1
|
Wu AG, Luch S, Slusher TM, Fischer GA, Lunos SA, Bjorklund AR. The novel LESS (low-cost entrainment syringe system) O 2 blender for use in modified bubble CPAP circuits: a clinical study of safety. Front Pediatr 2024; 12:1313781. [PMID: 38410763 PMCID: PMC10894966 DOI: 10.3389/fped.2024.1313781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/25/2024] [Indexed: 02/28/2024] Open
Abstract
Background Bubble continuous positive airway pressure (bCPAP) is used in resource-limited settings for children with respiratory distress. Low-cost modifications of bCPAP use 100% oxygen and may cause morbidity from oxygen toxicity. We sought to test a novel constructible low-cost entrainment syringe system (LESS) oxygen blender with low-cost modified bCPAP in a relevant clinical setting. Methods We conducted a clinical trial evaluating safety of the LESS O2 blender among hospitalized children under five years old in rural Cambodia evaluating the rate of clinical failure within one hour of initiation of the LESS O2 blender and monitoring for any other blender-related complications. Findings Thirty-two patients were included. The primary outcome (clinical failure) occurred in one patient (3.1%, 95% CI = 0.1-16.2%). Clinical failure was defined as intubation, death, transfer to another hospital, or two of the following: oxygen saturation <85% after 30 min of treatment; new signs of respiratory distress; or partial pressure of carbon dioxide ≥60 mmHg and pH <7.2 on a capillary blood gas. Secondary outcomes included average generated FiO2's with blender use, which were 59% and 52% when a 5 mm entrainment was used vs. a 10 mm entrainment port with 5-7 cm H2O of CPAP and 1-7 L/min (LPM) of flow; and adverse events including loss of CPAP bubbling (64% of all adverse events), frequency of repair or adjustment (44%), replacement (25%), and median time of respiratory support (44 h). Interpretation Overall the LESS O2 blender was safe for clinical use. The design could be modified for improved performance including less repair needs and improved nasal interface, which requires modification for the blender to function more consistently.
Collapse
Affiliation(s)
- Andrew G Wu
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
| | - Sreyleak Luch
- Department of Pediatrics, Chenla Children's Healthcare, Kratie, Cambodia
| | - Tina M Slusher
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Pediatrics Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
| | - Gwenyth A Fischer
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
| | - Scott A Lunos
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, MN, United States
| | - Ashley R Bjorklund
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Pediatrics Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Poletto S, Trevisanuto D, Ramaswamy VV, Seni AHA, Ouedraogo P, Dellacà RL, Zannin E. Bubble CPAP respiratory support devices for infants in low-resource settings. Pediatr Pulmonol 2023; 58:643-652. [PMID: 36484311 DOI: 10.1002/ppul.26258] [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: 07/13/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sofia Poletto
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | | | | | | | | | - Raffaele L Dellacà
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | - Emanuela Zannin
- Neonatal Intesive Care Unit at Fondazione Monza e Brianza per il Bambino e la sua Mamma (MBBM), Monza, Italy
| |
Collapse
|
4
|
Buys H, Kerbelker T, Naidoo S, Mukuddem-Sablay Z, Nxumalo Z, Muloiwa R. Doing more with less: The use of non-invasive ventilatory support in a resource-limited setting. PLoS One 2023; 18:e0281552. [PMID: 36795742 PMCID: PMC9934338 DOI: 10.1371/journal.pone.0281552] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 01/25/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES Bubble CPAP (bCPAP), a non-invasive ventilation modality, has emerged as an intervention that is able to reduce pneumonia-related mortality in children in low resourced settings. Our study primarily aimed to describe a cohort of children who were started on CPAP in the Medical Emergency Unit (MEU) of Red Cross War Memorial Children's Hospital 2016-2018. METHODS A retrospective review of a randomly selected sample of paper-based folders was conducted. Children started on bCPAP at MEU were eligible for inclusion. Demographic and clinical data, management, and outcomes regarding admission to PICU, need for invasive ventilation and mortality were documented. Descriptive statistical data were generated for all relevant variables. Percentages depicted frequencies of categorical data while medians with interquartile ranges (IQR) were used to summarise continuous data. RESULTS Of 500 children started on bCPAP, 266 (53%) were male; their median age was 3.7 (IQR 1.7-11.3) months and 169 (34%) were moderately to severely underweight-for-age. There were 12 (2%) HIV-infected children; 403 (81%) had received appropriate immunisations for their age; and 119 (24%) were exposed to tobacco smoke at home. The five most common primary reasons for admission were acute respiratory illness, acute gastroenteritis, congestive cardiac failure, sepsis and seizures. Most children, 409 (82%), had no underlying medical condition. Most children, 411 (82%), were managed in high care areas of the general medical wards while 126 (25%) went to PICU. The median time on CPAP was 1.7 (IQR 0.9-2.8) days. The median hospitalisation time was 6 (IQR 4-9) days. Overall, 38 (8%) children required invasive ventilatory support. Overall, 12 (2%) children with a median age of 7.5 (IQR 0.7-14.5) months died, six of whom had an underlying medical condition. CONCLUSIONS Seventy-five percent of children initiated on bCPAP did not require PICU admission. This form of non-invasive ventilatory support should be considered more widely in the context of limited access to paediatric intensive care units in other African settings.
