Tools
Bubble CPAP in Infants
Introduction
Respiratory diseases associated with prematurity continue to be a highly challenging condition to manage globally, even in today's modern medical landscape.[1] Each year, approximately 1 million children die worldwide as a result of complications associated with preterm birth, and a major cause of these deaths is respiratory distress syndrome (RDS).[2][3][4] In the United States, RDS still contributes to infant mortality, accounting for 2.2% of all infant deaths in 2022.[Birth/Infant Death Data] RDS can be managed by various methods such as exogenous surfactant administration or supportive respiratory care with mechanical ventilation via endotracheal intubation or noninvasive ventilatory methods like noninvasive positive pressure ventilation (NIPPV), bilevel positive airway pressure (BiPAP), or continuous positive airway pressure (CPAP).[5]
The CPAP system was first recognized for neonates in 1971.[6] After multiple revisions and iterations, CPAP is now recommended by the World Health Organization (WHO) as a first-line therapy for respiratory support in premature neonates worldwide.[4] CPAP administered through the nose, ie, nasal CPAP (nCPAP), can be classified into 2 main types based on the method of positive pressure generation. These include the continuous-flow CPAP, which are bubble CPAP (bCPAP) and ventilator-derived CPAP, also known as conventional CPAP, and variable-flow CPAP, which are infant flow driver (IFD) CPAP and Benveniste gas-jet valve CPAP.[7][8]
Briefly, bCPAP can be differentiated from other types of CPAPs by its key feature pressure oscillations (hence the name "bubble" CPAP), which promote airway opening and enhance lung recruitment.[9] Multiple bCPAP studies have shown to lower oxygen requirements, decrease respiratory decompensation, reduce the need for mechanical ventilation, reduce the incidence of chronic lung disease, and decrease the length of NICU stays.[10] This improved efficacy, ease of setup, and minimal equipment needs are reasons for its increased uptake in the NICUs, especially in low-to-middle-income countries.[11]
Anatomy and Physiology
Register For Free And Read The Full Article
Search engine and full access to all medical articles- 10 free questions in your specialty
- Free CME/CE Activities
- Free daily question in your email
- Save favorite articles to your dashboard
- Emails offering discounts
Learn more about a Subscription to StatPearls Point-of-Care
Anatomy and Physiology
A newborn's respiratory anatomy and physiology, let alone that of a preterm neonate, is vastly different from that of adults and presents unique challenges. While functional, the neonatal lung is not a miniature version of the adult. Term and preterm neonates are born with lungs that have reduced alveoli, which continue to develop and grow into childhood. Extremely preterm neonates (22-24 weeks gestation) have lungs in the canicular-saccular stage of development, where alveoli and capillaries are thin and extremely limited for gas exchange but allow just enough exchange for extra-uterine survival with modern medical therapies.[12] Interalveolar communications are also absent in neonates, leading to a higher risk of atelectasis in the dependent areas. Understanding such unique characteristics is essential for the effective application of bCPAP therapy.
Furthermore, proportional to the degree of prematurity, surfactant production is diminished in preterm neonates, reaching sufficient levels only after 36 weeks gestational age. This leads to neonatal RDS, where increased surface tension in the alveoli due to surfactant deficiency results in reduced lung compliance. This, in turn, causes alveolar collapse, ventilation-perfusion (V-Q) mismatch, decreased functional residual capacity (FRC), and reduced lung volumes, leading to impaired oxygenation and respiratory failure.[13] By addressing the primary issues, bCPAP stimulates/conserves endogenous surfactant production while providing end-distending pressure through positive end-expiratory pressure (PEEP) that prevents/reduces alveolar collapse and its downstream effects.[14]
Neonates also possess mechanical properties that contribute to ineffective breathing. The chest wall is very compliant due to the horizontally aligned, cartilaginous ribs, while the lung compliance may be decreased due to surfactant deficiency. The decreased elastic recoil property, higher likelihood for airway collapse, and slow endurance muscle fibers in the diaphragm result in neonates having low functional residual capacity at baseline and increased risk for desaturations.[15] Neonates are also obligate nose breathers with narrow nasal and glottic passages and, hence, high airway resistance. The bCPAP system benefits neonates by stabilizing the chest wall, reducing respiratory muscle fatigue, improving compliance, reducing airway resistance, and increasing FRC and lung volumes.
Aside from the above, neonates, especially preterm, are prone to mixed apneas. Obstructive apneas result from the collapse of the nasopharyngeal and lower airways due to reduced muscle tone and other properties mentioned earlier. Central apneas happen in preterm neonates due to apnea of prematurity resulting from immature respiratory control centers in the brain. Properly administered bCPAP stents open the airways prone to collapse by providing PEEP and are hypothesized to have the ability to alter the Hering-Breuer inflation reflex to reduce central apneas.[16]
Indications
Used in various neonatal respiratory conditions, bCPAP is a versatile tool, mainly in spontaneous breathing neonates who need additional respiratory support. The most common indications for bCPAP include neonatal respiratory distress, postextubation respiratory support, and apnea due to prematurity.
