Bubble CPAP in neonatal care: mechanisms, evidence, and pathways to optimization.

Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU.

To compare the efficacy of bubble and conventional nasal continuous positive airway pressure (CPAP) in preventing extubation failure (EF) in preterm infants. Infants of gestation ≤32wk and birth weight <1500g, ready for initial extubation within first wk of life were randomly allocated to either bubble (n = 16) or conventional (n = 16) CPAP. A standardized protocol was used for extubation. Bubble CPAP was delivered by Fischer and Paykel equipment using short binasal prongs and conventional CPAP was delivered by a ventilator using Argyle short binasal prongs. CPAP was initiated at a pressure of 4-6cm of H(2)O and FiO(2) of 0.4-0.5 and adjusted to maintain normal saturation (90-93%) and comfortable breathing. Primary outcome was EF, defined as need for mechanical ventilation within 72h of extubation. Baseline characteristics including birth weight (g; 1027 ± 243 vs. 1018 ± 227; p = 0.83), gestation (wk; 28.7 ± 1.8 vs. 28.4 ± 1.6; p = 0.30), infants <28wk gestation (6 vs. 7, p = 0.72) were comparable between the two groups. Respiratory distress syndrome was the indication for ventilation in 13 (81%) and 14 (87%) infants on bubble CPAP and conventional CPAP groups respectively. (p = 0.99). There was no difference in the EF rates between the bubble (n = 4) and conventional CPAP (n = 9) groups. (RR 0.49; 95% CI 0.20-1.2; p = 0.14). Median time to extubation failure was also comparable between the two groups (h; median [range]: 29 [14-49] vs. 17 [7-28]; p = 0.35). The possibility that bubble CPAP may be associated with reduced EF as suggested in this pilot study requires further investigation in an adequately powered multicentric study.

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...

Objective and methods: As the result of vigorous bubbling, infants receiving continuous positive airway pressure (CPAP) by an underwater seal (bubble CPAP) were observed to have vibrations of their chests at frequencies similar to high-frequency ventilation (HFV). We performed a randomized crossover study in 10 premature infants ready for extubation to test whether bubble CPAP contributes to gas exchange compared to conventional ventilator-derived CPAP. Measurements of tidal volume and minute volume were made using the Bear Cub neonatal volume monitor, and gas exchange was measured using an oxygen saturation monitor and a transcutaneous carbon dioxide (tcpCO₂) monitor. Results: There was a 39% reduction in minute volume (p < 0.001) and a 7% reduction in respiratory rate (p = 0.004) with no change in tcpCO₂ or O₂ saturation for infants supported with bubble versus ventilator-derived CPAP. Conclusions: The lack of difference in blood gas parameters associated with a decrease in the infant’s minute volume and respiratory rate with bubble CPAP compared with ventilator-derived CPAP suggests that the chest vibrations produced with bubble CPAP may have contributed to gas exchange. Bubble CPAP may offer an effective and inexpensive option for providing respiratory support to premature infants.

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!

Background: In this study, we aimed to compare ventilator-derived and bubble continuous positive airway pressure (CPAP) in neonates with respiratory distress syndrome admitted to Neonatal Intensive Care Unit of Vali-e-Asr Hospital, Birjand, Iran, in 2014. Methods: This cohort study was conducted among 68 patients assigned into two groups. The neonates in group A (32 infants) were treated with bubble CPAP and those in group B (36 infants) were treated with a ventilator-derived CPAP. The protocol of treatment was applying CPAP with the positive end-expiratory pressure (PEEP) of 5-6 cm H2O and fraction of inspired oxygen equivalent to 30-40%, depending on the gestational age. In case of need for higher oxygen levels to maintain oxygen saturation of arterial blood (SpO2) (90-95%), surfactant was administered and additional PEEP was applied (up to 8 cm H2O). Data analysis was performed using independent t-test and Chi-squared in the SPSS software, version 18. Results: The duration of CPAP and oxygen therapy was 1.67±1.22 days and 3.57±2.67 days in group A and 2.09±1.53 days (P=0.21) and 4.67±3.74 days (P=0.16) in group B, respectively. There was a significant difference between the groups in terms of discharge weight and surfactant dosage (P=0.042 and P=0.007, respectively). Moreover, although the length of stay in hospital in the ventilation group was almost 4 days longer than the other group, there was no significant difference between the groups in this regard. Conclusion: There was no significant difference between bubble CPAP and ventilator-derived CPAP. Moreover, further studies with larger sample size are recommended.

