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Specialist neonatal respiratory care for babies born preterm

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Quality statement 1: Respiratory support soon after birth

Quality statement

Preterm babies having respiratory support soon after birth and before admission to the neonatal unit, are given continuous positive airways pressure (CPAP) rather than invasive ventilation if clinically appropriate.

Rationale

Using CPAP, when clinically appropriate, to stabilise preterm babies reduces the use of unnecessary invasive ventilation. Using CPAP instead for preterm babies can reduce mortality before discharge and the incidence of bronchopulmonary dysplasia (BPD) in babies under 36 weeks.

Quality measures

Structure

a) Evidence of local arrangements and written clinical protocols to ensure that preterm babies having respiratory support soon after birth and before admission to the neonatal unit, are given CPAP where clinically appropriate.

Data source: Local data collection, for example, audits of stabilisation protocols.

b) Evidence of the availability of training in the use of neonatal CPAP.

Data source: Local data collection, for example, provision of training courses in neonatal CPAP.

Process

Proportion of preterm babies who had respiratory support before admission to the neonatal unit, who were given CPAP where clinically appropriate.

Numerator – the number in the denominator who were given CPAP where clinically appropriate.

Denominator – the number of preterm babies who had respiratory support before admission to the neonatal unit.

Data source: Local data collection, for example, local audit of patient records.

Outcome

Proportion of babies with BPD at 36 weeks' postmenstrual age.

Numerator – the number in the denominator with BPD.

Denominator – the number of babies at 36 weeks' postmenstrual age.

Data source: Local data collection, for example, audits of patient records. The National Neonatal Audit Programme (NNAP) measures the number of babies with BPD.

What the quality statement means for different audiences

Service providers (such as maternity and delivery units, and neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that systems are in place for preterm babies to be given CPAP, when it is clinically appropriate, if they need respiratory support soon after birth. They ensure that healthcare professionals are trained to provide CPAP and identify when invasive ventilation is clinically necessary.

Healthcare professionals (such as midwives, specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) ensure that they use CPAP for preterm babies who need respiratory support soon after birth, if clinically appropriate. They are trained to administer CPAP and to identify when invasive ventilation is clinically needed and provide this if necessary.

Commissioners (such as clinical commissioning groups and NHS England) ensure that the services they commission use CPAP for preterm babies who need respiratory support soon after birth, if clinically appropriate.

Preterm babies who need help with their breathing soon after birth are given continuous positive airways pressure if it is suitable for them. This is when air is given through a mask or through tubes into the nose to support breathing. It is preferable to using a ventilator which has a higher risk of other problems.

Source guidance

Specialist neonatal respiratory care in babies born preterm (2019) NICE guideline NG124, recommendation 1.2.1

Definitions of terms used in this quality statement

Bronchopulmonary dysplasia (BPD)

The most frequent adverse outcome for babies born at less than 30 weeks' gestation and the most common chronic lung disease in infancy. BPD is responsible for prolonged hospitalisation and readmissions after discharge, and can have a significant impact on quality of life for both the child and family. BPD is associated with significant healthcare costs. [NICE's guideline on specialist neonatal respiratory care for babies born preterm, evidence review A: diagnosing respiratory disorders]

Clinically appropriate

It would not, or is unlikely to, be clinically appropriate to use CPAP in the following circumstances:

  • for babies who are not breathing and need invasive ventilation

  • for preterm babies born very early, for example at less than 25 weeks' gestation, for whom invasive ventilation may be more appropriate.

Clinical judgement should be used to decide whether invasive ventilation with surfactant is more appropriate in the delivery room for babies born very early. Very early preterm babies may not have the necessary respiratory drive for CPAP to be effective, and the failure rate of non-invasive ventilation is high for these babies.

[NICE's guideline on specialist neonatal respiratory care for babies born preterm, rationale and impact information for recommendation 1.2.1]