Non-invasive respiratory support for infants in low- and middle-income countries

Maternal prenatal systemic inflammation indexes predicts premature neonatal respiratory distress syndrome

Neonatal respiratory distress syndrome (NRDS) is one of the leading causes of neonatal mortality in low-income countries. It is caused by a lack of surface-active substances in the lungs, and the maternal inflammatory response plays an important role in the formation of surface-active substances in the fetal lungs. We aimed to investigate the correlation between maternal prenatal systemic inflammatory indices and respiratory distress syndrome in preterm neonates. This is a retrospective case-control study that collected data from all patients who delivered between 28 and 36 weeks of gestation at Longhua District People's Hospital in Shenzhen City and whose infants were admitted to the neonatal unit, newborns with respiratory distress syndrome were in the experimental group (NRDS group), and newborns without NRDS were in the control group (non-NRDS group). To minimize the effect of confounders on the results, propensity score matching was performed on baseline characteristics. Totally, 524 patients were included (93 in the NRDS group and 431 in the non-NRDS group), and 71 matched pairs (142 patients). The neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), aggregate index of systemic inflammation (AISI) and neutrophil lymphocyte to platelet ratio (NLPR) were higher in the NRDS group than in the non-NRDS group (p < 0.05). The ROC curves of NLR, dNLR, SII, SIRI, AISI and NLPR for the diagnosis of NRDS were plotted, and it was found that the combined diagnostic efficacy of these six systemic inflammatory markers was better (AUC: 0.643, P = 0.003). Patients were divided into two groups based on the cut-off values determined from the ROC curves, and analysis using binary regression models revealed that SII ≥ 1199.94 (OR, 2.554; 95% CI 1.245-5.239, P = 0.011) and NLPR ≥ 0.0239 (OR, 2.175; 95% CI 1.061-4.459, P = 0.034) were independent risk factors predicting NRDS. Maternal prenatal SII ≥ 1199.94 and NLPR ≥ 0.0239 are independent risk factors for NRDS, and clinicians may be used to prevent neonatal respiratory distress in advance to reduce the incidence of NRDS.

A Novel CPAP Device With an Integrated Oxygen Concentrator for Low Resource Countries: In Vitro Validation and Usability Test in Field

Goal: To develop and validatea novel neonatal non-invasive respiratory support device prototype designed to operate in low-resource settings. Methods: The device integrates a blower-based ventilator and a portable oxygen concentrator. A novel control algorithm was designed to achieve the desired fraction of inspired oxygen (FiO2) while minimizing power consumption. The accuracy of the delivered FiO2 and the device power consumption were evaluated in vitro, and a formative usability test was conducted in a rural hospital in Uganda. Results: The agreement between the set and delivered FiO2 was high (limit of agreement:-5.6 ÷ 3.8%). For FiO2 below 60%, the control algorithm reduced the power drain by 50%. The device was also appreciated by intended users. Conclusion: The prototype proved effective in delivering oxygen-enriched continuous positive airway pressure in the absence of compressed air and oxygen, holding promise for a sustainable and effective implementation of neonatal respiratory support in low-resource settings.

Nasal intermittent positive pressure ventilation as a rescue therapy after nasal continuous positive airway pressure failure in infants with respiratory distress syndrome

OBJECTIVE

Evaluate whether nasal intermittent positive-pressure ventilation (NIPPV) as rescue therapy after initial nasal continuous positive airway (NCPAP) failure reduces need for invasive mechanical ventilation (IMV) in infants with respiratory distress syndrome (RDS).

DESIGN

Retrospective cohort involving 156 preterm infants who failed initial NCPAP and were then submitted to NIPPV rescue therapy and classified into NIPPV success or failure, according to need for IMV.

RESULT

Of all infants included, 85 (54.5%) were successfully rescued with NIPPV while 71 (45.5%) failed. The NIPPV success group had significantly lower rates of bronchopulmonary dysplasia, peri/intraventricular hemorrhage, patent ductus arteriosus and greater survival without morbidities (all p ≤ 0.01). Infants who failed NIPPV had earlier initial NCPAP failure (p = 0.09). In final logistic regression model, birthweight ≤1000 g and need for surfactant remained significant factors for NIPPV failure.

CONCLUSION

NIPPV rescue therapy reduced the need for IMV in infants that failed NCPAP and was associated with better outcomes.

