Minimizing the Duration of Invasive Mechanical Ventilation to Prevent Bronchopulmonary Dysplasia: A Quality Improvement Approach

Eunsong Bae; Susie Kang; Mi Jin Kim; Hyo Ju Yang; Chang Won Choi; Young Hwa Jung

doi:10.5385/nm.2025.32.2.79

Neonatal Med > Volume 32(2); 2025 > Article

Bae, Kang, Kim, Yang, Choi, and Jung: Minimizing the Duration of Invasive Mechanical Ventilation to Prevent Bronchopulmonary Dysplasia: A Quality Improvement Approach

Original Article

Neonatal Medicine 2025;32(2):79-89.

Published online: November 30, 2025

DOI: https://doi.org/10.5385/nm.2025.32.2.79

Minimizing the Duration of Invasive Mechanical Ventilation to Prevent Bronchopulmonary Dysplasia: A Quality Improvement Approach

Eunsong Bae, MD¹

, Susie Kang, MD¹

, Mi Jin Kim, MD¹

, Hyo Ju Yang, MD¹

, Chang Won Choi, MD, PhD^1,²

, Young Hwa Jung, MD, PhD^1,²

¹Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea

²Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea

Correspondence to: Young Hwa Jung, MD, PhD Department of pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea
Tel: +82-31-787-7302 Fax: +82-31-787-4054 E-mail: jyhtlcn@snubh.org

Received April 14, 2025 Revised May 26, 2025 Accepted May 29, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Bronchopulmonary dysplasia (BPD) is a chronic lung disease and a major cause of morbidity in preterm infants, especially in those requiring prolonged invasive mechanical ventilation. This quality improvement (QI) initiative aimed to reduce the duration of invasive ventilation, thereby lowering the incidence of BPD in very-lowbirth-weight infants.

Methods

A multidisciplinary QI initiative was conducted at the neonatal intensive care unit of Seoul National University Bundang Hospital from February 2022 to June 2024 and compared with historical controls from January 2019 to December 2021. Infants born at <32 weeks of gestation or with a birth weight of <1,500 g were included. Interventions involved standardized protocols addressing the following: minimizing unnecessary intubation in the delivery room; increasing the use of noninvasive surfactant administration; and conducting daily assessments of extubation readiness. The invasive ventilation duration, intubation in the delivery room, surfactant administration techniques, and incidence of BPD were assessed.

Results

A total of 358 infants (186 pre-QI and 172 post-QI) were analyzed. The rate of delivery room intubation decreased from 29.7% to 13.8% (P<0.001), and the use of noninvasive surfactant methods increased from 40.6% to 69.1% (P<0.001). The average ventilation duration decreased (17.1±31.8 days vs. 7.2±15.0 days, P<0.001). The incidence of BPD decreased from 57.5% to 45.9% (P=0.045). According to subgroup analysis of infants born at <29 weeks gestation, ventilation duration was significantly reduced (33.8±34.1 days vs. 20.2±20.7 days, P=0.01), but BPD incidence was not significantly different (85.5% vs. 92.7%, P=0.27). In the multivariate logistic regression analysis, only the duration of invasive ventilation was significantly associated with BPD (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.021 to 1.167; P=0.01), but not birth weight (OR, 0.997; 95% CI, 0.995 to 0.999; P=0.001).

Conclusion

A structured multidisciplinary intervention effectively reduced the duration of invasive ventilation and BPD. Continued emphasis on comprehensive care bundles may further benefit premature infants.

Keywords: Bronchopulmonary dysplasia; Respiration, artificial; Intubation; Infant, premature

INTRODUCTION

Bronchopulmonary dysplasia (BPD) is a chronic lung disease and a leading cause of morbidity and mortality among preterm infants, particularly those who require prolonged invasive mechanical ventilation [1,2]. While advances in neonatal care have significantly improved the survival rates of extremely preterm infants, these gains have been accompanied by an increased reliance on respiratory support and extended duration of mechanical ventilation, both of which contribute to the development of BPD [3].

