Success of bubble continuous positive airway pressure in preterm neonates admitted with respiratory distress syndrome at tertiary care center

Ajay K Keshwani; Ankush D Maindad

doi:10.4103/jpai.jpai_11_21

ORIGINAL RESEARCH

Year : 2020 | Volume : 9 | Issue : 4 | Page : 135-139

Success of bubble continuous positive airway pressure in preterm neonates admitted with respiratory distress syndrome at tertiary care center

Ajay K Keshwani, Ankush D Maindad
Department of Pediatrics, Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India

Date of Submission	25-May-2021
Date of Decision	05-Aug-2021
Date of Acceptance	01-Jun-2021
Date of Web Publication	22-Dec-2021

Correspondence Address:
Ankush D Maindad
Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpai.jpai_11_21

Abstract

Background: Application of continuous positive airway pressure (CPAP) in neonate with respiratory distress is associated with reduction of respiratory failure, complications, and mortality. Bubble CPAP (B-CPAP) is a most popular CPAP mode, but studies on B-CPAP as respiratory support for neonates are few. Therefore, the present study was conducted to assess the effectiveness of B-CPAP on immediate outcome of preterm infants of gestational age 28–36 weeks with respiratory distress syndrome (RDS) and to identify the risk factors associated with its failure. Materials and Methods: This longitudinal study was conducted in neonates admitted in the newborn unit with respiratory distress with Downe's score 4–6, SPO₂<85% even with supplemental oxygen during a period from August 1, 2019 to July 31, 2020. Investigations to diagnose the cause of respiratory distress were done including radiograph of the chest in all cases. Results: Out of total 330 neonates, 245 babies weaned from CPAP ventilation and discharged while 85 babies succumbed to the illness. Mortality was high in male babies, weighing <1.5 kg and babies with septicemia. At day 0 of administration of B-CPAP, 25.75% had Downes score 4, 33.03% were in score 5, and 41.21% were in score 6. All parameters such as cyanosis, grunting, tachypnea, chest indrawing, and air entry improved with B-CPAP administration. The various causes of respiratory distress were asphyxia, RDS, apnea of prematurity, meconium aspiration syndrome (MAS), and bronchopneumonia sepsis. Out of this, 22 babies with RDS and all babies with MAS and sepsis had significant radiological findings. Conclusion: We concluded that, this form of therapy should be adopted even by the smaller hospitals to improve the survival of neonates with respiratory distress.

Keywords: Bronchopneumonia, bubble continuous positive airway pressure, Downe's score, mortality, neonates, radiology, respiratory distress

How to cite this article:
Keshwani AK, Maindad AD. Success of bubble continuous positive airway pressure in preterm neonates admitted with respiratory distress syndrome at tertiary care center. J Pediatr Assoc India 2020;9:135-9

How to cite this URL:
Keshwani AK, Maindad AD. Success of bubble continuous positive airway pressure in preterm neonates admitted with respiratory distress syndrome at tertiary care center. J Pediatr Assoc India [serial online] 2020 [cited 2023 Mar 20];9:135-9. Available from: http://www.jpai.in//text.asp?2020/9/4/135/333365

Introduction

Worldwide each year, about three million babies die before 28 days of life, representing 4% of global fewer than 5 mortality.^[1],[2] The global neonatal mortality rate (NMR) currently stands at 23/1000 live births, but there is wide gradient between and within the countries.^[3] In India, despite remarkable progress in urban areas, neonatal and perinatal mortality rates are still high. The current NMR in India is 24/1000 live births.^[4] Literature reveals that nearly half of this is due to respiratory distress in the neonatal period. Respiratory distress is one of the most common problems of newborn occurring throughout the world, (3%–7% of all the births).^[5],[6],[7] In cases of respiratory distress – adequate and immediate resuscitation, oxygen supplementation, maintenance of optimal temperature, timely referral, and optimal ventilator support will reduce the mortality.