Bubble CPAP respiratory support devices for infants in low-resource settings

Approximately 46% of the 5.2 million annual under-5 deaths derive from neonatal conditions commonly associated with hypoxemia or acute respiratory distress. It has been estimated that 98% of these deaths occur in low- and middle-income countries (LMICs). Effective implementation of noninvasive respiratory support at all levels of healthcare could significantly reduce neonatal mortality. Several factors limit the widespread and effective implementation of noninvasive respiratory support in LMICs, including inadequate infrastructure, lack of proper instrumentation, shortage of skilled staff, costly disposables, and difficulties in the supply of consumables and spare parts. The aim of this state-of-the-art paper is to provide a detailed evaluation of the commercially available devices providing noninvasive respiratory support in LMICs, focusing on bubblecontinuous positive airway pressure (bCPAP). bCPAP might be administrated using a variety of different commercial devices, including devices specifically designed for LMICs, as well as using self-made systems. We described all the equipment required for safe and effective implementation of bCPAP, including air and oxygen sourced, pressure-reducing valves and flowmeters, air-oxygen blending systems, humidifiers, respiratory support devices, patient circuits, and airway interfaces. Specifically, we critically evaluated the advantages and disadvantages of various existing solutions within the context of low-resource settings.

Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

Innovations and adaptations in neonatal and pediatric respiratory care for resource constrained settings

Respiratory disease is a leading cause of death in children under 5 years of age worldwide, and most of these deaths occur in low- to middle-income countries (LMICs) where advanced respiratory care technology is often limited. Much of the equipment required to provide advanced respiratory care is unavailable in these areas due to high costs, the need for specialty trained personnel, and myriad other resource constraints that limit uptake and sustainable use of these devices, including reliable access to electricity, sensitive equipment needing frequent maintenance, single-patient-use supplies, and lack of access to sterilization equipment. Compounding the problem, pediatrics is uniquely challenging in that one size does not fit all, or even most patients. Despite these substantial barriers, numerous innovations in respiratory care technology have been made in recent years that have brought increasing access to high quality respiratory care in some of the most remote areas of the world. In this article, we intend to review the global burden of respiratory diseases for children, highlight the prototypical innovations that have been made in bringing respiratory care to LMICs, spotlight some of the technologies being actively developed to improve respiratory care in resource-constrained settings, and conclude with a discussion highlighting areas where further innovation is still needed.

Efficacy of pedagogical framework in neonatal resuscitation skill learning in a resource-limited setting: a randomized controlled trial

BACKGROUND

The educational efficacy in neonatal resuscitation relies on the subject and teaching strategies. Therefore, it is imperative to test diverse educational methods if they are more instructive to engage students in active learning and practicing knowledge. Hence, the present study aims to investigate the efficacy of a pedagogical framework in neonatal resuscitation skill learning among nursing students in a resource-limited setting.

METHODS

A single-blind randomized controlled trial was conducted between October 2020 to March 2021. Sixty nursing students in the 3rd and 4th year of professional training were randomly allocated to the pedagogy and the traditional group. The pedagogy group learned via 6-step LSPPDM (Learn, See, Practice, Prove, Do, Maintain) pedagogy including lectures, video, clinical observation, skill sessions under supervision, and self-directed practice. The traditional group learned through 2-step (Learn, Practice) method that included lectures and skill sessions under supervision. The outcomes measured included technical and non-technical skills in neonatal resuscitation. The technical skill deals with steps such as stimulation, ventilation, oxygenation, intubation, chest compression, medications, and reporting. Non-technical skills refer to teamwork skills that focus on the interaction between leader and helper. Both skills were measured through previously published validated tools two times before and after the intervention by blinded assessors in a simulated delivery room.

RESULTS

Overall, the skill was significantly improved in both groups after intervention. Yet, the results showed that the mean difference of technical skill score in the pedagogy group (24.3 ± 3.5) was significantly higher (p <  0.001) compared to the traditional group (16.2 ± 2.4). Likewise, the mean difference of non-technical skill score in the pedagogy (36.9 ± 1.9) was highly significant (p <  0.001) compared to the traditional group (31.2 ± 1.7).

CONCLUSIONS

The LSPPDM pedagogy was found more effective in enhancing technical and non-technical skills in neonatal resuscitation compared to the traditional method. The results of this study support the efficacy of the 6-step LSPPDM pedagogy in the education of nursing students regarding neonatal resuscitation in a resource-limited setting.

