Congenital > BPD

Bronchopulmonary Dysplasia/Chronic Lung Disease of Prematurity:

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Premature infants often have a surfactant deficiency- those who fail to respond to initial therapy often require prolonged mechanical ventilation and follow a typical clinical course. Bronchopulmonary dysplasia (BPD), now referred to as chronic lung disease of prematurity, follows prolonged respirator therapy and occurs secondary to the toxic effects of high oxygen concentrations, as well as barotrauma (interstitial emphysema, airway smooth muscle hypertrophy, epithelial squamous metaplasia, and peribronchial fibrosis)- essentially, it is the result of neonatal lung injury with slow resolution [1,4].

The incidence of BPD is difficult to determine. Probably less than 20% of premature infants who weigh less than 1500 grams at birth will develop BPD., while about 30% weighing less than 1000 gm will develop the condition [3]. Optimal treatment for BPD is the prevention of hyaline membrane disease. BPD has varying severity, but can be associated with significant early morbidity and mortality. The requirement for supplemental oxygen at 1 month of age has been shown to be a poor predictor of eventual outcome [1]. About 30% of affected neonates will have normal a CXR by age 3 years, and less than 10% have residual clinical or radiographic evidence of abnormal pulmonary function. However, up to 30% will have some form of neurodevelopmental handicap.

Given modern day ventilator strategies, premature infants now receive prenatal corticosteroids, will be ventilated for shorter periods of time, and with new ventilator settings, resulting in less-pronounced alveolar septal fibrosis and subtler imaging findings [6].

There are four distinct radiographic stages to BPD:

- Stage I: Day 1-4. Characterized by reticulogranularity (indistinguishable from respiratory distress syndrome) with air bronchograms. Pathologically there is bronchiolar mucosal necrosis and the air spaces are filled with fibrin, red cells, and desquamated pneumocytes.

- Stage II: Day 4-10. "White out" of the lung fields. CHF/pulmonary edema may complicate this stage if the ductus reopens. Pathologically there is exudative necrosis of the alveolar epithelium.

- Stage III: Day 10-30. Bubbly, rounded lucencies, with coarse lung markings appear on the CXR. Migrating atelectasis is a common feature of all stages of BPD. Pathologically the alveoli are over-distended due to small airway plugging with scarred lung, and widespread bronchial and bronchiolar mucosal metaplasia.

- Stage IV: After 30 days. Almost radiographically identical to stage III, but may have increasing fibrosis and enlarged cystic changes.

In Wilson-Mikity Syndrome the changes are identical to bronchopulmonary dysplasia, but the affected infants have never received respirator therapy. In these patients respiratory distress usually begins toward the end of the first week of life.

Changes in the treatment of surfactant deficiency syndrome with adaptation of low-pressure and oscillatory ventilation techniques, lower concentrations of supplemental oxygen, along with antenatal steroid administration and post natal exogenous surfactant, have reduced the incidence of classic BPD [4,5]. However, the increased survival of extremely premature (24-26 week gestation infants) has resulted in the emergence of a new type of BPD with less airway disease and less fibrosis, but histologic features of arrested lung development [4].


CXR will demonstrate coarsened lung markings/interstitial thickening, focal areas of overinflation or generalized overinflation, cystic areas of lucency, and bands of atelectasis/scarring.

CT findings in BPD survivors include areas of reduced lung attenuation and perfusion (mosaic appearance), bronchial wall thickening, linear opacities, and bullae [2].


(1) J Thorac Imag 1986; Williams JL, et al. Bronchopulmonary dysplasia. 1 (4): 16-24

(2) AJR 2000; Howling SJ, et al. Pulmonary sequelae of bronchopulmonary dysplasia survivors: High-resolution CT findings. 174: 1323-1326

(3) Radiographics 2005; Agrons G, et al. Lung disease in premature neonates: radiologic-pathologic correlation. 25: 1047-1073

(4) Radiographics 2017; Semple TR, et al. Interstitial lung disease in children made easier...well, almost. 37: 1679-1703

(5) AJR 2018; Liszewski MC, Lee EY. Neonatal lung disorders: pattern re to diagnosis. 210: 964-975

(6) AJR 2019; Liang T, et al. Childhood interstitial (diffuse) lung disease: pattern recognition approach to diagnosis in infants. 212: 958-967

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