Implementation of Bubble CPAP in a Rural Ugandan Neonatal ICU
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RESPIRATORY CARE Paper in Press. Published on November 11, 2014 as DOI: 10.4187/respcare.03438 Implementation of Bubble CPAP in a Rural Ugandan Neonatal ICU Ryan M McAdams MD, Anna B Hedstrom MD, Robert M DiBlasi RRT-NPS FAARC, Jill E Mant MBBS MA MRCPCH, James Nyonyintono MB ChB, Christine D Otai RNM, Debbie A Lester RN IBCLC, and Maneesh Batra MD MPH BACKGROUND: Respiratory distress is a leading cause of neonatal death in low-income and middle-income countries. CPAP is a simple and effective respiratory support modality used to support neonates with respiratory failure and can be used in low-income and middle-income countries. The goal of this study was to describe implementation of the Silverman-Andersen respi- ratory severity score (RSS) and bubble CPAP in a rural Ugandan neonatal NICU. We sought to determine whether physicians and nurses in a low-income/middle-income setting would assign similar RSS in neonates after an initial training period and over time. METHODS: We describe the process of training NICU staff to use the RSS to assist in decision making regarding initiation, titration, and termination of bubble CPAP for neonates with respiratory distress. Characteristics of all neonates with respiratory failure treated with bubble CPAP in a rural Ugandan NICU from January to June 2012 are provided. RESULTS: Nineteen NICU staff members (4 doctors and 15 nurses) received RSS training. After this, the Spearman correlation coefficient for respiratory severity scoring between doctor and nurse was 0.73. Twenty-one infants, all < 3 d of age, were treated with CPAP, with 17 infants starting on the day of birth. The majority of infants (16/21, 76%) were preterm, 10 (48%) were <1,500 g (birthweight), and 13 (62%) were outborn. The most common diagnoses were respiratory distress syndrome (16/21, 76%) and birth asphyxia (5/21, ,The average RSS was 7.4 ؎ 1.3 before starting CPAP, 5.2 ؎ 2.3 after 2–4 h of CPAP .(24% after 12–24 h of CPAP, and 3.5 ؎ 1.9 before CPAP was discontinued. Duration of 2.7 ؎ 4.9 treatment with CPAP averaged 79 ؎ 43 h. Approximately half (11/21, 52%) of infants treated with CPAP survived to discharge. CONCLUSIONS: Implementing bubble CPAP in a low-income/mid- dle-income setting is feasible. The RSS may be a simple and useful tool for monitoring a neonate’s respiratory status and for guiding CPAP management. Key words: low-income and middle-income countries; neonate; respiratory distress; respiratory severity score. [Respir Care 2015;60(3):1–•. © 2015 Daedalus Enterprises] Introduction common and serious complication of premature birth, re- sulting from surfactant deficiency and structural im- Preterm birth remains a major cause of neonatal mor- maturity of the lungs. In high-income countries, effective tality globally.1 Respiratory distress syndrome (RDS) is a strategies to treat RDS, such as exogenous surfactant re- placement therapy, CPAP, and mechanical ventilation have Drs McAdams, Hedstrom, and Batra are affiliated with the Department of Pediatrics, University of Washington, Seattle, Washington. Drs McAd- ams, Hedstrom, and Batra and Mr DiBlasi are affiliated with the Depart- Dr Batra presented a version of this paper at the AARC Congress 2012, ment of Pediatrics, Seattle Children’s Hospital, Seattle, Washington. Ms held November 10–13, 2012, in New Orleans, Louisiana. Mant is affiliated with the Paediatrics Department, York Hospital, York, United Kingdom. Mr Nyonyintono and Ms Otai are affiliated with Pe- Correspondence: Ryan M McAdams MD, Department of Pediatrics, Di- diatrics, Kiwoko Hospital, Luweero, Uganda. Ms Lester is affiliated with vision of Neonatology, University of Washington, Box 356320, Seattle, The ISIS Foundation, Edmonds, Washington. WA 98195-6320. E-mail: [email protected]. The authors have disclosed no conflicts of interest. DOI: 10.4187/respcare.03438 RESPIRATORY CARE • MARCH 2015 VOL 60 NO 31 Copyright (C) 2015 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE RESPIRATORY CARE Paper in Press. Published on November 11, 2014 as DOI: 10.4187/respcare.03438 BUBBLE CPAP IN A RURAL UGANDAN NICU resulted in markedly improved survival for preterm in- fants.2-4 Until recently, these therapies have not been rou- QUICK LOOK tinely available in low-income and middle-income coun- Current knowledge tries due to the cost and complexity of implementation. CPAP is a well-established and effective therapy for Respiratory distress syndrome (RDS) is a common and RDS. Several studies have shown that early CPAP can serious complication of premature birth, resulting from effectively treat RDS without invasive mechanical venti- surfactant deficiency and structural immaturity of the lation or surfactant therapy in preterm infants.5-7 Ventila- lungs. In high-income countries, effective strategies to tors and exogenous surfactant therapy