Bubble CPAPS (bCPAPS) for Respiratory Distress in Newborns
What is bCPAP Therapy and Why is It Important for Newborns?
Bubble Continuous Positive Airway Pressure (bCPAP) therapy is a common mode of treatment most suitable for respiratory distress syndrome (RDS) in premature babies and other respiratory illnesses in children. As a non-invasive ventilation strategy for newborns with infant respiratory distress syndrome (IRDS), bCPAP is a continuous flow variable pressure system for spontaneously breathing newborns to prevent lung collapse during exhalation. Although there are other alternatives to delivering positive airway pressure to a baby, they may be more invasive or pose risks due to relying on pure oxygen, which if not managed correctly, can lead to health complications to the newborn.
Appropriate and affordable bCPAP devices are considered a low-risk treatment with infrequent complications, and more importantly, can be safely administered by non-physicians. bCPAP is an effective strategy, when implemented in a timely manner, to treat RDS and prevent respiratory failure, at which point mechanical ventilation may be necessary. When comparing the impact of CPAP devices, bCPAP has been demonstrated to be superior in terms of reduced complications, cost, and duration of hospital stay. (2) However, not all infants with RDS are candidates for bCPAP and consultation with a medical provider is essential to determine appropriate treatment. As with all oxygen therapy and ventilation approaches, bCPAP will depend on clinical skills and facility infrastructure, as well as local guidelines and clinical protocols.
The bCPAP delivery systems consist of a gas source, an interface that connects the CPAP circuit to the infant’s airway through short nasal prongs, and a tube submerged in a bottle of water. As the gas exits the tube, it creates bubbles that produce small airway pressure oscillations which reach the neonate’s lungs, and improves gas exchange and lung function. The bCPAP method delivers blended oxygen through short nasal prongs or a nasal mask; the pressure in the circuit is maintained through immersion of tubing in water. As gas flows through the system, the “bubbling” of the gas prevents buildup of excess pressure. The pressure delivered to the airways of the infant depends on the depth at which the tubing is immersed. The vibrations resulting from the bubbling contribute to the gas exchange and reduce the infant’s work in breathing.
bCPAP systems have three main components:
- Continuous oxygen and airflow into the circuit: The gas flow rate required to generate CPAP is usually 5–10 L/min. Newborns with RDS may require supplemental oxygen, therefore, the system requires an oxygen blender, which connects an oxygen source (cylinder or concentrator) to the continuous airflow enabling appropriate Fi02 (Fi02 is fraction of inspired oxygen). Oxygen toxicity is an important concern, especially for preterm infants so setting the ranges according to clinical protocols is essential.
- A nasal interface connecting the infant’s airway with the circuit: short nasal prongs are generally used to deliver nasal CPAP and must be fitted to minimize leakage of air (otherwise, CPAP will not be achieved) and to reduce nasal trauma
- An expiratory limb with the distal end submerged in water to generate end-expiratory pressure; in bubble CPAP, the positive pressure is maintained by placing the far end of the expiratory tubing in water. The pressure is adjusted by altering the depth of the tube under the surface of the water.
Key Considerations When Selecting a bCPAP
There are differences between bCPAP that customers and users should understand based on their needs and clinical environments. The variability in bCPAP are largely related to:
- Patient Interface. Typically, bCPAP systems require tubing and short nasal prongs, some have additional accessories such as caps hats to help with positioning of prongs and tubing. Others may use masks or hoods in their patient interface. Understanding what is included, what is proprietary, and different sizes will help inform decisions related to cost and accessibility of critical parts of the bCPAP device.
- Humidification. A humidifier can provide warmth and moisture for the air and oxygen mix to be delivered to the patient. If the system does not include humidification, providers will likely need saline nasal drops to ensure adequate moisture in nasal passages, or a separate humidifier that can be integrated into the system. Humidification using compressed ambient air rather than gas cylinder sources is more complicated. The use of humidification depends on clinical preference
- Heated circuits. A heated tube added to the circuit can improve humidification efficiency. Heated tubing maintains the warm temperature of the air as it travels from the humidifier’s water chamber up to the mask.
- Integration of the air compressor into the CPAP unit. Some devices do not have an integrated air compressor which would need to be purchased separately
- Oxygen Source and Blender. It is important to know what the system requires in terms of oxygen source (facility central air, tanks, concentrator, etc.), and that there is an oxygen blender to ensure control of Fi02 delivery. The cost and availability of oxygen sources vary significantly in different settings, and if oxygen sources are not available, more integrated bCPAP systems may be more appropriate.
In addition, factors such as warranty, serviceability, certifications, and costs are available in the Buyers Guides. The chart below presents comparisons on different products offered by VIA that can help you and your customers make the decision that best meets your needs.
VIA Global Health is committed to supporting health systems access affordable and appropriate medical products to improve the health in their communities. Products included in our Buyers Guides are available for purchase at VIA Global Health.
(1) Martin S, Duke T, Davis P. Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2014;99:F495–F504.
(2) Gregory, GA; Kitterman, JA; Phibbs, RH; Tooley, WH; Hamilton, WK (Jun 17, 1971). “Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure”. The New England Journal of Medicine. 284 (24): 1333–40.
(3) Bahman-Bijari B, Malekiyan A, Niknafs P, Banesi MR. Bubble CPAP vs. Ventiliatory CPAP in preterm infants with respiratory distress. Iran J Pediatr. 2011;21(2):151‒159.
(4) Morley, CJ; Lau, R; De Paoli, A; Davis, PG (July 2005). “Nasal continuous positive airway pressure: does bubbling improve gas exchange?”. Archives of Disease in Childhood: Fetal and Neonatal Edition. 90 (4): F343–4. doi:10.1136/adc.2004.062588. PMC 1721902. PMID 16036895