Respiratory Distress in Spontaneously Breathing Neonate
Bubble CPAP is indicated for conditions that result in respiratory distress, eg, RDS of prematurity, chronic pulmonary insufficiency of prematurity, transitional tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pulmonary hypertension, and congenital pneumonia, to name a few. For example, surfactant deficiency in RDS causes the collapse of the terminal airways, leading to ventilation-perfusion mismatch and increased work of breathing. By providing constant distending pressure and stability to the highly compliant chest wall of preterm neonates, bCPAP maintains lung volume at the end of expiration, reducing atelectasis and respiratory fatigue and eventually preventing respiratory failure.[17][18] This is achieved even in a state of relative surfactant deficiency. Moreover, the oscillatory effect imposed by the bCPAP has been shown to enhance the natural release of surfactant in preterm infants with RDS.[19][20] Thus, in 2022, the WHO recommended using bCPAP over ventilator-CPAP for respiratory support in preterm or low birth weight neonates (conditional recommendation, low-certainty evidence).[4]
Postextubation Respiratory Support
Nasal CPAP, eg, bCPAP, has been used after extubation to reduce extubation failures and has also proven effective over other noninvasive respiratory methods.[21][22] The use of bCPAP specifically resulted in reduced extubation failure rates in preterm infants born at younger than 30 weeks gestation who were initially intubated for less than 14 days in a subgroup analysis of a randomized clinical trial (RCT) that included 140 preterm infants.[23] This can be attributed to bCPAP's ability to maintain adequate lung volumes, cause airflow stimulation of the nasal passage and upper airway, and reduce obstructive apnea in preterm infants.[24] Additionally, the pressure oscillations specific to bCPAP likely contribute further to reduced reintubation rates.[25]
Apnea of Prematurity
Preterm neonates are at risk for apnea, either from an immature central drive (central apnea), upper airway obstruction (obstructive apnea), or a mixture of both. Bubble CPAP has been shown to reduce apnea of prematurity; however, comparative studies with other treatment methods are lacking.[26] The mechanisms for such effects are poorly understood.[22] Bubble CPAP is believed to relieve obstructions in the extrathoracic airway by serving as a passive splint to maintain upper airway patency. It may also alter the Hering-Breuer inflation reflex, which allows the infants to adjust to increased respiratory work.[27] Further, authors have suggested that nasal CPAP reduces central apnea through constant nasopharyngeal stimulation and improved oxygenation by maintenance of FRC.[28]
Contraindications
The following are situations in which using bCPAP may be counterproductive or ineffective. In these cases, alternative methods of respiratory support are recommended.[28][29]
Unrepaired Congenital Diaphragmatic Hernia
Due to associated pulmonary hypoplasia, pulmonary hypertension, severe respiratory failure, and abdominal contents within the chest cavity, the use of bCPAP may result in overdistension of the hypoplasic lungs (barotrauma), V-Q mismatch, and impaired gas exchange. Moreover, bCPAP may not adequately recruit the collapsed alveoli to support the infant's oxygenation and ventilatory needs. The inadvertent spillage of pressurized gas into the stomach can further compromise lung volume. Hence, intubating neonates with unrepaired congenital diaphragmatic hernias after birth is recommended.[30]
Esophageal Atresia and Tracheoesophageal Fistula
Avoiding positive pressure/CPAP in esophageal atresia and tracheoesophageal fistula preoperatively is recommended as a risk for aspiration pneumonia and resultant respiratory compromise is present. Postoperatively, bCPAP should be avoided to reduce the risk of anastomotic leakage and fistula recurrence.[31]
Choanal Atresia
The use of nasal CPAP necessitates an unobstructed nasopharyngeal passage. With choanal atresia, especially bilateral, the posterior nasal apertures are physically blocked, rendering the NCPAP therapy ineffective and potentially dangerous.
Cleft Palate
While not an absolute contraindication, bCPAP is not recommended for cleft palate before surgical correction in a neonate. Effective use of CPAP requires an adequate seal between the nasal interface and the neonate's airway. In this instance, the anatomic defect hinders the formation of an adequate seal, leading to inadequate positive pressure delivery and rendering the NCPAP therapy suboptimal.[32]
Severe Cardiovascular Instability
In neonates with an already compromised cardiovascular state, the use of bCPAP could exacerbate hypotension and organ perfusion since it can affect venous blood return due to an increase in intrathoracic pressure.[33]
Severe Respiratory Failure
In this scenario, the pressure delivered by nasal CPAP is insufficient to address the severely compromised gas exchange. Hence, a higher level of support with invasive mechanical ventilation is required.
Equipment
The bubble CPAP system consists mainly of 3 components: the circuit for continuous flow of inspired gases, the interface connecting the CPAP circuit to the infant's airway, and a device for creating positive pressure. Flow through this circuit depends on the tubing's diameter, length, integrity, and the degree of the seal at the nasal interface.[34]
Circuit for Continuous Flow
The 2 common sources of oxygen for bCPAP are oxygen cylinders and concentrators. The oxygen flow rate generally starts at 5 L/min and may be increased to 10 L/min while looking for bubbles in the transparent container.[35]
For premature newborns who are particularly at high risk of oxygen toxicity and retinopathy of prematurity, WHO recommends blended O2 with fraction of inspired oxygen (FiO2) of 0.3 or room air (FiO2 of 0.21).[4] Moreover, without an O2 blender, regulating FiO2 and maintaining target oxygen saturation is challenging.[36]
Interface Between bCPAP and the Patient's Airway
Nasal interface to deliver PEEP
An optimal nasal interface must be easy to apply and maintain on the infant's face while exhibiting low resistance. It should also form a complete seal without any leakage to transmit PEEP adequately and should not cause any nasal injury, even with long-term use.
