New guidelines address outpatient management of post-prematurity respiratory disease

The American Thoracic Society has published a new clinical practice guideline to assist physicians in the outpatient management of infants, children, and adolescents with post-prematurity respiratory disease.

“There was an urgent need for updated guidelines for clinicians treating these patients,” ATS panel co-chairs A. Ioana Cristea, MD, MS, Associate Professor of Clinical Pediatrics in the Division of Neonatal-Perinatal Medicine at Riley Hospital for Children and Indiana University, Indianapolis, and Christopher D. Baker, MD, associate professor of pediatrics in the division of pediatric pulmonology and sleep medicine at the University of Colorado Denver School of Medicine, said in a related press release. “These recommendations are intended to assist clinicians in the outpatient management of patients with post-prematurity respiratory disease, regardless of the degree of prematurity, the severity of the disease or the patient’s age at the time of presentation. “

The multidisciplinary guidelines panel included 26 experts in pediatric pulmonology, neonatology, sleep medicine, radiology and nursing, as well as parents of children with post-prematurity respiratory disease. Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the committee made recommendations for clinical practice on when and how to treat infants, children and adolescents with post-prematurity respiratory disease.

The recommendations, published in the American Journal of Respiratory and Critical Care Medicine, are conditional and based on very low certainty evidence:

• Do not routinely prescribe short-acting inhaled bronchodilator therapy for people without recurrent respiratory symptoms, but a supervised short-acting bronchodilator trial is recommended to assess improvement in clinical symptoms in people with chronic respiratory symptoms. recurrent respiratory symptoms.
• Do not routinely prescribe inhaled corticosteroids to people without chronic cough and recurrent wheezing, but a trial of inhaled corticosteroids with monitoring is recommended to assess improvement in clinical symptoms in people with chronic cough or recurrent wheezing.
• Do not routinely use diuretics for people with post-prematurity respiratory disease, and discontinue chronic diuretic therapy wisely for people discharged from the neonatal intensive care unit.
• Use polysomnography for people with persistent apnea, intermittent desaturation, or bradycardia over 40 weeks postmenstrual age and who are ready to be discharged from neonatal resuscitation.
• Use polysomnography and / or sleep medicine referral for people with symptoms of sleep breathing disorders such as persistent snoring, growth retardation, or a persistent need for supplemental oxygen by age 2 and obtain night or 24 hour oximetry to screen for breathing sleep disturbances followed by polysomnography and / or referral to sleep medication when polysomnography is not available.
• Perform swallowing assessment for those who eat orally with a cough or persistent oxygen desaturation during feeding; suspected or confirmed vocal cord paralysis or other abnormalities; failure of weaning from oxygen therapy or ventilatory assistance; persistent or worsening pulmonary hypertension; growth retardation or chronic lung symptoms out of proportion to viral respiratory infections.
• Perform airway endoscopy in people with unexplained symptoms, including chronic cough, wheezing, ventilator addiction, persistent hypoxemia, or a history of persistent ductus arteriosus.
• Do not use dynamic airway imaging to screen for routine tracheobronchomalacia in people without symptoms suggestive of airway malacia; use dynamic airway imaging without sedation to diagnose or reassess tracheobronchomalacia in people with recurrent symptoms suggesting airway malacia when the risk of anesthesia is greater than that of radiation therapy or if bronchoscopy is not achievable or available.

“There is currently no universally indicated drug or diagnostic test for people with post-prematurity respiratory disease,” the authors wrote. “However, future studies will elucidate which patient subgroups will benefit from targeted therapies for the prevention and treatment of post-prematurity respiratory disease in a personalized approach.”

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