Bubble Continuous Positive Airway Pressure Oxygen Therapy in Children Under Five Years of Age with Respiratory Distress in Pediatric Intensive Care Unit

HIGHLIGHTS

Currently in the low resource settings, oxygen therapy via bubble CPAP (bCPAP) to children with respiratory distress is not standardized. Continuous positive airway pressure (CPAP) delivery through indigenous bCPAP is safe and effective with added advantage of easy titration and quantification of delivered CPAP and FiO₂.

INTRODUCTION

In India, pneumonia and other acute lower respiratory infections (ALRI) are the leading contributors to serious illness and death.¹ Pneumonia is currently the leading cause of death among children worldwide, and India has a huge burden of childhood pneumonia than any other country, accounting for 20% of deaths worldwide from the disease.²

Hypoxemia is the greatest risk factor for pneumonia-related mortality, and oxygen therapy can significantly decrease pneumonia-related mortality.^3–5 However, despite the provision of oxygen, antibiotics, and supportive care, case-fatality rate of severe pneumonia with hypoxemia remains high in developing countries (8–11%)⁶ In conjunction with oxygen therapy, CPAP may play a pivotal role in treating ALRI with respiratory distress. Continuous positive airway pressure has long been studied in children with bronchiolitis, neonates with respiratory distress syndrome, meconium aspiration syndrome, and prematurity-related apnea.⁷ The airway pressure is assumed to reduce the inspiratory resistance, improve the work of breathing, and alveolar ventilation.⁸

There are numerous methods for administering CPAP, and bCPAP being one of them. There is limited data from the Indian subcontinent on the usage of bCPAP in children with respiratory distress. In this pilot study, we explored the safety and utility of bCPAP in children with respiratory distress. In addition, we compared the effectiveness of bCPAP therapy to high-flow nasal cannula therapy.

MATERIALS AND METHODS

This was a prospective observational study conducted over 3 months (March 2019 to May 2019), in a 12-bed PICU of an academic and referral hospital. The study was reviewed and approved by the Institutional Ethics Committee (IEC) (142/2019) and clinical trial registry-India (CTRI/2021/08/035409). Written informed consent was obtained from the parents/ guardians.

Children from 6 months of age to 60 months of age, with difficulty in breathing, fast breathing (respiratory rate >50/min in 6–11 months, >40/minute if ages 12–59 months) or with hypoxemia (SpO₂ <90%) or respiratory distress despite oxygen therapy were recruited in the study. Severity of respiratory distress was assessed by the following variables – respiratory rate, air entry, retractions, grunt, saturation in room air and level of consciousness. Modified Wood-Downes score was used to grade the severity.⁹ Children with congenital heart disease, chronic lung disease or immediate need for invasive respiratory support were excluded.

RESULTS

A total of 52 children with respiratory infections were admitted to PICU. At the time of admission, bCPAP was administered in 20 children, and a low-flow oxygen device (simple face mask and nasal prongs) was used in 18 cases. 10 children (55%) on low-flow device were shifted to bCPAP for worsening distress. Four children (age >5 years) were treated with high-flow nasal canula, 10 patients were invasively ventilated and low-flow oxygen device (simple face mask and nasal prongs) was continued in 8 cases. The total number of children requiring bCPAP was 30. The median (IQR) age of study group was 24 months (11–48) with 60% males. The most common cause of respiratory distress requiring bCPAP was pneumonia (66.7%) followed by pleural effusion (20%) and bronchiolitis (13.3%). The median (IQR) CPAP duration in the study was 48 (27–48) hours. One child failed bCPAP therapy after 6 hours requiring ventilation. Blood gas analysis was done before the initiation of bCPAP in all children, 9 of them had PaO₂ less than 80 mm of Hg and the remaining had normal PaO₂ and PCo₂. The most common chest X-ray finding was bilateral alveolar infiltrates (Table 1). The median duration of PICU stay was 4 (4–5) days.

