Impact of Implementing 5 Potentially Better Respiratory Practices on Neonatal

Outcomes and Costs

Bernadette M. Levesque, Leslie A. Kalish, Justine LaPierre, Maureen Welch and
Virginia Porter
Pediatrics; originally published online June 13, 2011;
DOI: 10.1542/peds.2010-3265

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2011/06/08/peds.2010-3265

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

QUALITY REPORT

Impact of Implementing 5 Potentially Better

Respiratory Practices on Neonatal Outcomes and
Costs
AUTHORS: Bernadette M. Levesque, MD,a,b Leslie A. Kalish,
ScD,c Justine LaPierre, RRT-NPS,a Maureen Welch, NNP,a
and Virginia Porter, RNa
a

St Elizabeths Medical Center, bDivision of Newborn Medicine,

and cClinical Research Program, Childrens Hospital Boston,
Harvard Medical School, Boston, Massachusetts
KEY WORDS
bronchopulmonary dysplasia, mechanical ventilation, premature
infants, blood pressure, cost analysis, continuous positive
airway pressure
ABBREVIATIONS
RDSrespiratory distress syndrome
CPAPcontinuous positive airway pressure
BPDbronchopulmonary dysplasia
SEMCSt Elizabeths Medical Center
bCPAPbubble continuous positive airway pressure
FIO2fraction of inspired oxygen
All the authors made substantive intellectual contributions to
this report. Dr Levesque contributed to the conception and
design of the study, implementation, data collection, analysis,
and interpretation, drafted the article, and approved the version
submitted; Dr Kalish contributed to the data analysis and
interpretation and critical revising of the article for important
intellectual content and approved the nal version submitted;
and Ms LaPierre, Ms Welch, and Ms Porter participated in the
conception and design, implementation, data collection and
interpretation, and revising of the article and approved the
version submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-3265
doi:10.1542/peds.2010-3265
Accepted for publication Mar 29, 2011
Address correspondence to Bernadette M. Levesque, MD, St
Elizabeths Medical Center, 736 Cambridge St, Quinn 207, Boston,
MA 02135. E-mail: [email protected]

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 3267 weeks gestation, intubation (rst 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
(rst 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 stafng 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. Pediatrics 2011;128:e000

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.

PEDIATRICS Volume 128, Number 1, July 2011

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

e1

Respiratory distress syndrome (RDS)

is caused by lung immaturity and surfactant deciency and is common
among premature infants. Survival
and outcomes for infants with RDS
have improved in the past 30 years as a
result of the development of exogenous surfactant, continuous positive
airway pressure (CPAP), and better
mechanical ventilators. Exogenous
surfactant reduces mortality and
short-term respiratory morbidity in
premature infants with RDS1 but requires intubation and mechanical ventilation to administer. Mechanical
ventilation increases the risk of
subsequent bronchopulmonary dysplasia (BPD),2 a chronic lung disease
associated with adverse pulmonary
and neurodevelopmental outcomes.3,4
On the other hand, early treatment
with CPAP can preserve endogenous
surfactant and reduce the need for
mechanical ventilation and surfactant
administration511 but may be insufcient support for infants born before
26 weeks gestation.12 Although there
is a growing body of evidence to guide
decision making, there is not yet consensus on the best treatment approach for RDS.
It has long been known that management of RDS and the incidence of subsequent BPD vary among institutions.13,14 More than 20 years ago Avery
et al13 reported that Columbia University in New York had a comparatively
low incidence of BPD among infants
with birth weights of 1500 g and attributed this to early intervention with
CPAP and avoidance of mechanical
ventilation.13 This nding was conrmed by Van Marter et al15 in 2000.
There has been increasing interest in
pursuing respiratory management
strategies for RDS that minimize mechanical ventilation in an effort to reduce the incidence of BPD. These strategies include the provision of CPAP in
the delivery room511 and early extubae2

LEVESQUE et al

tion from mechanical ventilation to

CPAP.16 However, the growing body of
supportive evidence has not resulted
in widespread adoption of either of
these strategies in US NICUs. This may
be attributed to a perceived lack of evidence and/or lack of consensus at individual units.
In 2007, we undertook a major change
in practice for infants born before 33
weeks gestation at St Elizabeths Medical Center (SEMC). Although our use of
mechanical ventilation and incidence
of BPD approximated the Vermont
Oxford Neonatal Network averages,
they were higher than the bestperforming units. We implemented 5
potentially better respiratory practices with the goal of limiting mechanical ventilation and supplemental oxygen and reducing our
incidence of BPD. This is a report of
our rationale for these practices;
how we built an effective team,
achieved consensus, implemented
and ensured compliance; and the impact these new practices had on clinical care, outcomes, and cost of care.

