Bubble CPAP: An Alternative That Is as Good as it Gets!

Abstract

Source: Tagare A, Kadam S, Vaidya U, et al. Bubble CPAP versus ventilator CPAP in preterm neonates with early onset respiratory distress - a randomized controlled trial. J Trop Pediatr. 2013; 59(2): 113– 119; doi: 10.1093/tropej/fms061Researchers from India and Australia compared the safety and efficacy of bubble (B) continuous positive airway pressure (CPAP) with ventilator-derived CPAP (VCPAP) in preterm infants. They conducted a randomized controlled trial and enrolled infants at <37 weeks gestation who developed respiratory distress within 6 hours of birth. Only infants who had an oxygen requirement of >30% and who had at least moderate retractions and/or grunting as determined by a Silverman-Anderson (SA) score >4 (range of possible scores 0–10) were eligible for enrollment. At enrollment, study infants were randomized to BCPAP or VCPAP. Commercial brand equipment was used for both groups, including a bubble generator and blender for BCPAP, ventilator equipment for VCPAP, and nasal prongs. Both groups were started on 40% FiO2 and a CPAP pressure of 6 cm of water (cmW). Based on clinical assessment and a goal of maintaining an oxygen saturation of 88% to 93%, FiO2 was changed in increments of 5% and CPAP in increments of 1 cmW. After 1 hour of CPAP support, surfactant replacement was administered to infants requiring ≥40% FiO2, ≥6 cmW CPAP, and having x-ray findings consistent with respiratory distress syndrome (RDS).The primary study outcome was success of the allocated ventilation method. Success was defined as discontinuation of CPAP within 72 hours and no need for mechanical ventilation, oxygen requirement of <30%, and an SA score <3. Secondary outcomes included need for surfactant therapy, nasal injury from CPAP, and overall mortality.One hundred and fourteen infants were enrolled, with 57 in each group. The groups were comparable at baseline with respect to gestational age, birth weight, and SA score.Neonates treated with BCPAP were significantly more likely to have successful treatment than those randomized to VCPAP (82.5% and 63.2%, respectively, P = .3). Surfactant was given to more infants in the VCPAP than BCPAP group (18/57 vs 9/57, P < .05). Overall, infants who required surfactant were significantly less likely to have successful CPAP treatment, regardless of type of CPAP. VCPAP and BCPAP groups were comparable in terms of CPAP duration (30 hours and 36 hours, respectively) and mortality (8.8% and 7%, respectively). Injury to the nasal septum was more frequent in infants randomized to BCPAP (21.1%) than to those receiving VCPAP (7%) (P = .03).The authors conclude that BCPAP is safe and more effective than VCPAP when used early for preterm neonates with moderate to severe RDS.Drs Santisteban-Ponce and Bedrick have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.CPAP emerged in 1971 as an alternative to mechanical ventilation for preterm infants with RDS, reducing the need for intubation.1 CPAP regained popularity with the increased survival of very low birth weight (VLBW) infants, decreasing the incidence of chronic lung disease through its use with many modalities, including endotracheal tube and mechanical ventilator, or the nasal route with a flow-driver CPAP or BCPAP.2BCPAP delivers a pressurized flow of humidified gas through a breathing circuit with nasal prongs. The pressure delivered is controlled by adjusting the depth of a partially submerged tube in a water bottle (depth of 1 cm equals 1 cm of H2O pressure) attached to the end of the infant’s breathing circuit.3 The bubbling of BCPAP generates a small airway pressure oscillation, which is thought to reduce the work of breathing, improve gas exchange, and facilitate alveolar recruitment. BCPAP airway pressure waveforms are similar to those produced by high frequency oscillatory ventilation.3 It is a simple, low-cost apparatus.Studies in VLBW infants treated with BCPAP in the delivery room noted decreased intubations and fewer days on mechanical ventilation. 2,4 BCPAP has been shown to enhance alveolar gas exchange in premature infants compared to VCPAP.3 BCPAP has also been effective in maintaining spontaneous breathing following extubation of newborns and in treating apnea of prematurity, addressing multiple respiratory needs of premature infants.The use of BCPAP in developing countries could be expected to decrease health care costs for the treatment of neonatal RDS, as has been described in resource-rich environments.5 Many nasal septum injuries could be prevented by using experienced nurses.6 The results of the current study support the observation that less invasive respiratory therapy strategies can be successfully used in resource-limited areas, reducing demand for ventilators and exogenous surfactant. The application of respiratory support devices that are user-friendly, inexpensive, and effective for treatment of large numbers of premature babies is as good as it gets!