Decreasing delivery room CPAP-associated pneumothorax at ≥35-week gestational age.

OBJECTIVE: We previously reported an increase in pneumothorax after implementing delivery room (DR) continuous positive airway pressure (CPAP) for labored breathing or persistent cyanosis in ≥35-week gestational age (GA) neonates unexposed to DR-positive pressure ventilation (DR-PPV). We hypothesized that pneumothorax would decrease after de-implementing DR-CPAP in those unexposed to DR-PPV or DR-O2 supplementation (DR-PPV/O2). STUDY DESIGN: In a retrospective cohort excluding DR-PPV the primary outcome was DR-CPAP-related pneumothorax (1st chest radiogram, 1st day of life). In a subgroup treated by the resuscitation team and admitted to the NICU, the primary outcome was DR-CPAP-associated pneumothorax (1st radiogram, no prior PPV) without DR-PPV/O2. RESULTS: In the full cohort, occurrence of DR-CPAP-related pneumothorax decreased after the intervention (11.0% vs 6.0%, P < 0.001). In the subgroup, occurrence of DR-CPAP-associated pneumothorax decreased after the intervention (1.4% vs. 0.06%, P < 0.001). CONCLUSION: The occurrence of CPAP-associated pneumothorax decreased after avoiding DR-CPAP in ≥35-week GA neonates without DR-PPV/O2.

Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants.

BACKGROUND AND OBJECTIVES: Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). METHODS: A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS: Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). CONCLUSIONS: Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.

Delivery Room Continuous Positive Airway Pressure and Pneumothorax.

BACKGROUND: In 2011, the Neonatal Resuscitation Program (NRP) added consideration of continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room (DR). The objective of this study was to determine if DR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks' gestational age. METHODS: We included (1) a retrospective birth cohort study of neonates born between 2001 and 2015 and (2) a nested cohort of those born between 2005 and 2015 who had a resuscitation call leading to admission to the NICU and did not receive positive-pressure ventilation. RESULTS: In the birth cohort (n = 200 381), pneumothorax increased after implementation of the 2011 NRP from 0.4% to 0.6% (P < .05). In the nested cohort (n = 6913), DR-CPAP increased linearly over time (r = 0.71; P = .01). Administration of DR-CPAP was associated with pneumothorax (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 4.4-6.8); the OR was higher (P < .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9-12.3; P < .001) than in those receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5-5.0; P < .001). Among those with DR-CPAP, pneumothorax increased with gestational age and decreased with oxygen administration. CONCLUSIONS: The use of DR-CPAP is associated with increased odds of pneumothorax in late-preterm and term infants, especially in those who do not receive oxygen in the DR. These findings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and term infants.