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Bubble CPAP and Preterm Neonates: A Noninvasive Ventilation Approach to Quality Improvement — Six-Month Implementation Results Update

March 27, 2019 Preterm neonates — and particularly extremely preterm neonates who are less than 28-weeks gestational age — are at a high risk for developing bronchopulmonary dysplasia (BPD), which carries with it significant rates of morbidity and mortality. The use of mechanical ventilation for respiratory support, coupled with the use of pulmonary surfactants, increases these risks.

“In those neonates with a gestational age less than 28-weeks, the literature shows a nearly 40 percent rate of BPD. This has both short- and long-term complications for the patients and their families. With the implementation and use of bubble CPAP, a noninvasive, safe, and effective method of respiratory support for spontaneously breathing babies, we believe rates of BPD will be dramatically reduced, along with overall use of mechanical ventilation and other support measures that have been part of our existing standard of care,” says James Kiger, MD, MS, medical director for Newborn Respiratory Care and Bubble CPAP implementation lead.

Implementation of the bubble CPAP protocol is not without its risks and challenges. Because the protocol entails its use in neonates up to 32-weeks gestational age (more or less time on the device is possible depending on the specific needs of the patient), there is the potential that it may be required to support infants for up to nine weeks.

“The changes needed to administer this protocol are fairly intensive and require strict adherence to the use and safety measures that we have put in place,” says Dr. Kiger. Vigilant monitoring of the positioning of the breathing apparatus and airway pressure is required to ensure the proper levels of positive pressure ventilation are delivered at all times.

Implementing the Protocol 

Bubble CPAP protocol development began in February 2018. At that time, the implementation of a multidisciplinary committee was formed, consultations and training occurred with experts in the field from Columbia University in New York, and an extensive literature review of the established evidence of bubble CPAP use in preterm neonates was undertaken.

The protocol moved into active use in the NICUs at UPMC Children’s and UPMC Magee Womens Hospital on September 11, 2018, after all the necessary equipment, training, education, and protocol outcomes and practices were established and executed.

Outcomes and Benefits of the Protocol — Six-Month Metrics

The Bubble CPAP initiative in the UPMC Newborn Medicine Program is designed to provide a number of clinical benefits for preterm neonates. Achieving marked reductions in oxygen exposure, mechanical ventilation, morbidities associated with BPD, length of hospitalization, and the use of agents needed to treat the condition is paramount.

The administrative and cost-benefit potentials from the adoption of the bubble CPAP protocol includes reductions in the number of ventilator days and corresponding fleet size, secondary care costs associated with BPD (short- and long-term), and other financial benefits.
For the first six months of the Bubble CPAP initiative:

• Surfactant use has declined by more than 50 percent.
Within just the first two weeks of the Bubble CPAP initiative, surfactant use dropped by more than 50 percent. That trend in decreases versus baseline statistics has continued.

• Unplanned extubations have dropped considerably.
From September 2018 through January 2019, there were just five unplanned extubations. By comparison, in the five months preceding the use of bubble CPAP there were 12 unplanned extubations.

• The total number of ventilator days has decreased even more dramatically. 
Since the bubble CPAP protocol began in September 2018, the number of ventilator days has totaled 297 compared to 1,025 in the five months before implementation. That represents a nearly three-fold decrease in ventilator days.

The Future of Bubble CPAP at UPMC

The UPMC Newborn Medicine Program will continue its use of bubble CPAP, and the protocol will eventually be implemented system-wide at all UPMC NICUs, even in Level II units for late- or mid-term infants.

Bubble CPAP Implementation Team

James Kiger, MD, MS — Implementation Lead
Kalyani Vats, MD
Abeer Azzuqa, MD
Jennifer Kloesz, MD
Laura Jackson, MD
Thomas Diacovo, MD
Karen Ewing, NNP
Roberta Bell, RN, MSN
Jordan Kalivoda, RRT
William Vehovic, RRT
Kristen Brenneman, RN
Amy Farren, RN
Bradley Kuch, BS, RRT-NPS, FAARC