Early predictors of continuous positive airway pressure failure in preterm neonates.

OBJECTIVE: To develop a prediction model to identify infants admitted on continuous positive airway pressure (CPAP) requiring intubation within seventy-two hours of life (HOL). STUDY DESIGN: Infants born ≤29 weeks' gestational age between 2013 and April 2018 were randomly assigned to either a modeling cohort (MC) or a validation cohort (VC) in a 2:1 ratio. Variables available within two HOL were compared between the CPAP failure group (CFG) and the CPAP success group (CSG). RESULTS: Of the 189 infants in the MC, 50% failed CPAP. Compared to CSG, infants in the CFG had lower antenatal steroid exposure, birth weight, higher radiographic severe respiratory distress syndrome (RDS) and fraction of inspired oxygen (FiO2). A forward stepwise logistic regression modeling in both MC and VC showed that FiO2 >0.3 and radiographic severe RDS predicted CPAP failure. CONCLUSION: FiO2 >0.3 within two HOL and radiographic severe RDS predicts CPAP failure in preterm infants.

Quality Improvement Project to Decrease Delivery Room Intubations in Preterm Infants.

BACKGROUND AND OBJECTIVES: Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks' gestation. METHODS: Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO2 detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre-quality improvement cohort (QIC) (January 2014-September 2015) were compared with post-QIC (October 2015-December 2016). RESULTS: Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders. CONCLUSIONS: Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.