Журнал «Здоровье ребенка» 8 (51) 2013

The authors studied and analyzed a group of prenatal, intra-, and neonatal factors leading to the development of bronchopulmonary dysplasia (BPD). Nnegative impact of BPD on the development of chronic bronchopulmonary pathology in children in the first three years of life was determined.

Thanks to the success of modern neonatal intensive care over the past decade the survival rate of prematurely babies born has significantly increased, including those who was born with extremely low birth weight (ELBW). However, the quality of life of survivors, their level of disability does not allow us to consider the problem of nursing of premature infants solved. One of the most frequent complications of such children ICU is the formation of chronic lung diseases such as bronchopulmonary dysplasia (BPD) [3, 8]. The frequency of BPD according to the literature is in the range of 16 to 40 %, depending on gestational age and weight at birth [2, 5].

In the etiopathogenesis of BPD important role belongs to the damaging effects of artificial ventilation (AV) on the immature lung tissue. However, there is recent evidence of a «new» BPD, emerging in very preterm infants, despite treatment with surfactant and less aggressive ventilator undertaken for respiratory distress syndrome (RDS) in infants [3]. Other known causes of BPD are functioning ductus arteriosus (FDA), and perinatal infections. According retrospective study found that the presence of risk factors for BPD is not always correlated with a high probability of its occurrence. Therefore, forecasts of its possible outcome for an individual patient are limited. There is an opinion that BPD may be a causal factor in the development of chronic idiopathic pulmonary diseases, in particular lead to the formation of chronic obstructive pulmonary disease in adults [2, 5, 8]. In this regard, since the first days of life when the most effective preventive measures necessary to form a group of children at high risk for the development of BPD. It is known that in the early stages of its often prescribed corticosteroids, which may be justified only in children at high risk of formation of BPD, but not devoid of significant hormonal side effects. In this connection, clarification of the prognostic significance of the factors contributing to the development of BPD, is very important.

The purpose of the study — defining prognostic risk criteria of BPD for timely preventive measures and prevent the development of chronic lung disease.

Materials and methods. Research was conducted by the Department of Pediatrics 1 P. L. Shupyk’s NMAPE at the National Children's Specialized Hospital (NCSH) “OHMATDET”.

A comprehensive analysis of retrospective clinical and functional follow-up of 114 children who were treated at the NCSH «OHMATDET» from 2006 to 2012 years. The patients started with a moment of their admission to the hospital, the depth catamnesis ranged from 2 to 6 years.

Diagnosis of the disease was performed by analyzing the totality of anamnesis data, results of clinical, laboratory and instrumental investigations. The diagnosis of BPD is established according to the International Classification of Diseases 10 th version based on the presence or absence of a premature baby depends on supplemental oxygen at 36 weeks postconceptual age, or at the time of discharge home with the obligatory presence of a history of treatment with the use of mechanical ventilation (containing a mixture of more than 21 % oxygen) in for at least 28 days. The severity of BPD was assessed according to the classification of clinical forms of bronchopulmonary diseases in children Russian Respiratory Society (2009) [7].

Based on these results the following groups were formed observations: first — a group that included 64 (56.1 %) neonates with respiratory disorders who against the background of mechanical ventilation was formed BPD (boys — 31 girls — 29), the average post-conceptual age children in this group was 30.9 ± 2.1 weeks and the mean birth weight — 1585 ± 411,8 g, the second group included 40 (35.1 %) infants with documented respiratory disorders who against ventilator BPD not formed (boys — 23 girls — 17).The average post-conceptual age was 34,5 ± 3,4 weeks and the mean birth weight — 2100.0 ± 612.6 g The control group consisted of 10 (8.8%) infants with transient respiratory failure in the early neonatal period without mechanical ventilation.

We determine that most of the children were boys, which is probably due to the sexual anatomy of the respiratory system in the neonatal, early and pre-preschool age.

The children of the first and second groups surveyed were mechanically ventilated in the first minutes of life.

Results and discussion. Among the 109 children surveyed (95.6 %) were born prematurely in gestation of < 28 to 37 weeks, 5 kids — full-term (> 38 weeks), with a birth weight 2500–3700 g (Fig. 1).

Fig. 1 Distribution of children with bronchopulmonary dysplasia, dependent on gestational age

Figure 1 shows the distribution of sick children, depending on the gestational age: children born at term < 28 weeks — 39 children (35.5 %), 28–30 weeks — 39 patients (35.5 %), 31–37 weeks — 31 children (29 %), 38–40 weeks — 5 children (4.5 %). In the first and second groups, a significant majority of the children surveyed were infants born prematurely: 63 children (98.4 %)  and 38 children (95 %) respectively. 64 % of mothers of children surveyed had a family history of somatic history in the form of anemia, hypertension, chronic diseases of the digestive and urinary systems, the presence of chronic allergic diseases and other diseases. Burdened gynecological history was found in 56 % of the mothers, maternity — at 65 %. Pregnancy, most mothers proceeded with toxemia (92 %), the threat of an interruption (45 %), exacerbation of chronic somatic diseases (22 %). Acute respiratory infections during pregnancy were recorded in 34 % of women. Changes in the placenta (low placentation, signs of infection) occurred in 25 % of the mothers. Infectious factor is set at 13 % of the mothers : TORCH- infections — at 8.33 %, Chlamydia — at 1.85 %, ureaplasma, trichomonas, syphilis — at 0.93 %, candidosis infection — at 6.48 %. The delivery was rash in 38 % of women with surgical interventions — in 45 %. All of these perinatal factors, in our opinion, have a significant influence on the formation of BPD. This is especially true of infectious diseases from the mother. These data correspond to those obtained by other investigators [2, 4, 5, 9]. Mean gestational age of all children surveyed was 29.2 weeks, the average weight and length at birth — 1391.0 g and 38.2 cm, respectively. 70.8 % of children in this group were born weighing less than 1500 g, of which 46.1 % had a body weight less than 1000

Analysis of the status of children surveyed showed that the lower the weight and gestational age at birth, the higher the rate of formation of BPD. In preterm infants with birth weight less than 1000 g in 100 % of cases developed BPD. However, despite the increase in the number of children with extremely low birth weight infants, the frequency of formation of BPD in preterm infants with a gestational age < 32 weeks decreased from 31 % in 2006 to 21.4 % in 2012. Due to the improvement of modes of respiratory support and neonatal care [9].