Various options are available for the bCPAP interface, including short binasal prongs, nasopharyngeal tubes, nasal masks, and nasal cannulae.[22] A Cochrane review from 2008 found that short binasal prongs are the preferred interface to administer bCPAP as they have the lowest resistance to the flow of gas and improvement in respiratory parameters when compared to single nasal prongs and nasopharyngeal prongs.[37] The same review found that the rates of extubation failure within 7 days of extubation were significantly lower when extubated to short binasal prongs. Despite the advantages, binasal prongs are associated with increased nasal injuries compared to other interfaces.[38]
The more contemporary nasal mask is reported to have the lowest risk for nasal injury, albeit with concerns about an inadequate seal. However, the 2022 Cochrane review concluded that treatment failure rates with nasal mask interface were lower when compared to other nasal interfaces.[38]
The nasopharyngeal tubes are prongs that end at the nasopharyngeal level and have been perceived as challenging to use and poorly tolerated. It has the potential of being prone to kink, being easily blocked by secretions, and being proven to be inferior to other interfaces.[37]
Long tubing nasal cannula (eg, RAM cannula, Neotech, Valencia) is the other alternative for administering bCPAP. Long-tubing nasal cannulas are easy to apply and well-tolerated by neonates. Still, it has been associated with unreliable pressure delivery, decreased transmission of the oscillatory pressure, large air leaks, and increased need for CPAP pressure.[39]
Bonnets for the securement of the interface
Used if needed, the hat holds the prongs and tubing in place while the rim adds strength and helps prevent stretching when connecting the tubing.
Devices for Positive Pressure Generation
Expiratory tube
The expiratory limb for bCPAP is a tube of noncollapsible plastic leading from the patient interface to the pressure generator immersed in water.[40] The free end of the tube is submerged in a calibrated transparent container containing a liquid, most commonly and preferably sterile water. The immersion depth in centimeters represents the CPAP pressure (PEEP) generated (measured in cm H2O).[41]
An expiratory limb with a larger diameter (>10 mm) and more depth causes greater oscillatory pressure and volume, especially in neonates with stiff lungs.[42] To ensure that the immersion length remains constant, the tube may be secured to the bottle with adhesive tape to prevent contact with the bottom of the container.[41] The presence of constant bubbling is an indicator that positive pressure is being generated.[35]
Chin strap
Nonelastic tape and gauze may be used to prepare a chin strap that helps prevent air leaks from the mouth, avoiding the loss of positive pressure and increasing the system's effectiveness. Care must be taken to avoid completely closing the mouth, as this increases the risk of silent aspiration and inadvertently higher PEEP.
Pressure generator liquid
Sterile water is utilized to generate PEEP.
Backup Device
A T-piece resuscitator or self-inflating bag as a fail-safe is recommended.
Personnel
The successful implementation of bCPAP in the NICU relies on the comfort and knowledge of the hospital staff administering this therapy. An interprofessional team approach is recommended for the best outcomes. Bedside nurses, respiratory therapists, advanced practice practitioners, and physicians (eg, pediatricians and neonatologists) can be trained to administer bCPAP effectively.
Studies show that nurses and midwives can effectively start and maintain bCPAP after minimal training.[43] Each team member plays a crucial role. The bedside nurse is instrumental in preventing complications from bCPAP therapy by frequently assessing airway patency, adequacy of the nasal device seal, and cardiorespiratory status, to name a few.[44] They are integral in recognizing early signs of complications, including skin breakdown or abdominal distension, and promptly communicating it with the physicians for early intervention. A nurse-to-patient ratio of 1:3 in each shift is ideal to avoid missing critical problems.[45]
The respiratory therapist specializes in caring for bCPAP equipment and collaborates closely with the bedside nurse and physician to optimize the effective delivery of positive pressure and troubleshoot issues with the equipment and circuit. Physicians should guide the team with overall management by identifying neonates who would benefit from bCPAP, deciding on escalation or de-escalation, and treating complications that arise from using bCPAP.
Technique or Treatment
Initiation and Titration
Bubble CPAP can be initiated in the delivery room after initial stabilization of a spontaneously breathing neonate. In very preterm neonates, such use of CPAP right from birth has been shown to reduce the risk of BPD (bronchopulmonary dysplasia).[46] The optimal PEEP for initiating bCPAP is not known. Still, most studies recommend starting between 4 and 6 cm H20 and adjusting based on the infant’s clinical status.[47][48] This is the minimum level to avoid collapse of upper airways and alveoli at the end of expiration, thereby maintaining adequate lung expansion.
Neonates on bCPAP should have some form of monitoring for ventilation (either clinically by respiratory rate and work of breathing or by blood gas analysis or transcutaneous CO2 measurements) and oxygenation (by pulse oximetry, blood gas analysis, or chest x-ray). Based on these parameters, PEEP can be escalated to address the patient’s needs, including:
- If the CO2 levels or FiO2 requirement increases even on bCPAP (with or without chest x-ray findings of inadequate lung expansion), PEEP can be increased sequentially by 1 cm H2O.[47][49]
- Exogenous surfactant replacement is recommended when FiO2 is >40% on bCPAP (cut-off being variable) in a preterm neonate less than 37 weeks gestation.[50]
- When CPAP is used for postextubation support in extremely preterm neonates, a higher PEEP of 9 to 11 cm H20 is more effective in avoiding extubation failure.[51]
- Careful attention to complications (eg, pneumothorax) is necessary, especially when bCPAP PEEP is >8 cm H2O.[22]
- If the preterm infant develops apneas, especially if recurrent, a different mode of noninvasive or invasive ventilation is often recommended after addressing mechanical problems like airway obstruction from secretions. Clinicians must also explore the underlying reasons for recurrent apneas before escalating support.
- If arterial pCO2 continues to be >65 mm Hg or FiO2 >60%, other respiratory support modalities, eg, noninvasive positive pressure ventilation (NIPPV) or invasive mechanical ventilation, are strongly recommended.
