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Published in final edited form as: Semin Perinatol. 2025 Sep 18;49(7):152148. doi: 10.1016/j.semperi.2025.152148

Interdisciplinary Collaboration and Innovation in Established Bronchopulmonary Dysplasia

Matthew J Kielt 1, Lauren Sanlorenzo 2
PMCID: PMC13495111  NIHMSID: NIHMS2195391  PMID: 40973563

Abstract

Bronchopulmonary dysplasia (BPD) is the most common morbidity experienced by infants born extremely preterm. With improved survival of extremely preterm infants, rates of BPD have increased and the number of infants with established BPD being cared for in neonatal intensive care units (NICU) is increasing. To address the complex clinical needs of infants with established BPD, interdisciplinary BPD programs have been developed at level-IV NICUs throughout the United States. Interdisciplinary BPD programs adopt the principles of chronic care models that differ in size, scope, and practices when compared to traditional acute care NICU’s clinical programs. The purpose of this review is to summarize the collaborative and innovative features of interdisciplinary BPD clinical care programs.

Introduction

Bronchopulmonary dysplasia (BPD), the chronic lung disease of infancy, is the most common morbidity experienced by infants born extremely preterm.1 First described by Northway and colleagues in 1967,2 BPD remains a significant morbidity with over 50% of infants born extremely preterm developing BPD in the United States each year.3 As increasing numbers of infants with BPD are surviving to adulthood, BPD is increasingly recognized as an important contributor to respiratory health throughout the lifespan.4,5 BPD is an expensive disease with cost estimates exceeding $1 million per patient per year in the most severe forms of cases.6 Despite the availability of evidence-based therapeutics that have been shown to reduce the risk of BPD,7,8 rates of BPD are increasing.1 For infants with established BPD, care is largely supportive with no proven therapies that have been shown to cure disease.

As more extremely preterm infants survive with BPD, neonatal providers are placing greater emphasis on the care of infants with established BPD during the initial birth hospitalization.9 Clinical care of infants with established BPD is challenging owing to patient-level heterogeneity, the complex respiratory and neurodevelopmental needs of older patients who remain hospitalized in the neonatal intensive care unit (NICU), and the absence of high-quality evidence to inform best practice in this growing and vulnerable population. In response to these challenges, centers across the United States have developed interdisciplinary BPD care programs that are dedicated to ongoing care of infants with established BPD in the NICU.10 The objectives of this review are to summarize the philosophical underpinnings of these interdisciplinary BPD care programs and to provide pragmatic considerations for interdisciplinary BPD care program development.

Definition and Epidemiology of Established BPD

Since first described by Northway and colleagues in 1967, BPD definitions have changed over time to reflect changes in disease epidemiology and contemporary care practices.11 Though different BPD definitions have been recently proposed, consensus is emerging in favor of using 2019 National Institute for Child Health and Development Neonatal Research Network definition (commonly referred to as the “Jensen criteria”)12 for diagnosing BPD in infants born very preterm. In these criteria, BPD is diagnosed in infants born <32 weeks gestational age at birth who are treated with respiratory support at 36 weeks post-menstrual age (PMA). BPD severity is graded into three levels of severity based on the level of respiratory support prescribed at 36 weeks PMA. Infants with grade 1 (least severe grade) are prescribed low-flow nasal cannula <2 liters per minute. Infants with grade 2 (moderate severity) are prescribed non-invasive positive airway pressure modes of support including high-flow nasal cannula ≥2 liters per minute, continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV), and non-invasive neurally adjusted ventilatory assist (NIV-NAVA). Infants with grade 3 (the most severe grade) are prescribed invasive mechanical ventilation which includes both conventional and high-frequency ventilation. A notable strength of the Jensen BPD criteria is that definition is evidence-based wherein the definition was shown to accurately predict respiratory and neurodevelopmental outcomes through two years of age in extremely preterm infants and performed statistically better than the 2001 National Institutes of Health Consensus Criteria in predicting two-year respiratory and neurodevelopmental outcomes.12

