To study the effectiveness of
indigenous bubble CPAP in management of respiratory distress in newborns
Jain H1, Arya S2, Mandloi
R3, Menon S4
1Dr Hemant Jain, Professor, 2Dr Sunil Arya, Assistant Professor, 3Dr
Rashika Mandloi, P.G Student, 4Dr Suresh Menon, P.G Student. All are
affiliated with Department of Pediatrics, M.G.M. Medical College,
Indore ( MP)
Address for
Correspondence: Dr Sunil Arya, Email:
drsunilarya22@gmail.com
Abstract
Background:
CPAP has become a useful in management of respiratory distress,
especially in preterms. CPAP delivers a continuous distending pressure
via the neonates pharynx to the upper and lower airways. The main
indication for use of CPAP is RDS. Aim of study: To study the
effectiveness of indigenous bubble CPAP in management of respiratory
distress in newborn and to determine its outcome. Setting: Department
of Pediatrics, MGM Medical College and MY Hospital, Indore during the
period February-July 2005. Design:
Prospective Observational Study. Method:
This study was carried out on inborn neonates in the NICU of MY
Hospital over a period of six months. Matched controls were taken from
admissions during previous four months. It included the newborns
developing respiratory distress with grunting and chest retractions
within 6 hours of birth whose severity was measured by Silverman
Anderson Score and oxygen saturation.Neonates with increasing Silverman
Anderson Score or Oxygen saturation falling below 85%were taken on CPAP
and their outcome studied. Result:
There were 42 RDS cases in the study group of which 28 survived and 14
died. Indigenous BUBBLE CPAP was beneficial in managing babies with
RDS. Conclusion:
Indigenous BUBBLE CPAP is an effective and non-invasive way to provide
ventilation in a setup with limited resources. It can be used to manage
respiratory distress due to RDS, congenital pneumonia & MAS. It
resulted in significant reduction in mortality but prognosis was bad in
those who required CPAP >8 cm H2O.
Key words:
CPAP: continous positive airway pressure, RDS:respiratory distress
syndrome, MAS:Meconium aspiration syndrome
Manuscript received:
14th March 2016, Reviewed:
27th March 2016
Author Corrected;
10th April 2016, Accepted for Publication:
23rd April 2016
Introduction
Continuous positive airway pressure (CPAP) is anon invasive method for
applying a constant distending pressure level during inhalation and
exhalation to support spontaneously breathing newborns with lung
disease [1]. The main indication for use of CPAP is respiratory
distress syndrome.
Lack of awareness and suboptimal practice of antenatal steroids result
in frequent RDS in premature babies. Early use of CPAP will be
low-cost, simple and noninvasive option for a country like India, where
most places cannot provide invasive ventilation. With the cost of
surfactant likely to decrease markedly, use of early CPAP in
conjunction with surfactant, when indicated can prove to be a boon in
future for preterm in India. The present study was undertaken to
determine the effectiveness of indigenous BUBBLE CPAP as a non-invasive
approach for managing respiratory distress in newborns in a setup with
limited resources
Method
This study was carried out on inborn neonates in the NICU of Maharaja
Yashwant Rao Hospital over a period of six months. Matched
controls taken from cases admitted to the same NICU in the previous
four month period.
Inclusion criteria
1. Newborns developing respiratory
distress with grunting and chest retractions within 6 hours
of birth.
2. All newborns were above 1000 grams of
birth weight.
Exclusion Criteria
1. Any congenital malformations.
2. Onset of respiratory distress after 6 hours of birth.
3. Birth weight less than 1000 grams.
4. Newborns without grunting respiration.
Severity of respiratory distress was measured by Silverman Anderson
score [2] and oxygen saturation. Newborns having respiratory distress
with Silverman Anderson Score of 3 or more than 3 were started on
oxygen inhalation and :
A) If not improving.
B) Oxygen saturation falling less than 85%
C) Increasing Silverman Anderson Score were taken on CPAP and their
outcome studied. ABG was not done.
Under the study protocol, newborns with respiratory distress fulfilling
the inclusion criteria were started on CPAP. An indigenous BUBBLE CPAP
apparatus was assembled. The indigenous CPAP assembly is a simple and
least expensive NASAL BUBBLE CPAP SYSTEM.