Healthcare professionals should also consider a clinical pathway for bCPAP use since standardized protocols are associated with better clinical outcomes in preterm neonates.[52][53][54]
Weaning and Discontinuation
Weaning off bCPAP in neonates is an inadequately researched area and must be done carefully to avoid risks from premature weaning, eg, lung collapse, desaturations, and apneas.[55] A neonate may be considered ready for weaning when the following criteria are met:[52][54]
- CPAP pressure of ≤5 cm H2O and FiO2 requirement is <30%, preferably 21%
- Maintaining pulse oximetry saturations of higher than 90% (in preterm neonates, at least 88%, cut-off being variable)
- Respiratory rate is <60 breaths/min
- No significant retractions
- No episode of apnea, bradycardia, or desaturation requiring stimulation
- Tolerating transient durations (if any) off CPAP during nursing car
But, consensus guidelines for an optimal strategy to wean off bCPAP are lacking.[56] Several weaning methods exist—gradual titration of CPAP (ie, PEEP) and then off respiratory support; gradual transition to other modes of support like nasal cannula (high or low flow); increasing time off CPAP; or sudden withdrawal of CPAP to room air.[57] RCTs and meta-analyses suggest that extremely preterm neonates can be successfully weaned off CPAP by 32 to 33 weeks postmenstrual age and 1600 g of body weight.[54][55] Similarly, RCTs report preterm neonates, especially those born at less than 28 weeks gestation, have better success when gradually weaned off CPAP when compared to sudden weaning.[55][58][59] On the other hand, for a term infant, weaning from CPAP to no respiratory support can also be considered. No matter the strategy, close monitoring of FiO2, work of breathing, and airway patency are required while weaning.[60]
Infants are considered successfully weaned off bCPAP when their breathing is comfortable without respiratory acidosis, they are able to maintain adequate oxygen saturations for age, and apneas needing stimulation have resolved. If any of these stability criteria are not met, bCPAP should be restarted and monitored vigilantly. After 24 hours of stability, another trial off bCPAP can be attempted.[54]
Complications
Air Leak Syndromes
The use of CPAP in neonates enhances the functional residual capacity (FRC). Still, with excessive positive pressure, the alveoli can become inadvertently overdistended, causing increased transpulmonary pressures and resulting in air leak syndromes like pneumothorax and pneumomediastinum.[20][61][62] The Continuous Positive Airway Pressure or Intubation at birth (COIN) trial found that nasal CPAP started at a pressure of 8 cm H2O was found to be associated with an increased incidence of pneumothorax in infants with a birth gestational age of 25 to 28 weeks gestation.[63] However, an RCT of infants receiving early surfactant and bCPAP without invasive ventilation showed that these neonates were less likely to develop pneumothorax.[64] Additionally, more recent meta-analyses and Cochrane reviews have shown that bubble CPAP is not associated with an increased rate of air leak syndrome compared to other forms of CPAP.[65][66] Clinicians can prevent such complications by carefully monitoring oxygenation and ventilation and weaning off CPAP quickly when clinical improvement is noted, especially after exogenous surfactant administration.
Nasal Septal Injury
Both meta-analyses and a Cochrane review showed that bCPAP use is associated with twice the risk of any nasal injury when compared to other forms of CPAP.[65][66][67] Incorrect application of the CPAP device, inappropriate size of the nasal interface, inappropriate application or size of the head-securing device, and inadequate monitoring of skin and surrounding nose tissue are other risk factors for nasal septal injury.[68] Thus, preventing such pressure injuries is imperative through close monitoring during nursing care; a validated scoring system can also be used for an objective assessment.[53]
The type of nasal interface also plays a role in the nasal septal injury. Studies report that a nasal mask is associated with a significantly lower risk of nasal injury than binasal prongs.[69][70] While nasal masks can still cause pressure injury to the nasal bridge and philtrum, the binasal prong causes injuries to the columella. Such pressure or friction can eventually result in nasal septal erosion or necrosis. This can be avoided by using appropriately sized, snug-fitting nasal prongs, alternate use of short binasal prongs and nasal mask, applying a protective barrier (eg, hydrocolloid dressing or silicone gel), and correct positioning of the neonate.[45][71][72]
Gastric Distension
Gastric distention occurs when the infant inadvertently swallows the excessive air delivered through the nasopharynx. This is also known as “CPAP belly,” a benign condition that can be differentiated on the plain abdominal x-ray by the polygonal shape of diffusely dilated bowel loops, normal anatomic landmarks such as the central location of the small bowel, and the presence of haustral folds in the large intestine, and the absence of pneumatosis intestinalis or portal venous gas.[73] However, gastric distension from bCPAP can also delay the initiation or advancement of oral feeds by causing feeding intolerance and gastroesophageal reflux, as the positive pressure distends the intestines and stents open the lower esophageal sphincter.[74][75][76]
Gastric distension is typically managed by intermittent aspiration, “venting,” of stomach contents in between feeds using an orogastric/nasogastric tube. Prone positioning may also help.[73] When such measures fail, adjustments to bCPAP therapy by decreasing PEEP can also help reduce gastric distension, but respiratory status must be closely monitored while doing so. Some case reports exist of abdominal support with a flexible belly band as effective.[77] However, caution must be exercised for its use while awaiting further clinical trials with such devices.
Cardiovascular Compromise
High levels of CPAP can increase intrathoracic pressure, resulting in decreased venous return and impaired cardiac output.[33][78][79] This is especially true in preterm infants whose lung compliance is variable. Serial echocardiography done in preterm infants with resolving respiratory distress syndrome on CPAP showed a reduction in superior vena cava and right ventricular blood flow with accompanying increase in inferior vena cava diameter.[78] However, this was not associated with changes in systemic arterial pressure, similar to other published trials.[80][81] Even though the evidence is not clear one way or the other, clinicians must still be vigilant about the potential adverse effects of CPAP on cardiovascular markers, especially when making adjustments.
Impaired Ventilation-Perfusion Mismatch
Similar to systemic effects, impaired venous return from excessive distending pressure of bCPAP can also compromise the pulmonary blood flow. This may lead to increased pulmonary vascular resistance (PVR), worsening ventilation-perfusion (V-Q) mismatch, and impaired oxygenation.[62][33] Moreover, overdistension of alveoli can also compress extra-alveolar blood vessels, leading to increased PVR. At the same time, collapsed alveoli may also have similar effects on PVR. Thus, close attention to ventilation and oxygenation parameters is essential for achieving an optimal PVR to avoid such adverse effects.