TRIAL REGISTRATION

Prospectively registered at ClinicalTrials.gov ( NCT04748341 ).

Reducing neonatal mortality and respiratory distress syndrome associated with preterm birth: a scoping review on the impact of antenatal corticosteroids in low- and middle-income countries

BACKGROUND

The most common cause of death among preterm infants in low- and middle-income countries is respiratory distress syndrome. The purpose of this review was to assess whether antenatal corticosteroids given to women at risk of preterm birth at ≤ 34 weeks of gestation reduce rates of neonatal mortality and respiratory distress syndrome in low- and middle-income countries.

METHODS

Two reviewers independently searched four databases including MEDLINE (through PubMed), CINAHL, Embase, and Cochrane Libraries. We did not apply any language or date restrictions. All publications up to April 2020 were included in this search.

RESULTS

The search yielded 71 articles, 10 of which were included in this review (3 randomized controlled trials, 7 observational studies, 36,773 neonates). The majority of studies reported associations between exposure to antenatal corticosteroids and lower rates of neonatal mortality and respiratory distress syndrome. However, a few studies reported that antenatal corticosteroids were not associated with improved preterm birth outcomes.

CONCLUSIONS

Most of the studies in low- and middle-income countries showed that use of antenatal corticosteroids in hospitals with high levels of neonatal care was associated with lower rates of neonatal mortality and respiratory distress syndrome. However, the findings are inconclusive because some studies in low-resource settings reported that antenatal corticosteroids had no benefit in reducing rates of neonatal mortality or respiratory distress syndrome. Further research on the impact of antenatal corticosteroids in resource-limited settings in low-income countries is a priority.

The Influence of High Flow Nasal Cannulae on the Outcomes of Severe Respiratory Disease in Children Admitted to a Regional Hospital in South Africa

In settings where access to paediatric intensive care unit (PICU) facilities is constrained and transfer capacity is limited, High Flow Nasal Cannulae (HFNC) might fill an important service gap. The aim of this study was to document the effect of HFNC on the outcomes of children admitted with severe respiratory disease at a regional hospital without a PICU in Cape Town, South Africa. It is a 4-year retrospective analysis documenting two periods of 2 years each, one before (2013-15) and one after (2016-18) the initiation of HFNC use. Patients were between the ages of 2 months and 13 years and had been admitted to a paediatric ward. Outcomes were defined by the need for transfer to a tertiary hospital, the need for invasive ventilation and death. There were 90 instances of HFNC use with a significant reduction in the number of children who were transferred (59 vs. 31), invasively ventilated (20 vs. 6, p ≤ 0.01) and who died (3 vs. 0, p = 0.02). Before HFNC implementation, there was also a significantly greater proportion of transferred children who remained on low flow nasal cannulae (15 vs. 2, p ≤ 0.001) at the tertiary hospital. Children who failed HFNC use tended to do this within a day of initiation (Median 11 vs. 60 h for success, p ≤ 0.001). There were no complications related to its use. We believe that in our setting the utilization of HFNC has helped to timeously and accurately identify children needing to be transferred and may mitigate against severe respiratory disease progression.

Implementing bubble continuous positive airway pressure in a lower middle-income country: a Nigerian experience

Bubble CPAP (bCPAP) is used for respiratory distress (RD) in neonates. The leading causes of neonatal mortality can lead to severe RD. Many neonatal deaths are preventable using evidence-based interventions like bCPAP as part of a comprehensive approach. The study aimed to assess the implementation of a multi-center, comprehensive hospital-based bCPAP program in a low-middle-income country using a low-cost bCPAP device. Seven established hospitals in three Nigerian States were selected using purposive sampling. A respiratory support program was developed and implemented using the Pumani® bCPAP. Neonates <28 days old with severe RD, birth weight >1000g and breathing spontaneously, were eligible. The program lasted 22 months. Focus group discussions and in-depth interviews of healthcare workers and hospital administrators were used in program assessment. Content analysis of qualitative data completed. The staff reported that the bCPAP device was easy to use and effective. All staff reported comfort in eligible patient identification, effective set up and bCPAP administration. All study sites experienced varying degrees of electric power interruption and oxygen availability and affordability. Staff training, staffing disruptions, data collection challenges and use of improvised bCPAP contributed to low enrollment. Advocacy, direct program support, and innovation using locally available resources improved enrollment. Professional organization collaboration, competency-based training and peer mentoring contributed to program success. Thorough pre-program assessment, with comprehensive understanding of all aspects of the existing system within the local context which are likely to impact the introduction of a new program is important to implementation success.

