ORIGINAL ARTICLE

 

Impact of bronchopulmonary dysplasia on pulmonary function during childhood: a systematic review

 

Repercussão da displasia broncopulmonar na função pulmonar durante infância: revisão sistemática

 

 

Janaina Cristina Scalco^I; Rafaela Coelho Minsky^II; Francieli Camila Mucha^III; Camila Isabel Santos Schivinski^IV

^IM.A., Professor of the Department of Physiotherapy at the State University of Santa Catarina, Florianopolis/SC/Brazil
^IIPhysiotherapist, Master´s Degree in Physiotherapy from the State University of Santa Catarina, Florianopolis/SC/Brazil
^IIIPhysiotherapist, Graduate Student in the Graduate Program for Physiotherapy at the State University of Santa Catarina, Florianopolis /SC/Brazil
^IVPh.D., Full Professor of the Department of Physiotherapy at State University of Santa Catarina, Florianopolis/SC/Brazil

Correspondence

 

 

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ABSTRACT

INTRODUCTION: Bronchopulmonary dysplasia (BPD) is a multifactorial chronic lung disease that contributes to disruption of pulmonary development. It may impair pulmonary function in early childhood and persist throughout school-age, adolescence, and into adulthood.
OBJECTIVE: To analyze, through a systematic review, the impact of BPD on pulmonary function in early childhood. : Systematic searches were performed in three electronic databases (Medline, SciELO and PEDro). Two independent examiners analyzed the titles, abstracts and full texts, considering the following study inclusion criteria: studies of pulmonary function in up to 5-year-old children diagnosed with BPD in the neonatal period.
RESULTS: Initially, 1789 articles were identified, and the final sample included 22 articles. It could be observed that children diagnosed with BPD in early childhood showed expiratory flow limitation and reduced functional residual capacity. However, pulmonary function in children with a history of BPD remains reduced when compared with healthy full-term children. Moreover, there are no positive responses in pulmonary function values with the use of bronchodilators.
CONCLUSION: Children with BPD show changes in pulmonary function, which may improve with growth, and most of them do not respond positively to bronchodilators.

Keywords: bronchopulmonary dysplasia, lung diseases, infant, respiratory function testing, child.

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RESUMO

INTRODUÇÃO: A displasia broncopulmonar (DBP) é uma doença pulmonar crônica multifatorial que interrompe o desenvolvimento pulmonar, podendo repercutir em comprometimento da função pulmonar na primeira infância, que pode perdurar durante a idade escolar, adolescência, até a idade adulta.
OBJETIVO: Analisar, através de uma revisão sistemática, as repercussões da DBP na função pulmonar de crianças na primeira infância.
MÉTODO: Foram realizadas buscas sistematizadas em três bases de dados eletrônicas (Medline, SciELO e PEDro). Dois examinadores independentes analisaram sistematicamente os títulos, resumos e textos na íntegra, considerando os seguintes critérios de inclusão: estudos que avaliaram a função pulmonar de crianças com até 5 anos de idade que apresentaram diagnóstico de DBP no período neonatal
RESULTADOS: Inicialmente foram identificados 1789 artigos, sendo que a amostra final foi composta de 22 artigos. Evidenciou-se que crianças com DBP apresentam na primeira infância limitação dos fluxos expiratórios e redução da capacidade residual funcional. Estas alterações podem ser normalizadas ou minimizadas com o crescimento e adequação de peso, porém, a função pulmonar das crianças com história de DBP continua reduzida em comparação a crianças hígidas nascidas a termo. Ainda, a maioria delas não apresenta respostas positivas nos valores de função pulmonar com o uso de broncodilatadores.
CONCLUSÃO: Crianças com DBP apresentam alterações na função pulmonar, podendo melhorar com o crescimento, sendo que a maioria não responde positivamente ao broncodilatador.

Palavras-chave: displasia broncopulmonar, doenças pulmonares, lactente, testes de função respiratória, criança.

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INTRODUCTION

Neonatal chronic lung disease, also known as bronchopulmonary dysplasia (BPD), is defined as the need for respiratory support with oxygen and/or mechanical ventilation in the first 28 days of life^1-4. Children who developed the disease in the postnatal period may show abnormalities in pulmonary function⁵.

Currently, pulmonary function testing in early childhood, i.e., the time period ranging from 0 to 6 years including infants and preschoolers, can be performed by examinations, such as rapid chest compression, single breath occlusion, plethysmography and helium dilution⁶. Studies indicate that infants with BPD show compromised pulmonary function in the first years of life, with significant expiratory flow limitation, namely, forced expiratory volume in one second (FEV1), mean forced expiratory flow (FEF25-75%), as well as reduced pulmonary compliance, increased pulmonary resistance, higher respiratory rate, reduced functional residual capacity (FRC) and residual volume^7-24.

These results are characteristics of ventilatory and functional changes, the knowledge of which may provide a better understanding of the disease and, consequently, improve treatment and preventive strategies to manage the disease. Therefore, this study aimed to analyze the impact of bronchopulmonary dysplasia on the pulmonary function of infants and preschool children between 0 and 4 years of age.

 

METHODS

Search Strategy

The literature review strategy included electronic searching using three bibliographic online databases: SciELO (Scientific Electronic Library Online), PEDro (Physiotherapy Evidence Data base) and Medline (Medical Literature Analysis and Retrieval System Online via Ovid. The publications were selected until the date of online searching, i.e., September 2016, regardless of the language.

The authors developed a search strategy for Medline (via OVID web) and PEDro, which are shown in (Figure 1), due to the absence of this type of publication on the topic. The following keywords were used for the SciELO database: displasia broncopulmonar, bronchopulmonary dysplasia.