Among published validation studies, approximately 52% of infants are diagnosed with BPD per Jensen criteria.13,14 In these studies, rates of grade 3 BPD range from 9–16%.13,14 Most infants with BPD are discharged on supplemental oxygen at or beyond term PMA. Across all BPD grades, tracheostomy rates are low, ranging from 1–8%.15 For infants with grade 3 BPD, tracheostomy rates range from 12–31%.15 Surgical burden is high in infants with BPD with 71% of infants with BPD undergoing ≥1 surgical intervention during their initial NICU hospitalization.16 Approximately 11–24% of infants with BPD undergo gastrostomy placement and 13% undergo inguinal hernia repair.16,17 A diagnosis of BPD is associated with prolonged length of stay during the initial birth hospitalization.18 Most infants with BPD require hospitalization beyond term PMA with median PMAs at discharge ranging from 41 (Interquartile range (IQR) 39–44) weeks in infants with grade 1–2 BPD and 49 (IQR 43–58) weeks in infants with grade 3 BPD.13 Indeed, in infants with the most severe forms of BPD, a greater duration of time may be spent in the hospital between 36 weeks PMA and discharge than time between birth and 36 weeks PMA.19 Beyond the NICU, BPD is associated with serious respiratory morbidity and neurodevelopment impairment in early childhood.12,20,21 Approximately 32% of all infants with BPD experience death after 36 weeks PMA death or some form of serious respiratory morbidity by two years corrected age where serious respiratory morbidities include tracheostomy, prolonged NICU hospitalization beyond 50 weeks PMA, use of supplemental oxygen, home ventilation, or respiratory monitory at two year follow up, or ≥2 respiratory-related hospitalizations by two years corrected age.12 Fifty-five percent of all infants with BPD experience late death or moderate to severe neurodevelopmental impairment at two years corrected age.12

Opportunities for Innovation in the Care of Infants with Established BPD

Because BPD is defined at a single timepoint, 36 weeks PMA, the natural history of disease of can be conceptually dichotomized into two phases (Figure 1): evolving BPD and established BPD. To date most research and clinical care has focused on BPD pathogenesis and prevention in the evolving phase of BPD. Less emphasis has been placed on the care and investigation of infants, children, adolescents, and adults living with established disease.9 The respiratory, nutritional, and neurodevelopmental needs of infants with established BPD are complex and differ from the therapeutic needs of infants with evolving BPD. As such, the clinical care of infants with established BPD is complex and can be challenging for even the most experienced neonatal providers who historically have cared for infants in the evolving phase of disease. The improved survival of extremely preterm infants has resulted in an increasing number of infants with established BPD who remain hospitalized at or beyond term PMA in the NICU. Care of infants with established BPD is controversial and characterized by significant inter-center variability owing to patient-level heterogeneity and the absence of high-quality evidence to inform best practice.9,22–24 As such, real opportunities exist for innovation in care practices of infants with established BPD with implications for individualized patient care, systems-based practice, and NICU resource allocation.

Figure 1.

Figure 1.

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The central dichotomy of bronchopulmonary dysplasia (BPD). Because BPD is defined at a single point-in-time, 36 weeks post-menstrual age (PMA), the natural history of disease can be dichotomized into two phases: evolving BPD and established BPD. In this framework, established BPD includes the time from formal BPD diagnosis at 36 weeks PMA to initial neonatal intensive care unit (NICU) discharge.

Clinical Heterogeneity and BPD Phenotypes

The wide spectrum of clinical heterogeneity observed in infants with established BPD relates to sequelae of the primary lung compartments: the alveolar spaces and pulmonary parenchyma, conducting airways, and pulmonary vasculature.25 In a retrospective cohort study that utilized computed tomography, echocardiography, and bronchoscopy data, Wu and colleagues characterized infants with established BPD based on the presence or absence of disease affecting these lung compartments and classified three clinical BPD phenotypes: (a) moderate-severe parenchymal disease (b) large airway disease and (c) pulmonary vascular disease (Figure 2).26 In this study, the presence of these phenotypic subgroups was associated with the composite outcome of death, tracheostomy, or discharge with pulmonary vasodilator therapy, with risk increasing in a stepwise fashion based on an increasing number of identified phenotypic subgroups.26 The findings from this study are reinforced by other observational studies in which the presence of parenchymal disease severity,27,28 tracheobronchomalacia29, and pulmonary hypertension30,31 are critical and clinically meaningful BPD phenotypes that contribute to time-to-liberate from respiratory support22,32–34 and tracheostomy risk.15,26

Figure 2.

