Keep the PEEP: A quality improvement project assessing safety and feasibility of prolonged non-invasive positive end expiratory pressure

IntroductionInfants born less than 32-week gestation are at increased risk of respiratory distress syndrome due to underdeveloped pulmonary alveoli. Despite known respiratory benefits associated with positive end expiratory pressure (PEEP), our staff expressed concern that prolonged exposure to PEEP would contribute to increased risk of pneumothorax and delayed initiation of oral feeding.​ This quality improvement project aimed to standardize PEEP use with a guideline for early initiation, continuation, and subsequent discontinuation in infants born at less than 32-week gestation.MethodsWe developed and implemented a "Keep the PEEP" guideline, which included recommendations for initiation of PEEP at delivery, continuation through 32-week post-menstrual age (PMA), and discontinuation. Data collection occurred between July 2019-July 2021 (pre-intervention) and July 2021-August 2023 (post-intervention). Data analysis included run charts for monthly compliance, and bivariate analysis of pre- and post-intervention data. Interventions included team member education and team engagement through auditing.ResultsWe achieved a median compliance of 100% with PEEP use through 32-week PMA. We found no statistically significant differences in a pre- versus post-intervention comparison of pneumothorax incidence [14 versus 13, <i>p</i> = 0.86], bronchopulmonary dysplasia (BPD) incidence [82 versus 68, <i>p</i> = 0.65], median post-menstrual age at first oral feed [34.1 versus 34.1, <i>p</i> = 0.56], or median length of stay [55 versus 43, <i>p</i> = 0.2].ConclusionsWe successfully implemented a new respiratory guideline to standardize PEEP use in our unit during the study period. Despite initial concerns, the incidence of pneumothorax and the median gestational age at initiation of oral feedings remained unchanged.