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Truong N, Sciscent B, Lorenz FJ, Goldrich D, Goyal N. Letter to the Editor of Journal of Otolaryngology regarding "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study". J Otolaryngol Head Neck Surg 2023; 52:61. [PMID: 37726813 PMCID: PMC10510124 DOI: 10.1186/s40463-023-00662-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023] Open
Abstract
Obstructive sleep apnea (OSA) is associated with multiple chronic comorbidities with treatments including continuous positive airway pressure (CPAP), upper airway surgery (UAS), and hypoglossal nerve stimulation (HNS). Given the complexity of the condition and multiple treatment options, there is an ongoing debate to determine the best management. O'Connor-Reina et al. recently published a paper titled "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study." In their study, the authors stated that OSA patients who received surgery had a 50% less chance of developing diabetes compared to patients who only received CPAP treatment. However, we would like to point out some limitations that warrant attention and caution interpretation of the findings by physicians and patients.
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Affiliation(s)
| | - Bao Sciscent
- Penn State College of Medicine, Hershey, PA, USA
| | - F Jeffrey Lorenz
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - David Goldrich
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Neerav Goyal
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, PA, USA.
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Prakash R, De Paoli AG, Davis PG, Oddie SJ, McGuire W. Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2023; 3:CD015130. [PMID: 37009665 PMCID: PMC10064833 DOI: 10.1002/14651858.cd015130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
BACKGROUND Several types of pressure sources, including underwater bubble devices, mechanical ventilators, and the Infant Flow Driver, are used for providing continuous positive airway pressure (CPAP) to preterm infants with respiratory distress. It is unclear whether the use of bubble CPAP versus other pressure sources is associated with lower rates of CPAP treatment failure, or mortality and other morbidity. OBJECTIVES: To assess the benefits and harms of bubble CPAP versus other pressure sources (mechanical ventilators or Infant Flow Driver) for reducing treatment failure and associated morbidity and mortality in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2023, Issue 1); MEDLINE (1946 to 6 January 2023), Embase (1974 to 6 January 2023), Maternity & Infant Care Database (1971 to 6 January 2023), and the Cumulative Index to Nursing and Allied Health Literature (1982 to 6 January 2023). We searched clinical trials databases and the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials comparing bubble CPAP with other pressure sources (mechanical ventilators or Infant Flow Driver) for the delivery of nasal CPAP to preterm infants. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of the evidence for effects on treatment failure, all-cause mortality, neurodevelopmental impairment, pneumothorax, moderate-severe nasal trauma, and bronchopulmonary dysplasia. MAIN RESULTS We included 15 trials involving a total of 1437 infants. All trials were small (median number of participants 88). The methods used to generate the randomisation sequence and ensure allocation concealment were unclear in about half of the trial reports. Lack of measures to blind caregivers or investigators was a potential source of bias in all of the included trials. The trials took place during the past 25 years in care facilities internationally, predominantly in India (five trials) and Iran (four trials). The studied pressure sources were commercially available bubble CPAP devices versus a variety of mechanical ventilator (11 trials) or Infant Flow Driver (4 trials) devices. Meta-analyses suggest that the use of bubble CPAP compared with mechanical ventilator or Infant Flow Driver CPAP may reduce the rate of treatment failure (RR 0.76, 95% confidence interval (CI) 0.60 to 0.95; (I² = 31%); RD -0.05, 95% CI -0.10 to -0.01; number needed to treat for an additional beneficial outcome 20, 95% CI 10 to 100; 13 trials, 1230 infants; low certainty evidence). The type of pressure source may not affect mortality prior to hospital discharge (RR 0.93, 95% CI 0.64 to 1.36 (I² = 0%); RD -0.01, 95% CI -0.04 to 0.02; 10 trials, 1189 infants; low certainty evidence). No data were available on neurodevelopmental impairment. Meta-analysis suggests that the pressure source may not affect the risk of pneumothorax (RR 0.73, 95% CI 0.40 to 1.34 (I² = 0%); RD -0.01, 95% CI -0.03 to 0.01; 14 trials, 1340 infants; low certainty evidence). Bubble CPAP likely increases the risk of moderate-severe nasal injury (RR 2.29, 95% CI 1.37 to 3.82 (I² = 17%); RD 0.07, 95% CI 0.03 to 0.11; number needed to treat for an additional harmful outcome 14, 95% CI 9 to 33; 8 trials, 753 infants; moderate certainty evidence). The pressure source may not affect the risk of bronchopulmonary dysplasia (RR 0.76, 95% CI 0.53 to 1.10 (I² = 0%); RD -0.04, 95% CI -0.09 to 0.01; 7 trials, 603 infants; low certainty evidence). AUTHORS' CONCLUSIONS: Given the low level of certainty about the effects of bubble CPAP versus other pressure sources on the risk of treatment failure and most associated morbidity and mortality for preterm infants, further large, high-quality trials are needed to provide evidence of sufficient validity and applicability to inform context- and setting-relevant policy and practice.