METHODS
Team Formation, Guideline
Development, and Implementation
We assembled a team consisting of a
neonatologist (Dr Levesque), a respiratory therapist (Ms LaPierre), a neonatal nurse practitioner (Ms Welch),
and a bedside nurse (Ms Porter). All
team members were well known to the
clinical staff and were employed full
time in their positions. The team reviewed the contemporaneous institutional nursing and respiratory care
policies and physician guidelines regarding respiratory management of
premature infants with RDS and conducted a limited chart review. We
chose our target population of infants
born before 33 weeks gestation as
most likely to benet from this qualityimprovement effort on the basis of our

baseline rate of mechanical ventilation

use. As part of the planning phase, the
team attended the 18th Annual Respiratory Care of the Newborn: A Practical
Approach Conference at Morgan Stanley Childrens Hospital of New York
Presbyterian in New York, New York,
on October 2122, 2006, during which
details of the Columbia approach
were presented. A written proposal detailing 5 potentially better practices,
with rationales for each, was distributed to all neonatologists and neonatal
nurse practitioners, and a formal presentation was made at a faculty meeting. The nal guideline was approved
by the SEMC NICU Medical Director, the
Chair of Pediatrics, and the Directors
of Nursing and Respiratory Therapy. All
staff members were in-serviced by the
team member in their discipline or department regarding the details of the
guideline, the rationale for each
change, and the technical aspects regarding bubble CPAP (bCPAP). The
guideline was instituted on January 14,
2007. Flow diagrams outlining the
management of infants born before 26
weeks gestation, those born between
26 and 3267 weeks, and criteria for intubation, extubation, and trial of CPAP
are provided in Fig 1.
Rationale for Each Potentially
Better Practice
Exclusive Use of bCPAP
There are several modes of pressure
generation for CPAP, and although
there is not yet enough information to
conclude that one is more effective
than another,17 bCPAP may be more effective. For example, bCPAP enhances
gas exchange in premature infants
compared with ventilator-derived
CPAP18 and leads to less ventilation inhomogeneity and better gas exchange
in premature lambs.19 Extubation to
bCPAP is more successful than extubation to infant ow-driver CPAP in infants born between 24 and 29 weeks

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

QUALITY REPORT

A
<26 wk

26 to <33 wk

Intubate and give

surfactant

Apneic/unstable:
Intubate and give
surfactanta

Stable but
distressed:
bCPAP in DRb

Start
on SIMV
Start
on
with PS HFOV
if
SIMV/PS,
HFOV
meets
criteria
if needed

Intubate and give

surfactant if
meets criteria

Extubate to
Extubate to
bCPAP when
bCPAP when
meets criteriac
meets criteria

Start on
SIMV/PS, HFOV
if needed

Continue bCPAP

Pink and no
distress: to
NICU in room air
Start CPAP if
develops
distress

Continue room
air

Extubateto
CPAP when
meets criteriac

Trial off CPAP and

wean to room air
when meets criteria

B
Intubation Criteria

FiO2 > 0.4a

PaCO 2 > 65 mmHg more than
once
Recurrent apnea
Marked retractions
Severe respiratory distress
syndrome evident on chest
radiograph
Intractable metabolic acidosis

Extubation Criteria

FiO2 < 0.4a

PaCO2 < 60 mmHg
Peak inspiratory pressure less
than 20 cmH2O on ventilator
Ventilator rate < 20
Spontaneous breathing over
ventilator
Reintubation if meets
intubation criteria

Trial off CPAP Criteria

Acceptable saturationsa in
room air on CPAP
No tachypnea or retractions
No apnea or bradycardia

Restart CPAP if any of

following:
FiO2 > 0.21
respiratory rate consistently
>60
increased work of breathing
increased spells

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.

gestation after short-term ventilation.20 The equipment required for bCPAP is cheaper than that for ventilatorderived CPAP and is easily made
portable by mounting all components
on a heavy-duty pole with wheels. We
chose to change from ventilatorderived CPAP to bCPAP because of the
potential for improved efcacy, lower
cost, and excellent portability.
PEDIATRICS Volume 128, Number 1, July 2011

Provision of bCPAP in the Delivery

Room
Provision of CPAP in the delivery room
reduces the need for intubation and
subsequent mechanical ventilation of
premature infants511,21 and may decrease the incidence of BPD8,9,11 but is
successful in avoiding early mechanical ventilation in only 31% of infants
born before 26 weeks gestation.12 Be-

cause infants who require mechanical

ventilation for management of RDS
have improved outcomes if they receive early surfactant,22,23 we decided
to intubate and provide surfactant in
the delivery room for all infants born
before 26 weeks gestation but to start
CPAP in the delivery room for breathing but distressed infants born at 26
weeks gestation.