To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries

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.

Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review

BACKGROUND

Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization.

METHODS

A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082).

RESULTS

Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation.

CONCLUSIONS

With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.

Optimal Ventilation and Surfactant Therapy in Very-Low-Birth-Weight Infants in Resource-Restricted Regions

In resource-restricted regions, respiratory distress syndrome (RDS) data are often underreported, making the determination of effective interventions and their outcome difficult. The combination of oxygen, nasal continuous positive airway pressure (CPAP) and surfactant therapy has the potential to prevent 42% of RDS-related deaths in sub-Saharan Africa, despite the financial implications. This article provides a brief overview on the status of RDS management, mainly nasal CPAP and surfactant therapy in very-low-birth-weight infants, in resource-restricted regions of sub-Saharan Africa. Data from the public health sector, as compared to the private health sector, of the Western Cape province, South Africa, are used to illustrate what RDS management strategies are able to accomplish in a resource-restricted region. Upscaling of all components (antenatal care, antenatal corticosteroids, prevention of hypothermia and RDS management strategies) are required to decrease premature infant mortality rates in resource-restricted areas.

Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial

Background

Pneumonia is the leading cause of death among children globally. Most pneumonia deaths in low-income and middle-income countries (LMICs) occur among children with HIV infection or exposure, severe malnutrition, or hypoxaemia despite antibiotics and oxygen. Non-invasive bubble continuous positive airway pressure (bCPAP) is considered a safe ventilation modality that might improve child pneumonia survival. bCPAP outcomes for high-risk African children with severe pneumonia are unknown. Since most child pneumonia hospitalisations in Africa occur in non-tertiary district hospitals without daily physician oversight, we aimed to examine whether bCPAP improves severe pneumonia mortality in such settings.

Methods

This open-label, randomised, controlled trial was done in the general paediatric ward of Salima District Hospital, Malawi. We enrolled children aged 1–59 months old with WHO-defined severe pneumonia and either HIV infection or exposure, severe malnutrition, or an oxygen saturation of less than 90%. Children were randomly assigned 1:1 to low-flow nasal cannula oxygen or nasal bCPAP. Non-physicians administered care; the primary outcome was hospital survival. Primary analyses were by intention-to-treat and interim and adverse events analyses per protocol. This trial is registered with ClinicalTrials.gov, number NCT02484183, and is closed.

Findings

We screened 1712 children for eligibility between June 23, 2015, and March 21, 2018. The data safety and monitoring board stopped the trial for futility after 644 of the intended 900 participants were enrolled. 323 children were randomly assigned to oxygen and 321 to bCPAP. 35 (11%) of 323 children who received oxygen died in hospital, as did 53 (17%) of 321 who received bCPAP (relative risk 1·52; 95% CI 1·02–2·27; p=0·036). 13 oxygen and 17 bCPAP patients lacked hospital outcomes and were considered lost to follow-up. Suspected adverse events related to treatment occurred in 11 (3%) of 321 children receiving bCPAP and 1 (<1%) of 323 children receiving oxygen. Four bCPAP and one oxygen group deaths were classified as probable aspiration episodes, one bCPAP death as probable pneumothorax, and six non-death bCPAP events included skin breakdown around the nares.

Interpretation

bCPAP treatment in a paediatric ward without daily physician supervision did not reduce hospital mortality among high-risk Malawian children with severe pneumonia, compared with oxygen. The use of bCPAP within certain patient populations and non-intensive care settings might carry risk that was not previously recognised. bCPAP in LMICs needs further evaluation before wider implementation for child pneumonia care.

Funding

Bill & Melinda Gates Foundation, International AIDS Society, Health Empowering Humanity.