Assisted ventilation is one of the important methods in the management of respiratory distress in neonates. There are two basic types of assisted ventilation – (1) Invasive ventilation and (2) noninvasive ventilation. Invasive ventilation is one of the more expensive therapies in neonatal intensive care and is associated with morbidities such as increased incidence of bronchopulmonary dysplasia and retinopathy of prematurity in preterm infants and more chances of infection.^[8] Furthermore, it requires highly skilled medical personnel to operate and maintain the baby with frequent blood sampling (arterial blood gas monitoring). Another expensive consideration other than the equipment is nursing and respiratory practitioner labor cost.

Gentle noninvasive ventilation includes bubble continuous positive airway pressure (CPAP), which provides respiratory support to manage newborn with respiratory distress and is less invasive than mechanical ventilation for delivering respiratory support to neonates.^[9] B-CPAP provides continuous pressure that helps the collapse of alveoli on expansion, thereby increasing the lung functional residual capacity and decreasing the breathing work in neonates with respiratory distress.^[10] It is relatively inexpensive and easy to use, hence gaining lot of popularity especially in developing countries as the method of choice for delivering CPAP to distressed neonates.^{[11],[12],[13]} It is used in managing various respiratory conditions such as respiratory distress syndrome (RDS), transient tachypnea of the newborn, meconium aspiration, congenital pneumonia, pulmonary edema, and apnea. It can also be used in neonates, postextubation to support the respiratory system and reduce the rate of reintubation.^[14] The long-term morbidity is also less in bubble CPAP (B-CPAP) without any significant difference in mortality. The sorts of low cost intervention are the most cost-effective method to reduce the morbidity and mortality.

Materials and Methods

After obtaining written informed consent from parents of the participants, this longitudinal study was conducted in neonates admitted in newborn unit with respiratory distress with Downe's score 4–6, oxygen saturation SPO₂<85% even with supplemental oxygen during the study period of 1 year from August 1, 2019 to July 31, 2020. Babies with severe respiratory distress (score >7/10), unstable cardiovascular status, prolonged and refractory seizures, major congenital anomalies including upper airway anomalies, pulmonary hypoplasia diaphragmatic hernia, etc., were excluded from the study.

Detailed clinical history of each patient including the time of presentation was entered in the predesigned pro forma. Gestational age of the baby was calculated from the history of mother using Naegles formula (addition of 9 months and 7 days to 1^st day of Last menstrual period (LMP)) and by using new Ballard score. All neonates with respiratory distress were given routine care and stability.

Respiratory distress was diagnosed if any of the two of the following were present National Neonatology Forum (NNF): (1) respiratory rate >60/min during quiet breathing, (2) inspiratory retractions of the chest, and (3) expiratory grunting. Severity of respiratory distress was assessed by using Downe's score. Babies with total score <4 were managed with oxygen through hood at a rate of 6–8 L/min. If the distress increased, they were started on B-CPAP. Babies with total score >6 were intubated and given mechanical ventilation. If the distress decreased (score = 4–6), they were weaned to B-CPAP. Babies having initial total score between 4 and 6 were put on B-CPAP directly. If the distress increased, they were intubated and started on mechanical ventilation. If the distress decreased, they were weaned to oxygen gradually.

Investigations to diagnose the cause of respiratory distress were done including radiograph of the chest in all cases. Expert opinion was obtained from the radiologist. Blood sample was collected under sterile conditions and sent for the analysis (complete blood count, microerythrocyte sedimentation rate, peripheral smear study, glucose, urea, creatinine, calcium, other electrolytes, culture, and sensitivity). Blood pressure (BP) was monitored with a noninvasive BP monitor. Hypotension (mean BP <30 mm Hg) was corrected with intravenous fluid and dopamine drip as and when indicated. The sensor of a pulse oximeter was placed around the foot to continuously monitor the SPO₂ and heart rate, and it was shielded from light and heat. Indications for shifting to CPAP ventilation were – Downes score 4–6, oxygen saturation SPO₂<85% even with supplemental oxygen. B-CPAP system (Fisher and Paykel) was used to deliver CPAP through short nasal prongs placed in both anterior nares and secured firmly with a cotton tape tied around the head. The nasal prongs were checked for any displacement regularly and for blockage due to secretions every 4 h. Initial CPAP Settings: FiO_2:0.6–0.8; flow rate: 5–10 L/min; CPAP: 4–6 cm water with increment of 2 cm at a time, up to a maximum of 10 cm of water to achieve SPO2 of 85%–90%. All the infants recruited in the study were followed till discharge or death. Duration of CPAP, course of the illness, changing of treatment modalities from CPAP to intermittent mandatory ventilation (IMV), weaning from IMV to CPAP, weaning from CPAP to oxygen and complications of CPAP were meticulously documented.