Equipment required:
1. Container Bottle with lid, filled with normal saline with 0.25%
acetic acid to a depth of 10 cm H2O.
2. Column to fit through the lid of this container.
3. Two nasal catheters.
4. Two 3 way valves.
5. Two intravenous sets
6. Oxygen source
Setting up a cpap assembly: Fill the container bottle with normal
saline or sterile water with 0.25% acetic acid up to 10cm H2O and place
the container below the level of the newborn. The column should be
fitted into the container through the lid and placed under the fluid
level to desired pressure. i.e initially 3-4 cm H2O. The expiratory
circuit from the newborn is connected to the column.
Snug fitting nasal catheters are secured and the inspiratory circuit is
connected to the oxygen supply and flow meter. A starting flow of about
3-4 liters per minute is used, increasing to produce a steady stream of
bubbles in the water container. The column can then be lowered or
raised to the desired pressure to ensure steady bubbling.
The course and outcome were studied. Relevant antenatal data were
collected for each newborn.
Definition of respiratory distress: Respiratory distress is defined as
presence of tachypnea (respiratory rate >60/min), grunting,
chest retractions, with or without cyanosis, flaring of alae nasi and
reduced air exchange. None of the neonates were put on ventilator as no
ventilator available in NICU.
Observations
Table 1: Survival among various etiologies on CPAP
|
|
RDS
|
Congenital Pneumonia
|
MAS
|
Total
|
|
Total
|
42(75%)
|
9(16%)
|
5(8%)
|
56
|
|
Survived
|
28(66.67%)
|
7(77.78%)
|
4(80%)
|
39
|
|
Deaths
|
14(33.3%)
|
2(22.2%)
|
1(20%)
|
17
|
75% of newborns had RDS followed by congenital pneumonia in 16.07%.
66.7% of the babies with RDS put on CPAP survived.
Table 2: Distribution of deaths according to the gestational age
|
Gestational age
(weeks)
|
Number
|
Deaths
|
survivals
|
|
30-32
|
18(32.14%)
|
11(64.29%)
|
7(35.71%)
|
|
33-35
|
24(42.86%)
|
5(20.83%)
|
19(79.16%)
|
|
>35
|
14(25%)
|
0
|
0
|
21.4% of the babies were term and 78.6% were preterm.
64.29% of the deaths in babies with RDS was in the gestational age
group of 30-32 weeks, whereas 20.83% of the deaths were between 33-35
weeks.
Table 3: Distribution of total cases of RDS according to weight
|
Weight (grams)
|
Number
|
survival
|
|
1000-1250
|
10
|
5(23.81%)
|
|
1251-1500
|
22
|
15(68.18%)
|
|
>1500
|
10
|
8(80%)
|
50%(10) of the babies with RDS survived in the weight range of
1000-1250 grams, whereas the weight range of 1251-1500 grams showed a
better survival of 68.18%(22) and >1500 grams had a even better
survival of 80%(10).
Table 4: Distribution of cases of RDS survivors in relation to the
initiation of CPAP (in hrs)
|
Initiation of CPAP (hrs)
|
1
|
2
|
3
|
4
|
5
|
6
|
|
|
Number
|
4
|
6
|
10
|
3
|
4
|
1
|
28
|
|
Percentage
|
14.19%
|
21.42%
|
35.71%
|
10.71%
|
14.28%
|
3.57%
|
100%
|
Table 5: Comparing mortality of study cases and controls
|
|
Total
|
RDS
|
Cong. Pneumonia
|
MAS
|
|
Total
|
Mortality
|
total
|
mortality
|
Total
|
Mortality
|
|
Study cases
|
56
|
42
|
14(33.34%)
|
9
|
2(22.2%)
|
5
|
1(20%)
|
|
Controls
|
41
|
32
|
17(53.1%)
|
4
|
2(50%)
|
5
|
2(40%)
|
Discussion
This was a prospective study done in the NICU of M.Y. Hospital, Indore.