Background: Among children with severe pneumonia hypoxemia is the commonest complication leading to death. Some children will have both type I (hypoxemic) and type II (hypercarbic) respiratory failure. Together this accounts for high case-fatality rates in most populations with severe pneumonia. Standard oxygen supplementation by nasal prongs (low flow) can be lifesaving, but is not always sufficient to manage respiratory failure. In recent years continuous positive airway pressure (CPAP) has been used to relieve hypoxemia and reduce the work of breathing. There are several ways to give positive airway pressure; one is bubble CPAP (BCPAP), another is high flow nasal cannula (HFNC) oxygen therapy.Objective: To review the evidence for using BCPAP, and HFNC therapy in children with severe pneumonia and hypoxemia, particularly the experience of these therapies in developing countries.Methods: Two of our study investigators independently conducted searches of the existing literature in PUBMED in October 2014 to identify reports focusing on the use of BCPAP or HFNC therapy in children with severe pneumonia and hypoxemia, as defined by the World Health Organization.Results: 13 relevant studies were identified. Ten evaluated the efficacy of BCPAP among 3164 children, and three described the same for HFNC in 255 children. In all studies the entry criteria was severe respiratory distress. The study methodologies, the outcomes recorded and results were heterogeneous. The age range of the children in the studies was from the immediate newborn period on day 1 of life up to the age of 12 years. However, we evaluated the outcome of our review in two aged categories and found: children 0-28 days for 8 studies and &gt; 28 days for 2 studies. In 3 studies of children aged 0-28 days and 2 studies of older children had clinical features consistent with severe pneumonia and those who among them were treated with immediate BCPAP therapy had better outcome (p&lt;0.01 or CI &lt; 1) compared to those who were treated with delayed BCPAP, or historical control one each, or standard flow flow (LF) oxygen therapy (in two studies). Primary outcomes were comparable between BCPAP and ventilator driven CPAP in three studies and between BCPAP and low flow oxygen or variable flow nasal CPAP in two studies (95% CI contain 1) of children aged 0-28 days. Children treated with HFNC compared to those who did not receive HFNC in three relevant studies, all of them in older children had better outcome (p&lt;0.05).Conclusion: Studies of BCPAP and HFNC are heterogeneous with different populations, comparators, outcome measures and results. However limited studies suggest that BCPAP may be effective in managing respiratory distress and hypoxemia in developing countries, although evidence is not overwhelming. Studies of the use of HFNC therapy are more limited and do not allow firm conclusions to be made. Most studies of BCPAP and HFNC have been done in neonates with respiratory distress, and studies outside this age group, where the predominant pathologies are bacterial pneumonia, sepsis and viral bronchiolitis are needed.Bangladesh Crit Care J September 2014; 2 (2): 71-78

A Randomized Controlled Trial of Post-extubation Bubble Continuous Positive Airway Pressure Versus Infant Flow Driver Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress Syndrome

Comparison between Bubble CPAP and Ventilator-derived CPAP in Rabbits

The merits of high-flow nasal cannula oxygen versus bubble continuous positive airway pressure are debated in children with pneumonia, with suggestions that randomized controlled trials are needed. In light of a previous randomized controlled trial showing a trend for lower mortality with bubble continuous positive airway pressure, we sought to determine the probability that a new randomized controlled trial would find high-flow nasal cannula oxygen superior to bubble continuous positive airway pressure through a "robust" Bayesian analysis. Sample data were extracted from the trial by Chisti et al, and requisite to "robust" Bayesian analysis, we specified three prior distributions to represent clinically meaningful assumptions. These priors (reference, pessimistic, and optimistic) were used to generate three scenarios to represent the range of possible hypotheses. 1) "Reference": we believe bubble continuous positive airway pressure and high-flow nasal cannula oxygen are equally effective with the same uninformative reference priors; 2) "Sceptic on high-flow nasal cannula oxygen": we believe that bubble continuous positive airway pressure is better than high-flow nasal cannula oxygen (bubble continuous positive airway pressure has an optimistic prior and high-flow nasal cannula oxygen has a pessimistic prior); and 3) "Enthusiastic on high-flow nasal cannula oxygen": we believe that high-flow nasal cannula oxygen is better than bubble continuous positive airway pressure (high-flow nasal cannula oxygen has an optimistic prior and bubble continuous positive airway pressure has a pessimistic prior). Finally, posterior empiric Bayesian distributions were obtained through 100,000 Markov Chain Monte Carlo simulations. In all three scenarios, there was a high probability for more death from high-flow nasal cannula oxygen compared with bubble continuous positive airway pressure (reference, 0.98; sceptic on high-flow nasal cannula oxygen, 0.982; enthusiastic on high-flow nasal cannula oxygen, 0.742). The posterior 95% credible interval on the difference in mortality identified a future randomized controlled trial would be extremely unlikely to find a mortality benefit for high-flow nasal cannula oxygen over bubble continuous positive airway pressure, regardless of the scenario. Interpreting these findings using the "range of practical equivalence" framework would recommend rejecting the hypothesis that high-flow nasal cannula oxygen is superior to bubble continuous positive airway pressure for these children. For children younger than 5 years with pneumonia, high-flow nasal cannula oxygen has higher mortality than bubble continuous positive airway pressure. A future randomized controlled trial in this population is unlikely to find high-flow nasal cannula oxygen superior to bubble continuous positive airway pressure.

