Neonatal CPAP for Respiratory Distress Across Malawi and Mortality

Abstract

OBJECTIVES: Our aim in this observational study was to monitor continuous positive airway pressure (CPAP) usage and outcomes in newborn wards at 26 government hospitals in Malawi after the introduction of CPAP as part of a quality-improvement initiative. CPAP was implemented in 3 phases from 2013 through 2015. METHODS: Survival to discharge was analyzed for neonates treated with nasal oxygen and/or CPAP with admission weights of 1 to 2.49 kg at 24 government hospitals with transfer rates ,15%. This analysis includes neonates admitted with respiratory illness for 5.5 months before (621 neonates) and 15 months immediately after CPAP implementation (1836 neonates). A follow-up data analysis was completed for neonates treated with CPAP at all hospitals during an additional 11 months (194 neonates). RESULTS: On implementation of CPAP, survival to discharge improved for all neonates admitted with respiratory distress (48.6% vs 54.5%; P = .012) and for those diagnosed with respiratory distress syndrome (39.8% vs 48.3%; P = .042). There were no significant differences in outcomes for neonates treated with CPAP during the implementation and follow-up periods. Hypothermia on admission was pervasive and associated with poor outcomes. Neonates with normal mean temperatures during CPAP treatment experienced the highest survival rates (65.7% for all neonates treated with CPAP and 60.0% for those diagnosed with respiratory distress syndrome). CONCLUSIONS: A nurse-led CPAP service can improve outcomes for neonates in respiratory distress in low-resource settings. However, the results show that real-world improvements in survival may be limited without access to comprehensive newborn care, especially for small and sick infants.

Implementation of a Bubble CPAP Treatment Program for Sick Newborns in Nakuru, Kenya: A Quality Improvement Initiative

“…Multiple retrospective analyses following implementation of bCPAP in low-resource settings suggest that bCPAP does improve mortality from respiratory distress, but no randomized trials compare bCPAP with local standard of care, typically oxygen via nasal cannula. 21 - 23 Furthermore, it is widely accepted that bCPAP is an effective therapy in high-income countries, and the need for as well as the ethics of these randomized controlled trials in low-resource settings is debated. 24 , 25 Kawaza et al 26 reported a quasi-randomized study in which bCPAP delivered with the Pumani device was compared with oxygen via nasal cannula.…”

Peer mentorship in the scale‐up of neonatal continuous positive airway pressure in Malawi

“…Children with hypothermia at the time of admission had worse outcomes. 8,9 These findings highlight the need for health workers to be thoroughly competent in identifying CPAP-eligible children and appropriately targeting its use in sick children who are most likely to benefit.…”

“…Twenty-four of the 26 facilities were at district level. Improved survival was sustained11 months beyond the period of carefully managed deployment 8.…”

In vitro comparison of performance including imposed work of breathing of CPAP systems used in low-resource settings

“…Low-resource settings present unique challenges for the design of medical devices, including lack of financial resources to purchase equipment, weak supply chains for consumables, inconsistent power, and harsh environmental conditions [10,11]. For this reason, a number of CPAP systems have been designed for use specifically in LRS, including the Diamedica baby CPAP and the Pumani CPAP [12][13][14]. The Diamedica baby CPAP includes a built-in oxygen concentrator for provision of oxygen to infants requiring CPAP in environments that do not have reliable oxygen supplies.…”