All the children surveyed groups reported an inverse relationship between gestational age and mortality in the neonatal period: less than 28 weeks — 12.82 %, 28–30 weeks, 7.7 % — 31–37 weeks — 3.12 %, 38–40 weeks — the deaths were not detected.

Most of the children (110 -96.5 %) were born in asphyxia with Apgar scores at 1 minute less than 7 marks. The causes of respiratory disorders in the neonatal period were: respiratory distress syndrome — in 48 (42.1 %) children, meconium aspiration syndrome — in 43 (37.7 %), perinatal CNS damage — in 24 (21.1 %) children. Thus, the degree of asphyxia at birth has a direct correlation with the frequency of BPD in the neonatal period. We examined children of the first group Apgar score of less than 4 marks at 1 minute of life is a significant risk factor for the development of BPD. Hyaline membrane disease and pneumonia, both congenital and acquired nature, are also important risk factors for the development of BPD. The use of exogenous surfactant preparations in 46 (41.8 %) of children surveyed has reduced mortality from RDS but did not alter the incidence of chronic lung disease in preterm infants [2, 7]. Development BPD they occurred in 30.4 % of cases. The trend towards an increased incidence of BPD in children treated with surfactant therapy may be related to the fact that this drug is used in newborns with severe manifestations of RDS. Home mechanical ventilation was necessary for the period from the first minute until the first days of life, its duration ranged from 7 days to 6–8 weeks. Ventilator- associated pneumonia was diagnosed in 46 (40.4 %) neonates in 8 (7 %) children had pulmonary barotrauma place. One of the main causes of BPD is the use of mechanical ventilation in the first week of life, conduct which, above all, is one of the main methods of treatment and to reduce mortality among infants, especially in extremely low birth 5weight infants. The question of choosing a method of respiratory support is currently the subject of debate [5, 8]. Complications of mechanical ventilation due, above all, the toxic effects of exposure to oxygen, the use of which has become an integral part of resuscitation, as well as «hard» parameters of mechanical ventilation on the background of the immaturity of the lung tissue, leading to barotrauma — severe emphysema with rupture of alveolar hemorrhage in the lung tissue, the penetration of air the interstitial space, pleural cavity, mediastinum, and retroperitoneal fat [1, 9]. It is known that such indicators of mechanical ventilation, as the ratio of inspiratory time to expiratory time (Tin / Texp), the concentration of inspired oxygen (FiO2%) was significantly higher in children who subsequently formed BPD [1, 3, 5]. The data indicate that for adequate respiratory support in infants who subsequently developed BPD was an urgent need for «hard» modes of mechanical ventilation in the early neonatal period.

As a result of the follow-up study revealed a high rate of formation of chronic respiratory diseases — BPD, bronchial asthma, bronchitis, generally diagnosed in the first 3 years of life, 45 % of children who were in neonatal mechanical ventilation due to respiratory disorders. This is consistent with Russian scientists in the period 2002-2010 years [1, 3, 4]. Most often (in 60 children — 52.6 %) showed further persistence of the symptoms of BPD, in 14 (12.3 %) children — the development of asthma. Repeated pneumonia and frequent exacerbations in the form of bronchial obstruction were observed in 7.4 % and 5.6 % of children, respectively.

The children of the first group of BPD was formed on the background of severe RDS, complicated by the development of pneumonia, atelectasis, barotrauma, long-term depending on the respirator and supplemental oxygen. At the time of discharge from NCHB “OHMATDET « the children of the first group maintained clinical (asthma, wheezing local) and radiological signs of BPD in the absence of clinical signs of infection. During the first year of life all children had recurrent episodes of bronchial obstruction. In the dynamics of monitoring clinical radiological signs of BPD in 45 (70 %) of 64 children were eliminated in the first year of life in 19 (30 %) — were observed in the future.

Conclusions

1. In determining the prognostic significance of neonatal factors contributing to the development of chronic bronchopulmonary diseases, particularly BPD, found that the highest prognostic factors are:• extremely low birth weight;

• Gestational age;

• Apgar score below 4 points at 1 minute of life;

• RDS due to hyaline membrane disease;

• Exacerbations of mechanical ventilation (pulmonary barotrauma).

2. Every third young child, who was on the ventilator in the neonatal period, there are recurrent and chronic bronchopulmonary disease (BPD, bronchial asthma, bronchitis), whose development is closely connected with the pathology of perinatal and neonatal period.

3. Children who received prolonged mechanical ventilation in the neonatal period and early neonatal period, require careful follow-up with a number of specialists (pediatric pulmonologist, neurologist, etc.).

4. Accounting for Certain prognostic factors for the development of BPD in children will result in early detection of patients at high risk of developing the disease and the possibility of preventive measures that will prevent it from occurring or reduce the severity.