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

e3

Strict Intubation Criteria

Although ventilated premature infants
have better outcomes with early surfactant,22,23 there are limited data regarding the timing of surfactant for infants who are rst managed with
CPAP. The available data suggest that it
is better to receive surfactant early in
the course of RDS, when the fraction of
inspired oxygen (FIO2) requirement is
still low, rather than later.16,24 In a
study of infants born before 30 weeks
gestation initially managed with
delivery-room CPAP, Verder et al24 reported that infants who received early
surfactant (when arterial-to-alveolar
oxygen ratio 0.35, equivalent to an
FIO2 of 0.40 with arterial partial pressure of oxygen at 50 mm Hg) required less mechanical ventilation and
had a shorter hospital course than infants who received late surfactant
(arterial-to-alveolar oxygen ratio
0.22, equivalent to an FIO2 of 0.60 with
arterial partial pressure of O2 at 50
mm Hg). Although our practice had
been to give rescue surfactant to infants on CPAP when FIO2 requirement
reached 0.3 to 0.35 or higher to maintain saturations higher than 87%, we
decided to change our practice to give
rescue surfactant to infants on CPAP
when their FIO2 reached 0.4 or higher
and/or their arterial-to-alveolar oxygen ratio was 0.35 on the basis of the
Verder et al24 study.
Mechanical ventilation is indicated for
infants with recurrent apnea, hypoventilation, and hypercapnia. Maintaining
arterial partial pressure of carbon dioxide (PaCO2) levels of 45 to 55 mm Hg
is likely safe in ventilated premature
infants,25,26 but there are few data to
determine a threshold PaCO2 level that
alone should prompt intubation. Our
practice had been to intubate for any
PaCO2 level higher than 60 mm Hg. Elevated PaCO2 levels may be transient on
bCPAP and at Columbia they intubate
for PaCO2 levels of higher than 70
e4

LEVESQUE et al

mm Hg but only if it persists for more

than 1 arterial blood gas. We modied
our practice and intubated for PaCO2
higher than 65 mm Hg if it persisted for
more than 1 arterial blood gas.
Strict Extubation Criteria
Our practice had been to extubate to
CPAP after gradual weaning to low ventilator settings, but immediate or early
extubation after surfactant administration may be benecial. Early surfactant followed by extubation to CPAP
within 1 hour compared with later surfactant and continued ventilation is associated with a lower incidence of mechanical ventilation, air leaks, and
BPD.16 We changed our practice to extubate infants as soon as possible, ideally within 2 to 6 hours of reaching our
extubation criteria (Fig 1) and ideally
within the rst 24 hours of age.
Prolonged CPAP With Avoidance of
Nasal Cannula Oxygen Before 35
Weeks Postmenstrual Age
There are no studies regarding the
best time to wean premature infants
off CPAP, but prolonging the use of
CPAP and avoiding nasal cannula oxygen may be preferable. Excess supplemental oxygen increases the risk of
retinopathy of prematurity and BPD,27
whereas CPAP may improve lung
growth.28,29 In the absence of clinical
data but with the suggestion of the
added benet of prolonged CPAP, we
decided to adopt the Columbia criteria
for trial off CPAP (Fig 1).
Equipment
Three portable bCPAP units and 9 stationary bCPAP units were assembled,
mostly from previously purchased
components, and we changed from
Inca (Cooper Surgical, Trumbull, CT)
to Hudson RCI (Teleex, Arlington
Heights, IL) CPAP prongs. All nursing
and respiratory therapy staff members were instructed in the set up and
maintenance of bCPAP. Nine older-

model conventional ventilators that

were previously used for CPAP were
removed from the NICU.
Compliance
The majority of the staff was supportive of these changes in respiratory
management, but these were not easy
changes to make. In accordance, each
team member was vigilant in reminding staff members of the guideline, offering guidance and further explanation when needed. Because there was
a team member from each of the
key disciplines, reinforcement of the
guideline could be conducted among
peers. One team member (Dr
Levesque) visited or called the NICU
daily from January 14, 2007, until January 31, 2008, to review the daily management of all infants at 33 weeks
gestational age in the NICU, plan for
anticipated preterm deliveries, remind the medical staff of relevant aspects of the guideline, and encourage
compliance of all staff members. Deviations from the guideline were noted
and discussed with the clinical staff,
but formal assessment of compliance
was done by chart review after
discharge.
Data Collection
This project was done as a qualityimprovement project and not as a clinical study, but our goal was to evaluate
the impact of these practice changes
on outcomes. With SEMC institutional
review board approval, we collected
data from chart reviews after patient
discharge, without informed consent,
and analyzed deidentied data.
Cost Analysis
Data for nonpersonnel costs were collected and analyzed according to
methods described by Zupancic et al.30
Most infants were assigned as 1 nurse
to every 2 infants at SEMC, with sicker
infants assigned to 1 nurse for every 1
infant. Nursing personnel costs were

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

QUALITY REPORT

evaluated indirectly by analyzing the

percentage of time infants were assigned 1-to-1 stafng while at SEMC.
Equipment costs were tabulated separately. At the time of this project, the
hospital owned 9 soon-to-be-out-ofwarranty conventional ventilators that
were used for both CPAP and mechanical ventilation. Equipment costs for
replacement of these conventional
ventilators versus bCPAP units were
calculated.

