Continuous positive airway pressure in children with severe pneumonia and hypoxaemia in Papua New Guinea: an evaluation of implementation

Abstract

Aim To prospectively evaluate the use of bubble continuous positive airway pressure (CPAP) in children with very severe pneumonia and other acute lower respiratory infections, during its trial introduction in a low resource hospital in Papua New Guinea. Methods Prospective observational study of children treated with CPAP who had severe pneumonia and severe respiratory distress with hypoxaemia (SpO2 <90%). CPAP was driven by oxygen concentrators in which the fraction of inspired oxygen could be adjusted, and using low‐resistance tubing and nasal oxygen prongs. Results A total of 64 children were commenced on CPAP: 29 (45.3%) survived and were discharged well, 35 (54.7%) died. Prior to commencing CPAP, the median SpO2 was 78% (IQR 53.3–86.8%), at one hour SpO2 was 92% (IQR 80–97.75%, n = 64), and at 84 hours (3½ days) 98% (IQR 93–98%, n = 29), in survivors at each of these time points. A higher SpO2 at one hour after commencement of CPAP predicted survival (p = 0.013), and human immunodeficiency virus infection was an independent predictors of death (p = 0.017). Technical and clinical problems encountered are described. Conclusion Bubble CPAP improved oxygenation and reduced the severity of respiratory distress in some children with severe pneumonia; however, mortality was high reflecting high severity of illness and comorbidities. CPAP requires a quality system to be safe and effective.

Efficacy and safety of non-invasive ventilation in pediatric care in low-income and middle-income countries: a systematic review

“…A total of 2174 studies were screened and 20 met criteria for inclusion (Figure 1). These included five randomized control trials (RCTs) [9][10][11][12][13] , one cluster RCT 14 , one non-randomized comparative study 15 , eleven observational studies [16][17][18][19][20][21][22][23][24][25][26] (prospective and retrospective observational studies and case series) and two case reports 27,28 (Table 2). A majority of the studies evaluated the use of NIV in the form of bubble CPAP (bCPAP) or conventional nasal CPAP (nCPAP).…”

“…Four of these studies, all of which took place at tertiary hospitals, reported mortality rates >30%. 18, [24][25][26] Mortality was the primary endpoint for five prospective observational studies and was 2% 16 , 10% 17 , 29% 23 , 33% 24 , and 47%. 26 Multiple comorbidities likely play a detrimental role in outcomes, as evidenced by the study with the highest mortality rate (47%), which showed much lower mortality rates among lower risk patients (18% rate in HIV-uninfected and only single organ failure).…”

“…8 Five studies had unclear or high risk of selection bias due to inconclusive reporting of which patients were included and if all patients were captured. 16,23,25,27,28 All studies were considered low risk of ascertainment bias, which assesses if exposures and outcomes were adequately ascertained. Due to observational study design, 10/13 studies were considered unclear or high risk of causality bias.…”

How to do no harm: empowering local leaders to make care safer in low-resource settings

“…We believe such formal curricula need to be complemented by an accessible library of methods and interventions illustrated by implementation examples from LRS. 5 31 34 One critical task though is to empower national leaders, possibly through their national professional organisations, so they can offer the coaching, mentorship and support to local leaders that is needed. Where necessary, this may be facilitated by international collaborations.…”

“…This requires making sure key clinical tasks, such as monitoring, are carried out regularly and reliably. 5 To achieve this however, it may be necessary to strengthen the underlying system by, for instance, clarifying policies and team responsibilities. In addition to this, placing restrictions on when CPAP can be used makes care safer for the whole population of newborns in the unit.…”