The median (IQR) RDS gradually improved to 3.8 (3.4–4), 3.4 (3–3.6) and 1.8 (1.5–2.1) at 1 hour, 6 hours, and at 48 hours, respectively. Likewise, we observed significant (p < 0.05) improvement in the heart rate and respiratory rate at 1 hour, 6 hours, and 48 hours after commencing bCPAP therapy. No complications were observed in the study group.

On further analysis between HFNC and bCPAP group, we noted no significant difference in baseline parameters (Table 2). Although we found that there was a steady decrease in the heart rate and respiratory rate in both the groups over 48 hours, the rate of decline was faster in HFNC group during initial 12 hours (Fig. 3). On the contrary, there was no difference in the improvement in oxygen saturation and RDS between the groups. No significant difference was observed in the median PICU stay between nasal bCPAP and HFNC group [4 days (4–8) vs 4 (3–5)] (Table 2).

DISCUSSION

In our study, we noted that bCPAP was well tolerated and easily administered. Except for one, all were successfully treated.

As a mode of respiratory support, bCPAP is widely studied in neonates. Randomized study compared bCPAP with ventilator delivered CPAP in preterm found no difference in the work of breathing and respiratory parameters in both groups.¹⁰ A retrospective study by Lee et al. concluded that the initiation of bCPAP in the delivery room reduced the number of ventilated days.¹¹ In resource-limited setting, bCPAP is utilized as the first line respiratory support in newborns due to better safety profile, easy to administer and cost.^12–14

There is insufficient data to contemplate the beneficial effects of bCPAP in children with respiratory distress and it is mostly studied in the treatment of bronchiolitis.^15–18 CPAP delivered via a mechanical ventilator may not be available in most health facilities in developing countries. Anitha et al.¹⁹ used flow inflating device (Mapleson D and F circuits) as an indigenous way of providing CPAP and found successful in 89.7% of the study population. Children with bronchiolitis (98.3%) were successfully managed with CPAP but the amount of CPAP and FiO₂ could not be titrated. In a study by Jayshree et al.⁷ CPAP was delivered using a bubbling circuit and the height of the water column was adjusted to titrate the amount of CPAP. In our study, CPAP was delivered using ResPAPTM kit (indigenously prepared by Biodesign Innovation Labs Pvt Ltd) and accurate amount of CPAP was delivered by adjusting the regulator in the PAP valve.

Increased transpulmonary pressure generated by CPAP prevents the collapse of small airways during the expiration⁷ and it also abolishes the airway occlusion and improves diaphragmatic tone.⁸

In the present study, improvement in the heart rate, respiratory rate, and RDS was noted after commencing bCPAP. A study from the resource-limited setting by Jayashree et al.⁷ used bCPAP in 110 patients. The mean fall in respiratory rate in the bCPAP group at 2 and 6 hours was 6.3 ± 4.7 (4) and 12.1 ± 5.3 (10) (p = 0.001), respectively. Prospective observational study by Pulsan et al.²⁰ on 64 children also observed improvement in RDS and SpO₂ after the initiation of CPAP therapy. We compared the rate of decline in the heart rate and respiratory rate between bCPAP and HFNC group. We found that there was a steady decline in the heart rate and respiratory rate in both the groups over 48 hours although the decline in the heart rate and respiratory rate during the initial 12 hours was favorable in the HFNC group than the bCPAP group. Retrospective study by Metge et al.¹⁸ compared nasal CPAP (nCPAP) to HFNC in infants with acute bronchiolitis and found no difference with respect to respiratory rate and heart rate response. However, a study by Pedersen MB et al.¹⁷ observed that CPAP was superior to HFNC in reducing respiratory rates. On the contrary, results from prospective, randomized, open-label pilot study by Mihir S et al. on 31 children suffering from bronchiolitis showed HFNC was better tolerated than CPAP (delivered via ventilator) in decreasing the heart rate and lower incidence of nasal injury (46.66% vs 75%; p = 0.21).²¹

There was no significant difference in median PICU stay between the two groups in the present study. The result is comparable to the previous study.¹⁵ Randomized controlled trial (RCT) by Cesar RG et al.¹⁶ on infants with bronchiolitis showed similar results. There was no difference in the pediatric intensive care unit length of stay between the CPAP and HFNC groups [5 (4–7) days and 5 (4–8) days, p = 0.46, respectively].