Nasal Obstruction
Obstruction occurs from secretions or improper position of the NCPAP prongs. To avoid this, the nares should be suctioned at adequate intervals, and the prongs should be checked for proper placement with every nursing assessment.[52][67]
Clinical Significance
Cost and Use Benefits
Bubble CPAP has the advantage of being cost-effective compared to other forms of CPAP.[43][82] At its simplest setup, bCPAP requires an air compressor, oxygen blender, humidifier, tubing, and pressure generator, now available at a fraction of the cost of mechanical ventilation.[41] Current commercially available bCPAP can be relatively affordable at 15% of the cost of a mechanical ventilator.[43] Thus, bCPAP can be an economical way to provide respiratory support. Besides the cost-effectiveness, nurses can safely start and maintain bCPAP independently after minimal training, showing widespread applicability, especially in resource-limited settings.[43]
Impact on Invasive Ventilation
The use of NCPAP, like bCPAP, has been associated with a statistically significant reduction in the need for and duration of mechanical ventilation (the number needed to treat for additional benefit is equal to 6).[61][67][83] De Klerk et al demonstrated that bCPAP can reduce the number of infants ventilated and receiving surfactant and the mean duration of ventilator and oxygen therapy.[84] Moreover, bCPAP can reduce delivery room intubations, days on mechanical ventilation, and postnatal steroids.[85] Besides, a quality improvement initiative that implemented bCPAP showed that this respiratory support system is a potentially better practice among very low birth weight infants with RDS to reduce the need for mechanical ventilation.[83] Additionally, the effectiveness of bCPAP is also noted in animal studies; bCPAP was superior to conventional CPAP in maintaining airway patency, resulting in improved physiological outcomes in spontaneously breathing lambs with acute respiratory distress.[18]
Safety and Effectiveness
For several decades, bCPAP has been safely used. Prashanth et al performed a prospective observational study and noted that bCPAP was safe and effective for the treatment of mild and moderate-grade RDS.[11][86] In addition to improving respiratory outcomes, bCPAP reduced neonatal mortality among preterm babies with RDS by 30% in an RCT in Tanzania.[87] A systematic review of studies conducted in low- to middle-income countries has also found that bCPAP reduces in-hospital mortality effectively.[11]
Failure Rates
In a systematic review and meta-analysis, bCPAP was associated with lower failure rates when compared to other forms of CPAP in preterm neonates (RR 0.75; 95% CI was 0.57 to 0.98).[66] Another systematic review and meta-analysis also noted a similar finding, comparing bCPAP to ventilator CPAP.[11] In another study, bCPAP was associated with a shorter duration of noninvasive support in preterm infants less than 30 weeks gestation compared to infant flow devices.[23]
Effect on Distending Pressure
The bCPAP system confers a constant distending pressure, which is advantageous over using a humidified high-flow nasal cannula (HHFNC), where the amount of distending pressure varies and is difficult to measure.[8][88] Moreover, a loss of distending pressure caused by malfunctions, like a large leak around the nasal prongs or dislodgement of the nasal prongs, can be easily identified by the disappearance of bubbling, a unique feature of bCPAP.
Impact on Pulmonary Tissue and Airways
In preterm lambs, the application of bCPAP was associated with decreased alveolar structural damage, pulmonary edema, inflammation, and fibrosis. Additionally, a decrease in neutrophil migration and hydrogen peroxide production in bronchoalveolar lavage was demonstrated by the application of bCPAP.[89] Improved peripheral airway patency also resulted from bCPAP use, resulting in decreased lung inhomogeneity and reduced alveolar protein levels, suggesting a lesser degree of lung injury.[18]
Gaseous Exchange and Work of Breathing
FRC is increased and maintained by bCPAP, which in turn improves the gas exchange and lowers PaCO2.[90] Additionally, the high-frequency oscillatory ventilator-like effect produced by bCPAP may augment the ventilatory effect.[20] Lipsten et al have also noted an improvement in the observed breathing pattern and resistive work of breathing in former preterm infants with mild respiratory distress who received bCPAP therapy.[91] Animal studies have also noted a 40% increase in total lung capacity and a significant increase in lung weight and total protein and DNA content after receiving continuous bCPAP treatment for 2 weeks.[92]
Bronchopulmonary Dysplasia Treatment
Little evidence supports the idea that one nasal CPAP system is better than another for decreasing bronchopulmonary dysplasia (BPD).[11][93] The experience at the University of Vienna showed that early initiation of any CPAP resulted in lower rates of BPD in very low birth weight infants.[94] However, the experience at Columbia University, New York, USA, using bCPAP in the delivery room showed that early bCPAP was feasible and successful in 76% of infants with RDS weighing ≤1250 g, resulting in reduced incidence of BPD.[95] They suggested that the early initiation of bCPAP through nasal prongs was the reason for the noted effect, among others.[96] Subsequent studies concurred and emphasized the apparent advantages of this early CPAP approach. Since then, this has gradually become the primary mode of management of respiratory distress, even in the smallest neonates, to reduce the incidence of BPD.[97][98]
Tertiary Care Referral Considerations
By reducing the need for mechanical ventilation, bCPAP can effectively avoid referral to tertiary care units.[10][99] Studies have also reported reduced NICU stay with the use of bCPAP, thereby cutting associated healthcare costs.[28][84] Experts have estimated that treating every 6 neonates with bCPAP can save $10,000.[99]
Enhancing Healthcare Team Outcomes
The successful implementation of bCPAP for neonates experiencing respiratory distress relies on a well-coordinated, interprofessional team approach. Physicians and advanced practitioners play a key role in determining the appropriateness of bCPAP therapy, setting initiation parameters, and supervising patient progress. They must ensure that each institution follows established guidelines, including criteria for initiation, escalation, and weaning. Nurses, particularly those with specialized neonatal training, are essential in monitoring infants on bCPAP, ensuring equipment is functioning correctly, and recognizing early signs of complications. Respiratory therapists provide additional expertise in managing ventilatory strategies, optimizing pressure settings, and troubleshooting technical issues, making their role indispensable in effective bCPAP delivery.