Collapse
Affiliation(s)
- Heloise Buys
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Ambulatory and Emergency Paediatrics Division, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Tamara Kerbelker
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Ambulatory and Emergency Paediatrics Division, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Shirani Naidoo
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Ambulatory and Emergency Paediatrics Division, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Zakira Mukuddem-Sablay
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Ambulatory and Emergency Paediatrics Division, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Zanele Nxumalo
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Ambulatory and Emergency Paediatrics Division, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Rudzani Muloiwa
- Red Cross War Memorial Children’s Hospital, Cape Town, Western Cape Province, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Kiger J. Neonatal ventilation. Semin Pediatr Surg 2022; 31:151199. [PMID: 36038215 DOI: 10.1016/j.sempedsurg.2022.151199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- James Kiger
- University of Pittsburgh Medical Center, Department of Pediatrics, Pittsburgh, PA USA.
| |
Collapse
|
6
|
Coffey PS, Wollen A. Nonclinical Bench Performance Testing of a Very Low-Cost Nonelectric Bubble Continuous Positive Airway Pressure (bCPAP) and Blenders Device Designed for Newborn Respiratory Support. MEDICAL DEVICES (AUCKLAND, N.Z.) 2022; 15:187-197. [PMID: 35784612 PMCID: PMC9249094 DOI: 10.2147/mder.s318218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/16/2022] [Indexed: 11/23/2022]
Abstract
Purpose Bubble continuous positive airway pressure (bCPAP) is often used to treat respiratory distress experienced by some 15 million preterm infants born globally every year. In low- and middle-income countries, improvised bCPAP devices are used, often without a blender that protects the infant from the sequelae of excessive oxygen exposure. Materials and Methods The aim of this bench testing was to assess the mechanical safety and performance of the PATH bCPAP and blenders device, which provides a stable and reliable source of pressurized blended gas without the requirement for a source of compressed medical air or electricity. The device includes two fixed ratio blenders: a “low” blend that provides 37% oxygen and a “high” blend that provides 60% oxygen. We performed bench testing to characterize the performance of the bCPAP and blenders, including respiratory circuit verification, blender verification, conditioned humidity testing, and sound measurement. Results Test results for all performance variables met the acceptance criteria of our product requirement specification. The device provides a fixed ratio of air and oxygen that is consistent over the entire range of clinically relevant pressures (4 to 8 cmH2O) and remains consistent despite changes in flow (2 to 7 liters per minute). The blend is stable within ± 5% of the blenders’ nominal blend ratio when used with a 100% oxygen source, irrespective of the flow and pressure from the oxygen source or the flow and pressure of the blended gas delivered to the neonate. Sound and humidity test results were within specifications. Conclusion This very low-cost nonelectric bCPAP and blenders device is optimally designed to deliver a stable and reliable source of pressurized blended gas.
