# Structured continuous positive airway pressure weaning standardizes discontinuation and reduces instability events

## TL;DR

A structured CPAP-weaning protocol reduced instability events in neonates without extending respiratory support duration.

## Contribution

A seven-stage, pause-based CPAP-weaning protocol was implemented and shown to standardize care and reduce instability events.

## Key findings

- Median bradycardia episodes per day decreased significantly post-implementation.
- Oxygen desaturation events also decreased significantly following protocol adoption.
- Air leak syndromes occurred less frequently after the protocol was implemented.

## Abstract

Continuous positive airway pressure (CPAP) is a cornerstone of neonatal respiratory support, yet weaning practices remain highly variable and largely experience-based. This study evaluated whether implementing a structured, stage-based CPAP-weaning protocol could standardize clinical decision-making and reduce exposure to poorly tolerated CPAP-off periods, using safety-relevant instability markers.

In this single-centre interventional study with a historical control group, all neonates reaching ≥30 + 0 weeks corrected gestational age who received CPAP between March 2022 and February 2024 were included. The intervention introduced a seven-stage, pause-based CPAP-weaning protocol with predefined escalation criteria, bedside “monitor cards,” and electronic documentation. Primary endpoints were daily episodes of oxygen desaturation (SpO₂ < 85%) and bradycardia (heart rate < 100 bpm). Secondary endpoints included stimulation frequency, duration of respiratory support, and adverse events.

A total of 344 neonates were analyzed (169 pre-implementation and 175 post-implementation), representing 2,950 CPAP-weaning days. Following implementation, the median number of bradycardia episodes per day decreased [3 [IQR 1–5] vs. 2 [IQR 1–5]; p = 0.0004], as did oxygen desaturations [34 [IQR 11–76] vs. 30 [IQR 9–67]; p = 0.021]. Stimulation frequency, CPAP duration, and NICU length of stay remained unchanged. Air leak syndromes occurred less frequently after implementation (13% vs. 4%; p = 0.011). Protocol adherence was consistently high throughout the study period.

Implementation of a structured CPAP-weaning protocol was associated with fewer daily instability events without prolonging respiratory support. These findings most likely reflect improved safety and standardization of CPAP discontinuation rather than enhanced intrinsic respiratory stability, supporting the feasibility of protocolized weaning in routine NICU care.