Beyond clinical roles, effective interprofessional communication and care coordination are vital for achieving optimal patient-centered outcomes and safety. Frequent team discussions allow for real-time supervision, timely adjustments, and collaborative decision-making, which reduces the need for invasive mechanical ventilation and improves survival rates. Pharmacists contribute by ensuring safe and effective medication management, particularly for neonates requiring surfactant therapy or sedation. The availability of reliable equipment, cost-effective solutions, and ongoing mentorship programs further enhance bCPAP implementation. Additionally, hospital administration support and interactive training sessions covering respiratory physiology and bCPAP principles empower healthcare professionals to work as a cohesive unit, ultimately improving neonatal care and team performance.
References
Muhe LM, McClure EM, Nigussie AK, Mekasha A, Worku B, Worku A, Demtse A, Eshetu B, Tigabu Z, Gizaw MA, Workneh N, Girma A, Asefa M, Portales R, Bekele T, Bezabih M, Metaferia G, Gashaw M, Abebe B, Berta H, Alemu A, Desta T, Hailu R, Gebreyesus G, Aynalem S, Abdissa AL, Pfister R, Bonger ZT, Gizaw S, Abebe T, Berhane MA, Bekuretsion Y, Dhaded S, Patterson J, Goldenberg RL. Major causes of death in preterm infants in selected hospitals in Ethiopia (SIP): a prospective, cross-sectional, observational study. The Lancet. Global health. 2019 Aug:7(8):e1130-e1138. doi: 10.1016/S2214-109X(19)30220-7. Epub [PubMed PMID: 31303299]
Level 2 (mid-level) evidenceDyer J. Neonatal Respiratory Distress Syndrome: Tackling A Worldwide Problem. P & T : a peer-reviewed journal for formulary management. 2019 Jan:44(1):12-14 [PubMed PMID: 30675087]
Owuor HO, Akelo V, Murila F, Onyango D, Kuria M, Rogena E, Revathi G, Mitei P, Sava S, Were J, Igunza A, Khagayi S, Zielinski-Gutierrez E, Hawi S, Gethi D, Verani JR, Onyango C, Blau DM, Tippett Barr BA. Prevalence and Missed Cases of Respiratory Distress Syndrome Disease Amongst Neonatal Deaths Enrolled in the Kenya Child Health and Mortality Prevention Surveillance Network (CHAMPS) Program Between 2017 and 2021. Global pediatric health. 2023:10():2333794X231212819. doi: 10.1177/2333794X231212819. Epub 2023 Dec 5 [PubMed PMID: 38073666]
Level 3 (low-level) evidenceCare of Preterm or Low Birthweight Infants Group. New World Health Organization recommendations for care of preterm or low birth weight infants: health policy. EClinicalMedicine. 2023 Sep:63():102155. doi: 10.1016/j.eclinm.2023.102155. Epub 2023 Aug 16 [PubMed PMID: 37753445]
Chen IL, Chen HL. New developments in neonatal respiratory management. Pediatrics and neonatology. 2022 Jul:63(4):341-347. doi: 10.1016/j.pedneo.2022.02.002. Epub 2022 Mar 16 [PubMed PMID: 35382987]
Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. The New England journal of medicine. 1971 Jun 17:284(24):1333-40 [PubMed PMID: 4930602]
Committee on Fetus and Newborn, American Academy of Pediatrics. Respiratory support in preterm infants at birth. Pediatrics. 2014 Jan:133(1):171-4. doi: 10.1542/peds.2013-3442. Epub 2013 Dec 30 [PubMed PMID: 24379228]
Gupta S, Donn SM. Continuous positive airway pressure: Physiology and comparison of devices. Seminars in fetal & neonatal medicine. 2016 Jun:21(3):204-11. doi: 10.1016/j.siny.2016.02.009. Epub 2016 Mar 3 [PubMed PMID: 26948884]
Manilal-Reddy PI, Al-Jumaily AM. Understanding the use of continuous oscillating positive airway pressure (bubble CPAP) to treat neonatal respiratory disease: an engineering approach. Journal of medical engineering & technology. 2009:33(3):214-22. doi: 10.1080/03091900601164838. Epub [PubMed PMID: 19340692]
Level 3 (low-level) evidenceThukral A, Sankar MJ, Chandrasekaran A, Agarwal R, Paul VK. Efficacy and safety of CPAP in low- and middle-income countries. Journal of perinatology : official journal of the California Perinatal Association. 2016 May:36 Suppl 1(Suppl 1):S21-8. doi: 10.1038/jp.2016.29. Epub [PubMed PMID: 27109089]
Martin S, Duke T, Davis P. Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review. Archives of disease in childhood. Fetal and neonatal edition. 2014 Nov:99(6):F495-504. doi: 10.1136/archdischild-2013-305519. Epub 2014 Aug 1 [PubMed PMID: 25085942]
Level 1 (high-level) evidenceSmith LJ, McKay KO, van Asperen PP, Selvadurai H, Fitzgerald DA. Normal development of the lung and premature birth. Paediatric respiratory reviews. 2010 Sep:11(3):135-42. doi: 10.1016/j.prrv.2009.12.006. Epub 2010 Jan 25 [PubMed PMID: 20692626]
Davis RP, Mychaliska GB. Neonatal pulmonary physiology. Seminars in pediatric surgery. 2013 Nov:22(4):179-84. doi: 10.1053/j.sempedsurg.2013.10.005. Epub 2013 Oct 16 [PubMed PMID: 24331091]
