Kingma, 2021).

7. Educate parents that breathing support or oxygen inhalation either through nasal continuous positive airway pressure (NCPAP) or a ventilator may be required for the infant.
This maintains adequate ventilation and ensures the delivery of a concentrated amount of oxygen. The preference for nasal CPAP with or without surfactant and the minimized use of mechanical ventilation were reported to reduce the incidence of BPD in infants with a high risk. Previous studies have demonstrated that CPAP may be used as an alternative to intubation and mechanical ventilation in preterm infants (Pasha et al., 2018).

8. Administer supplemental oxygen as prescribed and strictly observe oxygen levels.
Preterm birth exposes the neonate to high oxygen concentrations, increasing the risk of injury due to oxygen-free radicals. Ideal oxygen saturation for a term or preterm neonates of various gestational and postnatal ages has not been definitively determined. Many clinicians have adopted the oxygen saturation target ranges of 90-95% following the results of the Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT) trial. Some infants, especially those living at high altitudes, may require oxygen therapy for many months (Ambalavanan & Aslam, 2020).

9. Educate the parents about the advantages of avoiding early intubation and ventilation.
Attempts to avoid lung injury in extremely premature preterm infants have led to recommendations to avoid intubation and ventilation in the first minutes of life and a preference for non-invasive respiratory support (Thebaud et al., 2019). It has been reported that early endotracheal intubation and mechanical ventilation in premature infants with a birth weight of 500-1500 grams are associated with an increased incidence of BPD (Pasha et al., 2018).