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Affiliation(s)
- Raj Prakash
- Paediatrics, York and Scarborough Teaching Hospitals NHS Trust, York, UK
| | | | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Anders AP, Murdock L, McQuay C, du Plessis E, Vachharajani A. Implementation of Bubble Continuous Positive Airway Pressure in the Delivery Room and NICU. Neoreviews 2022; 23:e225-e228. [PMID: 35229139 DOI: 10.1542/neo.23-3-e225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Anjali P Anders
- Women's and Children's Hospital and University of Missouri School of Medicine, Columbia, Missouri
| | - Linda Murdock
- Women's and Children's Hospital and University of Missouri School of Medicine, Columbia, Missouri
| | - Christine McQuay
- Women's and Children's Hospital and University of Missouri School of Medicine, Columbia, Missouri
| | - Elizabeth du Plessis
- Women's and Children's Hospital and University of Missouri School of Medicine, Columbia, Missouri
- Center for Education and Development, University of Missouri Healthcare, Columbia, Missouri
| | - Akshaya Vachharajani
- Women's and Children's Hospital and University of Missouri School of Medicine, Columbia, Missouri
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Standardized nCPAP Care Bundle to Decrease Days to Wean Off nCPAP: A Quality Improvement Initiative. Adv Neonatal Care 2021; 22:284-290. [PMID: 34743116 DOI: 10.1097/anc.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective bubble nasal continuous positive airway pressure (bnCPAP) implementation is a means to maintain functional residual capacity (FRC) and avoid pulmonary morbidities in neonates. PURPOSE A quality improvement project was introduced to establish a standardized bnCPAP care bundle. METHODS A bnCPAP care bundle focusing on shoulder roll use, bnCPAP positioning, assessment for suctioning need, and nasopharynx suctioning was created. The outcome measures collected were percentage of time the infant's pulse saturation was less than 86%, corrected gestational age (CGA) when off bnCPAP, length of time a neonate is on bnCPAP, Downes' score, and compliance to bnCPAP care bundle. RESULTS An independent-samples t test found a statistically significant higher mean prior to the initiative in the percentage of time the oxygen saturation was less than 86%, Downes' score, length of time, and CGA to wean off bnCPAP (M = 11.7% ± 10.1%, M = 1.6 ± 1.1, M = 27.7 days ± 29.0 days, and M = 35.0 weeks ± 3.38 weeks, respectively) than after the initiative (M = 4.0% ± 4.8%, M = 1.1 ± 0.8, M = 11.2 days ± 10.2 days, and M = 32.8 weeks ± 1.00 weeks, respectively). IMPLICATIONS FOR PRACTICE AND RESEARCH Implementing a standardized bnCPAP care bundle showed improvement in oxygen saturation and increased success of weaning off bnCPAP. Future studies to increase the collected data are needed to compare the outcomes on infants born at each gestational age.
