Algorithmic overview to prevent or reduce the severity of bronchopulmonary dysplasia (BPD) in extremely preterm infants (<28 weeks gestation)

SpO₂: oxygen saturation; FiO₂: fraction of inspired oxygen; nCPAP: nasal continuous positive airway pressure; PaCO₂: partial pressure of carbon dioxide; NIPPV: noninvasive intermittent positive pressure ventilation; H₂O: water.
* Refer to the UpToDate topic on prevention and treatment of respiratory distress syndrome in preterm infants.
¶ Prophylactic caffeine is recommended for all extremely preterm infants within the first day of life and given intravenously or enterally as a loading dose of 20 mg/kg of caffeine citrate (equivalent to 10 mg/kg caffeine base) followed by a daily maintenance dose of 5 to 10 mg/kg per dose (equivalent to 2.5 to 5 mg/kg caffeine base) started 24 hours after the loading dose.
Δ Noninvasive positive pressure support includes nCPAP and NIPPV.
◊ No additional preventive measures needed unless in the uncommon event of respiratory deterioration requiring oxygen supplementation with FiO₂ >0.40 or intubation and mechanical ventilation, which increases the risk of BPD. In these patients, assessment of concomitant respiratory disorders (pneumonia, pneumothorax, pulmonary hemorrhage) should be performed.
§ Targeted SpO₂ is between 90 and 95%.
¥ Vitamin A, if available, is administered to infants who require ventilatory support within 24 hours after birth as an intramuscular injection of 5000 international units (IU) three times per week for four weeks.
‡ Ventilatory settings are adjusted to maintain PaCO₂ at targeted values between 50 and 55 mmHg during the acute respiratory illness (first 10 to 14 days of life) and PaCO₂ up to 60 mmHg with pH ≥7.25 in infants who remain ventilator dependent after two weeks of life.
† Moderate ventilator settings are defined as mean airway pressure on conventional ventilation <12 cm H₂0 or peak inspiratory pressures <25 to 28 cm H₂0 to achieve target tidal volumes of 4 to 6 mL/kg.
** Refer to the UpToDate topic on the prevention of bronchopulmonary dysplasia: postnatal use of corticosteroids.