Bubble CPAP In Preterm Infants with Respiratory Distress In a Limited Resource Setting - without Blood gas, Surfactant And Ventilator Facilities (SNCU)

Dr. Damera Yadaiah, District Hospital, Nalgonda, , . DISTRICT HEAD QUARTERS HOSPITAL, NALGONDA. Introduction

Prematurity and it complications contribute to nearly 50% of neonatal mortality in India and developing countries. Establishment of nearly 700 special newborn care units (SNCU) under the National Health Mission is an important step in improving the neonatal survival in our country.

CPAP is an important device as a primary respiratory support for preterms with respiratory distress.

However, very few SNCUs in non-teaching hospitals of India are providing CPAP services. The SNCU Nalgonda started the CPAP services in the year 2013 as a pilot project .

• Neonatal Mortality reduction is possible by  Reduction of mortality in preterm infants  Reduction of mortality due to RD in term infants • CPAP  A cost effective strategy to improve the outcome of newborns with RD  Decreases need for MV and decreases the need for Up-transfers  Experience from SCNUs not evaluated and is the need of the hour Indian Scenario

Population 1.2 Billion (120 Crore)

Births per annum 26 Million (2.6 Crore)

Respiratory distress 2.6 Million (10%, 26 lakhs)

Need for pressure support 0.5 Million (20% of RD, 5 lakhs) Current Situation: Telangana

• Newborns admitted to 21 SNCUS : 24000

• Preterm Admissions : 8000

• Newborns with RDS : 4000 (15%)

• Preterm Deaths : 1400 (17%)

• Deaths due to RDS : 700 (9%) Causes of death in newborn - Telangana

RDS, ELBW and Prematurity constitute 53.5% of overall newborn deaths in SNCUs RDS contributes 50% preterm deaths Objective

• To evaluate the feasibility, safety and efficacy of Bubble CPAP respiratory support for preterm with RD admitted to SNCU Nalgonda.

Back Ground

Bubble CPAP (Fisher and Paykel, New Zealand) for management of respiratory distress in preterm infants was established at the SCNU, Nalgonda by Ministry of Health as a Pilot project in year 2013.

Methodology

• Design: Retrospective observational study • Study Period : August 2013 to December 2016 • Setting-  NNF Level-II 20 bed SCNU in Hospital, Telangana  4 Medical Officers and 14 Nurses trained in providing CPAP (CPAP Workshop and rotation is done in the unit using regular Bubble CPAP) Support Staff : 04 SNCU Data Entry Operator : 01 Lab technician : 01 Security : 03 Biomedical : Covered Portable X – Ray : 01 – 20 Bedded Oxygen Concentrator : 02 – 1 Nodal Officer CPAP UNIT : 01 KMC WARD : 10+6 – 4 Medical Officers Central oxygen supply C C Camera : 08 – Lactation Consultant Infusion pumps : 06 (Doctor) Syringe pumps : 10 Pulse oxymeters : 10 – 1 Head Nurse NIBP monitors : 02 – 14 Contract Nurses Electric breast pumps Audio Visual aids - TV , Posters, – Breast Feeding Handouts, Videos on ENBC& KMC 24 HRS POWER BACKUP Counsellor Embrace Transport incubator Bio medical waste facilities 1 NBCC corner at OT & LR Inclusion criteria Exclusion criteria

• Preterm Infants admitted to • Severe Asphyxia

SCNU with RD and with Downe • Intubated at admission

score >5 were started on CPAP • Multi organ dysfunction

• Preterm (Gestation <37 weeks) • Lethal Malformations. BUBBLE CPAP

O2 FLOW METER BLENDER

INSP LIMB EXP LIMB

THERMO SENSOR

MR 850 HUMIDIFIER

BUBBLE CHAMBER

HUDSON PRONGS CPAP ADMINISTRATION

• CPAP : Pressure, Oxygen, Humdification

– Selection of baby and interface

– Rule of 5 for initiation

– Titration

- CPAP Recessions / CXR

-FiO2 SpO2 -Flow Bubbling

Proportionality of FiO2 and CPAP CPAP, FiO2 and FLOW

CPAP :-

PEEP - 5CMS

Rule of 5 FiO2 - 50%

Flow - 5lts/min

TITRATION

• Flow

minimal bubbling (3 to 7 liters/min)