150 infants <33 wk gestation admitted to SEMC

1/1/20061/31/2008

RESULTS
A total of 150 infants born at 33
weeks gestation were admitted to
SEMC between January 1, 2006, and
January 31, 2008, 76 before and 74 after the guideline was implemented (Fig
2). Outborn infants and those with major congenital anomalies or major obstetric complications were excluded
from analysis, leaving 61 infants before and 60 infants after, for a total
analysis cohort of 121 infants. Most of
the infants were born between 26 and
3267 weeks gestation. Demographic
characteristics were similar between
the groups (Table 1). Compliance with
the 5 elements of the initiative was
100% (bCPAP), 95% (delivery room
CPAP), 97% (intubation criteria), 83%
PEDIATRICS Volume 128, Number 1, July 2011

74 after guideline
1/14/20071/31/2008

15 infants were
excluded:
Outborn
PPROM
Gastroschesis
FMH
Hydrops
Jejunal atresia

14 infants were
excluded:

9
2
1
1
1
1

Statistical Analysis
Categorical variables were summarized with percentages and compared
between subgroups using Fishers exact test. Continuous variables were
summarized by using means (SD)
and/or median (interquartile range)
and compared using the Mann-Whitney
test. We reported both means and medians for respiratory and cost outcomes, which tended to have skewed
distributions, and when medians were
not reported we veried that t tests
and Mann-Whitney tests gave similar P
values. All P values were 2-sided and
were considered statistically signicant at .05.

76 before guideline
1/1/20061/13/2007

7
3
1
1
2

Included in analysis
61

<26 wk: 3

Outborn
PPROM
Omphalocele
FMH
TTTS

Included in analysis
60

26 to <33
wk: 58

<26 wk: 4

26 to <33
wk: 56

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.

TABLE 1 Demographic Characteristics of All Infants

n
Gestational age, mean SD, wk
Gestational age 26 wk, n (%)
Birth weight, mean SD, g
Weight z score for gestational age,
mean SD
Small for gestational age
Chorioamnionitis
Male gender
Nonwhite race
No prenatal care
Betamethasone not complete
Cesarean delivery
5-min Apgar score, mean SD

(extubation criteria), and 88% (prolonged CPAP).

All infants born at 26 weeks gestation were intubated and given prophylactic surfactant in the delivery room,
but initial respiratory management of
infants born between 26 and 3267
weeks gestation changed signicantly
after the guideline (Table 2). Among
these infants, more infants had CPAP

Before

After

61
30.2 2.3
3 (5)
1393 446
0.22 0.76

60
30.0 1.9
4 (7)
1394 375
0.01 0.87

8 (13)
5 (8)
35 (57)
29 (48)
2 (3)
12 (20)
45 (74)
8.2 1.1

4 (7)
7 (12)
35 (58)
25 (42)
1 (2)
10 (17)
43 (72)
8.4 0.9

P
.19
.72
.98
.11
.36
.56
.99
.58
.99
.81
.84
.75

as their rst mode of respiratory support, more were started on CPAP in the
delivery room, fewer were intubated in
the delivery room or in the rst 72
hours of age, and fewer were given
surfactant replacement. Infants born
after the guideline were started on
CPAP earlier than those born before
but received their rst dose of surfactant, if required, at a similar age. Facial

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

e5

TABLE 2 Initial Respiratory Management for Infants at 26 Weeks Gestational Age

n
Maximum delivery-room support
None
CPAP
Mechanical ventilation
Maximum support during the rst 72 h
None
CPAP
Mechanical ventilation
Surfactant
Any administered
Age of rst dose, if givena
Minutes, median (25th75th percentiles)
CPAP
First mode of support
Age started, if rst modeb
Minutes, median (25th75th percentiles)

Before

After

58

56

P
.0001

44 (76)
0 (0)
14 (24)

12 (21)
39 (70)
5 (9)

15 (26)
13 (22)
30 (52)

4 (7)
46 (82)
6 (11)

28 (48)

8 (14)

75.5 (10677)

91 (21.5775)

.0001

27 (47)
29 (17,3)

48 (86)
4 (2.5,5)

.0001
.91
.0001
.0001

Calculated for infants who received surfactant (n 28 before, n 8 after).

b Calculated for infants who were managed rst with CPAP (n 25 before, n 48 after).
a

CPAP, which was commonly used in

the delivery room before the guideline, was not considered as CPAP in
these analyses, regardless of timing
or duration.

of the number of infants treated for

hypotension in the rst 24 hours of
age, which was lower after. Time to
start and to reach full feeds and length
of stay were similar.

Subsequent management and outcomes were analyzed including all infants born before 33 weeks gestational age (Table 3). Infants born after
the guideline received lower FIO2, while
maintaining similar arterial PaO2 and
PaCO2 in the rst 24 hours, were exposed to fewer days of supplemental
oxygen and fewer days of mechanical
ventilation and had more ventilatorfree days in the rst 30 days of life
compared with those born before.
There were no differences in number
of days on CPAP or overall length of
mechanical support among infants
who received these forms of support
and no differences in the incidence of
apnea of prematurity, pneumothorax,
or need for oxygen on discharge from
the hospital. The incidence of BPD, dened as supplemental oxygen requirement at 36 weeks postmenstrual age,
was reduced by 50%, although this
was not statistically signicant (P
.27). Mortality and nonrespiratory
morbidities were similar before and
after the guideline, with the exception