Our study did not show any difference in failure rate between CPAP and HFNC group. Our results align with the results of the study by Cesar RG et al.¹⁶ where CPAP therapy failed in 10 children (36%) and HFNC failure was seen in 13 patients (37%). An open, RCT by Chisti J et al.²² from Bangladesh noted no difference in the failure rate between bCPAP and high-flow nasal cannula (6% vs 13%).

Small sample size and non-randomized design are the major limitations of our study. We used India’s first indigenous bCPAP for pediatrics and uniqueness of ResPAPTM kit lies in its ease of use and easy to set-up. An accurate amount of CPAP was delivered by adjusting the regulator in the PAP valve. A unique feature of our study was the usage of bCPAP for respiratory distress due to varied etiology such as bronchiolitis, pneumonia and pleural effusion.

CONCLUSION

Our study found bCPAP to be effective in pediatric populations with respiratory distress. It can be used as safer mode of respiratory support, alternative to high-flow nasal cannula in children with respiratory distress. Larger prospective studies (RCTs) using bCPAP are required to confirm our findings.

ACKNOWLEDGMENTS

Authors are grateful to parents who consented for their children involvement in this study. We are thankful to Biodesign Innovation Labs Pvt. Ltd. for providing ResPAP™ Kit (Bubble CPAP circuit).

ORCID

Lalitha AV https://orcid.org/0000-0002-6168-1677

Chandrakant G Pujari https://orcid.org/0000-0002-0485-5802

John Michael Raj https://orcid.org/0000-0002-1526-7432

SUPPLEMENTARY MATERIALS

All the supplementary material are available online on the website of www.ijccm.org

REFERENCES

1. Hasan MM, Saha KK, Yunus RM, Alam K. Prevalence of acute respiratory infections among children in India: Regional inequalities and risk factors. Matern Child Health J 2022;26(7):1594–1602. DOI: 10.1007/s10995-022-03424-3.

2. McAllister DA, Liu L, Shi T, Chu Y, Reed C, Burrows J, et al. Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: A systematic analysis. Lancet Glob Health 2019;7:e47–e57. DOI: 10.1016/S2214-109X(18)30408-X.

3. Subhi R, Adamson M, Campbell H, Weber M, Smith K, Duke T, et al. The prevalence of hypoxaemia among ill children in developing countries. Lancet Infect Dis 2009;9:219–227. DOI: 10.1016/S1473-3099(09)70071-4.

4. Duke T, Frank D, Mgone J. Hypoxaemia in children with severe pneumonia in Papua New Guinea. Int J TB Lung Dis 2000;5:511–519. PMID: 11409576.

5. Graham SM, English M, Hazir T, Enarson P, Duke T. Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings. Bull World Health Organ 2008; 86:349–355. DOI: 10.2471/BLT.07.048512.

6. Ramachandran P, Nedunchelian K, Vengatesan A, Suresh S. Risk factors for mortality in community acquired pneumonia among children aged 1–59 months admitted in a referral hospital. Indian Pediatr 2012;49(11):889–895. DOI: 10.1007/s13312-012-0221-3.

7. Jayashree M, Kiran Babu HB, Singhi S, Nallasamy K. Use of nasal bubble CPAP in children with hypoxemic clinical pneumonia-report from a resource limited set-up. J Trop Pediatr 2016;62(1):69–74. DOI: 10.1093/tropej/fmv063.

8. Smith AG, Eckerle M, Mvalo T, Weir B, Martinson F, Calira A, et al. CPAP IMPACT: A protocol for a randomised trial of bubble continuous positive airway pressure versus standard care for high-risk children with severe pneumonia using adaptive design methods BMJ Open Resp Res 2017;4(1). DOI: 10.1136/bmjresp-2017-000195.

