Infant CPAP for low-income countries: An experimental comparison of standard bubble CPAP and the Pumani system

Falk, Markus; Donaldsson, Snorri; Drevhammar, Thomas

doi:10.1371/journal.pone.0196683

Cited by 25 publications

(33 citation statements)

References 23 publications

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“…The increased tubing resistance also leads to increased resistance to breathing (figure 3). This is expected and has been shown for other systems that generate CPAP using outflow resistance 29 30…”

Section: Discussionsupporting

confidence: 64%

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

Baldursdottir

Falk

Donaldsson

et al. 2020

Arch Dis Child Fetal Neonatal Ed

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BackgroundThe original bubble continuous positive airway pressure (bCPAP) design has wide-bore tubing and a low-resistance interface. This creates a stable airway pressure that is reflected by the submersion depth of the expiratory tubing. Several systems with alterations to the original bCPAP design are now available. Most of these are aimed for use in low-income and middle-income countries and have not been compared with the original design.ObjectiveWe identified three major alterations to the original bCPAP design: (1) resistance of nasal interface, (2) volume of dead space and (3) diameter of expiratory tubing. Our aim was to study the effect of these alterations on CPAP delivery and work of breathing in a mechanical lung model. Dead space should always be avoided and was not further tested.MethodsThe effect of nasal interface resistance and expiratory tubing diameter was evaluated with simulated breathing in a mechanical lung model without interface leakage. The main outcome was delivered CPAP and imposed work of breathing.ResultsHigh-resistance interfaces and narrow expiratory tubing increased the work of breathing. Additionally, narrow expiratory tubing resulted in higher CPAP levels than indicated by the submersion depth.ConclusionOur study shows the significant effect on CPAP delivery and imposed work of breathing when using high-resistance interfaces and narrow expiratory tubing in bCPAP systems. New systems should include low-resistance interfaces and wide-bore tubing and be compared with the original bCPAP. Referring to all systems that bubble as bCPAP is misleading and potentially hazardous.

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Section: Discussionsupporting

confidence: 64%

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

Baldursdottir

Falk

Donaldsson

et al. 2020

Arch Dis Child Fetal Neonatal Ed

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“…A 2002 Cochrane review showed that CPAP in spontaneously breathing preterm infants with respiratory distress syndrome reduced mortality by 48% [ 5 ]. Bubble CPAP (bCPAP) is one of several methods of CPAP generation that has been in use worldwide for more than 30 years [ 6 ]. It is safer than mechanical ventilation [ 7 ], simple to operate [ 8 ] and the commercial model is about one- tenth the cost of mechanical ventilators [ 9 ].…”

Section: Project Evaluationmentioning

confidence: 99%

“…It is safer than mechanical ventilation [ 7 ], simple to operate [ 8 ] and the commercial model is about one- tenth the cost of mechanical ventilators [ 9 ]. These factors make bCPAP an excellent candidate for use in LMICs [ 6 ].…”

Section: Project Evaluationmentioning

confidence: 99%

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Implementing bubble continuous positive airway pressure (bCPAP) in a lower middle-income country: a Nigerian experience

Aneji

Hartman

Oluyinka³

et al. 2020

Pan Afr Med J

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Bubble CPAP (bCPAP) is used for respiratory distress (RD) in neonates. The leading causes of neonatal mortality can lead to severe RD. Many neonatal deaths are preventable using evidence-based interventions like bCPAP as part of a comprehensive approach. The study aimed to assess the implementation of a multi-center, comprehensive hospital-based bCPAP program in a low-middle-income country using a low-cost bCPAP device. Seven established hospitals in three Nigerian States were selected using purposive sampling. A respiratory support program was developed and implemented using the Pumani® bCPAP. Neonates <28 days old with severe RD, birth weight >1000g and breathing spontaneously, were eligible. The program lasted 22 months. Focus group discussions and in-depth interviews of healthcare workers and hospital administrators were used in program assessment. Content analysis of qualitative data completed. The staff reported that the bCPAP device was easy to use and effective. All staff reported comfort in eligible patient identification, effective set up and bCPAP administration. All study sites experienced varying degrees of electric power interruption and oxygen availability and affordability. Staff training, staffing disruptions, data collection challenges and use of improvised bCPAP contributed to low enrollment. Advocacy, direct program support, and innovation using locally available resources improved enrollment. Professional organization collaboration, competency-based training and peer mentoring contributed to program success. Thorough pre-program assessment, with comprehensive understanding of all aspects of the existing system within the local context which are likely to impact the introduction of a new program is important to implementation success.

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“…The simplicity of bubble CPAP, combined with reports of favourable outcomes from centres with experience in its use, has long generated interest in this form of CPAP. There have been a number of trials comparing bubble CPAP with other CPAP forms but with heterogeneity in reported outcomes 9–16. In one recent systematic review, bubble CPAP was shown to be safe and reduced the need for mechanical ventilation, but only studies from low-income and middle-income countries were included 17.…”

Section: Introductionmentioning

confidence: 99%

Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis

Bharadwaj

Alonazi

Banfield

et al. 2020

Arch Dis Child Fetal Neonatal Ed

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BackgroundUse of bubble continuous positive airway pressure (CPAP) has generated considerable interest in neonatal care, but its comparative effectiveness compared with other forms of CPAP, especially in developed countries, remains unclear.ObjectiveTo systematically review and meta-analyse short-term clinical outcomes among preterm infants treated with bubble CPAP vs all other forms of CPAP.MethodsProspective experimental studies published from 1995 onward until October 2018 comparing bubble versus other CPAP forms in preterm neonates <37 weeks’ gestational age were included after a systematic review of multiple databases using pre-specified search criteria.ResultsA total of 978 articles were identified, of which 19 articles were included in meta-analyses. Of these, 5 had a high risk of bias, 8 had unclear risk and 6 had low risk. The risk of the primary outcome (CPAP failure within 7 days) was lower with bubble CPAP (0.75; 95% CI 0.57 to 0.98; 12 studies, 1194 subjects, I2=21%). Among secondary outcomes, only nasal injury was higher with use of bubble CPAP (risk ratio (RR) 2.04, 95% CI 1.33 to 3.14; 9 studies, 983 subjects; I2=42%) whereas no differences in mortality (RR 0.82, 95% CI 0.47 to 1.92; 9 studies, 1212 subjects, I2=20%) or bronchopulmonary dysplasia (BPD) (RR 0.8, 95% CI 0.53 to 1.21; 8 studies, 816 subjects, I2=0%) were noted.ConclusionBubble CPAP may lead to lower incidence of CPAP failure compared with other CPAP forms. However, it does not appear to translate to improvement in mortality or BPD and potential for nasal injury warrants close monitoring during clinical application.Trial registration numberCRD42019120411.

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Infant CPAP for low-income countries: An experimental comparison of standard bubble CPAP and the Pumani system

Cited by 25 publications

References 23 publications

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

Implementing bubble continuous positive airway pressure (bCPAP) in a lower middle-income country: a Nigerian experience

Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis

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