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Djagbletey R, Aniteye E, Darkwa EO, Sarpong P, Aryee G, Ohene BEK, Kpodonu J, Makowski L, Smallwood CD. A Simplified Adult Expiratory Support Device: First Clinical Cases in a Low Resource Setting. Ann Thorac Surg 2021; 113:1021-1025. [PMID: 34562461 DOI: 10.1016/j.athoracsur.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE In Low and Middle-Income Countries mechanical ventilators or commercially available devices used to offer continuous positive airway pressure (CPAP) are not readily affordable and available. In Ghana, nearly 10% of critically ill patients presenting to the emergency department require ventilator support. DESCRIPTION We designed, built and tested a simple expiratory positive airway pressure (EPAP) device to provide adult respiratory support in low resource environments with or without supplemental oxygen and without the need for electricity. EVALUATION Laboratory tests demonstrated that the device is capable of delivering EPAP at levels expected to provide significant assistance to some patients. We present the first two cases where the use of this simple EPAP device provided critical respiratory support during weaning of patients from mechanical ventilation. CONCLUSIONS A low cost 3D printable adult respiratory support device could provide substantial benefit to patients suffering from respiratory distress through the delivery of appropriate levels of EPAP in a low resource setting with limited infrastructure. Further clinical validation is needed for broader application in low resource settings.
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Affiliation(s)
- Robert Djagbletey
- Department of Anaesthesia, University of Ghana Medical School, Korle-Bu, Accra, Ghana
| | - Ernest Aniteye
- Department of Anaesthesia, University of Ghana Medical School, Korle-Bu, Accra, Ghana
| | - Ebenezer Owusu Darkwa
- Department of Anaesthesia, University of Ghana Medical School, Korle-Bu, Accra, Ghana
| | - Pokua Sarpong
- Department of Anaesthesia, Korle Bu Teaching Hospital
| | - George Aryee
- Department of Anaesthesia, University of Ghana Medical School, Korle-Bu, Accra, Ghana
| | - Bright E K Ohene
- Harvard Medical School, Boston MA; Department of Bioengineering, Northeastern University, Boston MA
| | - Jacques Kpodonu
- Harvard Medical School, Boston MA; Division of Cardiac Surgery Beth Israel Deaconess Medical Center.
| | - Lee Makowski
- Department of Bioengineering, Northeastern University, Boston MA; Departments of Chemistry and Chemical Biology at Northeastern University, Boston, MA, USA
| | - Craig D Smallwood
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain Medicine at Boston Children's Hospital
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Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
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Bharadwaj SK, Alonazi A, Banfield L, Dutta S, Mukerji A. Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2020; 105:526-531. [PMID: 31969457 DOI: 10.1136/archdischild-2019-318165] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Use 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 unclear. OBJECTIVE To systematically review and meta-analyse short-term clinical outcomes among preterm infants treated with bubble CPAP vs all other forms of CPAP. METHODS Prospective experimental studies published from 1995 onward until October 2018 comparing bubble versus other CPAP forms in preterm neonates <37 weeks' gestational age were included after a systematic review of multiple databases using pre-specified search criteria. RESULTS A total of 978 articles were identified, of which 19 articles were included in meta-analyses. Of these, 5 had a high risk of bias, 8 had unclear risk and 6 had low risk. The risk of the primary outcome (CPAP failure within 7 days) was lower with bubble CPAP (0.75; 95% CI 0.57 to 0.98; 12 studies, 1194 subjects, I2=21%). Among secondary outcomes, only nasal injury was higher with use of bubble CPAP (risk ratio (RR) 2.04, 95% CI 1.33 to 3.14; 9 studies, 983 subjects; I2=42%) whereas no differences in mortality (RR 0.82, 95% CI 0.47 to 1.92; 9 studies, 1212 subjects, I2=20%) or bronchopulmonary dysplasia (BPD) (RR 0.8, 95% CI 0.53 to 1.21; 8 studies, 816 subjects, I2=0%) were noted. CONCLUSION Bubble CPAP may lead to lower incidence of CPAP failure compared with other CPAP forms. However, it does not appear to translate to improvement in mortality or BPD and potential for nasal injury warrants close monitoring during clinical application. TRIAL REGISTRATION NUMBER CRD42019120411.