Infants born before 29 weeks gestation and/or who were born weighing
1500 g are at high risk for adverse
outcome. Mortality and complications
of prematurity were similar before
and after the guideline among infants
born before 29 weeks gestation. There
were no statistically signicant differences in mortality or complications of
prematurity among infants born
weighing 1500 g, although the incidence of BPD was reduced 60% after
the guideline was instituted (Table 4).

e6

LEVESQUE et al

The cohort of 121 infants was analyzed,

regardless of admission date, to assess
the impact of CPAP timing on CPAP success and the correlation of mechanical
ventilation days with subsequent BPD. Infants who succeeded on CPAP (n 56)
were started on CPAP earlier than those
who failed on CPAP (n 17) (median age
at starting CPAP: 4.3 minutes [interquartile range: 319] versus median age at
starting CPAP: 29 minutes [interquartile
range: 1533], respectively; P .007). Of
121 infants, 119 survived to 36 weeks

postmenstrual age and 15 developed

BPD, whereas 104 did not. Infants that
went on to develop BPD were ventilated
for a signicantly longer time (median:
11 [interquartile range: 4 48] versus
median: 0 [interquartile range: 0 1]
days, respectively; P .0001).
Overall nonpersonnel cost of care for
infants born before 33 weeks gestation was similar during the rst 12
weeks of hospitalization before and after the guideline. Specic cost for surfactant replacement therapy was signicantly lower after the guideline. The
percentage of SEMC days spent with a
1:1 stafng ratio was similar before
and after the guideline (Table 5). Using
this measure of personnel costs, there
was no difference from before to after
the guideline. The cost of the 9 stationary and 3 portable bCPAP units was
much lower than the estimated 2007
cost of replacing the 9 out-of-warranty
ventilators with new basic model conventional ventilators ($19 500 for
bCPAP vs $135 000 for ventilators).

DISCUSSION
We were able to implement 5 potentially better respiratory practices in
our unit with a team effort that
required preparation, written and
oral communication, buy-in and inservicing of all levels of staff, and ongoing support and encouragement.
The largest impact of this project was
on measures of respiratory care.
Fewer infants required mechanical
ventilation or surfactant administration, and more were managed exclusively with CPAP, but we did not nd
differences in average PaCO2 levels in
the rst 24 hours age or timing of the
rst dose of surfactant, when given.
The small decrease in FIO2 in the rst 24
hours of age was contrary to what
might have been expected, considering
many infants in the before group received surfactant, whereas most in the
after group did not. Days of supple-

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

QUALITY REPORT

TABLE 3 Respiratory Management and All Outcomes for Infants Born Before 33 Weeks Gestation
Before
n
FIO2 during the rst 24 h, mean SD
PaO2 for the rst 24 h of age, mean SD, mm Hg
PaCO2 for the rst 24 h of age, mean SD, mm Hg
Days supplemental oxygen
Means SD
Median (25th75th percentiles)
Days of mechanical ventilation, all infants
Mean SD
Median (25th75th percentiles)
Days of mechanical ventilation, if ventilated
Mean SD
Median (25th75th percentiles)
Ventilator-free days during the rst 30 d of life
Mean SD
Median (25th75th percentiles)
Days CPAP, if CPAP was provided
Mean SD
Median (25th75th percentiles)
Postmenstrual age off mechanical support, mean SD, wk
Apnea of prematurity
Caffeine for apnea of prematurity
Pneumothorax
BPDa
Home in oxygena
Death in hospital
Cardiovascular outcomes
Hypotension rst 24 h of age
Medically treated patent ductus arteriosus
Surgically treated patent ductus arteriosus
Neurologic outcomes
Any intraventricular hemorrhage
Periventricular leukomalacia
Retinopathy of prematurity
Necrotizing enterocolitis
Culture-positive sepsis
Packed red blood cell transfusion
Growth and nutrition
Day of life infant started feeds, mean SD
Day of life infant reached 130 mL/kg per day feeds,
mean SD
Feeds (mL/kg per day) rst 14 d, mean SD
Postmenstrual age at full oral feed, mean SD, wk
Weight at discharge or death, mean SD
Weight z score at discharge or death, mean SD
Length of stay
Total hospital days, mean SD
Postmenstrual age at death or discharge, mean SD

After

61
0.27 0.08
78.5 33.8
46.0 9.9

60
0.24 0.05
81.4 38.0
47.2 10.1

23.5 44.5
3 (033)

9.3 22.0
1 (03)

8.8 27.8
1 (04)

2.2 6.2
0 (01)

16.2 36.5
3 (111)

9.1 11.5
1.5 (116)

P
.0005
.70
.43
.04

.005

.63

.002
25.5 8.5
29 (2630)

28.0 5.3
30 (2930)
.20

9.5 10.4
4.5 (314)
32.8 4.6
48 (79)
37 (61)
1 (2)
10 (17)
3 (5)
1 (2)

13.0 14.8
6 (3.518)
32.1 1.6
45 (75)
39 (65)
2 (3)
5 (8)
1 (2)
1 (2)

.78
.67
.71
.62
.27
.62
.99

20 (33)
15 (25)
7 (11)

9 (15)
11 (18)
3 (5)

