Reduce chronic lung disease by 10% among very-low birth weight infants by implementing a consistent respiratory care bundle.
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.
Subscribe to Journal
Get full journal access for 1 year
only $20.67 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Pfister RH, Soll RF. Initial respiratory support of preterm infants. The role of CPAP, the INSURE method, and noninvasive ventilation. Clin Perinatol 2012;39:459–81.
Wright LL, Horbar JD, Gunkel H, Verter J, Younes N, Andrews EB, et al. Evidence from multicenter networks on the current use and effectiveness of antenatal corticosteroids in low birth weight infants. Am J Obstet Gynecol 1995;173:263–9.
Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk for preterm birth. Cochrane Database Syst Rev 2006;3:CD004454.
St John EB, Carlo WA. Respiratory distress syndrome in VLBW infants: changes in management and outcomes observed by the NICHD neonatal research network. Semin Perinatol 2003;27:288–92.
Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 1987;79:26–30.
Van Marter LJ, Allred EN, Pagano M, Sanocka U, Parad R, Moore M, et al. Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? Pediatrics 2000;105:1194–201.
Finer NN, Carlo WA, Walsh M, Higgins RD. Early CPAP versus surfactant in extremely preterm infants. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. N Engl J Med 2010;362:1970–9.
Dunn MS, Kaempf J, de Klerk A, de Kerk R, Reilly M, Howard D, et al. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011;128:e1069–76.
Fisher HS, Buhrer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics 2013;132:e1351–60.
Schmolzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung P. Non-invasive versus invasive respiratory support in preterm infants at birth: systemic review and meta-analysis. BMJ 2013;347:f5980.
Respiratory support in preterm infants at birth. Committee on Fetus and Newborn. Pediatrics 2014;133:171–4.
Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2012;11:CD001456.
Bhandari V. Nasal intermittent positive pressure ventilation in the newborn: review of literature and evidence-based guidelines. J Perinatol 2010;20:505–12.
Lemyre B, Davis PG, De Paoli AG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for apnea of prematurity. Cochrane Database Syst Rev 2002;10:CD002272.
Bhandari V, Gavino RG, Nedrelow JH, Pallela P, Salvador A, Ehrenkranz RA, et al. A randomized controlled trial of synchronized nasal intermittent positive pressure ventilation in RDS. J Perinatol 2007;27:697–703
Friedlich P, Lecart C, Posen R, Ramicone MS, Chan L, Ramanathan R, et al. A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999;19:413–8.
Barrington KJ, Bull D, Finner NN. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001;107:638–41.
Khalaf MN, Brodsky N, Hurley J, Bhandari V. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001;108:13–17.
Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001;163:1723–9.
Benaron DA, Benitz WE. Maximizing the stability of oxygen delivered via nasal cannula. Arch Pediatr Adolesc Med. 1994;148:294–300.
Burstein J, Papile L, Berstein R. Intraventricular hemorrhage and hydrocephalus in the premature newborn: a prospective study with CT. Am J Radiol 1979;132:631–5.
Committee for the Classification of Retinopathy of Prematurity. An International Classification of Retinopathy of Prematurity. Arch Ophthalmol 1984;102:1130–4.
Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am. 1986;33:179–201.
Provost LP, Murray S. The healthcare data guide: learning from data for improvement. San Francisco: Jossey-Bass Publishers; 2011. p. 107–36.
Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med 2013;369:611–20.
Gerdes JS, Sivieri EM, Abbasi S. Factors influencing delivered mean airway pressure during nasal CPAP with the RAM cannula. Pediatr Pulmonol 2016;51:60–9.
Kubicka ZJ, Limauro J, Darnall RA. Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continues positive airway pressure? Pediatrics 2008;121:82–8.
Nelin LD, Bhandari V. How to decrease bronchopulmonary dysplasia in your neonatal intensive care unit today and “tomorrow”. F1000Res. 2017;6:539. https://doi.org/10.12688/f1000research.10832.1.
Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards WH, Hocker J, et al. Collaborative quality improvement for neonatal intensive care. Pediatrics 2001;107:14–22.
Walsh M, Laptook A, Kazzi SN, Engle WA, Yao Q, Rasmussen M, et al. A cluster-randomized trial of benchmarking and multimodal quality improvement to improve rates of survival free of bronchoplulmonary dysplasia for infants with birth weights of less than 1250grams. Pediatrics 2007;119:876–90.
Wlodaver A, Blunt M, Satnes K, Escobedo M, Hallford G, Szyld E. A retrospective comparison of VLBW outcomes before and after implementing new delivery room guidelines at a regional tertiary care center. J Perinatol 2016;36:182–5.
Levesque BM, Kalish LA, LaPierre J, Welch M, Porter V. Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs. Pediatrics 2011;128:e218–26.
Birenbaum HJ, Dentry A, Cirelli J, Helou S, Pane MA, Starr K, et al. Reduction in the incidence of chronic lung disease in very low birth weight infants: results of quality improvement process in a tertiary level neonatal intensive care unit. Pediatrics 2009;123:44–50.
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.
Conflict of interest
The authors declare that they have no competing interests.
Electronic supplementary material
About this article
Cite this article
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
Current Opinion in Pediatrics (2019)
Journal of Perinatology (2019)