{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T11:56:01Z","timestamp":1762430161979,"version":"build-2065373602"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T00:00:00Z","timestamp":1762387200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In spontaneously breathing preterm infants, less invasive strategies, such as continuous positive airway pressure (CPAP) and less invasive surfactant administration, have been increasingly implemented to reduce lung injury. In 2018, our center initiated a noninvasive neonatal resuscitation protocol incorporating these approaches as quality improvement (QI) initiatives. We aimed to evaluate the feasibility, safety, and effectiveness of this protocol by comparing respiratory outcomes before and after its implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We retrospectively reviewed the medical records of 578 infants born at 25\u2009+\u20090 to 29\u2009+\u20096 weeks of gestation between 2014 and 2022 at Samsung Medical Center. Infants born in 2018 and those with severe congenital anomalies, delivery room deaths, or outborn status were excluded. The study population was divided into Period 1 (2014\u20132017, before noninvasive protocol implementation) and Period 2 (2019\u20132022, after protocol implementation) to assess the impact of QI initiatives on neonatal resuscitation practices. The year 2018 was excluded from the analysis as it represented a transitional period. We analyzed the rate of endotracheal intubation at birth and other respiratory outcomes, such as CPAP failure and bronchopulmonary dysplasia (BPD).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The rate of initial intubation was significantly lower in Period 2 than in Period 1 [77.0% vs. 45.9%; adjusted odds ratio (aOR), 0.24; 95% confidence interval (CI), 0.15\u20130.40;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.001], with declines observed across all gestational groups, particularly among infants \u226526 weeks\u2019 gestation. The rate of postnatal steroid use for BPD prevention was also significantly lower in Period 2 (50.0% vs. 15.3%, aOR, 0.12; 95% CI, 0.07\u20130.21;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.001). In Period 2, among 68 infants initially managed with CPAP during Period 2, 15 (22.1%) experienced CPAP failure within 48\u2005h, and 24 (35.3%) experienced failure at any time during hospitalization. Despite these failures, no significant differences in the incidence of BPD, duration of invasive ventilation, or mortality were observed between the two periods.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our findings suggest that even in extremely preterm infants, a noninvasive resuscitation strategy is feasible, associated with reduced postnatal steroid use, and does not worsen major neonatal outcomes, supporting its use as a viable alternative for those who do not require immediate intubation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fped.2025.1697565","type":"journal-article","created":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T11:48:03Z","timestamp":1762429683000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Increasing continuous positive airway pressure use rates in the delivery room for very preterm infants: a quality improvement initiative"],"prefix":"10.3389","volume":"13","author":[{"given":"Hanna","family":"Kim","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Na Hyun","family":"Lee","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hyeseon","family":"Kim","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Seung Hyun","family":"Kim","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Soo Jeong","family":"Choo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Misun","family":"Yang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"So Yoon","family":"Ahn","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Se In","family":"Sung","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yun Sil","family":"Chang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,11,6]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"e20153985","DOI":"10.1542\/peds.2015-3985","article-title":"Incidence and outcome of CPAP failure in preterm infants","volume":"138","author":"Dargaville","year":"2016","journal-title":"Pediatrics"},{"key":"B2","doi-asserted-by":"publisher","first-page":"F655","DOI":"10.1136\/archdischild-2018-316557","article-title":"Less invasive surfactant administration (LISA): chances and limitations","volume":"104","author":"Herting","year":"2019","journal-title":"Arch Dis Child Fetal Neonatal Ed"},{"key":"B3","doi-asserted-by":"publisher","first-page":"F17","DOI":"10.1136\/archdischild-2015-310299","article-title":"Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis","volume":"102","author":"Aldana-Aguirre","year":"2017","journal-title":"Arch Dis Child Fetal Neonatal Ed"},{"key":"B4","doi-asserted-by":"publisher","first-page":"252","DOI":"10.1159\/000346521","article-title":"Less invasive surfactant administration in extremely preterm infants: impact on mortality and morbidity","volume":"103","author":"Klebermass-Schrehof","year":"2013","journal-title":"Neonatology"},{"key":"B5","doi-asserted-by":"publisher","first-page":"225","DOI":"10.1097\/ANC.0000000000000194","article-title":"7th edition NRP brings big changes for NRP instructors: the American academy of pediatrics","volume":"15","year":"2015","journal-title":"Adv Neonatal Care"},{"key":"B6","doi-asserted-by":"publisher","first-page":"e0262446","DOI":"10.1371\/journal.pone.0262446","article-title":"Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria","volume":"17","author":"Usman","year":"2022","journal-title":"PLoS One"},{"key":"B7","doi-asserted-by":"publisher","first-page":"S21","DOI":"10.1038\/jp.2016.29","article-title":"Efficacy and safety of CPAP in low- and middle-income