9. Wood DW, Downes JJ, Lecks HI. A clinical scoring system for the diagnosis of respiratory failure. Preliminary report on childhood status asthmaticus. Am J Dis Child 1972;123(3):227–228. DOI: 10.1001/archpedi.1972.02110090097011.

10. Koyamaibole L, Kado J, Qovu JD, Colquhoun S, Duke T. An evaluation of bubble-CPAP in a neonatal unit in a developing country: Effective respiratory support that can be applied by nurses. J Trop Pediatr 2006;52(4):249–253. DOI: 10.1093/tropej/fmi109.

11. Lee KS, Dunn MS, Fenwick M, Shennan AT. A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol Neonate 1998;73(2):69–75. DOI: 10.1159/000013962.

12. Upadhyay A, Deorari AK. Continuous positive airway pressure – A gentler approach to ventilation. Indian Pediatr 2004;41(5):459–469. PMID: 15181296.

13. Kaur C, Sema A, Beri RS, Puliyel JM. A simple circuit to deliver bubbling CPAP. Indian Pediatr 2008;45(4):312–314. PMID: 18451452.

14. Cambonie G, Milési C, Jaber S, Amsallem F, Barbotte E, Picaud JC, et al. Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive Care Med 2008;34:1865–1872. DOI: 10.1007/s00134-008-1201-x.

15. Vamvakiti E, Saha A, Linney M. 510 Use of nasal Cpap in infants with bronchiolitis in the South of England: A prospective, multicentre, observational study. Pediatric Research 2010;68(1):261–261. DOI: 10.1203/00006450-201011001-00510.

16. Cesar RG, Bispo BRP, Felix PHCA, Modolo MCC, Souza AAF, Horigoshi NK, et al. High-flow nasal cannula versus continuous positive airway pressure in critical bronchiolitis: A randomized controlled pilot. J Pediatr Intensive Care 2020;9(4):248–255. DOI: 10.1055/s-0040-1709656.

17. Pedersen MB, Vahlkvist S. Comparison of CPAP and HFNC in management of bronchiolitis in infants and young children. Children (Basel) 2017;4(4):28. DOI: 10.3390/children4040028.

18. Metge P, Grimaldi C, Hassid S, Thomachot L, Loundou A, Martin C, et al. Comparison of a high flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: Experience in a pediatric intensive care unit. Eur J Pediatr 2014;173:953–958. DOI: 10.1007/s00431-014-2275-9.

19. Anitha GF, Velmurugan L, Sangareddi S, Nedunchelian K, Selvaraj V. Effectiveness of flow inflating device in providing continuous positive airway pressure for critically ill children in limited-resource settings: A prospective observational study. Indian J Crit Care Med 2016;20(8):441–447. DOI: 10.4103/0972-5229.188171.

20. Pulsan F, Sobi K, Duke T. Continuous positive airway pressure in children with severe pneumonia and hypoxaemia in Papua New Guinea: An evaluation of implementation. Acta Paediatr 2019;108(10):1887–1895. DOI: 10.1111/apa.14796.

21. Sarkar M, Sinha R, Roychowdhoury S, Mukhopadhyay S, Ghosh P, Dutta K, et al. Comparative study between noninvasive continuous positive airway pressure and hot humidified high-flow nasal cannulae as a mode of respiratory support in infants with acute bronchiolitis in pediatric intensive care unit of a tertiary care hospital. Indian J Crit Care Med 2018;22(2):85–90. DOI: 10.4103/ijccm.IJCCM_274_17.

22. Chisti MJ, Salam MA, Smith JH, Ahmed T, Pietroni MA, Shahunja KM, et al. Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: An open, randomised controlled trial. Lancet 2015;386(9998):1057–1065. DOI: 10.1016/S0140-6736(15)60249-5.

ANNEXURE 1