The Availability and Quality of Continuous Positive Airway Pressure (CPAP) for Neonatal Care in Public Health Facilities in India: A Cross- Sectional Cluster Survey

Abstract

Background: Continuous Positive Airway Pressure (CPAP) is increasingly used in low- and middle-income setting to manage respiratory distress in neonates. Methods: National cross-sectional cluster survey of neonatal care units (SNCU) in 79 medical colleges (MC) and 63 district hospitals (DH) to assess availability, use, and, outcomes of CPAP. Findings: 68·3% of MC and 36·6% of DH used CPAP. Basic infrastructure was widely available. Air-oxygen blenders were available in 50·7% (95%CI 41·4,60·9) of hospitals. Equipment needed for monitoring and/or the detection and management of complications was not always in place; screening for retinopathy in 89·9%(77·2,95·9) MC and 60·3%(44·0,75·6) DH, treatment for retinopathy in 44·3%(30·9,58·5) MC and 7·9%(2·9,20·0) DH, screening for bronchopulmonary dysplasia in 62·0%(49·0,73·5) MC and 22·2%(12·5,36·3) DH, management of pneumothorax in 63·3%(49·8,74·9) of MC and 20·6%(9·8,38·3) of DH. Medical staff trained in the use of CPAP was available in 56·0%(45·8,65·8) of hospitals. The nurse:patient ratio was 7·3(95% CI 6·4-8·5) in MC and 6·6 (5·5-8·3) in DH. 72% MC and 59·3% DH used an upper oxygen saturation limit of above 94%. Respiratory circuits were reused in 52·8% of hospitals. Case Fatality Rates for neonates admitted to a SNCU were 11·5%(9·7,13·3) [13·2%(10·7,15·7) at MC and 7·4%(5·7,9·1) at DC] and 21·4%(16·6,26·2) for neonates receiving CPAP [19·8%(14·6,24·9) MC; 26·3%(15·7,37·0) DH]. Complication rates ranged from 27·9%(21·2,34·5) for rescue mechanical ventilation and 0·7%(0·2,1·2) for pneumothorax. Interpretation: Further support to infrastructure, training, and revision of current guidelines is urgently needed to improve the quality of care and ensure successful scale up of CPAP. Funding Statement: World Health Organization (Reference:2016/613341-0) Declaration of Interests: The authors have no competing interests to declare. Ethics Approval Statement: The study was approved by the Ministry of Health and Family Welfare of India (Child Health Division) and by the Liverpool School of Tropical Medicine’s Research and Ethics Committee (Research protocol 15·032).