Bronchopulmonary Dysplasia (BPD) Medications
This section will provide information on BPD treatment.
Note: All medications have a commercial name, and a chemical name (generic products often use the chemical name). In this site, drugs' chemical names are given in brackets.
Disclaimer: No attempt has been made to list all BPD medications — in general, preference has been given to preparations more commonly used in the Ottawa (Canada) area.
Overview of BPD Therapy
Children grow new air sacks until about 8 years of age (after the age of 8, the lungs grow — but they grow by means of the air sacks getting larger, rather than growing new air sacks). For infants with BPD, it is vital to grow new air sacks to compensate for air sacks that have been damaged by scarring. With optimal treatment, infants and children with BPD should grow about as many air sacks as other children, and the severity of the BPD will steadily lessen as the proportion of the child's air sacks that are diseased falls. The aim of BPD therapy is to keep the child stable until the lungs can grow, and to promote lung growth. Five types of treatment are commonly used for infants or children with BPD:
- Oxygen Therapy
- Water Pills (Diuretics)
- Anti-Inflammatory Medications
- Nutritional Therapy
Information on some of the medications used to treat complications of BPD may be found on the Complications of BPD Page.
BPD medications may be prescribed as pills or syrups, or in the form of some kind of inhaler. Inhaled medications have become increasingly popular, as relatively large amounts of medication can be delivered directly to the lungs, and quite little medication reaches other parts of the body, where it can potentially cause side effects. The disadvantage of inhaled medications is that the inhaler must be used properly, and the inhaler must be in good working order, for the medication to reach the lungs.
Why use Home Oxygen?
Oxygen is needed by all the cells in the body, and is especially important for proper function of the brain and heart. Even mildly reduced levels of oxygen in the blood interfere with growth, and affect the blood vessels within the lungs.
Blood vessels that carry blood from the right side of the heart to the interior of the lungs, to pick up oxygen, are very sensitive to low oxygen levels. When they sense low oxygen levels, they narrow. Forcing blood flow through narrowed blood vessels is harder work for the right side of the heart, and can cause heart strain. Over time, this can lead to potentially-irreversible heart damage, which is one of the most serious potential complications of BPD.
How do you give Oxygen to a Baby?
Babies with BPD who have low blood oxygen levels need extra (or "supplemental") oxygen to assist growth and to prevent heart strain. If your baby needs oxygen at home, your hospital or a Medical Gas company will provide you with a supply of oxygen, usually in the form of compressed oxygen in a cylinder, or liquid oxygen, in a tank. Oxygen is usually given to the baby using nasal prongs, which are taped to fit just inside the nostrils. Your physician will prescribe a flow rate — in mL/minute (also known as cc/minute) or L/minute. Note that 1000 mL/minute of oxygen is the same as 1 L/minute, so 50 mL/minute and 0.05 L/minute are the same thing! Most families are provided with:
- A large compressed oxygen cylinder to keep beside the crib.
- A small "portable" oxygen cylinder for trips, or
- A small liquid oxygen tank for use during trips.
Liquid oxygen tanks are lighter, more compact, and therefore more portable, but most liquid oxygen tanks cannot provide very low oxygen flows (under 0.25 L/min.).
Experiment with different ways of taping the nasal prongs to your baby's face — sometimes surgical dressings like Op-site® or Tegaderm® cause less rash than ordinary medical tapes. Also, as your baby grows and gets more active, make sure he/she doesn't get tangled in the oxygen tubing at night!
Your baby may need more oxygen during colds (when the nose is blocked by secretions), during feeds, and when sleeping. In general, oxygen should be provided to ensure that the oxygen saturation is 92% or greater at night, at rest, and during feeds. Babies with heart strain (or cor pulmonale) may need enough oxygen to keep their oxygen saturations at 95% or higher at all these times.
Most infants with BPD are able to maintain adequate blood oxygen saturations without supplemental oxygen by about one year of age.
Oxygen Saturation Monitors
Oxygen is carried in the blood attached to a protein called hemoglobin. When the hemoglobin holds the maximum possible amount of oxygen, the hemoglobin is considered to be 100% saturated with oxygen. In general, the blood contains adequate amounts of oxygen when the hemoglobin is 90-100% saturated with oxygen. The percentage of the hemoglobin which is carrying oxygen is known as the oxygen saturation.
Blood oxygen saturation can be measured with a machine called a pulse oximeter. Your medical gas company may come out to measure the oxygen saturation with a pulse oximeter in your home. Some families can borrow an oximeter, or rent one.
Pulse oximeters work by shining a red light through a finger (or toe). The more oxygen the blood is carrying, the redder it is, which changes the colour of the light produced by the oximeter. The light's colour is read by a light sensor, held on the side of the finger (or toe) opposite the light source. Oximeters use a computer program to try to give an oxygen saturation reading only when fresh blood (ie. with lots of oxygen) has just been pumped from the heart.