are expensive, have treat RDS, such as exogenous surfactant replace- the potential for life-threatening complications, and re- ment therapy, CPAP, and mechanical ventilation, have quire placement of an endotracheal tube that requires sig- resulted in markedly improved survival. nificant technical expertise.8 Although expensive CPAP What this paper contributes to our knowledge devices exist in high-resource settings, provision of CPAP can be achieved with little technology or cost. The Implementing bubble CPAP in low-income/middle-in- components of CPAP include a gas source, nasal or face- come settings is feasible. The Silverman-Andersen re- mask airway interface, and a pressure-generating ap- spiratory severity score may be a simple and useful tool paratus. Oxygen concentrators can provide sufficient for monitoring respiratory status and for guiding CPAP operational flow and, along with low-resistance nasal can- management. nula interfaces, are readily available in many low-income and middle-income countries.9 Tubing submerged in a bot- tle of water can serve as the pressure valve, with the depth of the tubing in the water determining the pressure in the Methods circuit. An example of this simple noninvasive ventilation method is bubble CPAP, which has been safely and effec- Setting tively used in low-income and middle-income countries to improve survival in infants with many forms of neonatal The NICU at Kiwoko Hospital is a referral center for 3 respiratory distress.10-12 rural districts of central Uganda with a combined popula- CPAP applied to immature lungs helps to increase func- tion of 600,000. As of the 2002 census, 89.5% of the tional residual capacity, improve chest wall stability, and population was rural dwelling.15 In 2006, the estimated decrease work of breathing, thereby reducing the need for neonatal and child mortality rates in this region were 33 mechanical ventilation and surfactant administration.13 In and 129 per 1,000 live births, respectively.16 The majority high-income settings, deciding which patients will benefit of mothers (69.1%) deliver in a health-care facility,16 but from CPAP is often based on clinical exam, breathing referral systems for pregnant mothers at risk for birth com- frequency, S , blood gas measurements, and chest radio- plications are lacking. The majority of pregnant mothers pO2 graph. In low-income/middle-income settings, lack of are transferred to the hospital by motorcycle or taxi. blood gas machines and x-ray capability can hinder deci- Kiwoko Hospital, which has 2,100 births annually, pro- sion making regarding proper treatment modalities for neo- vides the only neonatal intensive care services in the re- natal respiratory distress. In these resource-limited set- gion and admitted 650 infants in 2012. The NICU staff tings, a clinical assessment tool that provides accurate and consists of an assigned physician who sees all patients reliable assessment of a neonate’s respiratory status may daily and a pool of 23 nurses; 2–4 nurses are assigned per appropriately guide clinical management. The Silverman- shift. During the period of this study, the average NICU Andersen respiratory severity score (RSS)14 is a validated census was 22, with a patient-nurse ratio of 5:1. There are bedside exam method for assessing the degree of respira- no laboratory blood gas analyzers available at the hospital, tory distress in neonates and can be used in any resource and x-ray capability is limited. Surfactant therapy was not setting. available at Kiwoko Hospital during the study period. Be- We describe training using the Silverman-Andersen RSS fore January 2012, the only treatment available for neo- bedside tool and implementation of an inexpensive bubble nates with respiratory distress was supplemental oxygen CPAP system in a rural neonatal ICU (NICU) in Uganda. provided via nasal cannula and oxygen concentrator. We sought to determine whether physicians and nurses in a low-income/middle-income setting would assign sim- RSS Training ilar RSS in neonates after an initial training period and over time. We report the physiologic responses to therapy Before the introduction of bubble CPAP, no standard- and outcomes for the first 6 months after bubble CPAP ized method to assess neonatal respiratory status existed in implementation. the Kiwoko Hospital NICU. The RSS evaluates 5 param- 2RESPIRATORY CARE • MARCH 2015 VOL 60 NO 3 Copyright (C) 2015 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE RESPIRATORY CARE Paper in Press. Published on November 11, 2014 as DOI: 10.4187/respcare.03438 BUBBLE CPAP IN A RURAL UGANDAN NICU Fig. 1. The respiratory severity score for assessing the degree of respiratory distress in neonates. Modified from reference 14. eters and assigns a numerical score for each parameter, (Ͻ 5) to evaluate the proportion that could correctly iden- with 0 being the best score possible in each category and tify severe distress.