Prevention Bundle Decreases Prevalence of Infant Bronchopulmonary Dysplasia

California investigators conducted a quality improvement study on infant patients with bronchopulmonary dysplasia (BPD), a chronic form of lung disease with high rates in California and the nation at large.

Roughly 20% of infant patients in the state of California suffer from BPD, a rate similar to the 28% reported in infants across the United States. In general, approximately 42% of all infants experience BPD in less than 28 weeks’ gestation.

The startling numbers prompted an investigative team, led by Maria Fe B. Villosis, MD, to evaluate 484 infants who were admitted into the neonatal intensive care unit (NICU) in Kaiser Permanente Southern California (KPSC).

Investigators included inborn and outborn NICU admissions with birthweights of 501-1500 grams for the study.

A majority of infant patients were inborn (89.9%); 232 (47.9%) were male, 252 (52.1%) were female, and 61 (12.6%) were Black infants. During the study period, the rates of GA less than 28 weeks and gestational age (GA) less than 26 weeks increased, rates of Black patients decreased, and 476 of 484 mothers (98.3%) received prenatal care.

The team set out to establish a detailed BPD system of care based on the data collected from 2009-2019.

“The limited effect of individual interventions, wide variation in outcomes, and difficulty in propagating individual centers’ success suggest that BPD prevention is a system problem involving many types of management decisions and many individuals,” the team wrote. “The system has a better chance to succeed if the mental model of the care team is shared, if the management decision points are identified, and if execution of these management decisions is more consistent.”

Villosis and colleagues established 4 key drivers for BPD prevention.

1. A shared mental model that prevention of BPD is possible.

2. Prevention vs rescue therapy to support postnatal lung growth and to minimize the inflammatory cascade and oxygen toxicity that lead to BPD.

3. Consistent management across the team to minimize variations in care.

4. Management decision points based on developmental stages of the lung.

A myriad of respiratory and nonrespiratory interventions were established after the 1-year baseline period in 2009. The researchers continued to develop an evolution of care practices.

The implementation of the key practices included daily sign-out rounds and debriefs on the process at weekly neonatology meetings, volume-targeted or high-frequency ventilation modalities for intubated patients, group decisions regarding rescue care involving dexamethasone, postextubation pathway, prophylactic caffeine, vitamin A, and surfactant therapy.

Villosis and colleagues recorded several deaths during their study, and 35 patients were later excluded from the study for the determination of BPD.

Despite this, the investigators collected significant data on BPD management and avoidance during the study.

The date collected showed that their methods for treating infant patients proved effective.

During the final implementation period for the study, the rate of BPD for patients less than 26 weeks was 1 of 39 patients (2.6%), though the decreasing trend was not considered significant as assessed by Cochran-Armitage test.

The team observed a sustained decrease in the metric BPD <33, from 31% at baseline to 1.6%. They attributed the change to the postnatal interventions implemented throughout the 10-year period such as high-frequency ventilation, surfactant therapy, vitamin A, and more.

The investigators recommended systems of care be put in place when caring for infants with BPD in future studies.

“We observed a substantial, sustained decrease in BPD rates in association with the development and implementation of a detailed BPD prevention bundle,” the investigators wrote. “Our success may be associated with a shared mental model of care that BPD is preventable, the details of the system of care, and the consistency of its execution. We believe the bundle of care described in this report is sufficiently detailed to enable researchers to assess whether these outcomes can be replicated at other centers.”

The study, "Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle,” was published online in JAMA Network Open.