Quality improvement to reduce chronic lung disease rates in very-low birth weight infants: high compliance with a respiratory care bundle in a small NICU

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Reduce chronic lung disease by 10% among very-low birth weight infants by implementing a consistent respiratory care bundle.

Study design

Prospective quality improvement study of infants below 32 weeks gestation in a small neonatal intensive care unit. A respiratory care bundle to eliminate inter-provider variability and minimize use of mechanical ventilation was implemented. This included: defining delivery room management with use of continuous positive airway pressure/nasal intermittent positive pressure ventilation, uniform intubation/extubation criteria, and standardizing ventilation/post-extubation support.


A total of 107 very-low birth weight infants were included in this project. Compliance with the respiratory care bundle was >90%. Chronic lung disease rates at 36 weeks postmenstrual age fell from 43 to 12% (P = 0.0006), rates of combined chronic lung disease/death decreased from 50 to 20% (P = 0.002, OR = 0.25, 95% CI 0.1–0.6), rates of severe intraventricular hemorrhage decreased from 13 to 0% (P = 0.005), and surgical ligation of patent ductus arteriosus decreased from 35 to 3% (P < 0.0001).


High compliance with the respiratory care bundle was achieved and a 73% reduction in chronic lung disease rates in very-low birth weight infants occurred.

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We wish to give special thanks to the very dedicated South Shore Hospital nurses, respiratory therapists, nurse practitioners, and neonatologists for embracing and mastering significant changes in our respiratory practices for the benefit of our patients. We would like to thank Martha Sola-Visner MD, Associate Professor of Pediatrics at Harvard Medical School and Dr. Munish Gupta from BIDMC for their intellectual support and assistance with preparing and reviewing this manuscript.

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Correspondence to Zuzanna Kubicka.

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Kubicka, Z., Zahr, E., Rousseau, T. et al. Quality improvement to reduce chronic lung disease rates in very-low birth weight infants: high compliance with a respiratory care bundle in a small NICU. J Perinatol 38, 285–292 (2018) doi:10.1038/s41372-017-0008-4

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