Collapse
Affiliation(s)
- Patricia S Coffey
- Medical Devices and Health Technologies, PATH, Seattle, Washington, USA
| | - Alec Wollen
- Medical Devices and Health Technologies, PATH, Seattle, Washington, USA
| |
Collapse
|
7
|
Tooke L, Ehret DEY, Okolo A, Dlamini‐Nqeketo S, Joolay Y, Minto’o S, Pillay S, Abdallah Y, Naburi H, Ndour D, Brobby N, Stevenson AG. Limited resources restrict the provision of adequate neonatal respiratory care in the countries of Africa. Acta Paediatr 2022; 111:275-283. [PMID: 34328232 DOI: 10.1111/apa.16050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022]
Abstract
AIM Over two thirds of newborn deaths occur in Africa and South Asia, and respiratory failure is a major contributor of these deaths. The exact availability of continuous positive airway pressure (CPAP) and surfactant in Africa is unknown. The aim of this study was to describe the availability of newborn respiratory care treatments in the countries of Africa. METHODS Surveys, in English, French and Portuguese, were sent to neonatal leaders in all 48 continental countries and the two islands with populations over 1 million. RESULTS Forty-nine (98%) countries responded. Twenty-one countries reported less than 50 paediatricians, and 12 countries had no neonatologists. Speciality neonatal nursing was recognised in 57% of countries. Most units were able to provide supplemental oxygen. CPAP was available in 63% and 67% of the most well-equipped government and private hospitals. Surfactant was available in 33% and 39% of the most well-equipped public and private hospitals, respectively. Availability of CPAP and surfactant was greatly reduced in smaller cities. Continuous oxygen saturation monitoring was only available in 33% of countries. CONCLUSION The availability of proven life-saving interventions in Africa is inadequate. There is a need to sustainably improve availability and use of these interventions.
Collapse
Affiliation(s)
- Lloyd Tooke
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | - Danielle E. Y. Ehret
- Vermont Oxford Network Burlington VT USA
- Department of Pediatrics Robert Larner MD College of MedicineUniversity of Vermont Burlington VT USA
| | | | | | - Yaseen Joolay
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | | | - Shakti Pillay
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | - Yaser Abdallah
- The Agakhan University Dar es Salaam Tanzania
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
| | - Helga Naburi
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
| | | | - Naana Brobby
- Department of Child Health School of Medicine and Dentisty KNUST Kumasi Ghana
| | - Alexander G. Stevenson
- Mbuya Nehanda Maternity Hospital Harare Zimbabwe
- Department of Paediatrics University of Zimbabwe Harare Zimbabwe
| |
Collapse
|
8
|
Wu A, Mukhtar-Yola M, Luch S, John S, Adhikari BR, Bakker C, Slusher T, Bjorklund A, Winter J, Ezeaka C. Innovations and adaptations in neonatal and pediatric respiratory care for resource constrained settings. Front Pediatr 2022; 10:954975. [PMID: 36389382 PMCID: PMC9659573 DOI: 10.3389/fped.2022.954975] [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: 05/27/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Andrew Wu
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | | | - Sreyleak Luch
- Department of Pediatrics, Chenla Children's Healthcare, Kratie, Cambodia
| | - Stephen John
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Bikash Raj Adhikari
- Department of Pediatrics, United Mission Hospital Tansen, Tansen, Palpa, Nepal
| | - Caitlin Bakker
- Discovery Technologies, Health Sciences Libraries, University of Minnesota, Minneapolis, MN, United States
| | - Tina Slusher
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States.,Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
| | - Ashley Bjorklund
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States.,Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
| | - Jameel Winter
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Chinyere Ezeaka
- Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
| |
Collapse
|
9
|
Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Osayame A Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| |
Collapse
|
10
|
Testing positive pressure delivered from commercial and WHO-style pediatric bubble CPAP devices. BMC Pediatr 2021; 21:524. [PMID: 34836539 PMCID: PMC8627031 DOI: 10.1186/s12887-021-03006-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background/aim Low-cost commercial bCPAP devices have been deployed in resource-limited settings to treat neonatal respiratory failure. The use of these devices has increased access to pediatric respiratory support for infants. However, constrained resources may result in substitution of recommended consumables and/or use in older age groups. We hypothesized that commercially available bCPAP devices, the standard WHO-style device and various improvised adaptations would all generate effective, safe positive pressure at the patient interface. Methods Performance of 2 commercially available bCPAP devices was tested against the standard WHO-style bCPAP device, as well as several improvised modifications of these devices, by measuring positive pressure delivered at the patient interface. Variables tested included different flow rates, patient interfaces and respiratory circuit tubing. Results Both commercial devices utilized according to manufacturer recommendations generated the expected positive pressure at the patient interface. When testing the recommended WHO-style bCPAP device with recommended materials as well as other improvised modifications, we found variable and potentially unpredictable generation of positive pressure at the patient interface. Conclusions Modified or improvised bCPAP devices should be used with extreme caution as the support provided may be more or less than expected depending on respiratory tubing and flow rates employed. Our data support the effectiveness of bCPAP in newborns and young infants. But, to our knowledge, there are no bCPAP patient interfaces for older children effective with low liter flow devices. Therefore, based on these results, we recommend against using WHO-style bCPAP devices for non-infant patients with respiratory failure and instead recommend using standard oxygen therapy with nasal cannulae or face-masks, as well as early consideration of transfer to a higher level of care.
