Advances in the medical care of Very Low Birth Weight (VLBW) infants have led to decreased mortality rates. Unfortunately, this has not been accompanied by a similar decline in the rate of Bronchopulmonary dysplasia (BPD). In fact, while severity of lung disease at many gestational ages has decreased, the improved survival of the most premature of infants has led to survival with significant respiratory morbidity. So while improvements in care have reduced the risk for severe lung disease in larger, more mature preterm infants, BPD continues to be a major cause of mortality and morbidity in extremely premature infants. For the subset of infants with most severe BPD, who still require ventilator support at 36 weeks post-conception, management remains a significant challenge. No standardized protocols exist to optimally treat severe BPD. Current available strategies include optimization of adequate gas exchange, including prolonged oxygen therapy or ventilator support, utilization of systemic steroid therapy, minimization of ongoing insults like aspiration, and treatment of other sequelae, including pulmonary hypertension. Each of these treatment strategies carries significant toxicities of their own, but individualized evaluation of risk/ benefit and appropriate use of such strategies may improve pulmonary outcomes.

The management of patent ductus arteriosus in the preterm infant is one of the areas of clinical care that is subjected to great practice variation. This is sadly one of the consequences of widespread adoption of closure of the patent ductus arteriosus by pharmacological or surgical means without subjecting the treatment approaches to rigorous randomized control trials. The diverse approaches to treatment currently range from early and aggressive closure of the ductus arteriosus to a conservative approach of watchful waiting for spontaneous closure. This review reviews the complex management strategies of the ductus arteriosus highlighting the areas of greatest controversy that need to be addressed in future trials to provide greatest benefit to the vulnerable preterm infant.