• FiO2 (21% to 60%) : SpO2 90% - 94%

• CPAP (4 TO 7 cms) : Recessions / CXR and SpO2 Assessing Interface

• Size,

• Fixation,

• Position

• Skin color,

• perfusion Adequacy of CPAP

Satisfactory cardiorespiratory status

 Comfortable baby

 Minimal retraction, no grunt Bubbling Breath  Normal capillary refill, BP sounds  Normal saturations : 90%-94% Bed side X-ray for all infants at admission and if deterioration

Before After Failure Of CPAP

• Continuing retractions, grunt

• Recurrent apneas

• SpO2 <90% : PEEP > 7cms & FiO2 > 60% • Poor respiratory efforts

• Baby not tolerating CPAP Referral

 If no response to Bubble CPAP : Referred to Tertiary care

 No Back-up ventilation was available

 No surfactant was given in the unit

 No ABG (1) Neonatal services has improved significantly in the last few years

Pre CPAP CPAP Epoch 2012 2013 2014 2015 2016

Admissions 703 877 1310 1037 960

Preterms 104 169 287 388 354 (<37 Wks)

Mortality 47 (7) 64 (7) 92 (7) 138 (13) 89 (9) (%)

Referral (%) 65 (9) 50 (6) 70 (5) 69 (7) 71 (7)

Inspite of Increase in admissions by 50% and admission of sicker neonates by four folds mortality and referrals remained the same. Results : Baseline Variables

 No of infants admitted : 4917

 No of infants on CPAP : 250 (5.1% )

 Mean birth weight : 1.45±0.50 kg

 Male Babies : 140 (56%)

 CPAP within in 6 hours : 66%

• Maximum pressure of only 5 cm : 130 (52%)

• Mean duration of CPAP was 54.5±19 hours

Results …

 205 infants discharge alive (82%)

 6 infants referred to higher centre

 1 had Pneumothorax

 39 infants died (15.6%)

 None had any major nasal injury B/o Rajeswari B/O JANAKI

GA: 30 WKS GA : 30 WKS BIRTH WEIGHT:1000 GM BIRTH WEIGHT: 900 GM DISCHARGE WEIGHT: 1900 GM DISCHARGE WEIGHT: 1630 GM B/o Anitha B/o Salma Twins

GA: 28WKS GA: 28 WKS BIRTH WEIGHT: 800GMS Birth weight twin I & II :750gms DISCHARGE WEIGHT: 1830 GMS Discharge weight : Twin:1440 gm Twin II : 1600 gm B/o Yasmeen

GA: 28WKS, BIRTH WEIGHTS : TWIN –I : 750GM, TWIN-II : 750GM DISCHARGE WEIGHTS: TWIN-I : 1580GM, TWIN-II : 1720GM B/O MAMATA 650 Gms B.W, 28 WK GA, 100 DAYS OF KMC

1 Year(9 months C.A) 6DOL, WT : 630 Gms 60 DOL, WT : 1.3 Kg WT : 7.3 Kg Conclusion

• Use of Bubble CPAP for preterm infants with respiratory distress is feasible in a

level II SCNU, at District Hospital

• Nearly 82% of infants were successfully managed on bubble CPAP

• Incidence of pneumothorax and severe nasal injury were negligible

• Although the admission rate and admission of sicker newborns increased

during the study period, overall mortality and referral rate remained similar

• Use of CPAP at SNCU is feasible, safe and effective, Functional CPAP services

should be made available at all SNCUs ( Level II units) in the country .

Implications of this study

• Need for Functional CPAP services at all SNCUs

• 82% of the infants supported on CPAP survived

• This extrapolates to nearly 40000 deaths /year saved if CPAP

available for all infants with RD in India

• Nearly 700 newborns saved in Telangana with this single

intervention

References

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