.03
.51
.32

13 (21)
2 (3)
12 (20)
4 (7)
11 (18)
17 (29)

10 (17)
3 (5)
9 (16)
2 (3)
7 (12)
15 (25)

.64
.68
.63
.68
.44
.68

2.5 2.9
12.1 6.9

.21
.59

69.7 45.2
35.4 1.7
2535 635
0.94 0.77

72.9 34.1
35.6 1.5
2624 532
0.70 0.81

.76
.37
.28
.19

52.6 39.9
37.7 4.3

51.3 23.5
37.3 2.3

.40
.99

3.7 4.9
13.4 11.5

PaO2 indicates arterial partial pressure of oxygen.

a Denominators are infants who survived to 36 weeks or discharge home (n 60 before, n 59 after).

mental oxygen were signicantly reduced, but it seems that this was not a
result of our proposed use of prolonged CPAP because the average
postmenstrual age when infants were
weaned off all mechanical support
was similar. This nding supports our
observation that most infants in the afPEDIATRICS Volume 128, Number 1, July 2011

ter group not only avoided mechanical

ventilation in favor of CPAP but also
weaned to room-air CPAP quickly.
We observed a 50% reduction in the
incidence of BPD after the guideline
was instituted, but this effect was not
statistically signicant, perhaps as a
result of our small patient population. Al-

though 1 randomized controlled study of

delivery room CPAP reported an increased incidence of pneumothorax,21
we did not nd this result with our approach in our patient population.
The most signicant nonrespiratory
outcome was a reduction in the incidence of hypotension requiring treatment. Increased mean airway pressure and tidal volumes associated with
mechanical ventilation are known to
decrease blood pressure and/or cardiac output in animal studies,31,32 but
there are limited data on this relationship in human infants. This nding
was not attributed to differences
in the use of sedatives and may be
clinically signicant because hypotension in the newborn period is associated with adverse neurodevelopmental outcomes.3335
Although compliance with each of the 5
elements of this quality-improvement
initiative was high, there was a learning curve for using bCPAP. Initial challenges were in maintaining bubbling in
the system and in positioning infants
prone with the Hudson prongs in place.
These challenges were met by our
nurses and respiratory therapists
mostly by persistent trial and error. It
was not difcult to start CPAP in the
delivery room or to achieve compliance with intubation criteria, but the
occasional and erroneous application
of the intubation criteria to infants
born at 33 weeks gestation had
some adverse results. Because of the
risk of pulmonary hypertension in infants born after 33 weeks gestation
and the low risk of BPD, we continue to
have a low threshold for administering
surfactant in this population. The most
difcult potentially better practice to
implement was early extubation, particularly for infants born at 25 weeks
gestation or earlier. Although these infants all met criteria for extubation at
24 hours of age, these extubations
initially caused anxiety. The presence

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

e7

TABLE 4 Morbidity and Mortality for Infants Born Before 29 Weeks Gestational Age or Those Born
Weighing Less Than 1500 g
Born before 29 wk gestational age
n
Death
BPDa
Retinopathy of prematurity
Intraventricular hemorrhage
Periventricular leukomalacia
Necrotizing enterocolitis
Any major complication
Born weighing 1500 gb
n
Death
BPDc
Retinopathy of prematurity
Intraventricular hemorrhage
Periventricular leukomalacia
Necrotizing enterocolitis
Any major complication

Before

After

14
1 (7)
5 (38)
7 (50)
4 (29)
1 (7)
3 (21)
10 (71)

16
1 (6)
3 (20)
7 (44)
2 (13)
1 (6)
2 (13)
10 (63)

.99
.41
.99
.38
.99
.64
.71

35
1 (3)
10 (29)
11 (31)
12 (34)
2 (6)
4 (11)
21 (60)

36
1 (3)
4 (11)
8 (23)
7 (19)
2 (6)
2 (6)
17 (47)

.99
.08
.59
.19
.99
.43
.34

Denominators are infants who survived to 36 weeks postmenstrual age (n 13 before, n 15 after).
Gestational age in weeks (means SD) for infants born weighing 1500 g 28.7 2.2.
c Denominators are infants who survived to 36 weeks postmenstrual age (n 34 before, n 35 after).
a

TABLE 5 Nonpersonnel and Nursing Personnel Cost Analysis

Nonpersonnel costsa
n
Week 1 cost, $b
Mean SD
Median (25th75th percentiles)
Total cost for weeks 112, $b
Mean SD
Median (25th75th percentiles)
Cost of surfactant, $
Mean SD
Median (25th75th percentiles)
Nursing personnel costs
n
Percentage in the 1-to-1 nursing assignmentc
Mean SD
Median (25th75th percentiles)

Before

After

58

60

1302 1353
752 (3071560)

855 871
493 (307918)

4116 5218
2104 (7645114)

3021 2906
1952 (11473578)

623 794
0 (0722)

193 438
0 (00)

61

60

.83

.0006

.46
19.0 22.2
12.5 (0.028.1)

21.5 23.0
11.5 (5.230.2)

Sample size excludes 2 patients with incomplete data in the before group.
Costs included surfactant, chest radiograph, red blood cell transfusion, platelet transfusion, head ultrasound, surgery,
abdominal radiograph, parenteral nutrition, and echocardiogram.
c Analysis excludes 62 (1.7%) of 3720 SEMC patient-days when the number of nurses was more than or equal to the number
of patients in the unit and all were 1-to-1.

