CASE REPORT

Niger J Paed 2013; 40 (3) : 303 –306

The Use of bubble nasal CPAP in the

management of IRDS -A Case

report and literature review

Abdulkadir I

Abdullahi F

Hassan L

Purdue S

Okpe M

Mohammed A

Aminu AT

Usman N

Aliyu H

Ogala WN

DOI:http://dx.doi.org/10.4314/njp.v40i3,22

Accepted: 27th January 2013

Abstract A one hour old baby

boy presented to the Special Care

Baby Unit (SCBU) of the

Ahmadu Bello University Teach-

ing Hospital (ABUTH), Shika,

Zaria, on account of respiratory

distress noticed from birth. He

was a product of supervised preg-

nancy, delivered at 37 weeks ges-

tation via emergency caeserien

section performed due to severe

pre eclampsia and fetal distress.

APGAR scores were 2 and 7 at

one and five minutes respectively.

He weighed 1850 grams and was

found to be dusky, inactive, hypo-

entertained with differential diag-

noses of pulmonary hypoplasia,

hyaline membrane disease and

Abdulkadir I,

(

)

Abdullahi F, Hassan L, Purdue S, Okpe

M, Mohammed A, Aminu AT, Usman

N, Aliyu H, Ogala WN

group

B

streptococcal (GBS)

pneumonia. He had a full sepsis

screen including chest radiograph

and was commenced on supple-

mental oxygen via nasal cannula,

antibiotics and other supportive

measures. The patient however

continued to have laboured breath-

ing and subsequently had an

apnoeic attack. He was resusci-

tated and commenced on bubble

nasal CPAP. He did remarkably

well and was weaned off CPAP

after a total of 60 hours. A repeat

chest radiograph showed remark-

able aeration of the lungs as

against an earlier one which

showed a reticulogranular (ground

glass) appearance.

Department of Paediatrics

Ahmadu Bello University Teaching

Hospital Shika – Zaria, Kaduna State

Nigeria.

0

thermic (T = 35.5 C) and in se-

vere respiratory distress (SPO

2

ranged between 60 % and 72 %).

He was tachypnoeic with respira-

tory rate persistently above 80

cycles/ min, and had reduced air

entry in the mid and lower zones

of the lungs bilaterally with wide

spread coarse crepitations. A di-

agnosis of perinatal asphyxia was

Key words: Neonates, Respiratory

distress, Bubble nCpap, Downes

score.

1

-6

Bubble CPAP is a

Introduction

the pressure generating source.

low cost nasal continuous positive airway pressure de-

livering system which has been in use since the seven-

ties but is regaining popularity due to its gentleness on

the fragile lungs of the neonate. Also, it is free of severe

complications associated w₃_-i₆th modern mechanical venti-

Newborns who develop respiratory distress may require

respiratory support which could be provided via various

methods. Continuous positive airway pressure (CPAP)

refers to a mode of respiratory support where positive

pressure is provided to a spontaneously breathing neo-

nate. This has become a popular and effective therapy in

the management of idiopathic respiratory distress syn-

drome (IRDS) which remains a common cause of respi-

lator usage in newborns.

Indications for the use of

CPAP include idiopathic respiratory distress syndrome

(IRDS), apnoea of prematurity or obstructive apnoea,

post-extubation in preterm VLBW infants and transie₃n_-₉t

tachypnoea of newborn (TTNB)/delayed adaptation.

Other indications include pneumonia, mild meconium

aspiration or other aspiration syndromes, pulmonary

1

ratory distress in the preterm neonate. CPAP can be

applied via different types of interface including nasal

prongs, nasopharyngeal tube and face mask using a con-

ventional ventilator, bubble circuit or a CPAP driver as

3

-9

edema, pulmonary hemorrhage and laryngomalacia.

3

04

The bubble CPAP system essentially consists of three

components: a continuous gas flow into the circuit, an

expiratory limb with the distal end submerged into a

liquid to generate positive end expiratory pressure

and heart sounds were normal. Other systems were es-

sentially normal.

A diagnosis of perinatal asphyxia was made with differ-

ential diagnoses of pulmonary hypoplasia, hyaline mem-

brane disease, GBS pneumonia, early onset neonatal

sepsis and cyanotic congenital heart disease.

Investigations including Full Blood Count (FBC) and

differential, blood culture, RBS, serum urea and electro-

lytes, chest radiograph and intermittent oxygen satura-

tion monitor were conducted.