Data analysis

Descriptive statistics were presented in mean and standard deviation for the numerical variables and frequency percentages for the categorical variables. Data were entered in Microsoft Excel sheet, and result was analyzed using the SPSS software version 20 (IBM, India). Required statistical tests were used to test the hypothesis.

Observations and Results

Out of 5,202 babies born at our hospital during the study period from August 1, 2019 to July 31, 2020, total of 358 babies were admitted to the neonatal intensive care unit for respiratory distress, of which 28 cases were excluded from the study due to various reasons such as severe respiratory distress, unstable cardiovascular status, and refractory seizures during the admission. Among of them, 12 babies were delivered at home and 20 babies were delivered at the nearby government hospital and referred here for the management of respiratory distress, whereas six babies were delivered in the private hospital. The rest of the babies were delivered at our hospital. A total of 25% (83) of the babies were delivered by the cesarean section.

Out of total 330 neonates with respiratory distress, 245 (74.24%) babies weaned from CPAP ventilation and discharged. Eighty-five (25.75%) babies succumbed to the illness or death, [Figure 1]. Mortality was high in babies weighing <1.5 kg and babies with septicemia. There were 117 (35.45%) males and 213 (64.54%) females' babies with a male-to-female ratio of 1:2.

Figure 1: Pictorial representation of survived and died babies

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The outcome in the terms of mortality was 33.33% for male and 21.59% for female. The mean birth weight of the babies under the study was 2400 g (900–4000 g). The overall prognosis of babies weighing more than 1500 g was good with the survival of 76%. Survival of babies in the weight <1500 g was 23.68%. The mortality was found to be high in term appropriate for gestational age (AGA) babies followed by the preterm and then term intrauterine growth restriction babies [Table 1].

Table 1: Survival distribution according patient characteristics

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At day 0 of institution of B-CPAP, 25.75% had Downes score 4, 33.03% were in score 5, and 41.21% were in score 6, as shown in [Figure 2].

Figure 2: Downe's score at day 0 and at day 3

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All parameters such as cyanosis, grunting, tachypnea, chest indrawing, and air entry improved with B-CPAP administration, as shown in [Table 2].

Table 2: Cyanosis, respiratory rate, grunting, sound, respiratory effort, and total score at day 0 and day 3 (paired t-test), (n=330)

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[Table 3] shows the various variables of the study.

Table 3: Statistical analysis of various variables of the study

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The outcome of B-CPAP ventilation is shown in [Table 4]. There was significant improvement of respiratory distress in the babies treated B-CPAP and also significant reduction of mortality in babies with respiratory distress while using B-CPAP (P < 0.0001).

Table 4: Outcome of bubble continuous positive airway pressure ventilation

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[Figure 3] shows the various causes of respiratory distress and their outcome observed in this study were, (1) Perinatal asphyxia = total 80 babies, out of these 40 babies (50%) survived; (2) Preterm – RDS = total 44 babies, out of these 27 babies (61.3%) survived; (3) Preterm - Apnea of prematurity – total 8 babies, of which 2 babies (25%) were weaned from CPAP; (4) meconium aspiration syndrome (MAS) = total 15 babies, out of these 4 babies (26.6%) survived; (5) bronchopneumonia – Sepsis = total 14 babies, out of these three babies (2.4%) survived. Out of this, 22 babies with RDS and all babies with MAS and sepsis had significant radiological findings.

