83 - Rising Incidence with Evolving Care of Bronchopulmonary Dysplasia: A Five-Year Nationwide Trend Study in Chinese Neonatal Network (CHNN)

Publication Number: 2079.83

Ge Yang, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (People's Republic); Huayan Zhang, Children's Hospital of Philadelphia-University of Pennsylvania, Philadelphia, PA, United States; Jie yang, Fudan Children's Hospital, Shanghai, Shanghai, China (People's Republic)

Background: Bronchopulmonary dysplasia (BPD) remains a major morbidity in very preterm infants. While advances in respiratory care have improved survival, the widespread adoption of "gentler" respiratory support technologies has not consistently reduced BPD rates. This is a persistent paradox suggesting variations in practice may drive the epidemiology. Given its diversity, understanding the temporal trends, geographic disparities, and evolving care in China may give insight in addressing this global challenge.

Objective: To quantify the incidence and temporal trends of BPD and BPD-associated outcomes across different regions in China from 2019-2023, and to analyze the association between respiratory care practices and BPD.

Design/Methods: This retrospective cohort study analyzed data from the Chinese Neonatal Network (CHNN), including 43,312 preterms born at < 32 weeks' gestation in 112 tertiary NICUs. We examined key respiratory practices including antenatal corticosteroids, intubation in delivery room, surfactant and caffeine use, postnatal corticosteroids, prolonged invasive/non-invasive ventilation, and inhaled nitric oxide before 36 weeks postmenstrual age (PMA). Outcomes included death before 36 weeks' PMA and/or BPD and grade 2-3 BPD (as per 2019 Jensen definition), and respiratory support at discharge. To identify key drivers of BPD, we employed a gradient boosting decision tree model, with feature contribution ranked by SHAP (SHapley Additive exPlanations) values, adjusting for gestational age, sex, and clinical covariates.

Results: From 2019 to 2023, a significant increasing trend was observed for BPD and grade 2-3 BPD, while death before 36 weeks' PMA remained stable (Table 1). This rise was most pronounced in infants born at 26-32 weeks' GA (Figure 1). Marked geographical variations persisted, with the highest adjusted BPD rates in Southwest and Northeast China. Machine learning-based contribution ranked ventilation strategies and postnatal corticosteroid use as the top modifiable factors associated with BPD risk, a pattern consistent across most regions in China (Figure 2).

Conclusion(s): This nationwide trend study reveals a rising incidence of BPD in China despite stable mortality, particularly among infants 26-32 weeks' GA. The identified geographic disparities and key modifiable respiratory care practices provide critical insights for developing targeted interventions to mitigate BPD in very preterm infants in China, with implications for large, diverse and rapidly developing healthcare systems globally.

Table 1. Incidence and inter-center variations of BPD-associated outcomes from 2019 to 2023
PMA, postmenstrual age; BPD, bronchopulmonary dysplasia; FiO2, fraction of inhaled oxygen
1 Yearly trend assessed using linear regression models for weighted CV and the Cochran-Armitage trend test for crude rates.
2 Adjusted for gestational age, sex and random effect on study center.
3 Discharge with respiratory pressure support including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), non-invasive and invasive mechanical ventilation.

Figure 1. Heatmap of the temporal trend of the crude rate of BPD-associated outcomes from 2019 to 2023, stratified by gestational age
BPD, bronchopulmonary dysplasia; PMA, postmenstrual age; Data presented as the percentage of infants with the respective BPD-associated outcomes within each cell.

Figure 2. Contribution ranking of neonatal practice and respiratory management to the outcome of BPD between 2019 and 2023, stratified by 6 geographical regions.
Features of care practice (occurred before 36 weeks' postmenstrual age) including antenatal corticosteroids, resuscitation with intubation in delivery room, surfactant use, caffeine use, postnatal corticosteroids, receiving invasive ventilation >= 7 days, receiving non-invasive ventilation >= 7 days), postnatal corticosteroids use and inhaled nitric oxide (iNO) use. Contribution ranked by SHAP calculated by gradient boosting decision tree (GBDT) model adjusting for gestational age, sex, small for gestational age, multiple gestation, vaginal delivery, 5-minute Apgar Score <7, respiratory distress syndrome, TRIPS score at admission, inborn, antenatal steroids (ever), antenatal magnesium (ever), maternal age, primigravida, maternal comorbidities.