Reducing CPAP Failure in Extremely Preterm Infants

BACKGROUND: Extremely preterm infants (<29 weeks EGA) have high rates of respiratory distress syndrome (RDS). Continuous positive airway pressure (CPAP) ± intubation and surfactant administration provide a safe and effective way of treating RDS without the need for prophylactic intubation and surfactant administration. CPAP failure occurs when infants on CPAP must be subsequently intubated within the first 72 hours of life. LOCAL PROBLEM: The CPAP failure rate at Parkland Hospital is elevated compared to the gold standard neonatal ICU (NICU) at Columbia University. METHODS: Quality improvement tools were applied to assess areas for improvement in the CPAP process. The baseline rates of CPAP failure at the Parkland NICU were determined through chart review. Observation of the CPAP process and interviews with NICU staff was performed. INTERVENTIONS: A CPAP failure checklist was developed and placed in each NICU room. Quarterly training led by a respiratory therapist was provided to NICU staff. CPAP audits were updated, and a visual display of the proper CPAP setup was placed in each NICU pod. RESULTS: There was no significant change in the CPAP failure rate from 2015 to 2017. However, there was a reduction in the variation in the CPAP failure rate from 2015 to 2017. There was no change seen in the secondary outcome of the bronchopulmonary dysplasia rate but there was a significant decrease in the total ventilator days. During this time frame, there was also an increase in the number of infants arriving to the NICU on CPAP. CONCLUSION: Our interventions were not successful in lowering the CPAP failure rate. However, our interventions did have a measurable effect in lowering the variability of the failure rate. The decrease in the total ventilator days and increase in the number of infants being managed solely on CPAP indicates a culture shift in the NICU.