Continuous Positive Airway Pressure (CPAP) has an established role in the care of Very Low Birth Weight (VLBW) babies with respiratory distress. Bubble CPAP (BCPAP) is a cheap alternative for countries where resources are limited. However, data comparing efficacy of BCPAP with conventional ventilator derived (VCPAP) is limited. To compare CPAP failure rates between BCPAP and VCPAP among VLBW, with moderate respiratory distress. Secondary objectives were to compare the rates of Intraventricular Haemorrhage (IVH), pulmonary air leaks and deaths between the two groups and determine the predictors of CPAP failure. VLBW babies with moderate respiratory distress (Silverman Anderson score 4-7), born or admitted in Neonatal Intensive Care Unit (NICU) within 28 days of life were randomized to receive either BCPAP (n=34) or VCPAP (n=34). CPAP failure rate in both the groups was compared. The baseline characteristics were similar in both the groups. Five out of 34 (14.70%) babies in BCPAP group and 11 out of 34 (32.35%) in VCPAP failed CPAP (p=0.08). IVH (BCPAP group 24% and VCPAP group 9%, p= 0.10) and mortality (BCPAP group 6% and VCPAP group 9%, p=0.642) were comparable in both the groups. Factors such as gestational age <30 weeks, weight <1000 grams, Respiratory Distress Syndrome (RDS), shock, pulmonary haemorrhage, Disseminated Intravascular Coagulation (DIC) and multi-organ dysfunction were significantly associated with CPAP failure in our study. The CPAP failure rates in VLBW babies with moderate respiratory distress were found to be similar whether bubble CPAP or ventilator CPAP was used. There was no difference in complication rates of IVH or mortality with either method of CPAP.

The technique used to provide continuous positive airway pressure (CPAP) to the newborn may influence lung function and breathing efficiency. To compare differences in gas exchange physiology and lung injury resulting from treatment of respiratory distress with either bubble or constant pressure CPAP and to determine if the applied flow influences short-term outcomes. Lambs (133 d gestation; term is 150 d) born via cesarean section were weighed, intubated, and treated with CPAP for 3 hours. Two groups were treated with 8 L/minute applied flow using the bubble (n = 12) or the constant pressure (n = 12) technique. A third group (n = 10) received the bubble method with 12 L/minute bias flow. Measurements at study completion included arterial blood gases, oxygraphy, capnography, tidal flow, multiple breath washout, lung mechanics, static pressure-volume curves, and bronchoalveolar lavage fluid protein. Birth weight and arterial gas variables at 15 minutes were comparable. Flow (8 or 12 L/min) did not influence the 3-hour outcomes in the bubble group. Bubble technique was associated with a higher pH, Pa(O2), oxygen uptake, and area under the flow-volume curve, and a decreased alveolar protein, respiratory quotient, Pa(CO2), and ventilation inhomogeneity compared with the constant pressure group. Compared with constant pressure technique, bubble CPAP promotes enhanced airway patency during treatment of acute postnatal respiratory disease in preterm lambs and may offer protection against lung injury.