Recent reports from international neonatal networks have shown a rising trend in the incidence of BPD among extremely preterm infants. In the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network, BPD rates increased from 44.7% (2008–2012) to 49.8% (2013– 2018) [4]. Japan’s Neonatal Research Network similarly reported an increase from 41.4% in 2003 to 52% in 2016 among infants born at 22 to 27 weeks’ gestation [5]. In the Korean Neonatal Network (KNN), BPD incidence among infants born at 23 to 27 weeks between 2014 and 2021 rose from 51.2% to 62.7% [6].

Among infants born at <28 weeks of gestation, approximately 70% are intubated within the first week of life, primarily because of respiratory distress syndrome and apnea of prematurity [7]. Approximately 38% of these patients required invasive mechanical ventilation. Intubation rates are particularly high among extremely preterm infants, with approximately 50% of them requiring intubation, and these rates increase further with decreasing gestational age. Moreover, prolonged invasive ventilation is a well-established risk factor for BPD3, [8]. Strategies that avoid or minimize invasive respiratory support have been identified as effective in reducing BPD [9].

In response to these concerns, many neonatal intensive care units (NICUs) have implemented quality improvement (QI) initiatives aimed at reducing the incidence of BPD [10,11]. However, to date, no such studies have been conducted in Korea. Therefore, we initiated a QI initiative aimed at reducing the use and duration of invasive mechanical ventilation in our NICU, with the ultimate goal of lowering BPD rates in preterm infants.

MATERIALS AND METHODS

1. Setting and selection of patients

This QI initiative was conducted as part of ongoing QI efforts within the KNN. Seoul National University Bundang Hospital is a 40-bed regional perinatal center, where approximately 80 to 120 very low-birth-weight infants (VLBWIs) are enrolled in the KNN each year, representing the primary population targeted by this initiative [12]. This study included patients who were born at <32 weeks of gestation or whose birth weight was <1,500 g.

The project encompassed all patients admitted to the NICU during a 17-month period following the initiation of the QI projects (February 1, 2022, to June 30, 2024), as well as all patients admitted during the 24-month pre-intervention period (January 1, 2019, to December 31, 2021). The exclusion criteria were outborn status, gestational age at birth of <23 weeks, and prolonged hospitalization exceeding 1 year.

2. Interventions

The QI initiative aimed to reduce the incidence of BPD by minimizing the duration of invasive mechanical ventilation in VLBWIs. A multidisciplinary team comprising neonatologists, neonatal nurses, delivery room staff, and QI specialists was formed. This team conducted a comprehensive assessment of the existing clinical practices, focusing on delivery room intubation rates, surfactant administration methods, and extubation protocols.

A driver diagram was constructed to guide the structured development and implementation of QI interventions (Figure 1). This diagram outlines the logical framework connecting the project’s overarching goal of reducing the duration of invasive mechanical ventilation in preterm infants with the associated primary and secondary drivers. The primary drivers identified were (1) minimizing unnecessary intubation in the delivery room; (2) promoting noninvasive surfactant administration methods; and (3) standardizing daily assessments of extubation readiness. Each driver was linked to targeted interventions based on existing evidence and analysis of institutional clinical workflows.

To further support the objectives of the initiative, three key clinical questions were developed, each serving as the foundation for an evidence-based protocol. Detailed explanations and corresponding protocols for these questions are provided in the Appendix 1.

Question 1: Is intubation necessary for preterm infants in the delivery room?

Question 2: Is intubation necessary for preterm infants for surfactant administration?

Question 3: Is the patient intubated, and do they need to remain intubated today?

3. Monitoring and data analysis

Key clinical indicators, including delivery room intubation rates, methods of surfactant administration, duration of invasive mechanical ventilation, and associated clinical outcomes, were continuously monitored (Figure 2).

All intervention-related data were collecffted using an electronic case form (Figure 3), including documented reasons for intubation and daily assessments of extubation readiness in intubated patients. The primary outcome measure was the average monthly cumulative duration of intubation per patient. Secondary outcome measures included the proportion of patients intubated in the delivery room and the proportion of surfactants administered via intubation in the total patient population. BPD was defined according to the 2001 guidelines of the NICHD, which classify BPD based on the level of respiratory support required at 36 weeks postmenstrual age in infants born at less than 32 weeks gestation [2].