(

airway to the circuit. It was developed and first used

by Dr. Jen-Tien Wung at the Columbian Presbyterian

PEEP) and the nasal_,₄ interface connecting the infant's

1

Medical Center, New York. Subsequently the use of

bubble CPAP has been associated with a reduction in

the number of newborns requiring mechanical ventila-

5

tion. A retrospective study of neonates at Columbia

University, where the predominant mode of respiratory

support was the use of nasal CPAP, revealed that treated

babies had the lowest incidence of chronic lung disease₆

(

CLD) without any significant difference in mortality.

Other studies have also shown that the use of bubble

CPAP is not assoc_-₁i₂ated with increase in short or long

Results

7

term morbidities. In Nigeria, management of new-

Packed cell volume (PCV) of 0.40 L/L, total white cell

count of 4.7 x 10 /L, with differential white cell count of

56.4% neutrophils and 34.6% lymphocytes and platelet

count of 167 x 10 /L. Serum urea and electrolyte were

9

borns with respiratory distress continues to pose chal-

lenge to neonatal care providers and experience with the

use of bubble CPAP remains very low. The use of bub-

ble CPAP was introduced in our centre in June 2012.

We present the case of a neonate who was admitted and

successfully managed for IRDS using bubble CPAP to

highlight the practicability of providing this mode of

respiratory support to neonates with respiratory distress

in resource - poor setting like ours.

9

normal and blood culture was negative.

He was commenced on parenteral antibiotics - crystal-

line penicillin, gentamicin; intravenous fluids and subse-

quently upgraded to partial parenteral feeding with addi-

tion of amino acids after 24 hours. Respiratory distress

worsened and_t_hhe eventually had an episode of apnoea at

about the 24 hour of life. The baby was resuscitated

using bag and mask ventilation and after resumption of

spontaneous breathing he was commenced on bubble

Case report

An hour old baby boy, who was delivered via emer-

gency caesarien section to a 31 yr old Para 3 mother was

admitted to the Special Care Baby Unit of Ahmadu

Bello University Teaching Hospital (ABUTH) due to

respiratory distress.

2

nasal CPAP at a PEEP of 5cmH O and a flow of 7 L/

min (Fig 1).

Fig 1: Neonate under Bubble Nasal CPAP

An early obstetric scan revealed a normal singleton

pregnancy which was subsequently booked at the 28th

week of gestation with normal booking parameters at a

private hospital in Zaria. She had a total of three visits at

4

-weekly intervals before she pres_te_hnted to the Obstetric

unit of ABUTH at about the 37 week of gestation

where she was evaluated and subsequently delivered of

a live male neonate via emergency caesarien section

performed on account of complications of hypertension

in pregnancy, severe oligohydramnios and fetal distress.

APGAR scores were 2 and 7 at one and five minutes

respectively, and the baby was dried, covered, kept

warm, suctioned and oxygen administered via face mask

before he was transferred to the SCBU.

With the commencement of bubble nasal CPAP he pro-

gressively stabilized. Respiratory rate declined from 86

to 54 cycles/ min over 36 hours, his Downes’ score im-

proved to < 3, oxygen saturation rose from 70% to 98%

almost immediately while heart rate and temperature

remained within normal limits (Fig 2). Warmth was pro-

vided from a radiant warmer before he was transferred

to an incubator.

In the SCBU he was found to be dusky, in severe respi-

ratory distress and moderately hypothermic (T = 35.5

0

C). He weighed 1850 grams and was adjudged small

for gestational age (SGA). He was floppy, tachypnoeic

with respiratory rate of 80 cycles/ min and had reduced

air entry in the mid and lower zones of the lungs with

5

widespread coarse crepitations. His Downes’ score was

6

(cyanosis = 1, retraction =1, respiratory rate = 2, air

entry = 1, grunting = 1) and oxygen saturation ranged

between 60% and 72% but rose to 80% with commence-

ment of oxygen supplementation via nasal cannula at a

flow of 2L/ min. He had a heart rate of 142 beats/min

3

05

Fig 2: Line Plot Showing Parameters of Neonate on

Discussion

Bubble Nasal CPAP

This is the first report of the use of CPAP in the man-

agement of IRDS in our centre. The patient presented

with features of respiratory distress from birth which

progressively worsened, with a falling oxygen saturation

pressure, apnoea and a Downes’ score of 6 suggesting

the requirement of respiratory support and heralding an

impending respiratory failure. The chest radiograph also

showed reticulogranular (ground glass) appearance sug-

gestive of a grade IV idiopathic respiratory distress of

the newborn. These factors were indications for the use

of CPAP. Though IRDS is thought to be uncommon

among SGA neonates due to the common assumption

that intrauterine stress led to accelerated pulmonary

maturation of such neonates and decreased incidence of

IRDS, recent published stud₁i₂e_-s₁₅however have not been

In addition impaired

He was weaned off CPAP after 36 hours when all pa-

rameters were normal. He however began to desaturate

eight hours later with SPO2 dropping from between 88 –

supportive of this concept.

maturation of type II alveolar epithelial cells and re-

duced surfactant content and activity have also been

reported in infants with IUGR possibly resulting from

the effect₁o₃f_-₁c₅hronic hypoxia and acidosis on surfactant

9

4% to 80 – 86% and respiratory rate rose from 54

cycles/ min to above 80 cycles/ min. He was recom-

menced on CPAP for a further 24 hours before weaning.

He maintained normal oxygen saturation on supplemen-

tal oxygen at 1.5 L/min for another 18 hours before he

was completely weaned off oxygen. Nasogastric tube

feeding was gradually introduced and intravenous fluids

gradually withdrawn.

synthesis.

Oligohydramnious a known cause of

pulmonary hypoplasia, which was a presentation in the

index c₆ase, has also been shown to increase the risk of

1

IRDS. Conversely meconium aspiration syndrome and

polycythaemia which are other possible causes of respi-

ratory distress in a small for gestational age neonate

were less likely in this patient with no history of me-

conium stained liquor and a packed cell volume of 0. 40

L/ L.

Results of chest radiograph revealed a uniform reticulo-

granular (ground glass) appearance of the lung fields

suggestive of grade IV IRDS (Fig 3A. taken within the

first 24 hours of life) which subsequently became clear

with management (Fig 3B taken on the fifth day of life).

Initiation of CPAP resulted in a sharp rise in oxygen

saturation, a decline in respiratory rate and an improve-

ment in his Downes score. The improvement followed

well known principles. By maintaining positive pressure

in the airway during spontaneous breathing, alveoli are

prevented from collapsing, functional residual capacity

is increased, gaseous ex₁c_-h₄ange is enhanced and oxygen

Fig 3A: Chest radiograph showing reticulogranular

(ground glass) appearance

saturation is improved.

After initial discontinuation

of CPAP, our patient experienced deterioration which

we attribute to excessive airway secretions or inadequate

recruitment of alveoli. However, recommencement of

CPAP for a further 24-hour period resulted in sustained

improvement. Management of IRDS sometimes in-

volves the use of exogenous surfactant. However, this

potentially useful agent was not available to us and was

thus not employed. This modality of treatment may or

may not have influenced the cour_,s₁e₇ of illness in the in-

1

dex case because some studies have compared the

Fig 3B: Chest radiograph showing normal findings after CPAP

use of early CPAP alone to the use of a combination of

surfactant and intubation and did not find superiority of

either technique. Similarly the initiation of CPAP also

prevented the recurrence of obstructive apnoea in this

patient, a benefit which is a known indication of CPAP

use.

Complications like pneumothorax, nasal septal erosion

or necrosis and gastric distention (CPAP belly syn-

drome) may arise with use of bubble CPAP. However,

our patient did not suffer any such complication possibly

because care was taken to use appropriate snug–fitting

3

06

nasal prongs among other measures. The patient also did

well on CPAP even on a low PEEP of 5cmH O. Occa-

Conclusion

2

sionally some babies may require higher PEEP and yet

are not able to maintain saturation suggesting the re-

quirement of more respiratory support in form of me-

chanical ventilation.

The successful use of nasal bubble CPAP, a simple and

inexpensive respiratory support in the management of

this case of idiopathic respiratory distress syndrome in

our unit promises an improved care to newborns who

may require respiratory support particularly in our poor

socio economic setting where there is paucity of neona-

tal intensive care units with ventilator support and inade-

quate skilled manpower to provide such care. We

The provision of optimal newborn care and adequate

management of hypothermia, an important contributor

to neonatal morbidity and mortality which aggravates

IRDS, would have contributed the outcome in this pa-

tient. Similarly the use of antibiotics and provision of

optimal fluid and electrolytes are important. While anti-

biotics were employed as possible treatment for group B

streptococcal pneumonia, an important differential diag-

nosis which may be clinically and radiographically in-

distinguishable from IRDS, the optimal fluid and elec-

trolytes management provided adequate caloric require-

ments and prevented fluid overload, all of which are

essential determinants of outcome in newborn care.

recommend therefore, that neonatal care providers be

trained and acquainted with the use of bubble CPAP to

improve newborn care in the country.

Conflict of interest: None

Funding: None

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