ObjectiveApplication of Continuous Positive Airway Pressure (CPAP) in neonate with respiratory distress is associated with reduction of respiratory failure, reduced complications and mortality. Bubble CPAP (B-CPAP) and ventilator-derived CPAP (V-CPAP) are two most popular CPAP modes. We aimed to determine whether B-CPAP and V-CPAP would have different survival rate and possible complications.MethodsThis prospective clinical trial was performed on 50 preterm neonates weighing 1000-2000 gr who were admitted to the neonatal intensive care unit of Afzalipoor Hospital because of respiratory distress between June 2009 and May 2010. Patients were randomly allocated into treatment groups using minimization technique. Survival analysis was applied to estimate and compare survival rates. Duration of oxygen therapy, hospital stay as well as hospitalization costs were compared using independent sample t-test.FindingsEstimated survival rates at 24 hours in B-CPAP and V-CPAP groups were 100% and 77% respectively. Corresponding figures at 48 hours were 100% and 71%. In addition the hospitalization cost in V-CPAP group was significantly higher than in B-CPAP group.ConclusionAccording to our results, B-CPAP was effective in the treatment of neonates who were suffering from respiratory distress and reduced the duration of hospital stay. In addition to mentioned benefits, its low cost may be the reason to use B-CPAP broadly compared with V-CPAP.

Background: Respiratory distress is a major cause of neonatal morbidity and mortality, especially in preterm infants. Continuous positive airway pressure (CPAP) is a widely used non-invasive respiratory support. However, the cost of conventional bubble CPAP (B-CPAP) systems limits their availability in resource-constrained settings. Aims and Objectives: This study aimed to compare the effectiveness and safety of indigenous CPAP (I-CPAP) versus B-CPAP in preterm neonates with respiratory distress. Materials and Methods: A randomized controlled trial was conducted involving 82 preterm neonates (28–&lt;37 weeks gestation) with respiratory distress syndrome. Participants were randomized into two groups: I-CPAP (n=41) and B-CPAP (n=41). The primary outcomes were CPAP failure, survival rates, and complications. Data were analyzed using the Statistical Package for the Social Sciences version 22.0, with P&lt;0.05 considered statistically significant. Results: The demographic characteristics were comparable between the groups. CPAP failure requiring mechanical ventilation was significantly higher in the I-CPAP group (43.90%) compared to the B-CPAP group (21.95%) (P=0.034). Survival rates were similar between groups (I-CPAP: 75.7% and B-CPAP: 72.9%). Complications such as nasal septal injury (P=0.045), skin erosion (P=0.007), dislodgement (P=0.040), and abdominal distension (P=0.023) were significantly higher in the B-CPAP group. Conclusion: I-CPAP demonstrated comparable effectiveness to B-CPAP in managing respiratory distress in preterm neonates, with fewer complications but a higher need for mechanical ventilation. Given its low cost and ease of assembly, I-CPAP can be a viable alternative in resource-limited settings.

Background: Self-assembled, bubble continuous positive airway pressure is a low-cost noninvasive respiratory support modality used to manage newborns with respiratory distress. Very few local studies have been conducted regarding its use in the management of neonatal respiratory distress. This study was conducted to evaluate the effectiveness of this device as a primary treatment modality for neonatal respiratory distress. Methods: This cross-sectional study was conducted in the Department of Pediatrics, Ziauddin Hospital, Karachi from 1st February 2018-31st July 2018 on neonates (n=200) admitted with respiratory distress, in whom self-assembled bubble continuous positive airway pressure was used as a primary respiratory support. The effectiveness of its use was determined, based on the absence of associated complications, signs of respiratory distress, and oxygen saturation at room air of 94% or more. Data were analyzed by SPSS version 20. The Chi-square test was used for categorical variables and a p-value &lt;0.05 was considered statistically significant. Results: The mean gestational age was 34.3+2.73 weeks, the mean age at initiation of bubble continuous positive airway pressure was 7.7 4 hours, and the mean duration of hospital stay was 4.2 days. The observed failure rate in the study population was 8.5%, while the mortality was only 2%. The finding of respiratory distress syndrome on chest- X-ray with (FiO2) &gt; 60% was observed. In addition, bubble CPAP after 6 hours of the onset of respiratory distress showed significant results (p&lt;0.001). Conclusion: Self-assembled bubble continuous positive airway pressure is a significant and effective treatment modality (p=0.001) in neonatal respiratory distress. Keywords: Bubble Continuous Positive Airway Pressure; Neonates; Respiratory Distress.