G494(P) The use of bubble continuous positive airway pressure (bCPAP) for critically ill children in Lilongwe, Malawi

Abstract

In low resource-countries, the mortality of critically-ill children remains high. Severe pneumonia remains one of the leading causes of death. Malaria and intercurrent bacteraemia adversly affects survival in this setting. Low cost bubble continuous positive airway pressure (bCPAP) set-ups are used in some reference centres in sub-Saharan Africa. More evidence for use beyond the neonatal period is needed. We evaluated the role of bCPAP for the care of critically-ill children in Lilongwe, Malawi.This observational study was conducted between 26 February-15 April 2014, in a busy, urban paediatric unit with >20,000 admissions/year (in-hospital mortality ~ 3%). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. The inclusion criteria was a convenience sample of non-neonates initiated on bCPAP at the discretion of a clinician. BCPAP failure was defined as; death during bCPAP treatment, within 48 h of bCPAP weaning, or escalation to intubation. Ethical approval was from the Malawi National Health-Sciences Research-Committee.116 children with symptoms of WHO defined very severe pneumonia (VSPNA) were included. Median age: 8 months. Median duration of bCPAP treatment: 2.5 days. Malaria rapid-tests were positive in 36 (31%) cases. 34 (29%) had severe anaemia (Hb <7.0 g/dL). 58 (50%) children had > 1 organ-failure (MOF). 23 (20%) children were HIV-positive/exposed. 24 (21%) were malnourished. The over-all survival was 74/116 (64%). 33/34 (97%) with signs of uncomplicated VSPNA survived and HIV infection/exposure did appear to affect survival in this group. Treatment failure rates rose with the presence of respiratory depression, MOF or signs of shock (delayed capillary refill time etc.)The higher survival rates among children with uncomplicated VSPNA indicates that bCPAP could be used in resource-limited, malaria-endemic settings with a high HIV prevalence. This is important to explore, as Malawi has been reported as doing well to reduce under 5 mortality. This success has been attributed to following and implementing new evidence based interventions and policies. The time may have come when critical care skills and technologies from developed settings can be used to benefit those suffering the inordinate burden of disease in the developing world.

Continuous Positive Airway Pressure (CPAP) for severe pneumonia in low- and middle-income countries: A systematic review of contextual factors

“…Four observational studies enrolled children with respiratory failure (failing standard oxygen therapy), mostly related to severe pneumonia. Mortality ranged from 33% to 55% (urban Papua New Guinea and Malawi) [ 46 , 47 , 50 ], except for one Indian study involving children with influenza-like illness during the swine flu epidemic (zero mortality) [ 44 ]. These studies reported improved respiratory signs and did not include a comparison group.…”

“…Across all these studies, older children (especially >12 months), children with HIV, severe acute malnutrition, multi-organ failure, or other comorbidities generally fared worse on CPAP that those without [ 39 , 46 , 50 ]. Early response to CPAP (specifically correction of hypoxaemia) was a strong predictor of survival [ 47 ].…”

“…Of 19 studies providing original clinical data, only 3 observational studies from urban hospitals in Africa reported nurse to patient ratios (range = 1:2 to 1:40) ( Table 1 ) [ 46 , 47 , 50 ]. Similarly, few studies reported doctor supervision, generally involving a mid-level doctor or medical officer available onsite during the day and on-call overnight with at least daily senior medical ward round [ 39 , 46 , 47 , 50 ]. The notable exception was one trial in rural Malawi that was nurse-led (doctor available by phone for advice only) and was stopped early due to excess mortality in the CPAP arm [ 36 ].…”

“…Studies typically required nursing review within 1-2 hours of commencing CPAP or changing settings [ 34 - 41 , 43 , 45 , 47 ], then just 2-4 times per day [ 36 , 38 , 39 , 41 , 44 - 47 , 50 ], with only three studies from tertiary hospitals in India and Bangladesh continuing 1-2 hourly observations [ 34 , 40 , 43 ]. Many studies used pulse oximetry [ 33 - 44 , 46 , 47 , 50 ], and sometimes blood gas analysis and/or formal severity scores [ 34 , 35 , 37 , 41 , 43 , 44 , 47 ], to monitor clinical response, but frequency of monitoring was rarely documented.…”

“…Nasogastric or orogastric tubes (NGT/OGT) for gastric decompression and/or feeding were commonly included in study protocols but adherence to this was poorly reported [ 34 , 36 , 37 , 40 , 41 , 46 , 47 , 50 , 54 , 55 ]. In one study although 96% of patients met criteria for NG tube insertion, only 16% received one [ 36 ].…”