Nasal Intermittent Positive Pressure Ventilation: Guideline Implementation Guided by Practice Preference Measurement.

Abstract

Introduction: Extremely preterm infants face a high risk of bronchopulmonary dysplasia from prolonged mechanical ventilation. Early extubation to noninvasive respiratory support may reduce lung injury. Evidence suggests that nasal intermittent positive pressure ventilation (nasal IPPV) lowers reintubation compared with continuous positive airway pressure. Understanding neonatal intensive care unit providers' practice preference, an aspect of unit culture, can facilitate adoption of practice change. This quality improvement initiative aimed to reduce rates of reintubation within 7 and 10 days of first extubation among intubated infants born before 28 weeks' gestational age within 1 year of implementing the practice change and to assess changes in unit culture following guideline implementation.

Methods: A guideline recommending extubation to nasal IPPV for infants born before 28 weeks' gestational age and/or 1250 g or less at birth was developed following measurement of staff practice preferences using the Neonatology Survey of Interdisciplinary Groups in Healthcare (NSIGHT) and internal data review, implemented in a level III neonatal intensive care unit in 2023. Data from January 2020-September 2025 were analyzed using statistical process control charts. The validated NSIGHT was repeated in August 2025 and compared with preimplementation results.

Results: Over 5.5 years, 200 eligible infants were extubated. Reintubation rates within 7 days changed (from 39% in 2020 to 13% in 2025; P = 0.058). Rare-events analysis demonstrated special cause variation in 2025, with an increasing number of extubations between reintubation events. A significant shift was detected in the extubation rate to nasal IPPV from 32% to 83%. The 2025 NSIGHT results showed a net unit preference for nasal IPPV after extubation (P < 0.001).

Conclusions: A practice guideline, informed by NSIGHT results and internal data, was implemented to promote extubation of extremely preterm infants to nasal IPPV. Changes were achieved in clinical practice, reintubation rates, and unit culture.