Bubble CPAP devices for infants and children in resource-limited settings: review of the literature

Background: Early management of respiratory distress is critical to reducing mortality in infants and children in resource-limited settings. Bubble continuous positive airway pressure (bCPAP) can offer effective and affordable non-invasive respiratory support. Objective: To determine the best physical components of bubble CPAP circuits for respiratory support of children in low-resource settings. Methods: Using PubMed, CINAHL and LILACS, studies of any design in any language published before June 2017 which examined the physical components of bCPAP circuits were identified and reviewed. Results: After screening, the review included 45 articles: 17 clinical trials, 11 literature reviews, 10 technical assessments of bCPAP components, three reports of real-world implementation in low-resource settings, three cost analyses and one case report. There is no ideal bCPAP circuit for all settings and patients, but some choices are generally better than others in designing a circuit for low-resource settings. Oxygen concentrators are usually the best source of oxygen. As yet, there is no affordable and accurate oxygen blender. Nasal prongs are the simplest patient interface to use with the fewest complications but are not the cheapest option. Expiratory limbs should be at least 1 cm in diameter. Home-made pressure generators are effective, safe and affordable. Conclusion: This narrative review found many studies which evaluated the real clinical outcomes with bCPAP in the target population as well as technical comparison of bCPAP components. However, many studies were not blinded or randomised and there was significant heterogeneity in design and outcome measures. Abbreviations: bCPAP, bubble continuous positive airway pressure; CPAP, continuous positive airway pressure; FiO₂, fractional oxygen concentration; HFNC, high-flow nasal cannula; HIC, high-income countries; LMIC, low- and middle-income countries; NP, nasopharyngeal; O₂, oxygen; PEEP, positive end-expiratory pressure; PICO, Population, Intervention, Comparison and Outcome.

Key considerations prior to nasal high flow deployment in a Peruvian PICU from providers' perspectives

AIM

Implementation of healthcare interventions in resource-limited settings remains challenging. This exploratory qualitative study describes social and institutional factors to consider prior to nasal high flow deployment in a middle-income country.

METHODS

Researchers conducted eight nursing focus groups and four semi-structured physician interviews at Instituto Nacional de Salud del Niño in Lima, Peru. Participants were identified via purposive sampling. Data were transcribed, translated and coded using a rigorous and iterative process. Pertinent themes were identified using thematic analysis with Dedoose software.

RESULTS

Thirty-nine nurses and four physicians participated in focus groups and interviews, respectively. Participants identified five major factors: (i) Adequate training, (ii) Clinician buy-in, (iii) Resource-limited setting, (iv) Local social context and (v) Organizational change management. To create buy-in, physicians and nurses emphasised the need to recognise benefit of the intervention and agree with clinical practice standardization. Physicians and nurses described barriers specific to resource-limited settings, including unreliable supply chain, whereas nurses shared concerns about increasing workload and physician-nurse social hierarchy. Participants recognised the importance of team commitment and ongoing interdisciplinary communication for sustainability.

CONCLUSION

While some factors to consider prior to deployment of healthcare technology are universal, resource-limited settings have unique implementation barriers.

Risk and benefits of Bubble Continuous Positive Airway Pressure for neonatal and childhood respiratory diseases in Low- and Middle-Income countries

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.

Provider Perceptions of Bubble Continuous Positive Airway Pressure and Barriers to Implementation in a Level III Neonatal Unit in South India

BACKGROUND

Bubble continuous positive airway pressure (bCPAP) is a simple, safe, and cost-effective strategy to provide respiratory support to newborns with respiratory distress syndrome in resource-limited settings.

PURPOSE

To understand whether implementation of bCPAP, relative to other modes of respiratory support in the care of newborns with respiratory distress syndrome, increases positive attitudes about its potential for consistent and widespread use among providers in neonatal intensive care units (NICUs) of lower middle-income countries.

METHODS

Semistructured qualitative interviews with 14 healthcare providers, including 5 neonatal nurses, 2 respiratory therapists, 5 postgraduate trainees in pediatrics, and 2 attending physicians, were conducted at a level III NICU in south India where bCPAP had been in consistent use for 6 years. Interviews were transcribed and then coded and categorized using NVivo 10 Software (QSR International, Victoria, Australia).

FINDINGS

Categories that emerged from our data include (1) perceived indications, (2) learning curve, (3) perceived costs, (4) perceived shortages, and (5) barriers to use. Providers believed that bCPAP was easy to learn and that it helped empower neonatal nurses in decision-making process. Participants provided a nuanced perspective of cost-benefit associated with bCPAP and that it helped make optimal use of limited resources. Participants identified several barriers to the implementation of bCPAP.