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Affiliation(s)
| | | | - Laura Banfield
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Sourabh Dutta
- Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Mukerji
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Chiu HY, Chu SM, Lin HY, Tsai ML, Chen YT, Lin HC. Evidence base multi-discipline critical strategies toward better tomorrow for very preterm infants. Pediatr Neonatol 2020; 61:371-377. [PMID: 32201157 DOI: 10.1016/j.pedneo.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/30/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
Despite advances in neonatal intensive care in the recent decade, a large number of very preterm infants (VPIs) remain at risk for significant neurodevelopmental impairment (NDI). Given that there are many interventions need to be implemented during the critical perinatal period so that complications of these vulnerable VPIs could be minimized, it is urgent to develop multi-discipline strategies based on evidence to be carried out. The objective of this new term evidence-based perinatal critical strategies (EBPCS), is to provide beneficial intervention towards better neurodevelopmental outcomes, specifically for preterm infants below 28 weeks gestational age. EBPCS is defined as the management of the VPIs during the perinatal period which would include antenatal counseling with team briefing and share decision making, treat the chorioamnionitis, antenatal MgS04, antenatal steroid, delayed cord clamping/milking, neonatal resuscitation team preparation, prevention of hypothermia, immediate respiratory support with continuous positive airway pressure at delivery room, less invasive surfactant administration, early surfactant with budesonide therapy, support of cardiovascular system, early initiate of probiotics administration, early caffeine, early parenteral and enteral nutrition, promptly initiating antibiotics. These critical strategies will be discussed detail in the text; nonetheless, standardized protocols, technical skills and repeated training are the cornerstones of successful of EBPCS. Further experience from different NICU is needed to prove whether these very complicate and comprehensive perinatal critical strategies could translate into daily practice to mitigate the incidence of NDI in high-risk VPIs.
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Affiliation(s)
- Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chih Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan.
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Nørgaard M, Stagstrup C, Lund S, Poulsen A. To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries. J Trop Pediatr 2020; 66:339-353. [PMID: 31599959 DOI: 10.1093/tropej/fmz069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Bubble-continuous positive airway pressure (bCPAP) is a simple, low-cost ventilation therapy with the potential to lower morbidity and mortality in children in low- and middle-income countries (LMICs). AIM To examine (i) whether bCPAP is a safe and effective treatment for children in all age-groups presenting with respiratory distress from any cause, (ii) LMIC-implemented bCPAP devices including their technical specifications and costs and (iii) the setting and level of health care bCPAP has been implemented in. METHOD A systematic search was performed of Embase, PubMed and Web of Science. Inclusion criteria: bCPAP for children with respiratory distress in all age groups in LMICs. Database searches were performed up to 1 November 2018. RESULTS A total of 24 publications were eligible for the review. For neonates bCPAP was superior in improving survival and clinical progression compared with oxygen therapy and mechanical ventilation (MV). In two studies bCPAP was superior to low flow oxygen in reducing mortality in children 29 days to 13 months. Respiratory rate reductions were significant across all ages. Only three of six studies in children of all ages evaluated serious adverse events. In 12 studies comprising 1338 neonates treated with bCPAP, pneumothorax was reported 27 times. The majority of studies were carried out at tertiary hospitals in middle-income countries and 50% implemented the most expensive bCPAP-device. CONCLUSION In neonates and children below 13 months bCPAP is a safe treatment improving clinical outcomes and reducing the need for MV, without an increase in mortality. High-quality studies from non-tertiary settings in low-income countries are needed.
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Affiliation(s)
- Mathilde Nørgaard
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Cecilie Stagstrup
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Stine Lund
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anja Poulsen
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Decreasing Chronic Lung Disease Associated with Bubble CPAP Technology: Experience at Five Years. Pediatr Qual Saf 2020; 5:e281. [PMID: 32426643 PMCID: PMC7190251 DOI: 10.1097/pq9.0000000000000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 03/11/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction: Bubble continuous positive airway pressure (bCPAP) is associated with a decreased risk for chronic lung disease (CLD) in preterm neonates. This report examined the effectiveness of adopting bCPAP to reduce respiratory complications and medication usage in a community hospital NICU. Methods: The efficacy of bCPAP was assessed by retrospective examination and comparison of 45 neonates who received bCPAP and 87 neonates who received conventional ventilation only. Data on medication usage were also collected and analyzed. Results: After introduction of the bCPAP protocol, the median number of days on oxygen decreased in the bCPAP group compared with the conventional ventilation only group (median = 33 days, IQR = 7.5–66 vs median = 0, IQR = 0–0; P < 0.001). The exposure to conventional ventilation decreased in the bCPAP group compared with the conventional ventilation only group (median = 18 days, IQR = 5–42.5 vs median = 0, IQR = 0–7; P < 0.001). Postimplementation of bCPAP revealed decreases in CLD from 26 (30%) in the conventional ventilation only group to 2 (4%) in the bCPAP group (P = 0.002); there was also a significant decrease in the use of sedative medications in the bCPAP group compared with the conventional ventilation only group (mean = 5.20 doses, SD = 31.97 vs mean = 1.43, SD = 9.98; P < 0.001). Conclusion: The use of bCPAP results in significant decreases in the use of conventional ventilation, the risk for CLD, and the need for sedative medication.