Most better oximeters have a bar graph that rises and falls with each heartbeat (or pulse), telling you that the machine is measuring fresh blood oxygen saturations accurately. In other machines, a green/red light tell you if the machine "believes" it is getting accurate readings. You should watch this graph to make sure that the oximeter is getting accurate readings — otherwise, the "oxygen saturation" may be way, way off. False "pulses" may be picked up by the machine especially if your baby is moving around a lot. If the circulation to the limb is decreased — for example, if you're holding the limb too tight or if the limb is cold, the machine won't be able to pick up an accurate pulse. Most pulse oximeters also display your baby's pulse. You can also check whether you're getting accurate oxygen saturation readings by measuring your baby's pulse at the same time yourself (you can feel it on the wrist on the thumb-side. Measure the pulse for 15 seconds, and multiply by 4).
This Diagram shows the oximeter's bar graph tracing (above) and the blood pressure (or pulse) at the same time (below)
Water Pills (or Diuretics)
Why use Water Pills in BPD?
Fluid accumulation in the lungs occurs in many babies with BPD, particularly if they are receiving alot of fluids to help them grow. Fluid can accumulate in the walls of the airsacs as well as in the walls of the bronchial tubes. Fluid in the walls of the airsacs makes them stiffer and makes breathing more difficult, and interfers with the transfer of oxygen from the inside of the airsacks to the blood vessels in the airsac walls. This can reduce blood oxygen saturations. Fluid accumulating in the walls of the bronchial tubes causes the bronchial tubes to swell, making the air-passages tighter. This can cause wheezing and increase the work of breathing.
Water pills work by moving excess water from the lungs and the body to the kidneys for urination, which helps correct these problems. Some babies with BPD need water pills for many months. Water "pills" are available as syrups for babies. Commonly-used water pills include Lasix® (or Furosemide), HydroDiuril® (hydrochlorothiazide) and Aldactazide® (a mixture of two water pills, hydrochlorothiazide and spironolactone). Lasix® is a stronger water pills than these other medications, but has a somewhat-higher potential for side effects.
How are these Medications Used?
These medications may be taken regularly, or used only when your child is having increased difficulties breathing and/or increased requirements for extra oxygen. Lasix® is usually given once-a-day; HydroDiuril® (hydrochlorothiazide) and Aldactazide® are usually given once or twice-a-day.
Side effects can occur with water pills, and your doctor will check your baby regularly for these problems. Side effects that can occur with any water pill include: (1) removal of too much water from the body, leading to dehydration, and (2) removal of too much salt from the body (particularly sodium and potassium). Babies on water pills should have their blood sodium and potassium levels checked regularly. These side effects are particularly common with Lasix (or Furosemide®), the strongest water pill available. Long-term use of Lasix® can also lead to kidney stones and hearing problems. Other side effects of water pills include:
||Vomiting, High Blood Sugar|
||Hydrochlorothiazide + Spironolactone
||Spironolactone helps the body retain potassium, and this combination can lead to too high potassium. Vomiting, High Blood Sugar, Breast enlargement|
Why use Bronchodilators in BPD?
Many infants and children with BPD have asthma, or asthma-like symptoms due to airway narrowing caused by inflammation, and/or tightening up of the muscle bands that surround the bronchial tubes (known as bronchospasm or bronchoconstriction). For such infants and children, Bronchodilators (or "Reliever" medications) temporarily relax these muscle bands when they bronchoconstrict during an asthma (or "asthma-like") attack. In some babies with BPD, these muscle bands stay tightened-up for long periods of time, and these babies receive bronchodilator medications on a regular basis.
For infants and children with asthma/asthma-like attacks that improve with bronchodilators, bronchodilators are essential for making certain that enough air gets in and out of the lungs during an attack, and such patients should always have a reliever medication available to him or her.
There are three types of reliever (or bronchodilator) medications for BPD. They are Beta-2-Agonists, Anti-Cholinergics, and Theophyllines. Each works in a slightly different way.
Beta-2-Agonists are distantly related to Adrenaline, but are chemically altered to have much, much less effect on the heart and the blood pressure. They are the most powerful, and most rapid, type of reliever medication. Beta-2-Agonists are available for use in inhalers, and as syrups. Ventolin® (Salbutamol or Albuterol) is a commonly-used inhaled Beta-2-Agonist, which can be inhaled using a number of different devices. Ventolin® and Alupent® (or Orciprenaline) are available as syrups. Beta-2-Agonists are more effective, and have fewer side effects, when given by inhaler. If your child is having an asthma-type attack and you have a Beta-2-Agonist syrup and a Beta-2-Agonist inhaler available at home, using the Beta-2-Agonist inhaler is preferable.
