NICU bedside caregivers sustain process improvement and decrease incidence of bronchopulmonary dysplasia in infants < 30 weeks gestation

Respir Care. 2015 Mar;60(3):309-20. doi: 10.4187/respcare.03235. Epub 2014 Nov 25.


Background: The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation.

Methods: A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1-T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010.

Results: A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03-0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11-2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07-0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period.

Conclusions: In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.

Keywords: NICU; bedside caregiver; bronchopulmonary dysplasia; mechanical ventilation; prematurity; very low birthweight.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Bronchopulmonary Dysplasia / epidemiology
  • Bronchopulmonary Dysplasia / therapy*
  • Caregivers*
  • Female
  • Gestational Age
  • Humans
  • Incidence
  • Infant, Newborn
  • Infant, Very Low Birth Weight*
  • Intensive Care Units, Neonatal*
  • Male
  • Point-of-Care Systems*
  • Pulmonary Surfactants / therapeutic use*
  • Respiration, Artificial / methods*
  • Retrospective Studies
  • Time Factors
  • United States / epidemiology


  • Pulmonary Surfactants