LEVESQUE et al

Institution of this guideline decreased

the need for intubation, surfactant,
mechanical ventilation, and supplemental oxygen in infants born before
33 weeks gestation. The biggest impact was on measures of respiratory
care and a reduction in treated hypotension. Overall, nonpersonnel cost-ofcare and nurse stafng ratios were unchanged, but equipment costs and the
cost of surfactant were lower. The success of this effort is largely attributed
to a multidisciplinary team approach,
leadership support, and good timing.
Additional studies comparing bCPAP
with other modes of CPAP and investigating the potential benet of prolonged CPAP would be useful.

ACKNOWLEDGMENTS

e8

CONCLUSIONS

.51

of at least 1 team member at each extubation was useful. Achieving compliance with early extubation of infants
26 weeks gestation was less
challenging.
This effort followed the transition of
our unit from an independent NICU to a

tal, and publicity around the effort

arranged by the Chair encouraged
compliance.

Childrens Hospital Boston community

NICU in 2006. This transition provided a
good opportunity to introduce change,
but fortitude on the part of team members was necessary. Ongoing support
from the chair of pediatrics and the
NICU medical director was instrumen-

Dr Kalishs contributions to this project were supported in part by Harvard

Clinical and Translational Science Center grant 1 UL1 RR025758 from the National Center for Research Resources.
We appreciate Drs Charles Anderson
and Silvia Testa (past and present, respectively, SEMC chairpersons of pediatrics), Dr Terri Gorman (chief of neonatology and medical director of SEMC
NICU), Joseph Curro, RT (past director
of respiratory care), and Nancy
Gayden, RN, MSN (past NICU nurse
manager) for their trust and support.
Our special appreciation goes to the
talented staff of the SEMC NICU, including John Nunes, RT, Brian Fournier, RT,
John Herr, RT, and the SEMC NICU
nurses who perfected the art of bCPAP
and ultimately championed the cause.

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

QUALITY REPORT

REFERENCES
1. Soll RF. Prophylactic natural surfactant extract for preventing morbidity and mortality in preterm infants. Cochrane Database
Syst Rev. 2000;(2):CD000511
2. Northway WH Jr, Rosan RC, Porter DY. Pulmonary disease following respirator therapy of hyaline-membrane disease: bronchopulmonary dysplasia. N Engl J Med. 1967;
276(7):357368
3. Greenough A. Long-term pulmonary outcome in the preterm infant. Neonatology.
2008;93(4):324 327
4. Doyle LW, Anderson PJ. Long-term outcomes of bronchopulmonary dysplasia. Semin Fetal Neonatal Med. 2009;14(6):
391395
5. Finer NN, Carlo WA, Walsh MC, et al. Early
CPAP versus surfactant in extremely preterm infants. N Engl J Med. 2010;27 (21):
1970 1979
6. Jacobsen T, Gronvall J, Petersen S, Andersen GE. Minitouch treatment of very lowbirth-weight infants. Acta Paediatr. 1993;
82(11):934 938
7. Gittermann MK, Fusch C, Gittermann AR, Regazzoni BM, Moessinger AC. Early nasal continuous positive airway pressure treatment
reduces the need for intubation in very low
birth weight infants. Eur J Pediatr. 1997;
156(5):384 388
8. Lindner W, Vossbeck S, Hummler H,
Pohlandt F. Delivery room management of
extremely low birth weight infants: spontaneous breathing or intubation? Pediatrics.
1999;103(5 pt 1):961967
9. De Klerk AM, De Klerk RK. Nasal continuous
positive airway pressure and outcomes of
preterm infants. J Paediatr Child Health.
2001;37(2):161167
10. Narendran V, Donovan EF, Hoath SB, Akinbi
HT, Steichen JJ, Jobe AH. Early bubble CPAP
and outcomes in ELBW preterm infants. J
Perinatol. 2003;23(3):195199
11. Aly H, Milner JD, Patel K, El-Mohandes AA.
Does the experience with the use of nasal
continuous positive airway pressure improve over time in extremely low birth
weight infants? Pediatrics. 2004;114(3):
697702
12. Ammari A, Suri M, Milisavljevic V, et al. Variables associated with the early failure of
nasal CPAP in very low birth weight infants.
J Pediatr. 2005;147(3):341347
13. Avery ME, Tooley WH, Keller JB, et al. Is
chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics. 1987;79(1):26 30

