Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants

Abstract

BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks’ gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks’ GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre–OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks’ GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks’ GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.

EBNEO commentary: Umbrella review evaluating interventions to decrease risk of bronchopulmonary dysplasia in preterm neonates

“…6 Other studies have successfully decreased rates of intubation and BPD via respiratory care bundle implementation that includes initiation of CPAP in the delivery room, strict intubation and extubation criteria, and standardisation of respiratory care provided. [7][8][9] URL LINK: https://ebneo.org/ebneo-commentary-umbrella-review- Ellen Diego: Writing -review and editing; supervision.…”

Should less invasive surfactant administration (LISA) become routine practice in US neonatal units?

“…Based on the threshold criteria used in the RCTs and observational studies described above, if there is no reduction in FiO 2 after initially escalating CPAP, it seems reasonable to use a threshold of FiO 2 ≥0.3 at CPAP 7 cm H 2 O for LISA. 90 Observational studies describing experience with LISA A large body of observational evidence on LISA has been generated from Europe and Australia. In a study of 22-31 weeks GA infants born between 2009 and 2012 Göpel et al 91 compared the outcomes of infants receiving LISA (n = 1103) against matched control infants receiving selective surfactant therapy and MV (n = 1103).…”

“…95 Our center introduced LISA as part of a quality improvement project (named OPTISURF) to minimize lung injury, which included optimization of CPAP and use of LISA in ≤29 weeks GA infants admitted to NICU on CPAP. 90 The CPAP level was increased stepwise from 5 to 7 cm H 2 O if the FiO 2 was ≥0.3, followed by LISA. 90 Compared to historical controls, infants managed with the new algorithm (Fig.…”

“…90 The CPAP level was increased stepwise from 5 to 7 cm H 2 O if the FiO 2 was ≥0.3, followed by LISA. 90 Compared to historical controls, infants managed with the new algorithm (Fig. 1) received CPAP 7 cm H 2 O within 4 HOL more often, and had a lower rate of MV (within the first 72 HOL as well as during overall hospital stay), pneumothorax, and patent ductus arteriosus treatment.…”

“…All relevant unit personnel should be educated about the guideline, preferably using simulation, 3,102 and readily available instructional videos. 90 It is important to establish role clarity for individual team members of multidisciplinary teams during these simulation training sessions. The training of nurses and respiratory therapists is best conducted by discipline-specific team champions prior to practice change.…”