Quality standard

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), if clinically appropriate, rather than invasive ventilation.

Rationale

Using CPAP, when clinically appropriate, to stabilise preterm babies reduces the use of unnecessary invasive ventilation. It can also reduce mortality before discharge and the incidence of bronchopulmonary dysplasia (BPD) in babies at 36 weeks postmenstrual age. BPD can result in longer hospital stays and readmission after discharge, and can have a significant impact on quality of life for babies and their families and carers.

Quality measures

Structure

a) Evidence of local arrangements 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 staff training available for neonatal CPAP.

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

Process

a) Proportion of preterm babies born under 28 weeks of pregnancy who had invasive ventilation in the delivery room.

Numerator – the number in the denominator who had invasive ventilation in the delivery room.

Denominator – the number of preterm babies born under 28 weeks of pregnancy.

Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, 'in the delivery room' means 'soon after birth and before admission to the neonatal unit'. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.

b) Proportion of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy who had invasive ventilation in the delivery room.

Numerator – the number in the denominator who had invasive ventilation in the delivery room.

Denominator – the number of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy.

Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, 'in the delivery room' means 'soon after birth and before admission to the neonatal unit'. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.

c) Proportion of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy who had invasive ventilation in the delivery room.

Numerator – the number in the denominator who had invasive ventilation in the delivery room.

Denominator – the number of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy.

Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, 'in the delivery room' means 'soon after birth and before admission to the neonatal unit'. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.

Outcome

Number of preterm babies with BPD.

Data source: The National Neonatal Audit Programme (NNAP) measures the number of eligible babies alive at 36 weeks with sufficient data to attribute BPD outcome.

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 can identify when invasive ventilation is clinically needed.

Healthcare professionals (such as midwives, specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) 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 (known as CPAP) if it is suitable for them. This is when blended air and oxygen 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 leading to a longer stay in hospital and readmission after discharge.

Definitions of terms used in this quality statement

Bronchopulmonary dysplasia (BPD)

A chronic lung disease that develops in preterm babies. [NICE's guideline on specialist neonatal respiratory care for babies born preterm, supplement 1: glossary and abbreviations]

Clinically appropriate

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

  • for babies who are persistently not breathing after initial stabilisation

  • for babies with an unstable heart rate, or whose oxygen saturations are not improving, despite high oxygen levels and standard newborn life support

  • for some extremely preterm babies 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. Some extremely preterm babies may not have the necessary respiratory drive for CPAP to be effective, and the failure rate of non-invasive ventilation is higher for these babies.

[NICE's guideline on specialist neonatal respiratory care for babies born preterm, rationale and impact section for recommendation 1.2.1, evidence review on respiratory support, and expert opinion]

Invasive ventilation

Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator. [NICE's guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section]