The optimal weaning of bubble CPAP in infants: a quality improvement project

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Nasal CPAP has many benefits in the management of preterm infants with respiratory distress. It is associated with less surfactant use, decreased extubation failure, and increased alveolar recruitment .1-3 Introduction of CPAP bundles and guidelines have been shown to decrease BPD.4 Successful weaning from BCPAP will facilitate oral feeding and developmentally appropriate activities. There have been two RCTs5,6 and one systemic review7 investigating stability criteria and weaning methods. However, no consensus has been reached about the optimal timing to successfully wean BCPAP. 


The study aims to increase first attempt successful weaning from BCPAP in a level-IV NICU from an existing baseline of 60% to 95% over a 1 year period.


This ongoing QI initiative used the Institution of Healthcare model for improvement, and specific weaning criteria were implemented as PDSA cycles to improve the successful weaning from BCPAP, defined as wean to room air in first attempt and no failure for 5 days. The study patients were any spontaneously breathing infant with respiratory distress requiring non-invasive support, or infants requiring post-extubation support. The key measurements were: (1) postmenstrual age and weight at time of wean, (2) adequate and consistent weight gain, (3) respiratory effort (tachypnea, work of breathing, apnea, and need for bag-mask ventilation), (4) caffeine use,9 and (5) sleeping events. The stability criteria were based on prior published data.5 Run charts were used to observe change over time of success rates. 


Between March 2020 and November 2020, 59 neonates were studied. Concept changes included managing variation (standardization), changing work environment (developing alliance and providing access to information), and designing a system to avoid mistakes (use of reminders). Practice changes (shown in the run chart-Figure1) resulted in an increase in successful weaning on the first attempt to an average of 87% after the second PDSA cycle (Table 1).


Implementation of weaning criteria lead to a greater success when transitioning infants from BCPAP to room air. The authors note that this study is limited as only 2 PDSA cycles have been completed and plan to complete more PDSA cycles before recommendation of finalized weaning criteria.

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Penn State College of Medicine
PennState University
PennState Health
PennState Health
PennState Health

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