Selection Strategy

The articles were screened by 2 examiners, who independently analyzed the results of the online search for potentially eligible articles. The publications which met all previously established inclusion criteria were selected, and doubtful cases were discussed. First, the reviewers read the titles, followed by an analysis of the abstracts. The studies that proved to be eligible were reviewed in full, in agreement with the recommendations of the Main Items for Reporting Systematic Reviews and Meta-analysis (PRISMA)^25,26 (Figure 2).

Analysis of data

Inclusion criteria were: clinical trials that assessed pulmonary function of infants and preschool children aged 0-4 years with a diagnosis of BPD in the neonatal period. The diagnosis of BPD was defined as the need for supplemental oxygen above 21% during 28 days or more.24 Studies that were not available through the Program Manager Bibliographic Commuting (Comut), the newspaper's website or Ovid database, were not used for analysis.newspaper's website or Ovid database, were not used for analysis.

 

RESULTS

A total of 1789 articles were identified, 61 titles of which were selected for analysis of their respective abstracts. Next, 33 articles were shortlisted for full review, and 11 were excluded because they did not meet the inclusion criteria. The final sample consisted of 22 articles as shown in the flowchart (figure 2).

Of the 22 articles included (table 1), 12 assessed children with a history of BPD at different moments (longitudinal)^7-16,27,28 and the maximum follow-up was the interval between the neonatal hospital stay and five years of life. The remaining ten reviewed studies performed pulmonary function testing in one single moment (transversal).^17-22,29-32

 

DISCUSSION

Notably, maintaining the integrity of the respiratory system in the first two years of life is essential and will determine the improvement of gas exchange and respiratory reserve after infancy³³ as this is the period of greatest alveolar growth³⁴. In this review, the studies suggest that respiratory symptoms and pulmonary function seem to improve in early childhood^7,8,10,12,27 with the growth and development of the child with a history of BPD. Farstad et al.¹² found that, at 50 weeks of corrected age (CA), 80% of the children with BPD in their study sample had severe peripheral obstruction, compared to 58% of preterm infants without BPD. In the reevaluation period (120 weeks of CA), only 38% of the children with BPD presented with severe obstruction versus no preterm children. According to Sanchez et al.³⁵ the progressive improvement of capacity and flow-volume curves in this population is proportional to the increase in weight and length of infants. On the other hand, Hjalmarson et al.¹³ observed that the pulmonary function in infants using bronchodilators remains reduced even after normalization of weight, compared to healthy infants. However, these alterations may not be significant considering the normal values of pulmonary function parameters^12,17. In this context, some authors^7,8,10 point out that improved pulmonary function during infancy is more evident in children with moderate/severe BPD, compared to those with mild BPD, or in preterm infants without BPD²⁸.

It is well-established that some complications caused by BPD in early childhood may favor high rates of respiratory infections, recurrent wheezing and hospital readmissions^{12,28,33,34,36}. According to a study conducted by Tepper et al.¹⁴ 55% of infants with BPD required prehospitalization during the first year of life due to diseases of the lower respiratory tract. The incidence of respiratory morbidity and prehospitalization has been lower in healthy full-term infants²⁸, as well as in preterm infants who developed respiratory distress syndrome¹² when compared to infants with bronchopulmonary dysplasia . However, Mahut et al.²⁹ observed that there is no difference in pulmonary function among BPD infants with frequent symptoms and those with fewer or no symptoms, and all of them showed reduced FRC. These results suggest that pulmonary function as well as other factors may be involved in the high susceptibility to respiratory infections in this population.

Another topic identified in the current review is the response of BPD children to bronchodilators. The selected studies demonstrate no reduction in inspiratory and expiratory resistance after the use of bronchodilators in most children with a history of BPD.

Children who respond to these medications show greater abnormalities in pulmonary function parameters than non-responders^22,32. According to Fakhoury et al.²³ up to 3 years of age, only 20 to 30% of children with moderate to severe BPD show bronchodilator response. Therefore, this drug should not be indicated for all patients with BPD, but only for responders or patients show worsening in wheezing during acute respiratory exacerbation^22,32

Current articles and reviews have shown limited pulmonary function, functional capacity and quality of life of schoolchildren³⁷ and adults³⁸ with BPD. However, the impact of BPD on infants and preschool children has not been often discussed. This review was able to collect results of current studies about the disease in this age group. A limitation of this review is the lack of classification of the methodological quality, by means of valid instruments.

In summary, children with a history of BPD usually show alterations in pulmonary function in the first three years of life, which seems to improve with growth and become non-significant after body weight adequacy. However, when comparing BPD children with full-term children, this limitation can still be observed. Also, most BPD children do not show positive response in pulmonary function after the use of inhaled bronchodilator. But, responders have compromised pulmonary function.

Admittedly, there is a gradual improvement of pulmonary function in the first years of life. Therefore, public health professionals involved in the care of this population should consider the importance of nutritional aspects and prevention of respiratory infections in this period, in order to allow conditions for adequate pulmonary growth and development. This may attenuate alterations in pulmonary function due to neonatal injury. Furthermore, early identification of possible impairment of pulmonary function may help pediatricians and/or pulmonologists to prevent disease complications by means of strategies, e.g., to encourage children to keep regular physical activities as soon as possible, and to refer patients for physical therapy as a preventive measure or during acute respiratory events.

 

CONCLUSION

It could be observed that children diagnosed with BPD during the neonatal period showed expiratory flow limitation and reduced FRC when assessed in early childhood, compared to healthy full-term and preterm children. Most children show improved values of pulmonary function with growth and normalization of weight.

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Correspondence:
Camila I. S. Schivinski
E-mail: cacaiss@yahoo.com.br

Manuscript submitted Nov 2015
Accepted for publication Jan 2016