Figure 2.

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Association of BPD clinical phenotypes and tracheostomy placement. In a single-center, retrospective cohort study, (25) Wu and colleagues classified infants with established severe BPD (Panel A). The authors observed a stepwise increase in the proportion of infants who underwent tracheostomy placement with an increase in identified phenotype subgroups (Panel B). Modified and reprinted with permission from Wu KY, Jensen EA, White AM, et al. Characterization of Disease Phenotype in Very Preterm Infants with Severe Bronchopulmonary Dysplasia. Am J Respir Crit Care Med. 2020;201(11):1398–1406.

Copyright © 2023 American Thoracic Society. All rights reserved. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

Interdisciplinary Chronic BPD Care Model

In response to the clinical challenges faced by caring for infants with established BPD, a growing number of level IV NICUs have developed multidisciplinary BPD clinical care programs.10 The overarching goals of these programs have been to adopt chronic care models to enhance respiratory care, multidisciplinary consultation, continuity of care, family support, and smooth transitions of care at the time of NICU discharge for infants with established BPD.9,10 Indeed, the heterogeneous clinical characteristics of infants with BPD that present as different phenotypes requires an interdisciplinary approach to care. A chronic approach to care can facilitate gradual weaning from respiratory support as these infants convalesce from disease. Nonetheless, adopting a chronic care culture in an acute level-IV NICU can prove challenging. Consequently, when developing an interdisciplinary BPD team much thought should be given to building a culture that emphasizes a chronic approach to care, a shared long-term vision, and open, collaborative communication.35

Chronic Approach to Respiratory Care

Owing to differences in respiratory pathophysiology, the respiratory management for infants with established BPD differs markedly from infants born extremely preterm suffering from respiratory distress syndrome (RDS) in the first days to weeks of life.9 Infants born extremely preterm exhibit a highly dynamic respiratory pathophysiology that requires vigilant monitoring, frequent therapeutic interventions, and rapid weaning from invasive mechanical ventilation.36 In contrast, infants with established BPD have a relatively stable respiratory pathophysiology that changes slowly over time and often improves in response to somatic and linear growth alone rather than frequent therapeutic interventions.37 Indeed, frequent exposure to respiratory support weans, blood gas sampling, and medications may be harmful to infants in the established phase of BPD who require the provision of adequate respiratory support to sustain adequate lung growth while minimizing exposure to painful procedures and medications that are toxic to the developing central nervous system, such as systemic corticosteroids.38,39 Whereas infants with RDS may wean multiple times per day, most infants with establish BPD undergo respiratory support weans at much slower intervals, generally 1–2 times per week.9 A slower approach to respiratory support weaning facilitates clinical progress by redirecting the clinical focus away from a day-to-day focus on respiratory care and towards non-respiratory aspects of care that promote gradual weaning from respiratory support: nutrition, developmental therapies, and family bonding.

Nutrition

Nutrition is an essential component of BPD care.9 The nutritional needs of infants with established BPD are complex owing to the presence of hypermetabolic states, increased work of breathing, growth suppression from chronic stress and inflammation, and chronic exposure to medications that impede growth, such as systemic corticosteroids and diuretics.37 Delivery of optimal nutritional substrates that match a patient’s specific needs is the goal of nutritional care. Nonetheless this can be challenging given that these needs will change over time as infants wean from support and experience unexpected clinical setbacks in the setting of respiratory exacerbations. Caloric needs are generally high in infants with established BPD owing to a high resting energy expenditure.37 Care should be exercised in delivering calories in excess of 130 kcal/kg/d as infants with established BPD can be sensitive to high volumes of total fluid intake and so enteral feeds are often fortified above 24 kcal/oz. Achievement of linear growth, which has been shown to correlate with lung growth, should be prioritized but can be difficult to achieve owing to the absence of high-quality evidence.40 Integrating the expertise of a registered dietitian into daily rounds for the purpose of monitoring anthropomorphic data, reviewing nutritional plans, and providing recommendations for nutritional modifications can help facilitate achieving the nutritional goals for hospitalized infants with established BPD.

