Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs

Abstract

Objective: We implemented 5 potentially better practices to limit mechanical ventilation (MV), supplemental oxygen, and bronchopulmonary dysplasia in newborn infants born before 33 weeks' gestation.

Methods: The methods used in this study included (1) exclusive use of bubble continuous positive airway pressure (bCPAP), (2) provision of bCPAP in the delivery room, (3) strict intubation criteria, (4) strict extubation criteria, and (5) prolonged CPAP to avoid supplemental oxygen. We excluded outborn infants and those with major anomalies and obstetric complications from analysis.

Results: Demographics were similar in 61 infants born before and 60 born after implementation. For infants born at 26 to 32(6/7) weeks' gestation, intubation (first 72 hours) decreased from 52% to 11% (P < .0001) and surfactant use decreased from 48% to 14% (P=.0001). In all infants, the mean ± SD fraction of inspired oxygen requirement (first 24 hours) decreased from 0.27 ± 0.08 to 0.24 ± 0.05 (P=.0005), days of oxygen decreased from 23.5 ± 44.5 to 9.3 ± 22.0 (P=.04), and days of MV decreased from 8.8 ± 27.8 to 2.2 ± 6.2 (P=.005). Hypotension decreased from 33% to 15% (P=.03). The percentage of infants with bronchopulmonary dysplasia was 17% before and 8% after (P=.27). Nurse staffing ratios remained unchanged.

Conclusions: Implementation of these potentially better practices reduced the need for MV, surfactant, and supplemental oxygen as well as reduced hypotension among infants born before 33 weeks' gestation without adverse consequences. The costs for equipment and surfactant were lower.

FIGURE 1

A, Respiratory management of infants based on gestational age. ^a Give surfactant in delivery room (DR) if the infant is <28 weeks' gestational age and requires intubation in the delivery room for resuscitation or apnea; ^b goal to start bCPAP by 5 minutes of age; ^c goal is extubation by 24 hours. SIMV/PS indicates synchronized intermittent mandatory ventilation with pressure support; HFOV, high-frequency oscillatory ventilation. B, Criteria for intubation, extubation, and trial off CPAP. ^a Goal pulse-oximetry saturations: 87% to 94% for infants ≤32 weeks' postmenstrual age and 87% to 97% for infants >32 weeks' postmenstrual age.

FIGURE 2

Flow diagram of infants. PPROM indicates preterm prolonged rupture of the membranes for >2 weeks' duration or at before 24 weeks' gestation at >2 weeks' or before 24 weeks' gestation; FMH, fetal-to-maternal hemorrhage; TTTS, twin-to-twin transfusion syndrome.