Figure 3: Various causes of respiratory distress and their outcome observed in this study

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Discussion

We found nasal CPAP ventilation complemented with pulse-oximetry, a simple and efficient method for treating neonates with respiratory distress. CPAP is effective in preventing extubation failure and also in the management of apnea of prematurity. The low cost of CPAP systems coupled with a standardized training for physicians and nursing staff may be of benefit in the developing world with finite finances for supporting newborn babies with respiratory distress. Even though B-CPAP is less costly when compared to mechanical ventilator the cost could still be reduced by making it with indigenous products for the benefit of our community. Many multicentric trials have to be done in this regard for the benefit of the community at large.

In the present study, 245 (74.24%) babies out of 330 who were treated with B-CPAP were considered successful treatment which was higher than that founded by Byram et al.^[15] (64%) and Sharba et al. (66%),^[16] whereas 25.75% failed B-CPAP in our study which was lower than that founded in Byram et al.^[15] (36%) and Gupta et al. (38%) study.^[17] In a case–control study by Boo et al.^[18] of the 97 preterm babies with RDS on ventilator CPAP or B-CPAP, 38% failed CPAP and require mechanical ventilation. However, in other uncontrolled studies and in the studies comparing INSURE with ventilation, CPAP failure rate ranges from 14% to 40%.^[19] Koti et al.^[20] conducted a retrospective analytical study on 56 neonates with 25% B-CPAP failure which was similar to our study. We found a success rate of 66.66% in males and 78.40% in females. Thus the survival rate was more in female as similar to the study done by Sajjan et al.^[21] where the success rate of 78.10% in males and 94.40% in females. There was high mortality in babies with birth weight <1.5 kg, while the babies with birth weight >1.5 kg had good survival chances.

In the current study, there was significant improvement of respiratory distress in the babies treated B-CPAP. All parameters such as cyanosis, grunting, tachypnea, chest indrawing, and air entry improved with B-CPAP administration. There was significant reduction of mortality in babies with respiratory distress while using B-CPAP, (P < 0.0001). The mean duration of CPAP administered was 28 h (range 6–72 h). Among the 100 CPAP failures, 70 failed within the first 24 h. While 30 did well for the first 24 h they failed to maintain the desired SaO₂ and had to be shifted to Intermittent positive-pressure ventilation (IPPV) after 24 h. Among these 30 babies, 15 improved and weaned to CPAP again after 24–48 h.

Various causes of respiratory distress were perinatal asphyxia, preterm, apnea of prematurity, MAS, bronchopneumonia – sepsis. Out of this, 22 babies with RDS and all babies with MAS and sepsis had significant radiological findings. Various studies have stated that, CPAP is useful in the treatment of RDS with survival rates of 67%–83%. In our study, 27 (61.3%) out of the 44 neonates with RDS were survived on CPAP. We treated 15 infants of MAS with CPAP ventilation, of which 4 (26.6%) survived. The distending pressure of CPAP directly stimulates the pulmonary stretch receptors increasing the ventilator drive. Infants suffering from septicemia had high mortality, with only 3 of the 11 cases treated surviving; however, the cause of death in such cases is multifactorial. Overall, neonatal mortality due to respiratory distress had come down in our newborn unit after using B-CPAP. Neonatal mortality due to respiratory distress was 45% before the use of B-CPAP. After using B-CPAP, neonatal mortality due to respiratory distress was 25.75% only.

There were few complications of nasal CPAP in our study. Displacement of the nasal prongs was a very common problem, whereas blockage due to secretions occurred rarely. Displacement of nasal prongs was quite troublesome and required dedicated staff to replace it frequently. However, this has to be seen in comparison with the expertise required for intubation, the problems of keeping it free of secretions and its long-term complications. Mild ulcerations of nasal mucosa occurred in four (4%) infants that healed without scarring. Six babies (6%) developed gastric distension which subsided within 24 h. Transient hypotension noted in two babies which was corrected with fluid bolus. Pneumothorax did not occur. None had the complications of oxygen toxicity. CPAP failures were faired poorly on IPPV also, irrespective of their weight. There was no incidence of skin injury or burn due to the probe of the pulse oximeter.

Conclusion

Considering that inexpensive CPAP resuscitators and pulse oximeters are now available, we conclude that, this form of therapy should be adopted even by the smaller hospitals to improve the survival of neonates with respiratory distress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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