To evaluate temporal trends in the primary outcome, a statistical process control (SPC) chart was constructed using the X-bar chart methodology. The centerline represented the baseline mean, and control limits were set at ±3 standard deviations (upper and lower control limits) based on pre-intervention data. Monthly data points were plotted sequentially, and special cause variations were assessed using standard SPC rules, such as the appearance of a single point outside the control limits. The vertical lines in the chart indicate the phase changes in the QI implementation strategy. The SPC chart was created using Microsoft Excel (Microsoft Corporation) with manually calculated control limits.

In accordance with the Plan-Do-Study-Act cycle, SPC chart data were reviewed, and corresponding interventions were evaluated every 3 months to monitor progress and identify opportunities for improvement.

Statistical analyses were performed using SPSS version 27.0 (IBM Corp.). Normally distributed continuous variables were compared using Student’s t-test or Fisher’s exact test. Nonnormally distributed continuous variables were analyzed using the Mann-Whitney U-test. Chi-square tests were conducted to assess the differences between the pre- and post-intervention periods. Multivariate logistic regression analysis was performed to identify risk factors independently associated with the development of BPD.

4. Ethical issues

The use of data from the KNN registry was approved by the Institutional Review Board, and written informed consent was obtained from parents or legal guardians. As the interventions implemented in this study did not involve randomization or comparison of invasive procedures or therapies, they were considered part of routine clinical care. Data for histological comparisons were retrospectively obtained from anonymized case report forms in the KNN database.

RESULTS

Of the 413 patients initially assessed, 55 were excluded because of death (n=43; 27 in the pre-QI period and 16 in the post-QI period), outbirth (n=4), gestational age <23 weeks (n=6), or prolonged hospitalization exceeding 1 year (n=2). The final analysis included 358 patients: 186 in the pre-QI period (January 1, 2019, to December 31, 2021) and 172 in the post-QI period (February 1, 2022, to June 30, 2024).

The baseline characteristics of the pre- and post-QI periods are provided in Table 1. No significant differences were observed in prenatal factors between the two groups, except for histological chorioamnionitis (32.2% vs. 13.5%, P<0.001). Gestational age and other neonatal morbidities, including sepsis, patent ductus arteriosus (PDA) requiring treatment, and necrotizing enterocolitis, did not differ significantly between the two groups. However, infants in the pre-QI period had significantly lower birth weights (1,068.3±292.5 g vs. 1,201.8±324.8 g, P<0.001). Systemic steroid use for the development of BPD was significantly higher in the pre-QI period (21.4% vs. 9.3%, P<0.002), and the proportion of infants discharged with home oxygen was significantly greater (24.6% vs. 16.0%, P<0.001).

Significant respiratory improvements were observed across all study groups following the QI intervention. The rate of delivery room intubation decreased markedly from 29.7% in the pre- QI period to 13.8% in the post-QI period (P<0.001). Similarly, the use of minimally invasive surfactant therapy (MIST)/less invasive surfactant administration (LISA) or intubation-surfactant-extubation (INSURE) increased substantially from 40.6% to 69.1% (P<0.001). The duration of invasive ventilation was significantly reduced from 17.1±31.8 to 7.2±15.0 days (P<0.001). The prevalence of moderate or severe BPD decreased from 57.5% to 45.9% (P=0.045).

Figure 4 shows an SPC chart illustrating the average monthly cumulative intubation per patient over time. The chart demonstrates temporal trends and highlights the changes observed before and after the QI intervention. Following the implementation of the QI measures, a significant and sustained reduction in the average monthly cumulative intubation duration was observed.

In the multivariate logistic regression analysis, only the duration of invasive ventilation was significantly associated with BPD (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.021 to 1.167; P=0.01), but not birth weight (OR, 0.997; 95% CI, 0.995 to 0.999; P=0.001) (Table 2).

Given that premature infants, particularly those born before 29 weeks of gestation, were more likely to require intubation and prolonged mechanical ventilation, we conducted a subgroup analysis of infants with a gestational age <29 weeks (Table 3). A total of 75 and 56 infants from the pre-QI and post-QI periods, respectively, were included in the subgroup analysis. No significant differences were observed between the two groups in terms of gestational age, birth weight, or other neonatal morbidities, except for histological chorioamnionitis (50.0% vs. 21.8%, P<0.001). Systemic steroid use for BPD development was higher in the pre-QI period, although the difference was not statistically significant (46.7% vs. 29.6%, P=0.068). The proportion of infants discharged with home oxygen decreased significantly (42.7% vs. 20.4%, P=0.009).