PEDIATRICS Volume 128, Number 1, July 2011

14. Horbar JD, McAuliffe TL, Adler SM, et al. Variability in 28-day outcomes for very low birth
weight infants: an analysis of 11 neonatal
intensive care units. Pediatrics. 1988;82(4):
554 559
15. Van Marter LJ, Allred EN, Pagano M, et al. Do
clinical markers of barotrauma and oxygen
toxicity explain interhospital variation in
rates of chronic lung disease? The Neonatology Committee for the Developmental
Network. Pediatrics. 2000;105(6):
1194 1201
16. Stevens TP, Harrington EW, Blennow M, Soll
RF. Early surfactant administration with
brief ventilation vs. selective surfactant and
continued mechanical ventilation for preterm infants with or at risk for respiratory
distress syndrome. Cochrane Database
Syst Rev. 2007;(4):CD003063
17. De Paoli AG, Davis PG, Faber B, Morley CJ.
Devices and pressure sources for administration of nasal continuous positive airway
pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008;(1):
CD002977
18. Lee KS, Dunn MS, Fenwick M, Shennan AT. A
comparison of underwater bubble continuous positive airway pressure with
ventilator-derived continuous positive airway pressure in premature neonates ready
for extubation. Biol Neonate. 1998;73(2):
69 75
19. Pillow JJ, Hillman N, Moss TJ, et al. Bubble
continuous positive airway pressure enhances lung volume and gas exchange in
preterm lambs. Am J Respir Crit Care Med.
2007;176(1):63 69
20. Gupta S, Sinha SK, Tin W, Donn SM. A randomized controlled trial of post-extubation
bubble continuous positive airway pressure versus Infant Flow Driver continuous
positive airway pressure in preterm infants
with respiratory distress syndrome. J Pediatr. 2009;154(5):645 650
21. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. Nasal CPAP or intubation
at birth for very preterm infants. N Engl J
Med. 2008;14 (7):700 708
22. Yost CC, Soll RF. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane
Database Syst Rev. 2000;(2):CD001456
23. Soll RF, Morley CJ. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2001;(2):
CD000510
24. Verder H, Albertsen P, Ebbesen F, et al. Nasal

continuous positive airway pressure and

early surfactant therapy for respiratory
distress syndrome in newborns of less than
30 weeks gestation. Pediatrics. 1999;
103(2). Available at: www.pediatrics.org/
cgi/content/full/103/2/E24
25. Varughese M, Patole S, Shama A, Whitehall
J. Permissive hypercapnia in neonates: the
case of the good, the bad, and the ugly. Pediatr Pulmonol. 2002;33(1):56 64
26. Miller JD, Carlo WA. Safety and effectiveness
of permissive hypercapnia in the preterm
infant. Curr Opin Pediatr. 2007;19(2):
142144
27. Sola A, Rogido MR, Deulofeut R. Oxygen as a
neonatal health hazard: call for detente in
clinical practice. Acta Paediatr. 2007;96(6):
801 812
28. Harding R, Hooper SB. Regulation of lung
expansion and lung growth before birth. J
Appl Physiol. 1996;81(1):209 224
29. Zhang S, Garbutt V, McBride JT. Straininduced growth of the immature lung. J
Appl Physiol. 1996;81(4):14711476
30. Zupancic JA, Richardson DK, OBrien BJ,
Schmidt B, Weinstein MC. Daily cost prediction model in neonatal intensive care. Int J
Technol Assess Health Care. 2003;19(2):
330 338
31. Mirro R, Busija D, Green R, Lefer C. Relationship between mean airway pressure,
cardiac output, and organ blood ow with
normal and decreased respiratory compliance. J Pediatr. 1987;111(1):101106
32. Cheifetz IM, Craig DM, Quick G, et al. Increasing tidal volumes and pulmonary overdistention adversely affect pulmonary vascular mechanics and cardiac output in a
pediatric swine model. Crit Care Med. 1998;
26(4):710 716
33. Martens SE, Rijken M, Stoelhorst GM, et al. Is
hypotension a major risk factor for neurological morbidity at term age in very preterm infants? Early Hum Dev. 2003;75(12):
79 89
34. Fanaroff JM, Wilson-Costello DE, Newman
NS, Montpetite MM, Fanaroff AA. Treated hypotension is associated with neonatal morbidity and hearing loss in extremely low
birth weight infants. Pediatrics. 2006;
117(4):11311135
35. Batton B, Zhu X, Fanaroff J, et al. Blood
pressure, anti-hypotensive therapy, and
neurodevelopment in extremely preterm
infants. J Pediatr. 2009;154(3):351357,
357e351

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014

e9

Impact of Implementing 5 Potentially Better Respiratory Practices on Neonatal

Outcomes and Costs
Bernadette M. Levesque, Leslie A. Kalish, Justine LaPierre, Maureen Welch and
Virginia Porter
Pediatrics; originally published online June 13, 2011;
DOI: 10.1542/peds.2010-3265
Updated Information &
Services

including high resolution figures, can be found at:

http://pediatrics.aappublications.org/content/early/2011/06/08
/peds.2010-3265

Citations

This article has been cited by 2 HighWire-hosted articles:

http://pediatrics.aappublications.org/content/early/2011/06/08
/peds.2010-3265#related-urls

Permissions & Licensing

Information about reproducing this article in parts (figures,

tables) or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xht
ml

Reprints

Information about ordering reprints can be found online:

http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on August 8, 2014