Collapse
|
11
|
L Dundek M, Ng EK, M Brazil A, DiBlasi RM, Poli JA, Burke TF. Evaluation of a Bubble CPAP System for Low Resource Settings. Respir Care 2021; 66:1572-1581. [PMID: 33824173 PMCID: PMC9993569 DOI: 10.4187/respcare.08948] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite its established safety, efficacy, and relative simplicity, CPAP treatment is not widely available for newborns and infants in low- and middle-income settings. A novel bubble CPAP system was designed to address the gaps in quality and accessibility of existing CPAP systems by providing blended, humidified, and pressurized gases without the need for electricity, compressed air, or manual power. This was the first study that tested the performance of the system with a simulated patient model. METHODS: In a spontaneously breathing 3-dimensional printed nasal airway model of a preterm neonate, CPAP performance was assessed based on delivered pressure, oxygen level, and humidity at different settings. RESULTS: Preliminary device performance characteristics were within 5% among 3 separate devices. Performance testing showed accurate control of CPAP and oxygen concentration at all settings with the bubble CPAP system. Lung model pressure and oxygen concentration were shown to stay within ±0.5 cm H2O and ±4% of full scale of the device settings, respectively, with relative humidity > 80%. CONCLUSIONS: Performance testing of the bubble CPAP system demonstrated accurate control of CPAP and oxygen concentration with humidity levels suitable for premature newborns on noninvasive support.
Collapse
Affiliation(s)
- Michelle L Dundek
- Vayu Global Health Foundation, Boston, Massachusetts.
- Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ellie K Ng
- Vayu Global Health Foundation, Boston, Massachusetts
| | | | - Robert M DiBlasi
- Department of Respiratory Care Therapy, Seattle Children's Hospital and Regional Medical Center, Seattle, Washington
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Jonathan A Poli
- Department of Respiratory Care Therapy, Seattle Children's Hospital and Regional Medical Center, Seattle, Washington
| | - Thomas F Burke
- Vayu Global Health Foundation, Boston, Massachusetts
- Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
12
|
Abstract
BACKGROUND Non-invasive respiratory support for neonates using bubble continuous positive airway pressure (bCPAP) delivery systems is now widespread owing to its safety, cost effectiveness and easy applicability. Many innovative solutions have been suggested to deal with the possible shortage in desperate situations like disasters, pandemics and resource-limited settings. Although splitting of invasive ventilation has been reported previously, no attempts to split non-invasive respiratory support have been reported. OBJECTIVE The primary objective was to test the feasibility of splitting the bCPAP assembly using a T-piece splitter in a simulation model. METHODS A pilot simulation-based study was done to split a single bCPAP assembly using a T-piece. Other materials consisted of a heated humidification system, an air oxygen blender, corrugated inspiratory and expiratory tubing, nasal interfaces and two intercostal chest tube drainage bags. Two pressure manometers were used simultaneously to measure delivered pressures at different levels of set bCPAPs at the expiratory limb of nasal interfaces. RESULTS Pressures measured at the expiratory end of two nasal interfaces were 5.1 and 5.2 cm H2O, respectively, at a flow of 6 L/min and a water level of 5 cm H2O in both chest bags. When tested across different levels of set continuous positive airway pressure (3-8 cmH2O) and fractional inspired oxygen concentration (0.30-1.0), measured parameters corresponded to set parameters. CONCLUSION bCPAP splitting using a T-piece splitter is a technically simple, feasible and reliable strategy tested in a simulation model. Further testing is needed in a simulated lung model.
Collapse
Affiliation(s)
- Akanksha Verma
- Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rahul Jaiswal
- Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kirti M Naranje
- Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Girish Gupta
- Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anita Singh
- Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|