Similar positive outcomes following QI intervention were observed in this cohort. The rate of delivery room intubation decreased significantly from 57.5% to 31.6% (P<0.001), whereas the use of MIST/LISA or INSURE increased significantly from 34.8% to 56.8% (P=0.031). Additionally, the duration of intubation decreased from 33.8±34.1 to 20.2±20.7 days (P=0.010). In this subgroup of very premature infants born at less than 29 weeks of age, the incidence of BPD was very high (85.5% vs. 92.7%, P=0.270) and did not differ significantly.

DISCUSSION

A comparison of the periods before and after implementation of the QI project revealed a significant reduction in delivery room intubation, a significant increase in noninvasive surfactant administration, and a significant decrease in the duration of invasive mechanical ventilation. This QI initiative demonstrated the feasibility and benefits of a structured multidisciplinary approach to reducing the need for invasive ventilation in preterm infants.

Numerous randomized controlled trials have been conducted to reduce the incidence of BPD. A multipronged strategy comprising continuous positive airway pressure (CPAP) in the delivery room, early selective surfactant administration using less invasive techniques, prophylactic early hydrocortisone for high-risk infants, inhaled corticosteroids, and volume-targeted ventilation for those requiring invasive respiratory support has been shown to reduce the combined risk of BPD or death by 36 weeks postmenstrual age [13]. In addition, prolonged duration of invasive mechanical ventilation is strongly associated with an increased risk of BPD [14]. Based on these findings, many QI initiatives have been implemented to reduce the incidence of BPD by incorporating these evidence-based interventions into clinical practice [11,15,16] .

Previous studies evaluating the outcomes of QI initiatives have yielded mixed results. Several NICUs have demonstrated reductions in mechanical ventilation use and BPD in relatively small cohorts ranging from 107 to 314 infants [17-19]. Although the specific QI strategies varied, common elements included the use of multidisciplinary teams, the promotion of early CPAP over mechanical ventilation, standardized intubation and extubation criteria, and regular debriefings and feedback throughout the QI implementation process [19,20]. In contrast, studies reported reduced rates of delivery room intubation following the introduction of delivery room care bundles, but without significant changes in BPD incidence rates or, in certain cases, without reductions in either mechanical ventilation or BPD [21-23].

QI interventions should be tailored to each institution, considering available resources such as staffing, time, workload, equipment, and organizational culture. At our center, the incidence of moderate or severe BPD among infants enrolled in the KNN database was 45% to 50%, which was higher than the median KNN of approximately 25% to 30%. Therefore, the QI initiative was designed to address the high incidence of BPD. BPD is a multifactorial disease influenced by various prenatal and postnatal factors [3,24]. Effective prevention requires a comprehensive approach, including thorough infection control, maintaining cardiovascular stability, optimal nutrition, and lung-protective respiratory strategies [13,24]. Our QI initiative specifically targeted a critical contributor to BPD, prolonged invasive mechanical ventilation, through a structured threestep approach: (1) optimizing resuscitation in the delivery room to minimize the need for intubation; (2) using alternative surfactant administration techniques, such as MIST/LISA or INSURE; and (3) conducting daily assessments to evaluate extubation readiness in intubated infants.

Following the implementation, the overall incidence of moderate or severe BPD significantly decreased. In multivariate logistic regression analysis, among all QI interventions, only a reduction in the duration of invasive ventilation was significantly associated with a decrease in BPD. These findings underscore the importance of implementing a daily checklist to facilitate early extubation and adopting broader strategies to minimize the duration of invasive ventilation throughout the NICU stay.

Unlike other studies that reported successful reductions in BPD incidence through a similar respiratory strategy bundle care [16], our respiratory intervention alone did not lead to a reduction in BPD incidence among infants born at <29 weeks of gestation. This high-risk subgroup is inherently more vulnerable to various complications, such as sepsis, pulmonary hemorrhage, hypotension or shock, and necrotizing enterocolitis, all of which contribute to the development of BPD. Moreover, variability in center-specific practices may limit the effectiveness of respiratory-focused interventions. Previous studies have shown that a multidisciplinary team approach integrated into comprehensive care bundles can significantly reduce the incidence of BPD in extremely preterm infants [15,16]. In addition to the respiratory strategies, these bundles typically include optimal nutrition, early caffeine therapy, infection prevention, PDA management, careful fluid regulation, vitamin A supplementation, and steroid administration [13]. Therefore, broader and more integrated care bundles should be considered to achieve meaningful improvements in outcomes for this vulnerable population.