Mulrooney N, Champion Z, Moss TJ, Nitsos I, Ikegami M, Jobe AH. Surfactant and physiologic responses of preterm lambs to continuous positive airway pressure. American journal of respiratory and critical care medicine. 2005 Mar 1:171(5):488-93 [PubMed PMID: 15502113]
Neumann RP, von Ungern-Sternberg BS. The neonatal lung--physiology and ventilation. Paediatric anaesthesia. 2014 Jan:24(1):10-21. doi: 10.1111/pan.12280. Epub 2013 Oct 24 [PubMed PMID: 24152199]
Martin RJ, Nearman HS, Katona PG, Klaus MH. The effect of a low continuous positive airway pressure on the reflex control of respiration in the preterm infant. The Journal of pediatrics. 1977 Jun:90(6):976-81 [PubMed PMID: 323448]
Mukerji A, Wahab MGA, Mitra S, Mondal T, Paterson D, Beck J, Fusch C. High continuous positive airway pressure in neonates: A physiological study. Pediatric pulmonology. 2019 Jul:54(7):1039-1044. doi: 10.1002/ppul.24312. Epub 2019 Mar 11 [PubMed PMID: 30859756]
Pillow JJ, Hillman N, Moss TJ, Polglase G, Bold G, Beaumont C, Ikegami M, Jobe AH. Bubble continuous positive airway pressure enhances lung volume and gas exchange in preterm lambs. American journal of respiratory and critical care medicine. 2007 Jul 1:176(1):63-9 [PubMed PMID: 17431223]
Gie AG, Hubble TR, Regin Y, Salaets T, Zamora M, Deprest J, Toelen J. A Systematic Review of the Influence of Continuous Positive Airway Pressure on Fetal and Newborn Animal Models: Suggestions to Improve Neonatal Respiratory Care. Neonatology. 2021:118(1):5-14. doi: 10.1159/000511086. Epub 2020 Oct 22 [PubMed PMID: 33091899]
Level 1 (high-level) evidenceShaffer TH, Alapati D, Greenspan JS, Wolfson MR. Neonatal non-invasive respiratory support: physiological implications. Pediatric pulmonology. 2012 Sep:47(9):837-47. doi: 10.1002/ppul.22610. Epub 2012 Jul 6 [PubMed PMID: 22777738]
Iyer NP, Rotta AT, Essouri S, Fioretto JR, Craven HJ, Whipple EC, Ramnarayan P, Abu-Sultaneh S, Khemani RG. Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis. JAMA pediatrics. 2023 Aug 1:177(8):774-781. doi: 10.1001/jamapediatrics.2023.1478. Epub [PubMed PMID: 37273226]
Level 1 (high-level) evidenceDavis PG, Morley CJ, Owen LS. Non-invasive respiratory support of preterm neonates with respiratory distress: continuous positive airway pressure and nasal intermittent positive pressure ventilation. Seminars in fetal & neonatal medicine. 2009 Feb:14(1):14-20. doi: 10.1016/j.siny.2008.08.003. Epub 2008 Oct 4 [PubMed PMID: 18835546]
Gupta S, Sinha SK, Tin W, Donn SM. A randomized controlled trial of post-extubation bubble continuous positive airway pressure versus Infant Flow Driver continuous positive airway pressure in preterm infants with respiratory distress syndrome. The Journal of pediatrics. 2009 May:154(5):645-50. doi: 10.1016/j.jpeds.2008.12.034. Epub 2009 Feb 23 [PubMed PMID: 19230906]
Level 1 (high-level) evidenceDavis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. The Cochrane database of systematic reviews. 2003:(2):CD000143 [PubMed PMID: 12804388]
Level 1 (high-level) evidenceJane Pillow J. Which continuous positive airway pressure system is best for the preterm infant with respiratory distress syndrome? Clinics in perinatology. 2012 Sep:39(3):483-96. doi: 10.1016/j.clp.2012.06.007. Epub [PubMed PMID: 22954264]
Ho JJ, Zakarija-Grkovic I, Lok JW, Lim E, Subramaniam P, Leong JJ. Continuous positive airway pressure (CPAP) for apnoea of prematurity. The Cochrane database of systematic reviews. 2023 Jul 18:7(7):CD013660. doi: 10.1002/14651858.CD013660.pub2. Epub 2023 Jul 18 [PubMed PMID: 37481707]
Level 1 (high-level) evidenceMiller MJ, Carlo WA, Martin RJ. Continuous positive airway pressure selectively reduces obstructive apnea in preterm infants. The Journal of pediatrics. 1985 Jan:106(1):91-4 [PubMed PMID: 3917503]
Diblasi RM. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respiratory care. 2009 Sep:54(9):1209-35 [PubMed PMID: 19712498]
. AARC (American Association for Respiratory Care). Application of continuous positive airway pressure to neonates via nasal prongs or nasopharyngeal tube. Respiratory care. 1994 Aug:39(8):817-23 [PubMed PMID: 10137266]
Snoek KG, Reiss IK, Greenough A, Capolupo I, Urlesberger B, Wessel L, Storme L, Deprest J, Schaible T, van Heijst A, Tibboel D, CDH EURO Consortium. Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology. 2016:110(1):66-74. doi: 10.1159/000444210. Epub 2016 Apr 15 [PubMed PMID: 27077664]
Level 3 (low-level) evidenceFerrand A, Roy SK, Faure C, Moussa A, Aspirot A. Postoperative noninvasive ventilation and complications in esophageal atresia-tracheoesophageal fistula. Journal of pediatric surgery. 2019 May:54(5):945-948. doi: 10.1016/j.jpedsurg.2019.01.023. Epub 2019 Jan 31 [PubMed PMID: 30814037]