Developmental Therapies

Infants with established BPD are at high-risk of experiencing delayed achievement of developmental milestones and neurodevelopmental impairment, including cerebral palsy.20,21,41 Because these patients remain hospitalized at and beyond term PMA, their care presents a unique opportunity to provide early intervention services during the NICU hospitalization.42 Consequently, interdisciplinary BPD clinical care teams often consist of physical therapists, occupational therapists, and speech therapists with niche expertise in neurodevelopmental evaluations and interventions. Integrating feedback from developmental therapy sessions and following progress through objective standardized assessments, such as the Behavioral Signs of Respiratory Instability (BSRI), can help the team evaluate the efficacy and tolerance of therapeutic interventions, particularly in the setting of respiratory support weans.43 Neuroplasticity peaks in the earliest years of life.44 Developmental therapies and early intervention services that are provided in the NICU therefore offer a high return on investment in promoting optimal developmental gains for infants with established BPD. Additionally, exposure of families to interventional therapies provided during the NICU stay can facilitate outpatient developmental therapies once infants are discharged home.45

Medical Co-Morbidities

Infants with established BPD are at increased risk ofa number of neonatal co-morbidities including: growth failure, feeding problems, neurodevelopmental delay and impairment, airway disease, pulmonary hypertension, retinopathy of prematurity, renal disease, skeletal fractures, adrenal insufficiency, and various surgical morbidities.16,26,46,47 Owing to the presence of multiple non-respiratory co-morbidities, BPD care programs have developed to include providers representing multiple disciplines (Figure 3).10 Hospital-based interdisciplinary care programs have been shown to improve patient outcomes in other complex disease processes that require evaluation from different medical specialties.48 The inclusion of a large number of disciplines within the BPD team is essential to ensure that the medical, developmental, and social needs for infants with established BPD are met as infants convalesce from their disease.9,10

Figure 3.

Figure 3.

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Disciplines involved in the comprehensive care of the patient with established BPD. As programs evolve from early (white) to growing (light grey) to established (dark grey) development, additional interdisciplinary team members are incorporated into the comprehensive clinical care program.

Abbreviations: BPD bronchopulmonary dysplasia, PM&R Physical Medicine and Rehabilitation, RT Respiratory Therapist, ST Speech Therapist, OT Occupational Therapist, PT Physical Therapist, MSW Medical Social Worker. Modified and reprinted with permission from House M, Lagoski M, DiGeronimo R, Eldredge LC, Manimtim W, Baker CD, Coghill C, Fernandes CJ, Griffiths P, Ibrahim J, Kielt MJ, Lagatta J, Machry JS, Mikhael M, Vyas-Read S, Weems MF, Yallapragada SG, Murthy K, Nelin LD. Interdisciplinary clinical bronchopulmonary dysplasia programs: development, evolution, and maturation. J Perinatology. 2024 Jul 17.

Family Support

For families and caregivers of infants with established BPD, prolonged hospitalization in the NICU can prove to be a time of exceptional stress and trauma.49 Consequently, inclusion of family support systems in the interdisciplinary BPD team can help alleviate caregiver burden, stress, and fatigue.50 It is common for interdisciplinary BPD teams to include clinical psychologists and licensed social workers who attend rounds, meet with families at regular intervals (generally weekly), and organize interdisciplinary family care conferences. Regularly scheduled care conferences, occurring often as monthly, can provide families with a safe, collaborative space away from the bedside to receive clinical updates, express their concerns, and receive compassionate counseling in the context of high-stakes medical decision making, such as in the case of tracheostomy placement.15

Transitions of Care

Discharge from the NICU can be a challenging time for infants with established BPD and their families. Infants with established BPD are often discharged on home medical equipment including supplemental oxygen, tube feedings, and, in rare cases, a portable home ventilator.51 Following hospital discharge, these infants frequently have follow-up appointments scheduled with providers across a wide range of pediatric specialties: pulmonology, cardiology, ophthalmology, surgery, endocrinology, and neurology. Given the complexities inherent in discharging infants with established BPD to the home environment, BPD care programs frequently consists of a dedicated case manager who schedules follow-up appointments, coordinates delivery of home medical equipment to families, and ensures safe discharge planning.51 A considerable amount of time may be required for teaching of families prior to discharge, particularly for infants being discharged with durable medical equipment including home oxygen, gastrostomy tube feedings, and/or tracheostomy with a portable home ventilator. A particularly important area of discharge teaching includes high-fidelity simulation-based discharge education for patients discharged with tracheostomies.52,53 Given the amount of time required for this teaching, discharge planning may occur over multiple days with different members of the multidisciplinary care team providing education focused on their specific area of expertise.

