An Evaluation of Bubble-CPAP in a Neonatal Unit in a Developing Country: Effective Respiratory Support That Can Be Applied By Nurses

Abstract

To describe the implementation of bubble-CPAP in a referral hospital in a developing country and to investigate: the feasibility of nurses implementing bubble-CPAP and the impact of bubble-CPAP on need for mechanical ventilation and mortality. Retrospective evaluation of prospectively collected data from two time periods: 18 months before and 18 months after the introduction of bubble-CPAP. The introduction of bubble-CPAP was associated with a 50 per cent reduction in the need for mechanical ventilation; from 113 of 1,106 (10.2 per cent) prior to bubble-CPAP to 70 of 1,382 (5.1%) after introduction of CPAP (chi2, p<0.001). In the 18 months prior to bubble-CPAP there were 79 deaths (case fatality of 7.1 per cent). In the 18 months after bubble-CPAP there were 74 deaths (CF 5.4 per cent), relative risk: 0.75 (0.55-1.02, chi2, p=0.065). Nurses could safely apply bubble-CPAP after 1-2 months of on-the-job training. Equipment for Bubble-CPAP cost 15 per cent of the cost of the cheapest mechanical ventilator. The introduction of bubble-CPAP substantially reduced the need for mechanical ventilation, with no difference in mortality. In models of neonatal care for resource-limited countries, bubble-CPAP may be the first type of ventilatory support that is recommended. Its low cost and safety when administered by nurses makes it ideal for this purpose. Bubble-CPAP has the potential for being available at even lower cost than the current commercially available bubble systems used in this study.

Implementation of Bubble CPAP in a Rural Ugandan Neonatal ICU

“…18 The use of CPAP is effective for the treatment of respiratory failure in high-income countries, [5][6][7] but there are few reports of the use of CPAP in low-income settings. [10][11][12]19 Bubble CPAP is an attractive device for treating neonates with respiratory distress due to its simple design, low cost, and potential to improve survival rates in settings lacking mechanical ventilation. However, in an effort to provide bubble CPAP to neonates with respiratory distress in low-income and middle-income countries, health-care providers may use untested homemade devices despite uncertainty about the devices' ability to deliver CPAP reliably.…”

“…[10][11][12]21 In a study from South Africa, Pieper et al 21 reported the use of nasal CPAP in 11 extremely lowbirthweight infants with respiratory distress following birth compared with 10 control infants. Infants treated with nasal CPAP had a mean birthweight of 915 g and a mean gestational age of 28.6 weeks.…”

“…An example of this simple noninvasive ventilation method is bubble CPAP, which has been safely and effectively used in low-income and middle-income countries to improve survival in infants with many forms of neonatal respiratory distress. [10][11][12] CPAP applied to immature lungs helps to increase functional residual capacity, improve chest wall stability, and decrease work of breathing, thereby reducing the need for mechanical ventilation and surfactant administration. 13 In high-income settings, deciding which patients will benefit from CPAP is often based on clinical exam, breathing frequency, S pO 2 , blood gas measurements, and chest radiograph.…”

Predictors of mortality and morbidity in extremely low birth weight neonates

“…intraventicular hemorrhage, asphyxia) might be influenced by this long interval to intensive care via cold stress and delay in establishing adequate respiratory support. Alternatively, programs to train local personnel in basics of resuscitation, provision of warmth, and simple mechanisms to provide CPAP support to preterm infants in respiratory distress would be reasonable local goals [4,5]. Lastly, the incidence of sepsis was very high in this cohort.…”

Bubble CPAP: Not All Bubbling Is Good Bubbling

“…The simplicity of this system makes it attractive to many centers, especially resource-limited neonatal units in developing countries. 2 Bubble CPAP also differs from ventilator-derived CPAP mechanistically. The mean pressure applied to the infant's airway in bubble CPAP is not constant, as it is in ventilator-derived systems, but, rather, resonant, with the airway pressure actually fluctuating approximately 4 cm H 2 O around the mean.…”