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Myers S, Dinga P, Anderson M, Schubert C, Mlotha R, Phiri A, Colbourn T, McCollum ED, Mwansambo C, Kazembe P, Lang HJ. Use of bubble continuous positive airway pressure (bCPAP) in the management of critically ill children in a Malawian paediatric unit: an observational study. BMJ Open Respir Res 2019; 6:e000280. [PMID: 30956794 PMCID: PMC6424262 DOI: 10.1136/bmjresp-2018-000280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 10/27/2018] [Accepted: 11/16/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction In low-resource countries, respiratory failure is associated with a high mortality risk among critically ill children. We evaluated the role of bubble continuous positive airway pressure (bCPAP) in the routine care of critically ill children in Lilongwe, Malawi. Methods We conducted an observational study between 26 February and 15 April 2014, in an urban paediatric unit with approximately 20 000 admissions/year (in-hospital mortality <5% approximately during this time period). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. Children up to the age of 59 months with signs of severe respiratory dysfunction were recruited. Survival was defined as survival during the bCPAP-treatment and during a period of 48 hours following the end of the bCPAP-weaning process. Results 117 children with signs of respiratory failure were included in this study and treated with bCPAP. Median age: 7 months. Malaria rapid diagnostic tests were positive in 25 (21%) cases, 15 (13%) had severe anaemia (Hb < 7.0 g/dL); 55 (47%) children had multiorgan failure (MOF); 22 (19%) children were HIV-infected/exposed. 28 (24%) were severely malnourished. Overall survival was 79/117 (68%); survival was 54/62 (87%) in children with very severe pneumonia (VSPNA) but without MOF. Among the 19 children with VSPNA (single-organ failure (SOF)) and negative HIV tests, all children survived. Survival rates were lower in children with MOF (including shock) (45%) as well as in children with severe malnutrition (36%) and proven HIV infection or exposure (45%). Conclusion Despite the limitations of this study, the good outcome of children with signs of severe respiratory dysfunction (SOF) suggests that it is feasible to use bCPAP in the hospital management of critically ill children in resource-limited settings. The role of bCPAP and other forms of non-invasive ventilatory support as a part of an improved care package for critically ill children with MOF at tertiary and district hospital level in low-resource countries needs further evaluation. Critically ill children with nutritional deficiencies and/or HIV infection/exposure need further study to determine bCPAP efficacy.
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Affiliation(s)
| | | | - Margot Anderson
- United States Peace Corps, Washington, DC, USA.,Malawian College of Medicine, Lilongwe, Malawi
| | - Charles Schubert
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA.,Division of Emergency Medicine, Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Ajib Phiri
- Malawian College of Medicine, Lilongwe, Malawi
| | - Tim Colbourn
- University College London Institute for Global Health, London, UK
| | | | | | - Peter Kazembe
- Baylor College of Medicine, Children Clinical Centre of Excellence, Lilongwe, Malawi
| | - Hans-Joerg Lang
- Malawian College of Medicine, Lilongwe, Malawi.,Centre for International Migration and Development (CIM)/German International Cooperation (GIZ), Eschborn, Germany
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12
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Ekhaguere OA, Mairami AB, Kirpalani H. Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries. Paediatr Respir Rev 2019; 29:31-36. [PMID: 29907334 DOI: 10.1016/j.prrv.2018.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/27/2018] [Indexed: 10/17/2022]
Abstract
Over 80% of the global burden of childhood deaths occur in Low- and Middle-Income Countries (LMIC). Of the leading causes of death, respiratory failure is common to the top three. Bubble Continuous Positive Airway Pressure (bCPAP) is a standard therapy considered safe and cost effective in high resource settings. Although high-quality trials from LMIC are few, pooled available trial data considered alongside studies from high-income countries suggest that bCPAP: (i) reduces mortality; (ii) reduces the need for mechanical ventilation; and (iii) prevents extubation failure. Wider availability and optimal use at all levels of the health care system in LMIC are important steps to improve childhood survival. Studies aimed at effectively implementing, and sustaining safe use of bCPAP in the resource limited setting of LMIC are required.
