Post-N/IICU Inpatient BPD Clinical Pathway

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Goals and Metrics

Patient Education

Provider Resources

Related Pathway

Pulmonary Hypertension Screening in Patients with BPD, ICU and Inpatient

N/IICU Patients with Severe Bronchopulmonary Dysplasia (BPD) on ≤ 4 L HFNC

Review Criteria for Transfer from N/IICU
High flow nasal cannula flow of ≤ 4 LPM and ≤ 40% FiO₂ for at least 24 hr with stable respiratory status and appropriate growth
No significant bradycardia/desaturation events requiring intervention
Pulmonary hypertension stable on enteral meds
No imminent neurosurgical interventions planned
Limited changes to the care plan for 24-48 hr prior to expected transfer

Consult
- Pulmonary BPD Team
- Complex Care Blue Team

Prepare family for transfer; consider family transition meeting
Initiate bed request for Complex Care Blue when bed available
N/IICU hand-off to Complex Care

Transfer to Complex Care Blue Team

Assess Readiness to Wean Weekly
- Review:
  - Trends in O₂ saturations, FiO₂ needs, RR, resting HR
  - All growth parameters
  - Ability to tolerate and progress with therapies
  - Recommendations from BPD team

Feeding and Nutrition

Allow patient to adjust to weaning of respiratory support; avoid changing feeding regimen for 1-2 days following wean
Feeding Schedule
GERD
Oral Stimulation and Feeding
Enteral Tube Considerations

Wean Respiratory Support When Clinically Appropriate

Failure to Wean
Return to previously tolerated level of support
Consider differential diagnosis
Review with Pulmonary BPD Team
Reattempt wean when stable

Step	LPM
1	4	HFNC with Blended O₂
2	3	HFNC with Blended O₂
3	2	FiO₂ 100% Delivery via NC from oxygen source provides lower effective FiO₂ than 100%
4	1
5	0.5
6	RA	0.25 LPM (FiO₂ 100%) may be an intermediate step prior to RA depending on patient condition and discussion with BPD team

Successful Wean to Discharge Level of Respiratory Support
RA preferred; may consider ≤ 0.5 LPM in discussion with BPD team

Monitor tolerance
Observe patient for minimum of 3 days

Discharge Planning

Posted: April 2022
Revised: May 2022
Authors: M. Dunn, MD; P. Mazzeo MD; K. Gibbs, MD; K. Mckenna, MD; A. Hogan, MD; D. Tauber, MD; J. Fierro, MD; J. Welc, SLP; K. Nilan, RN; C. Ehritz, RN; E. Becker, RN; L. Soorikian, RT

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Inpatient Clinical Pathway for the Post-N/IICU Management of Infants with Severe Bronchopulmonary Dysplasia (BPD)

Evidence