Our study has certain limitations, including its relatively short duration and its focus on a limited set of outcomes. Although this project successfully reduced the duration of invasive mechanical ventilation, future efforts should incorporate comprehensive care strategies encompassing infection prevention measures, optimal nutritional strategies, and hemodynamic management. Ongoing evaluation and reinforcement of QI strategies and adaptation based on evolving evidence are essential to sustain these improvements and achieve further reduction in BPD, especially among the most vulnerable, extremely premature infants.

In conclusion, this QI initiative demonstrated the feasibility and impact of a structured multidisciplinary approach targeting invasive ventilation practices in preterm infants. Although significant reductions in invasive ventilation duration and overall BPD incidence have been achieved, additional strategies are needed to address the persistent risk among extremely preterm infants. Future QI efforts should incorporate broader integrated care bundles to further improve the respiratory and overall outcomes in this high-risk population.

ARTICLE INFORMATION

Ethical statement

The use of data from the Korean Neonatal Network registry was approved by the Institutional Review Board (IRB No. B-1305-202-005), and written informed consent was obtained from parents or legal guardians.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

Conception or design: E.B., C.W.C., Y.H.J.

Acquisition, analysis, or interpretation of data: E.B., C.W.C., Y.H.J.

Drafting the work or revising: E.B., S.K., M.J.K., H.J.Y., C.W.C., Y.H.J.

Final approval of the manuscript: All authors read and approved the final manuscript.

Funding

This research was supported by the National Institute of Health (NIH) research project (2022-ER0603-02#).

Acknowledgments

None

Figure 1.

Driver diagram in minimizing the duration of invasive mechanical ventilation to reduce the incidence of bronchopulmonary dysplasia (BPD). Abbreviations: CPAP, continuous positive airway pressure; PPV, positive pressure ventilation; NRP, neonatal resuscitation program; MIST, minimally invasive surfactant therapy; INSURE, intubation-surfactant-extubation.

Figure 2.

The process of patient selection and the interventions. Abbreviations: GA, gestational age; Bwt, birth weight; DR, delivery room; NICU, neonatal intensive care unit.

Figure 3.

Electronic case report form of daily assessments of extubation readiness for intubated patients.

Figure 4.

Statistical process control chart of average monthly cumulative intubation duration per patient before and after quality improvement (QI) intervention. The arrow indicates the start of the QI intervention in February 2022. Gaps in the chart represent months with no eligible patient birth. The mean intubation duration±standard deviation is presented annually since 2019.

Table 1.

Comparison of Patient Characteristics and Outcomes before and after Quality Improvement Implementation

Characteristic	Pre-QI period (January 2019–December 2021) (n=186)	Post-QI period (February 2022–June 2024) (n=172)	P-value
Gestational age (d)	29.5±2.8	29.9±2.7	0.203
Birth weight (g)	1,068.3±292.5	1,201.8±324.8	<0.001
Male sex	86 (45.7)	87 (50.3)	0.401
1-min Apgar score	5.04±1.92	5.15±1.76	0.560
5-min Apgar score	7.63±1.36	7.64±1.30	0.954
Intubation in DR	56 (29.7)	24 (13.8)	<0.001
MIST/LISA or INSURE	41 (40.6)	56 (69.1)	<0.001
MIST/LISA	36	16
INSURE	6	40
Cesarean section	148 (78.7)	145 (83.8)	0.228
Prenatal factors
IVF	46 (24.5)	68 (39.3)	0.003
Maternal DM	23 (12.2)	27 (15.7)	0.363
Pregnancy induced hypertension	80 (42.6)	63 (36.4)	0.238
PPROM	28 (14.9)	33 (19.1)	0.326
Histologic chorioamnionitis	55 (32.2)	23 (13.5)	<0.001
ACS administration	86 (47.5)	62 (37.1)	0.052
In hospital outcomes
RDS	103 (54.8)	83 (48.0)	0.207
PDA treatment	34 (18.1)	31 (17.9)	1.000
Culture proven sepsis	43 (22.9)	35 (20.2)	0.609
NEC ≥ stage II	3 (1.6)	8 (4.6)	0.127
Systemic steroid use	40 (21.4)	16 (9.3)	<0.002
Discharge with home oxygen	46 (24.6)	28 (16.0)	<0.001
Duration of intubation (d)	17.1±31.8	7.2±15.0	<0.001
Moderate or severe BPD	107 (57.5)	79 (45.9)	0.045
No. of death	27	26

