How do you approach weaning respiratory support in established BPD?

I am caring for a former 23 week infant now 47 wk CGA. On Fisher Paykel CPAP +12, 21% FiO2, serum bicarbonate 26. No pulmonary hypertension on echo. On Pulmicort and Atrovent. Not having desaturation events. Hx NEC s/p 3 bowel resections, ROP, G4 bilateral IVH with PHH. S/p DART steroids x2.

How do you wean from here? We have some team members who are reluctant to wean respiratory support because linear growth is suboptimal, but I feel that is likely due to multiple GI surgeries and periods of NPO and fluid shifts post-op. while not ideal, it doesn't seem like a reason NOT to wean the respiratory support when the baby appears comfortable, is on mostly 21%, and bicarb is acceptable.

Would you wean to a certain PEEP and then try high-flow? How fast/slow and how frequently do you wean? how often are you checking labs?

This baby is in air but requires quite high CPAP. It looks like there is not much parenchymal disease and little V:Q mismatch or pulmonary hypertension. Most likely cause for the high CPAP need is likely to be malacia - either tracheomalacia (which should be obvious from suprasternal and sternal recessions) or small airway malacia which is rather difficult to pick up clinically (although these babies tend to have marked lower intercostal recessions when CPAP is weaned) and bronchoscopy would be helpful. Suggest consulting the paediatric respiratory team, who can perform bronchoscopy to assess for this possible ability; if present, then a BiPap and long-term respiratory support would be needed.

In the first instance though have you tried weaning the baby of CPAP and see if you succeed? Given the baby's age, it is imperative to get the baby off respiratory support as it would help with oral feeding and possible discharge home on low-flow nasal cannula oxygen.

Go down with PEEP and then change to High flow. Sometimes I wean directly from CPAP, depends how the child is doing during care. Why is your PEEP still that high? Just curious.

Yours Katja

Something here doesn’t make sense. Cpap 12 and 21%fio2. Agree with above tracheobronchomalacia possible. What happened actually when you wean cpap? Is work of breathing increased or oxygen. I would advise wean cpap to lowest possible number and then low flow. HFNC is not a weaning mode from cpap, it’s a wrong concept.

On 8/10/2025 at 4:53 PM, chandas said:

This baby is in air but requires quite high CPAP. It looks like there is not much parenchymal disease and little V:Q mismatch or pulmonary hypertension. Most likely cause for the high CPAP need is likely to be malacia - either tracheomalacia (which should be obvious from suprasternal and sternal recessions) or small airway malacia which is rather difficult to pick up clinically (although these babies tend to have marked lower intercostal recessions when CPAP is weaned) and bronchoscopy would be helpful. Suggest consulting the paediatric respiratory team, who can perform bronchoscopy to assess for this possible ability; if present, then a BiPap and long-term respiratory support would be needed.

In the first instance though have you tried weaning the baby of CPAP and see if you succeed? Given the baby's age, it is imperative to get the baby off respiratory support as it would help with oral feeding and possible discharge home on low-flow nasal cannula oxygen.

I got curious on small airway malacia... do you have anything to read on that? Thank you!

On 8/13/2025 at 12:40 PM, Greice Batista said:

I got curious on small airway malacia... do you have anything to read on that? Thank you!

Hi Greice, see - Bush D, Juliano C, Bowler S, Tiozzo C. Development and Disorders of the Airway in Bronchopulmonary Dysplasia. Children. 2023; 10(7):1127. https://doi.org/10.3390/children10071127