Bubble CPAP and Preterm Neonates: A Noninvasive Ventilation Approach to Quality Improvement

As the literature shows, 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.

Implementing the Protocol

Bubble CPAP protocol development began in February 2018, at which time the implementation of a multidisciplinary committee was formed, consultations and training with experts in the field from Columbia University in New York occurred, 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 in September 2018 after all the necessary equipment, training, education, and protocol outcomes and practices were established and executed. “Longer-term, it is absolutely part of our plan to implement the Bubble CPAP protocol at all of the NICUs in our system once testing and initial outcomes are determined. One of the benefits of using Bubble CPAP is that it is not an invasive mechanical ventilatory support, so it could easily be implemented in level II NICUs for late- or mid-term infants,” says Dr. Kiger.

Protocol Complexities and Implementation Challenges

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

For premature infants with respiratory effort, the goal is for application of Bubble CPAP immediately after delivery and maintenance on it for as long as necessary. In fact, implementation at the time of delivery is key to prevent the development of BPD. “We see so many infants in the NICU for a variety of reasons. There will be cases when intubation and the use of surfactant simply cannot be avoided. However, by placing the majority of spontaneously breathing premature babies on Bubble CPAP, we will minimize the need for potentially injurious endotracheal intubation and invasive ventilation,” says Dr. Kiger.

Outcomes and Benefits of the Protocol

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

The administrative and cost benefit potentials from the adoption of Bubble CPAP extend to 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.

“Within just the first two weeks of starting our Bubble CPAP program, the Division has been able to reduce the use of mechanical ventilation and surfactant administration by 50 percent measured against baseline occurrence. I suspect that we’ll see the incidence and severity of BPD drop as well, and we’ll of course be monitoring this as part of our outcomes measurements,” says Thomas Diacovo, MD, chief, UPMC Newborn Medicine Program and director of Neonatal Cardiovascular Research.

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