Values are expressed as mean±standard deviation or number (%).

Abbreviations: OI, quality improvement; DR, delivery room; MIST, minimally invasive surfactant therapy; LISA, less invasive surfactant administration; INSURE, intubation-surfactant-extubation; IVF, in vitro fertilization; DM, diabetes mellitus; PPROM, premature rupture of membrane; ACS, antenatal corticosteroid; RDS, respiratory distress syndrome; PDA, patent ductus arteriosus; NEC, necrotizing enterocolitis; BPD, bronchopulmonary dysplasia.

Table 2.

Comparison of Patient Characteristics and Outcomes before and after Quality Improvement Implementation in Preterm Infants <29 Weeks of Gestation

Characteristic	Pre-QI period (January 2019–December 2021) (n=75)	Post-QI period (February 2022–June 2024) (n=56)	P-value
Gestational age (d)	26.7±1.5	26.6±1.6	0.606
Birth weight (g)	857.4±261.1	875.6±226.8	0.678
Male sex	36 (47.4)	26 (47.3)	1.00
1-min Apgar score	4.14±1.72	3.96±1.58	0.539
5-min Apgar score	7.03±1.41	6.76±1.14	0.258
Intubation in DR	42 (57.5)	18 (31.6)	<0.001
MIST/LISA or INSURE	23 (34.8)	25 (56.8)	0.031
MIST/LISA	21	8
INSURE	2	17
Cesarean section	51 (67.1)	41 (74.5)	0.440
Prenatal factors
IVF	18 (23.7)	22 (40.0)	0.055
Maternal DM	4 (5.3)	5 (9.1)	0.491
Pregnancy induced hypertension	26 (34.2)	17 (30.9)	0.711
PPROM	17 (22.4)	14 (25.5)	0.683
Histologic chorioamnionitis	34 (50.0)	12 (21.8)	0.001
ACS administration	34 (45.3)	15 (28.8)	0.067
In hospital outcomes
RDS	67 (88.2)	45 (81.8)	0.326
PDA treatment	27 (35.5)	24 (43.6)	0.369
Culture proven sepsis	31 (40.8)	29 (52.7)	0.214
NEC ≥ stage II	2 (2.6)	5 (9.1)	0.130
Systemic steroid use	35 (46.7)	16 (29.6)	0.068
Discharge with home oxygen	32 (42.7)	11 (20.4)	0.009
Duration of intubation (d)	33.8±34.1	20.2±20.7	0.010
Moderate or severe BPD	65 (85.5)	51 (92.7)	0.270

Values are expressed as mean±standard deviation or number (%).

Abbreviations: OI, quality improvement; DR, delivery room; MIST, minimally invasive surfactant therapy; LISA, less invasive surfactant administration; INSURE, intubation-surfactant-extubation; IVF, in vitro fertilization; DM, diabetes mellitus; PPROM, premature rupture of membranes; ACS, antenatal corticosteroid; RDS, respiratory distress syndrome; PDA, patent ductus arteriosus; NEC, necrotizing enterocolitis; BPD, bronchopulmonary dysplasia.

Table 3.

Multivariate Analysis of Moderate or Severe Bronchopulmonary Dysplasia

Factor	Odds ratio	95% CI	P-value
Birth weight	0.997	0.995–0.999	0.001
Chorioamnionitis	0.881	0.294–2.639	0.821
QI implementation^*	0.853	0.335–2.173	0.739
Intubation in delivery room	1.014	0.404–2.546	0.976
Non-invasive surfactant administration	0.687	0.254–1.854	0.458
Invasive ventilation duration	1.092	1.021–1.167	0.010

^* Adjusted for QI period (pre-QI period=0, post-QI period=1)

Abbreviations: CI, confidence interval; QI, quality improvement.