Common Uses of Beta-2-Agonists
There are several common ways Beta-2-Agonists are used in BPD. For more information on how Beta-2 Agonists are used in asthma, click here.
- Inhaled Beta-2-Agonists (ie. via "puffer" or Metered-Dose Inhaler), or Nebulizer) are usually given every 4-6 hours "as needed" for asthma-type symptoms such as coughing, wheezing, chest tightness, or trouble breathing. Beta-2-Agonist syrups can be given up to every 6 hours.
- If your child needs his/her Beta-2-Agonist inhaler more than every 4 hours, it is a sign of a severe attack. You should discuss with your doctor — ahead of time — what to do if this happens. Many doctors will recommend that you should talk to a doctor, bring your child to a doctor, or bring your child to an emergency room, if this happens.
- Beta-2-Agonists are used regularly (up to every 6 hours) in some infants with BPD.
- Because Beta-2-Agonists are related to adrenaline, even when they are used properly, they can cause a muscle tremor or jitteriness, excitability and a mild increase in the heart rate.
- Very high doses can cause serious heart problems, which is why giving very frequent doses of Beta-2-Agonists should be done in a hospital setting, carefully supervised by medical staff. If your child needs his/her inhaled Beta-2-Agonist more than every 4 hours, you should carry out your doctor's plan of action. If you don't have a plan of action prepared in advance, or you have any worries about your child, you should speak to or see a doctor, or take your child to an emergency room.
- Recent studies suggest that regular, prolonged, use of short-acting Beta-2-Agonists can lead to worsening of asthma. It is unclear whether this happens in BPD.
Anti-cholinergic medications relax the muscles that surround the bronchial tubes by using chemical messages which are different from the ones used by Beta-2-Agonists. One anti-cholinergic medication is presently available — Atrovent® (Ipratropium Bromide). Atrovent® is available as puffer (or Metered-Dose Inhaler) and for use in a nebulizer. Anti-cholinergic medications cause gradual, fairly mild relaxation of the muscles that surround the bronchial tubes. Because it works through messages that are different than the ones used by Beta-2-Agonists, doctors often use anti-cholinergics together with a Beta-2-Agonist, to achieve more relaxation of tightened bronchial muscles than you could achieve with a Beta-2-Agonist by itself.
Common Uses of Anti-Cholinergics
- Anti-cholinergic medication can be used to help relieve asthma-type attacks that usually don't get relieved enough by a Beta-2-Agonist by itself.
- Anti-cholinergic medication can be useful as a reliever medication in children who can't tolerate, or use, a Beta-2-Agonist.
- Anti-cholinergic medicines can be given regularly to babies with BPD and persistent bronchospasm.
Anti-cholinergic medication rarely cause side effects. It occasionally causes a dry throat. The medication should not be aimed towards the eyes.
Theophyllines are available as pills and syrups. They produce relaxation of the muscles around the bronchial tubes, but cause side effects fairly commonly. For these reasons, they're used less often to treat patients with BPD in Canada. Theophylline-type drugs available in Canada include Somophyllin-12 (Theophylline), Theo-Dur® (Theophylline), Choledyl® (Oxtriphylline), and Phyllocontin® (Aminophylline). Theophyllines have to build up a certain level in the blood, to be effective. If the blood level is too low, the medication may not work. If the blood level is too high, serious side effects can happen. People on theophyllines should have their blood levels checked periodically by their doctors.
Common Uses of Theophyllines
- Theophyllines can be given regularly to babies with BPD and persistent bronchospasm.
- Theophylline-type medicines are used to treat apnea in babies with apnea spells.
- Common side effects, which can occur even when the blood level is where it should be, include stomach aches and loss of appetite, and over-activity.
- Theophyllines can worsen regurgitation (or Gastro-esophageal reflux).
- Extremely high blood levels can cause serious heart problems and convulsions (or seizures).
- Many medications interact with Theophyllines, including Erythromycin (a commonly-used antibiotic), Cimetidine (used to treat Gastro-esophageal reflux), and many anti-epileptic drugs (or anti-convulstants). If your child is on Theophylline and a doctor wants to prescribe a new medication for your child, you should make sure the doctor knows that the child is taking Theophylline.
Why use Anti-Inflammatory Medications?
Anti-Inflammatory medications (or Preventer medications) make inflammatory cells in the lungs less likely to release the chemicals that cause inflammation in the lungs. Some preventer medications even decrease the number of inflammatory cells in the lungs. Inflammation can worsen lung function, increase mucous production by the lungs, and promote bronchospasm. Anti-inflammatory medictions can also make the lungs less likely to become inflammed after exposure to various factors that can trigger inflammation (such as viral infection or things the child might be allergic to). Preventer medications (as the name suggests) prevent attacks of difficulty breathing, and reduce the severity of such attacks. In general, these medications must be used regularly to be effective.