Pragmatic Framework for BPD Program Development

A pragmatic framework for the development of a BPD interdisciplinary team includes the following considerations: What is the ideal team structure for your unit and population? How will you build structure to include the time and input of critical staff, consultants, and families? To what extent will your team follow set guidelines or protocols for common complications of BPD?

A needs assessment is a critical early step in the development of a BPD team. Retrospectively quantify the number of infants at risk for BPD, those born < 32 weeks, and the number of infants diagnosed with BPD at your center. Stratifying the diagnosis of BPD using the Jensen Criteria12 can help visualize the range of BPD severity in your center. Stratification by inborn and outborn may add benefit if you work in a center who receives many infants after the diagnosis of BPD, as this may impact the flow of patients onto a BPD team or service. As you start to identify the BPD population in your unit, obtain insight into how many NICU faculty have interest in devoting clinical time to the care of infants with established BPD. Large faculty groups and NICUs may have faculty who spend most of their clinical time on a specific team such as cardiac, small-baby or surgical teams. This time is likely aligned with the service needs of the unit and the academic and clinical interests of the faculty members. Depending on the volume of infants with BPD at your center, and the faculty interest, two possible team structures are a dedicated BPD team or a BPD consult team.

Team composition is driven by the unique needs of former preterm infants affected by BPD.54 Critical team members include, but are not limited to, the following: nursing, respiratory therapists, pharmacists, advance practice providers, and therapists. The therapy team composition should include physical therapists, occupational therapists, and speech language pathologists. Consider the inclusion of other support staff such as music therapy, child life, and family support specialist including social work, case managers and staff psychologists. Critical medical team members include neonatology, pediatric pulmonary medicine, and cardiology. The involvement of otolaryngology teams for airway evaluation and tracheostomy care and gastroenterology for feeding and aerodigestive needs should also be considered. It is essential to develop a plan for how to educate, engage and involve families in the care of infants with BPD as severe disease can have impact across the lifespan.50

Highly successful teams have reliable communication and dependable behavior. As such developing a team structure that is centered on interdisciplinary communication, feedback loops, and inclusive of team members who are genuinely committed to caring for infants with BPD is critical.55 Develop a plan for when your team will meet, who will be present, what information will be shared, and who will run the meeting. Consult teams can set specific time of day or week to round, which will help the primary team and family know when to expect updates related to lung health. In a primary BPD team model, rounds can be crafted to include different aspects of care on different days of the week, aligned with which team members are present on given days. For example, if clinical pharmacists round with the team on Monday this could be the day to address current medication regimens and similar plans could be developed for social work, therapists or dietitians.

The heterogenous nature of BPD requires individual care plans to address unique disease phenotypes and the recognition of key pillars of care such as screening for associated pulmonary hypertension, providing adequate ventilatory support and facilitating optimal growth37,56,57. Development of unit specific pathways for how to approach nutrition, feeding modalities, pharmacologic trials of diuretics or steroids, and screening for associated pulmonary vascular disease are critical in the development of a BPD team.

Conclusion

The improved survival of infants born extremely preterm has resulted in increasing numbers of infants with established BPD receiving care in the NICU. To address the complex clinical needs of infants with established BPD, innovative interdisciplinary BPD care programs have been developed at level IV NICUs. Even providers at level III NICUs have adopted the care strategies outlined in this review such as measured respiratory weans, pulmonary hypertension screening, and incorporation of developmental therapies in the care of infants with established BPD who do not require level IV care. Interdisciplinary BPD programs adopt a collaborative approach to BPD care by integrating the feedback and input from providers spanning a broad range of expertise and pediatric sub-specialties. As growing number of infants with established BPD receive care in the NICU and interdisciplinary BPD care programs evolve and grow, high-quality prospective research studies are needed to identify optimal therapeutic interventions that improve respiratory, nutritional, and developmental outcomes for infants and children with BPD.

Funding Sources:

NHLBI K23HL175207-01A1 (MJK)

Footnotes

Conflicts of Interest: None

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