REFERENCES

1. Walsh MC, Szefler S, Davis J, Allen M, Van Marter L, Abman S, et al. Summary proceedings from the bronchopulmonary dysplasia group. Pediatrics 2006;117:S52–6.

2. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001;163:1723–9.

3. Thebaud B, Goss KN, Laughon M, Whitsett JA, Abman SH, Steinhorn RH, et al. Bronchopulmonary dysplasia. Nat Rev Dis Primers 2019;5:78.

4. Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, et al. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022;46:151638.

5. Nakashima T, Inoue H, Sakemi Y, Ochiai M, Yamashita H, Ohga S. Trends in bronchopulmonary dysplasia among extremely preterm infants in Japan, 2003-2016. J Pediatr 2021;230:119–25.

6. Jeon GW, Oh M, Chang YS. Increased bronchopulmonary dysplasia along with decreased mortality in extremely preterm infants. Sci Rep 2025;15:8720.

7. Moya FR, Mazela J, Shore PM, Simonson SG, Segal R, Simmons PD, et al. Prospective observational study of early respiratory management in preterm neonates less than 35 weeks of gestation. BMC Pediatr 2019;19:147.

8. Jensen EA, Dysart K, Gantz MG, McDonald S, Bamat NA, Keszler M, et al. The diagnosis of bronchopulmonary dysplasia in very preterm infants. an evidence-based approach. Am J Respir Crit Care Med 2019;200:751–9.

9. Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG, Laptook AR, et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010;362:1970–9.

10. Xu YP, Shi LP, Du LZ. Continuing interventions in a quality improvement bundle to reduce bronchopulmonary dysplasia. World J Pediatr 2022;18:278–82.

11. Bapat R, Nelin L, Shepherd E, Ryshen G, Elgin A, Bartman T. A multidisciplinary quality improvement effort to reduce bronchopulmonary dysplasia incidence. J Perinatol 2020;40:681–7.

12. Chang YS, Park HY, Park WS. The Korean neonatal network: an overview. J Korean Med Sci 2015;30 Suppl 1:S3–11.

13. Gilfillan MA, Mejia MJ, Bhandari V. Prevalence, prevention and management of bronchopulmonary dysplasia. Res Reports Neonatol 2024;14:1–33.

14. Yang Y, Gu XY, Lin ZL, Pan SL, Sun JH, Cao Y, et al. Effect of different courses and durations of invasive mechanical ventilation on respiratory outcomes in very low birth weight infants. Sci Rep 2023;13:18991.

15. White H, Merritt K, Martin K, Lauer E, Rhein L. Respiratory support strategies in the prevention of bronchopulmonary dysplasia: a single center quality improvement initiative. Front Pediatr 2022;10:1012655.

16. Villosis MF, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of bronchopulmonary dysplasia following implementation of a novel prevention bundle. JAMA Netw Open 2021;4:e2114140.

17. Birenbaum HJ, Dentry A, Cirelli J, Helou S, Pane MA, Starr K, et al. Reduction in the incidence of chronic lung disease in very low birth weight infants: results of a quality improvement process in a tertiary level neonatal intensive care unit. Pediatrics 2009;123:44–50.

18. Kakkilaya V, Jubran I, Mashruwala V, Ramon E, Simcik VN, Marshall M, et al. Quality improvement project to decrease delivery room intubations in preterm infants. Pediatrics 2019;143:e20180201.

19. Kubicka Z, Zahr E, Rousseau T, Feldman HA, Fiascone J. Quality improvement to reduce chronic lung disease rates in very-low birth weight infants: high compliance with a respiratory care bundle in a small NICU. J Perinatol 2018;38:285–92.

20. Dylag AM, Tulloch J, Paul KE, Meyers JM. A Quality improvement initiative to reduce bronchopulmonary dysplasia in a level 4 NICU-golden hour management of respiratory distress syndrome in preterm newborns. Children (Basel) 2021;8:301.

21. Gagliardi L, Bellu R, Lista G, Zanini R. Do differences in delivery room intubation explain different rates of bronchopulmonary dysplasia between hospitals? Arch Dis Child Fetal Neonatal Ed 2011;96:F30–5.