George L, Jain SK. Use of Biphasic Continuous Positive Airway Pressure in Premature Infant with Cleft Lip-Cleft Palate. AJP reports. 2015 Oct:5(2):e083-4. doi: 10.1055/s-0034-1396449. Epub 2015 Apr 27 [PubMed PMID: 26495158]
Sehgal A, Ruoss JL, Stanford AH, Lakshminrusimha S, McNamara PJ. Hemodynamic consequences of respiratory interventions in preterm infants. Journal of perinatology : official journal of the California Perinatal Association. 2022 Sep:42(9):1153-1160. doi: 10.1038/s41372-022-01422-5. Epub 2022 Jun 11 [PubMed PMID: 35690691]
Alexiou S, Panitch HB. Physiology of non-invasive respiratory support. Seminars in fetal & neonatal medicine. 2016 Jun:21(3):174-80. doi: 10.1016/j.siny.2016.02.007. Epub 2016 Feb 28 [PubMed PMID: 26923501]
Nørgaard M, Stagstrup C, Lund S, Poulsen A. To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries. Journal of tropical pediatrics. 2020 Jun 1:66(3):339-353. doi: 10.1093/tropej/fmz069. Epub [PubMed PMID: 31599959]
Level 1 (high-level) evidenceMuhe L, Webert M. Oxygen delivery to children with hypoxaemia in small hospitals in developing countries. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease. 2001 Jun:5(6):527-32 [PubMed PMID: 11409579]
De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. The Cochrane database of systematic reviews. 2008 Jan 23:2008(1):CD002977. doi: 10.1002/14651858.CD002977.pub2. Epub 2008 Jan 23 [PubMed PMID: 18254011]
Level 1 (high-level) evidencePrakash R, De Paoli AG, Oddie SJ, Davis PG, McGuire W. Masks versus prongs as interfaces for nasal continuous positive airway pressure in preterm infants. The Cochrane database of systematic reviews. 2022 Nov 14:11(11):CD015129. doi: 10.1002/14651858.CD015129. Epub 2022 Nov 14 [PubMed PMID: 36374241]
Level 1 (high-level) evidenceClaassen CC, Strand ML, Williams HL, Hillman NH. Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations. American journal of perinatology. 2021 Sep:38(11):1167-1173. doi: 10.1055/s-0040-1710557. Epub 2020 May 23 [PubMed PMID: 32446255]
Won A, Suarez-Rebling D, Baker AL, Burke TF, Nelson BD. Bubble CPAP devices for infants and children in resource-limited settings: review of the literature. Paediatrics and international child health. 2019 Aug:39(3):168-176. doi: 10.1080/20469047.2018.1534389. Epub 2018 Oct 30 [PubMed PMID: 30375281]
Egesa WI, Waibi WM. Bubble Nasal Continuous Positive Airway Pressure (bNCPAP): An Effective Low-Cost Intervention for Resource-Constrained Settings. International journal of pediatrics. 2020:2020():8871980. doi: 10.1155/2020/8871980. Epub 2020 Sep 8 [PubMed PMID: 33014078]
Wu CS, Lee CM, Yuh YS, Hua YM. Influence of changing the diameter of the bubble generator bottle and expiratory limb on bubble CPAP: an in vitro study. Pediatrics and neonatology. 2012 Dec:53(6):359-65. doi: 10.1016/j.pedneo.2012.08.013. Epub 2012 Sep 27 [PubMed PMID: 23276440]
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. Journal of tropical pediatrics. 2006 Aug:52(4):249-53 [PubMed PMID: 16326752]
Khan J, Sundaram V, Murki S, Bhatti A, Saini SS, Kumar P. Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress. European journal of pediatrics. 2017 Dec:176(12):1629-1635. doi: 10.1007/s00431-017-3016-7. Epub 2017 Sep 15 [PubMed PMID: 28914355]
McCoskey L. Nursing Care Guidelines for prevention of nasal breakdown in neonates receiving nasal CPAP. Advances in neonatal care : official journal of the National Association of Neonatal Nurses. 2008 Apr:8(2):116-24. doi: 10.1097/01.ANC.0000317260.99072.ae. Epub [PubMed PMID: 18418209]
Level 3 (low-level) evidenceSchmölzer GM, Kumar M, Pichler G, Aziz K, O'Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ (Clinical research ed.). 2013 Oct 17:347():f5980. doi: 10.1136/bmj.f5980. Epub 2013 Oct 17 [PubMed PMID: 24136633]
Level 1 (high-level) evidenceSankar MJ, Sankar J, Agarwal R, Paul VK, Deorari AK. Protocol for administering continuous positive airway pressure in neonates. Indian journal of pediatrics. 2008 May:75(5):471-8. doi: 10.1007/s12098-008-0074-x. Epub 2008 Jun 8 [PubMed PMID: 18537009]
Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology. 2019:115(4):432-450. doi: 10.1159/000499361. Epub 2019 Apr 11 [PubMed PMID: 30974433]
Level 3 (low-level) evidenceFischer HS, Schmölzer GM, Cheung PY, Bührer C. Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: a meta-analysis. European respiratory review : an official journal of the European Respiratory Society. 2018 Dec 31:27(150):. doi: 10.1183/16000617.0083-2018. Epub 2018 Nov 28 [PubMed PMID: 30487291]
Level 1 (high-level) evidenceRamaswamy VV, Bandyopadhyay T, Abiramalatha T, Pullattayil S AK, Szczapa T, