Improvised bubble continuous positive airway pressure BCPAP device at the National Hospital Abuja gives immediate improvement in respiratory rate and oxygenation in neonates with respiratory distress.html

Niger J Paed 2015; 42 (1): 12 –16

ORIGINAL

Audu LI

Improvised bubble continuous

Otuneye AT

positive airway pressure (BCPAP)

Mairami AB

Mukhtar MY

device at the National Hospital

Abuja gives immediate

improvement in respiratory rate

and oxygenation in neonates with

respiratory distress

DOI:http://dx.doi.org/10.4314/njp.v42i1,4

Accepted: 15th August 2014

Abstract: Background: Prematur-

was applied to preterm babies with

ity accounts for 25% of Neonatal

RDS as well as some term babies

Audu LI

(

)

mortality in Nigeria and Respira-

with respiratory distress admitted

Otuneye AT, Mairami AB

tory Distress Syndrome is respon-

into the neonatal intensive care

Mukhtar MY

Department of Paediatrics,

sible for half of these deaths.

units. Respiratory rate, SPO2 and

National Hospital Abuja, Nigeria.

Introducing continuous positive

other signs of respiratory distress

Email: drauduli@yahoo.com

airway pressure for the treatment

were monitored before and at 1

of RDS in Nigeria where health

hour, 6 hours and 12 hours after

care financing is predominantly

the application.

out-of-pocket is quite challenging.

Results: Forty eight newborn

It was hypothesized that applying

babies with respiratory distress

the principle of under-water-seal

were treated with the device out of

pressure generation could convert

whom twenty three (48%) were

a simple oxygen delivery system

very low birth weight with respira-

into an effective Bubble CPAP

tory distress syndrome. The mean

device.

respiratory rate dropped from 64.5

Objectives: To provide evidence

(19.2)/min before commencement

in support of the immediate clini-

of CPAP to 59.5(11.6)/min, 56.6

cal effectiveness of the NH-

(10.5), and 56.6(10.7) at 1, 6 and

BCPAP device.

12 hours respectively, p<0.05. The

Design/Methods: At the neonatal

corresponding values for SPO2

unit of the National Hospital

were 84.5(14) before and 95.9

Abuja, we assembled a circuit of

(5.3), 95.9(6.5) and 96.9(6.4) at 1,

tubing connecting a gas source

6 and 12

hours respectively,

(oxygen concentrator or cylinder)

p<0.05. The respiratory changes

through

interface

(nasal

were however less marked among

prongs) to the baby and this was

very low birth weight babies.

further connected through an ex-

Conclusion: The simplified cus-

piratory tube to an under-water-

tomized device produces clinical

seal bottle to generate CPAP. The

responses similar to those reported

device is activated by turning on

for the conventional CPAP

the oxygen source. The device

devices.

Introduction

tions including chronic lung disease of prematurity ³ .

Continuous Positive Airway Pressure (CPAP) is increas-

Prematurity accounts for 25% of neonatal mortality in

ingly used in the management of preterm babies with

Nigeria and respiratory distress syndrome (RDS) is

RDS, with a concomitant decrease in the use of

responsible for half of these deaths . Effective manage-

mechanical ventilation in tertiary and non- tertiary

health institutions . Respiratory assistance with continu-

ment of respiratory distress syndrome is therefore a criti-

cal factor in their survival. Some form of respiratory

ous positive airway pressure (CPAP) is often sufficient

support is required with or without surfactant replace-

to tide a preterm infant through RDS. Introducing CPAP

ment. Mechanical ventilation which was used as the

in a low-resource setting is quite challenging and this

main thrust of respiratory intervention over the years to

has limited its use to a few centers in Nigeria. CPAP

salvage these babies is fraught with several complica-

use may be associated with nasal septum erosion,

under-water-seal bottle to generate bubble CPAP . The

interference with enteral intake (“CPAP belly”) and

rarely, pneumothorax. Careful selection of appropriate

oxygen flow meter is connected to a humidifier contain-

size nasal prongs, passage of orogastric tube for inter-

ing warm distilled water and this ensures the delivery of

mittent gastric decompression and careful attention to

warm humidified air to the baby. The high flow rate (6-

pressure delivered will minimize these challenges.

8L/Min) prevents re-breathing and carbon dioxide accu-

mulation while also ensuring adequate bubbling and

Adaptation of Bubble –CPAP: Driven by the desire to

under-water pressure generation.

provide effective and yet affordable treatment for RDS

we resorted to the use of locally sourced materials and

Forty eight babies admitted into the newborn unit with

applied the principle of ‘under-water seal’ pressure gen-

respiratory distress (intercostal, subcostal or sternal re-

eration in BCPAP and arrived at a modification of the

cessions, grunting and nasal flaring) over a period of 6

existing bubble CPAP device which is effective, easy to

months were treated with this device. They were clini-

use and remarkably affordable. This has been previously

cally assessed on admission and at 1, 6 and 12hours af-

described .

ter commencement of CPAP. Respiratory rates, cyano-

sis, grunting and SPO 2 were documented. Also noted

and documented were baby’s gestational age ( using

Fig 1: NHA B-

mothers’ EDD and Ballard’s score within 24 hours of

CPAP system

birth) , birth weight and diagnosis. The mean (SD) value

of RR and SPO 2 before CPAP was commenced was

compared with the corresponding mean (SD) values at

1,6 and 12 hours after commencement of CPAP and

subjected to statistical analysis (Student t-test) to deter-

mine the significance of observed differences. Babies

who did not improve on CPAP or died while still on

Physiologically, CPAP causes airway splinting, alveolar

CPAP were classified as CPAP failures. The overall

expansion and stabilization, improved alveolar ventila-

mortality rates as well as the case specific mortality rates

tion and enhanced oxygenation . The clinical conse-

were also noted.

quences of these are; disappearance of grunting sounds a

drop in the respiratory rate and an improvement in

SPO 2 .