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Affiliation(s)
- Osayame A Ekhaguere
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Amsa B Mairami
- Neonatal Unit, National Hospital Abuja, Federal Capital Territory, Nigeria
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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13
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Al-Lawama M, Alkhatib H, Wakileh Z, Elqaisi R, AlMassad G, Badran E, Hartman T. Bubble CPAP therapy for neonatal respiratory distress in level III neonatal unit in Amman, Jordan: a prospective observational study. Int J Gen Med 2018; 12:25-30. [PMID: 30636889 PMCID: PMC6307683 DOI: 10.2147/ijgm.s185264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Bubble continuous positive airway pressure (bCPAP), a noninvasive respiratory support modality used to manage newborns with respiratory distress, provides continuous pressure that helps prevent derecruitment of alveoli, increasing the lungs' functional residual capacity, and thus decreasing the work of breathing. bCPAP can be used to manage various respiratory conditions in the newborn. In this prospective study, we describe our experience using bCPAP therapy as the primary respiratory support in a level III neonatal unit in Amman, Jordan. In addition to reporting therapeutic indications, durations, and side effects, we aimed to identify areas requiring improvement in bCPAP therapy in our population. PATIENTS AND METHODS This prospective observational study investigated the usage of bCPAP in the management of respiratory distress in newborns admitted to a Jordan University Hospital in Amman. The newborns were followed until discharge. The patients' demographic and clinical data were recorded. RESULTS A total of 143 babies (mean gestational age, 36±2.7 weeks; mean birth weight, 2,770±1,800 g) were included. All received bCPAP as the primary respiratory support. The most common underlying cause of respiratory distress was transient tachypnea of the newborn (42%), followed by prolonged respiratory transition (34%). The therapy success rate was 93.7%; only nine infants failed bCPAP. The most common side effect was physical facial injury. CONCLUSION The use of neonatal bCPAP therapy is well established in Jordan University Hospital. The area of potential improvement was the low rate of bCPAP use as a primary respiratory support in extremely premature infants.
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Affiliation(s)
- Manar Al-Lawama
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Haitham Alkhatib
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Zaid Wakileh
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Randa Elqaisi
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Ghada AlMassad
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Eman Badran
- Pediatric Department, School of Medicine, Jordan University Hospital, The University of Jordan, Queen Rania Street, Amman 11942, Jordan,
| | - Tyler Hartman
- Pediatric department, Geisel School of Medicine, Dartmouth University, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Evidence Regarding the Use of Bubble Continuous Positive Airway Pressure in the Extremely Low Birth-Weight Infant: Benefits, Challenges, and Implications for Nursing Practice. Adv Neonatal Care 2018; 18:199-207. [PMID: 29746270 DOI: 10.1097/anc.0000000000000509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gentle ventilation with optimal oxygenation is integral to prevention of chronic lung disease in the extremely low birth-weight (ELBW) infant. Various types of noninvasive ventilation are used in neonatal intensive care units worldwide. Bubble continuous positive airway pressure (BCPAP) has been in use in newborn intensive care since 1975. PURPOSE To synthesize the current evidence on the use of BCPAP in the ELBW infant and its relationship to outcomes, particularly morbidity and mortality. METHODS/SEARCH STRATEGIES A literature review was completed using PubMed, EMBASE, CINAHL, and Cochrane with a focus on BCPAP use in the ELBW population. FINDINGS/RESULTS No study found was exclusive to the ELBW population. All studies ranged from ELBW to full-term neonates. Studies supported the use of BCPAP in the ELBW, demonstrating decreased incidence of chronic lung disease and barotrauma through the use of oscillation and permissive hypercapnia. IMPLICATIONS FOR PRACTICE Literature supports the use of nasal bubble CPAP in the ELBW population. Barriers such as septal erosion, pneumothorax, inconsistent pressures, and air in the abdomen were identified and management recommendations were provided. IMPLICATIONS FOR RESEARCH Studies are needed comparing outcomes of nasal bubble CPAP use with other forms of CPAP in the ELBW infant, comparison of prongs to mask for nasal bubble CPAP, and comparing interventions to recommend optimal care bundles to prevent nasal septum injuries.