22. Biniwale M, Wertheimer F. Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants. Resuscitation 2017;116:33–8.

23. Lo SC, Bhatia R, Roberts CT. Introduction of a quality improvement bundle is associated with reduced exposure to mechanical ventilation in very preterm infants. Neonatology 2021;118:578–85.

24. Higgins RD, Jobe AH, Koso-Thomas M, Bancalari E, Viscardi RM, Hartert TV, et al. Bronchopulmonary dysplasia: executive summary of a workshop. J Pediatr 2018;197:300–8.

Appendices

Appendix 1. Three Key Clinical Questions

Question 1: Is intubation necessary for preterm infants in the delivery room?

Answer:

Intubation is not necessary for all preterm infants at birth. The need can often be minimized by applying appropriate resuscitation techniques. Less invasive methods, such as continuous positive airway pressure (CPAP) or positive pressure ventilation (PPV) with a mask, can effectively support spontaneous breathing without requiring intubation [1,2]. However, intubation remains necessary in patients with severe respiratory distress syndrome or apnea who are unresponsive to noninvasive methods.

To support decision-making, a checklist was developed for delivery room personnel.

1) Intubation due to perinatal risk factors, e.g., perinatal distress, fetal hydrops, and maternal general anesthesia

2) Congenital anomalies: airway anomalies requiring secure airway access, congenital diaphragmatic hernia

3) Failure to achieve effective PPV: inability to observe the chest rise

4) No improvement despite effective PPV after 30 seconds with confirmed chest movement and MRSOPA steps (mask adjustment, reposition airway, suction, open mouth, pressure increase, and alternative airway)

5) Other reasons, e.g., equipment malfunction and transport concerns

A debrief and checklist review were encouraged after each resuscitation to promote process improvement and reduce unnecessary intubation.

Question 2: Is intubation necessary for preterm infants for surfactant administration?

Answer:

Intubation is not always required for surfactant administration in preterm infants. Historically, surfactant was administered via an endotracheal tube, which required intubation. However, newer techniques allow for noninvasive delivery.

1) Less invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST): Surfactant is delivered through a thin catheter while the infant is maintained on CPAP [3].

2) INSURE (Intubation-Surfactant-Extubation): Surfactant is administered via brief intubation, followed by prompt extubation and the transition to noninvasive support [4].

When surfactant is administered after intubation, the following checklist should be reviewed:

1) The infant was already intubated at birth

2) Hemodynamic instability requiring immediate intervention

3) Poor respiratory effort despite adequate noninvasive support

4) Others (to be specified)

Regular debriefing after surfactant administration was introduced to minimize unnecessary intubation and improve technique adherence.

Question 3: Is the patient intubated, and does he or she need to remain intubated today?

Answer:

Continued intubation should be evaluated daily. If a patient no longer shows signs of respiratory failure, such as improved oxygen saturation, acceptable blood gas levels, and reduced breathing effort, extubation should be considered.

To reinforce this practice, a daily extubation assessment protocol was implemented. This assessment required the following steps:

1) Explicit documentation of the indications for ongoing mechanical ventilation

2) Multidisciplinary confirmation of intubation necessity

3) Immediate extubation when clinically appropriate

These protocols were embedded into daily clinical workflows through structured communication plans to ensure consistency, adherence, and sustained improvement. Figure 2 illustrates the patient selection process and the interventions applied.

APPENDIX REFERENCES

1. Thebaud B, Goss KN, Laughon M, Whitsett JA, Abman SH, Steinhorn RH, et al. Bronchopulmonary dysplasia. Nat Rev Dis Primers 2019;5:78.

2. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010;362:1970-9.

3. More K, Sakhuja P, Shah PS. Minimally invasive surfactant administration in preterm infants: a meta-narrative review. JAMA Pediatr 2014;168:901-8.

4. Pareek P, Deshpande S, Suryawanshi P, Sah LK, Chetan C, Maheshwari R, et al. Less invasive surfactant administration (LISA) vs.intubation surfactant extubation (InSurE) in preterm infants with respiratory distress syndrome: a pilot randomized controlled trial. J Trop Pediatr 2021;67:fmab086.