The objective of this communication is to provide evi-

Results

dence in support of the immediate clinical effectiveness

of the NHA-BCPAP device. The findings would provide

Table 1: General characteristics

justification for a planned comparative evaluation of this

(n=45)

device with other conventional commercial CPAP de-

Sex

17(37.8%)

vices. It was hypothesized that application of the NHA

Male

28 (62.2%)

Female

bubble CPAP device to a baby with respiratory distress

Place of delivery (n=48)

would result in an immediate functional improvement in

Inborn

23 (47.9%)

the respiratory status.

Out born

25(52.1%)

Birth weight category (n=48)

ELBW

5(10.4%)

VLBW

18(37.5)

Subjects and methods

LBW

12(25%)

NBW

13(27.1)

This was a prospective observational study in which

Clinical diagnosis

Respiratory Distress Syndrome

30(62.5%)

babies admitted into the newborn unit of the National

Congenital pneumonia

11(22.9%)

Hospital Abuja with respiratory distress were eligible if

Cyanotic Congenital heart disease

3(6.2%)

they had no congenital abnormalities (bilateral choanal

Transient Tachypnoea of the Newborn

2(4.2%)

atresia, congenital diaphragmatic hernia and cleft lip/

Recurrent Apnea

1(2.1%)

palate). These babies would otherwise have received

Hypoxic Ischaemic encephalopathy

1(2.1%)

supplemental intranasal oxygen in addition to other

management relevant to their primary pathologic diag-

Indicators of clinical effectiveness (tables 2-5 )

nosis. There are no facilities for mechanical ventilation

and only a limited number of variable-flow nasal CPAP

The respiratory rate dropped from a mean (SD) value of

devices are available in the unit. Babies were recruited

64.1 (18.3)/min to 59.5 (11.7)/min within 1 hour of

into the study following parental informed consent and

commencing CPAP and this downward trend was main-

Hospital ethics committee approval.

tained, achieving a level of statistical significance at 6

and 12 hours post commencement. The changes ob-

A circuit of tubing attached to a gas source (oxygen cyl-

served in the SPO 2 levels also followed the same pattern

inder or concentrator) was connected through an inter-

albeit more rapidly and this was synchronous with im-

face (nasal prongs) to the baby and this was further con-

provement in the level of cyanosis and the disappear-

nected through an expiratory limb of the tube to an

ance of grunting sound. Further stratification of the

babies into different Birth Weight categories as shown

in tables shows that respiratory rate changes are only

were: ELBW (60%), VLBW (33%), LBW (44%) and

significant for the LBW and NBW babies, whereas the

NBW (30%).

changes in SPO2 are uniformly significant across birth

Table 6 shows the case specific mortality rates with

weight categories .

100% mortality for recurrent apnoea and severe hypoxic

Two extremely low birth weight babies and two with

encephalopathy.

suspected cyanotic congenital heart disease had SPO2

persistently below 82% throughout the period of obser-

Table 6: Case specific mortality rate

vation. In six babies (4 VLBW, 2 ELBW), CPAP was

Diagnosis

Mortality Rate

reapplied after weaning, as a result of worsening respira-

Respiratory Distress Syndrome

5(16.7%)

tory distress. The P values were determined by compar-

Congenital pneumonia

1(9.1%)

ing the mean (SD) values at 1 hr, 6 hrs and 12 hrs inde-

Cyanotic Congenital heart disease

2 (66.7%)

pendently with the mean (SD) at 0 hr.

Transient Tachypnoea of the Newborn

0(0%)

Recurrent Apnea

1(100%)

Hypoxic Ischaemic Encephalopathy

1(100%)

Table 2: Indicators of clinical effectiveness

Variable

CPAP

Duration

Discussion

0 hr

1hr

6hrs

12hrs

Mean (SD)RR/min

64.1

59.5

56.6

Low-cost and simplified forms of the CPAP delivery

systems have been described

7,8

(18.3)

(11.7)

(10.4)

(10.7)

. The uniqueness of our

P value

0.145

0.015

0.016

customized device lies in its simplicity and cost effec-

tiveness. Some other modified BCPAP devices report-

edly use corrugated tubes, Hudson’s nasal prongs or

Mean (SD)

84.5

95.9

96.9

shortened endotracheal tubes which need to be sourced

SPO 2

(14.0)

(5.3)

(6.5)

(6.4)

P value

0.0001

separately, with additional cost burden.

Respiratory Distress Syndrome in very premature neo-

nates is an important indication for nasal CPAP

10,11,12

Table 3: Respiratory rates (per minute) before and after com-

However, CPAP has also been successfully used in

mencement of B CPAP in relation to birth weight category

infants with other respiratory conditions, for instance,

NS=not significant

Jocelyn Brown et al

in Malawi, demonstrated the ef-

Birth

0 hour

1 hour

6 hour

12 hour

fectiveness of CPAP in the management of congenital

weight

pneumonia and as well as in an infant with Bronchioli-