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Abelenda VLB, Valente TCO, Marinho CL, Lopes AJ. Effects of underwater bubble CPAP on very-low-birth-weight preterm newborns in the delivery room and after transport to the neonatal intensive care unit. J Child Health Care 2018; 22:216-227. [PMID: 29325421 DOI: 10.1177/1367493517752500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The development of less invasive ventilatory strategies in very-low-birth-weight (VLBW) preterm newborns has been a growing concern in recent decades. This study aimed to measure differences in the clinical progression of preterm newborns using two distinct periods in a university hospital: before and after using underwater bubble continuous positive airway pressure (ubCPAP). This is a retrospective study of VLBW preterm newborns with gestational ages less than or equal to 32 weeks admitted to the neonatal intensive care unit. The time series was divided into two groups: a pre-CPAP group ( n = 45) and a post-CPAP group ( n = 40). The post-CPAP group had fewer resuscitations, required fewer surfactant doses, spent fewer days on mechanical ventilation, and demonstrated less of a need for fraction of inspired oxygen > 30%. UbCPAP is an easy to use, minimally invasive, and effective ventilatory strategy for VLBW preterm newborns that can be used in environments with limited resources. Thus, adopting this simple strategy as part of a service organization and health policy can positively impact outcomes.
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Affiliation(s)
- Vera Lucia Barros Abelenda
- 1 Department of Physical Therapy, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Vila Isabel, Rio de Janeiro, Brazil.,2 Federal University of the State of Rio de Janeiro (UNIRIO), Urca, Rio de Janeiro, Brazil
| | | | - Cirlene Lima Marinho
- 1 Department of Physical Therapy, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Vila Isabel, Rio de Janeiro, Brazil.,3 School of Medical Sciences, State University of Rio de Janeiro, Avenida Professor Manuel de Abreu, Vila Isabel, Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- 4 Augusto Motta University Center, Avenida Paris, Bonsucesso, Rio de Janeiro, Brazil
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A Pilot Study of Responses to Suctioning Among Neonates on Bubble Nasal Continuous Positive Airway Pressure. Adv Neonatal Care 2017; 17:E3-E11. [PMID: 29210760 DOI: 10.1097/anc.0000000000000442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Maintenance of a patent airway while the neonate is on nasal continuous positive airway pressure (nasal CPAP) requires vigilant monitoring and oral/nasopharyngeal suctioning. Currently, no evidence-based guidelines for safe suctioning in neonates while on bubble nasal CPAP have been published. PURPOSE (1) To characterize the clinical and behavioral responses of neonates on bubble nasal CPAP in a level III neonatal intensive care unit following routine oral and nasopharyngeal suctioning. METHODS This pilot study has a 1-sample within-subject repeated-measures design in which neonates (N = 16) served as their own control. Data on a neonate's physiological and behavior measures (heart rate, respiratory rate, oxygen saturation [SaO2], and Premature Infant Pain Profile [PIPP] score) were collected before, during, and after the completion of suctioning sequence. FINDING/RESULTS A total of 16 neonates with a mean gestational age of 29.76 weeks and an average day of life of 3.4 were enrolled. The infant's heart rates did not differ significantly (P = .51) across the suctioning sequence. There were no statistical significant changes in the average respiratory rate across the suctioning sequences (P = .79). SaO2 demonstrated a drop between baseline and after each suctioning (P < .001). The PIPP score demonstrated a precipitous increase throughout the procedure (P < .001). On average, it took 9.5 seconds (SD = 4.9) to complete the suctioning sequences. IMPLICATIONS FOR PRACTICE Our results suggest that the guideline tested is safe and tolerated by infants. IMPLICATIONS FOR RESEARCH This guideline should be tested in a larger sample and with neonates on other nasal CPAP systems.
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