The period of study was between February 2005 and July 2005. A total of
56 cases with respiratory distress fulfilling the inclusion criteria
were enrolled during this period. The outcome of these babies on
indigenous BUBBLE CPAP was studied. The results were compared with the
babies with respiratory distress, who were managed in the same setting
in the preceding 4 months without CPAP. These babies served as the
control group. Gestational age wise and birth weight wise
categorization of babies was evenly matched in the two groups. The
etiology of respiratory distress was similar in both the groups.
There were 42 cases of RDS in the study group. Out of them 28 (66.7%)
survived and 14 died. While in a study by Gregory GA et al [3] they
have taken 20 cases of RDS out of which 16 survived (80%). Out of total
56 cases, 30 were males and 26 females.
The mortality of male babies on CPAP was higher (46.66%) in comparison
to females (11.54%) in the study group though the sex distribution of
cases taken was similar. Amongst controls 53.66% (22) were males and
46.34% (19) were female. The distribution of mortality between males
(52.38%) and females (47.62%) were comparable in the control group. In
our study, 80.49% were preterm and 19.51% were term. Out of these
31.71% (13) were between 30-32 weeks,39.02%(16) between 33-35 weeks and
29.27%(12) more than 35 weeks.
Ventilation has a major role in the management of respiratory distress
(RDS) in the newborn babies as studied by Singh M et.al [4] Singh M et.
al [5] and P.P. maiya et al [6]. But it requires costly equipments and
is often invasive. Noninvasive ventilation in the form of CPAP has
increasingly come to play a significant role in the management of
respiratory distress in newborns. In a country like India where most
places lack facilities, an alternative indigenous way to provide CPAP
in a set up with limited resources was explored. This study was aimed
at finding out whether indigenously assembled BUBBLE CPAP was effective
in the management of respiratory distress in the newborn and to compare
the outcome of these babies with that of the babies managed previously
without CPAP.
In our study babies with MAS showed survival rate of 80% with
CPAP same as study done by maiya PP et al [7] also observed
CPAP has a role in MAS.
Early nasal CPAP was found to reduce the need for subsequent
intubations and mechanical ventilation by roughly 50% without affecting
overall mortality or the incidence of chronic lung disease [8].
In this study, the mean time of starting CPAP among survivors of RDS
was 3 hrs (range 1-6hrs). There are various other studies which show
that infants who could be managed on nasal CPAP alone had a lower
mortality and a reduced incidence of chronic lung disease and severe
intracranial hemorrhage. All of these studies suffer from the lack of
randomized group of control infants, and many of the outcomes may
reflect other changes in practice or differences in underlying disease
severity. However, their results are intriguing and call for randomized
control trials to determine the safety and utility of early nasal CPAP.
Another study by D Millar, H. Kirpilani [9] showed benefits of non
invasive ventilation.
CPAP has been extensively used in the treatment of RDS which is an
excellent indication for CPAP. The survival rates reported are 67-83%.
In our study 28 out of the 42 babies with RDS survived on CPAP. This
compares favorably with immediately previous four months figures of
46.9% survival of the 32 babies with RDS. According to the Cochrane
review[10], use of CPAP was associated with lower rates of failed
treatment by about 30%, overall mortality by 50%, and mortality in
babies with birth weight above 1500 grams by as much as 75%.
The Silverman Anderson Score was used to assess the severity of
respiratory distress. The babies with RDS who expired had a high
Silverman Score compared to the babies who survived. 85.71% of babies
with RDS who survived had a Silverman Anderson Score of 5 or 6. This is
in contrast to the fact that 78.57% of babies with RDS who died had a
Silverman Anderson Score of 8 or above.
In an interesting study from South Africa have demonstrated that nasal
CPAP even in the absence of surfactant replacement therapy increases
the survival rate of extremely immature babies with moderate to severe
underlying RDS.
Conclusion
The survival of babies on indigenous BUBBLE CPAP was significantly
higher than that of those managed without CPAP. An indigenously
assembled BUBBLE CPAP is an effective and non-invasive way to provide
ventilation in a setup with limited resources.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
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How to cite this article?
Jain H, Arya S, Mandloi R, Menon S. To study the effectiveness of
indigenous bubble CPAP in management of respiratory distress in newborns.Int J Pediatr Res
2016;3(5):291-294.doi:10.17511/ijpr.2016.5.03.