IMPLICATIONS FOR PRACTICE

Providers of a level III NICU in a lower- to middle-income country viewed the use of bCPAP favorably. Addressing context-specific barriers will be important for the successful widespread implementation of bCPAP.

IMPLICATIONS FOR RESEARCH

Further research will need to focus on whether bCPAP can be safely implemented at level II NICUs.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Short term evaluation of respiratory effort by premature infants supported with bubble nasal continuous airway pressure using Seattle-PAP and a standard bubble device

Background

Almost one million prematurely born infants die annually from respiratory insufficiency, predominantly in countries with limited access to respiratory support for neonates. The primary hypothesis tested in the present study was that a modified device for bubble nasal continuous positive airway pressure (Bn-CPAP) would provide lower work of spontaneous breathing, estimated by esophageal pressure-rate products.

Methods

Infants born <32 weeks gestation and stable on Bn-CPAP with FiO₂ <0.30 were studied within 72 h following delivery. Esophageal pressures during spontaneous breathing were measured during 2 h on standard Bn-CPAP, then 2 h with Bn-CPAP using a modified bubble device presently termed Seattle-PAP, which produces a different pattern of pressure fluctuations and which provided greater respiratory support in preclinical studies, then 2 h on standard Bn-CPAP.

Results

All 40 infants enrolled completed the study and follow-up through 36 wks post menstrual age or hospital discharge, whichever came first. No infants were on supplemental oxygen at completion of follow-up. No infants developed pneumothoraces or nasal trauma, and no adverse events attributed to the study were observed. Pressure-rate products on the two devices were not different, but effort of breathing, assessed by areas under esophageal pressure-time curves, was lower with Seattle-PAP than with standard Bn-CPAP.

Conclusion

Use of Seattle-PAP to implement Bn-CPAP lowers the effort of breathing exerted even by relatively healthy spontaneously breathing premature neonates. Whether the lower effort of breathing observed with Seattle-PAP translates to improvements in neonatal mortality or morbidity will need to be determined by studies in appropriate patient populations.

Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science-Lessons Learned

Acute lower respiratory infections are the leading cause of death outside the neonatal period for children less than 5 years of age. Widespread availability of invasive and non-invasive mechanical ventilation in resource-rich settings has reduced mortality rates; however, these technologies are not always available in many low- and middle-income countries due to the high cost and trained personnel required to implement and sustain their use. High flow nasal cannula (HFNC) is a form of non-invasive respiratory support with growing evidence for use in pediatric respiratory failure. Its simple interface makes utilization in resource-limited settings appealing, although widespread implementation in these settings lags behind resource-rich settings. Implementation science is an emerging field dedicated to closing the know-do gap by incorporating evidence-based interventions into routine care, and its principles have guided the scaling up of many global health interventions. In 2016, we introduced HFNC use for respiratory failure in a pediatric intensive care unit in Lima, Peru using implementation science methodology. Here, we review our experience in the context of the principles of implementation science to serve as a guide for others considering HFNC implementation in resource-limited settings.

The Effect of the Treatment with Heated Humidified High-Flow Nasal Cannula on Neonatal Respiratory Distress Syndrome in China: A Single-Center Experience

Background. Noninvasive respiratory support is considered the optimal method of providing assistance to preterm babies with breathing problems, including nasal continuous positive airway pressure (NCPAP) and humidified high flow nasal cannula (HHHFNC). The evidence of the efficacy and safety of HHHFNC used as the primary respiratory support for respiratory distress syndrome (RDS) is insufficient in low- and middle-income countries. Objective. To investigate the effect of heated humidified high flow nasal cannula on neonatal respiratory distress syndrome compared with nasal continuous positive airway pressure. Methods. An observational cross-sectional study was performed at a tertiary neonatal intensive care unit in suburban Wenzhou, China, in the period between January 2014 and December 2015. Results. A total of 128 infants were enrolled in the study: 65 in the HHHFNC group and 63 in the NCPAP group. The respiratory support with HHHFNC was similar to that with NCPAP with regard to the primary outcome. There is no significant difference between two groups in secondary outcomes. Comparing with NCPAP group, the incidence of nasal damage was lower in HHHFNC group. Conclusions. HHHFNC is an effective and well-tolerated strategy as the primary treatment of mild to moderate RDS in preterm infants older than 28 weeks of GA.