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 Broncho pulmonary 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.