countries","volume":"36","author":"Thukral","year":"2016","journal-title":"J Perinatol"},{"key":"B8","doi-asserted-by":"publisher","first-page":"20959","DOI":"10.1038\/s41598-024-69680-1","article-title":"Neonatologist staffing is related to the inter-hospital variation of risk-adjusted mortality of very low birth weight infants in Korea","volume":"14","author":"Lee","year":"2024","journal-title":"Sci Rep"},{"key":"B9","article-title":"Statistics on Very Low Birth Weight Infants Seoul: Korean Neonatal Network","year":"2022"},{"key":"B10","doi-asserted-by":"publisher","first-page":"751","DOI":"10.1164\/rccm.201812-2348OC","article-title":"The diagnosis of bronchopulmonary dysplasia in very preterm infants. An evidence-based approach","volume":"200","author":"Jensen","year":"2019","journal-title":"Am J Respir Crit Care Med"},{"key":"B11","doi-asserted-by":"publisher","first-page":"741","DOI":"10.1016\/j.jpeds.2008.08.016","article-title":"Reducing lung injury during neonatal resuscitation of preterm infants","volume":"153","author":"Schm\u00f6lzer","year":"2008","journal-title":"J Pediatr"},{"key":"B12","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1111\/j.1651-2227.1986.tb10197.x","article-title":"The functional residual capacity of infants with respiratory distress syndrome","volume":"75","author":"Richardson","year":"1986","journal-title":"Acta Paediatr Scand"},{"key":"B13","doi-asserted-by":"publisher","first-page":"322","DOI":"10.1542\/peds.2007-0114","article-title":"A randomized, controlled trial of delivery-room respiratory management in very preterm infants","volume":"120","author":"te Pas","year":"2007","journal-title":"Pediatrics"},{"key":"B14","doi-asserted-by":"publisher","first-page":"1970","DOI":"10.1056\/NEJMoa0911783","article-title":"Early CPAP versus surfactant in extremely preterm infants","volume":"362","author":"Finer","year":"2010","journal-title":"N Engl J Med"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1660","DOI":"10.1542\/peds.2004-2493","article-title":"Is it safer to intubate premature infants in the delivery room?","volume":"115","author":"Aly","year":"2005","journal-title":"Pediatrics"},{"key":"B16","doi-asserted-by":"publisher","first-page":"f5980","DOI":"10.1136\/bmj.f5980","article-title":"Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis","volume":"347","author":"Schm\u00f6lzer","year":"2013","journal-title":"Br Med J"},{"key":"B17","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1038\/jp.2016.237","article-title":"Effects of delivery room quality improvement on premature infant outcomes","volume":"37","author":"Lapcharoensap","year":"2017","journal-title":"J Perinatol"},{"key":"B18","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1016\/j.siny.2018.04.001","article-title":"Effective ventilation: the most critical intervention for successful delivery room resuscitation","volume":"23","author":"Foglia","year":"2018","journal-title":"Semin Fetal Neonatal Med"},{"key":"B19","doi-asserted-by":"publisher","first-page":"F398","DOI":"10.1136\/adc.2009.182162","article-title":"Leak and obstruction with mask ventilation during simulated neonatal resuscitation","volume":"95","author":"Schilleman","year":"2010","journal-title":"Arch Dis Child Fetal Neonatal Ed"},{"key":"B20","doi-asserted-by":"publisher","first-page":"F295","DOI":"10.1136\/adc.2009.165878","article-title":"Respiratory monitoring of neonatal resuscitation","volume":"95","author":"Schm\u00f6lzer","year":"2010","journal-title":"Arch Dis Child Fetal Neonatal Ed"},{"key":"B21","doi-asserted-by":"publisher","first-page":"961","DOI":"10.1542\/peds.103.5.961","article-title":"Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation?","volume":"103","author":"Lindner","year":"1999","journal-title":"Pediatrics"},{"key":"B22","doi-asserted-by":"publisher","first-page":"700","DOI":"10.1056\/NEJMoa072788","article-title":"Nasal CPAP or intubation at birth for very preterm infants","volume":"358","author":"Morley","year":"2008","journal-title":"N Engl J Med"},{"key":"B23","doi-asserted-by":"publisher","first-page":"e2229105","DOI":"10.1001\/jamanetworkopen.2022.29105","article-title":"Hospital and neurodevelopmental outcomes in nano-preterm infants receiving invasive vs noninvasive ventilation at birth","volume":"5","author":"Shukla","year":"2022","journal-title":"JAMA Netw Open"},{"key":"B24","doi-asserted-by":"publisher","first-page":"3879","DOI":"10.1002\/ppul.25678","article-title":"Early nasal continuous positive airway pressure failure prediction in preterm infants less than 32 weeks gestational age suffering from respiratory distress syndrome","volume":"56","author":"Dell'Orto","year":"2021","journal-title":"Pediatr Pulmonol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1136\/adc.68.3_Spec_No.330","article-title":"The effectiveness and side effects of dexamethasone in preterm infants with bronchopulmonary dysplasia","volume":"68","author":"Ng","year":"1993","journal-title":"Arch Dis Child"},{"key":"B26","doi-asserted-by":"publisher","first-page":"e221947","DOI":"10.1001\/jamanetworkopen.2022.1947","article-title":"Dexamethasone, prednisolone, and methylprednisolone use and 2-year neurodevelopmental outcomes in extremely preterm infants","volume":"5","author":"Puia-Dumitrescu","year":"2022","journal-title":"JAMA Netw Open"}],"container-title":["Frontiers in Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2025.1697565\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T11:48:03Z","timestamp":1762429683000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2025.1697565\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,6]]},"references-count":26,"alternative-id":["10.3389\/fped.2025.1697565"],"URL":"https:\/\/doi.org\/10.3389\/fped.2025.1697565","relation":{},"ISSN":["2296-2360"],"issn-type":[{"value":"2296-2360","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,6]]},"article-number":"1697565"}}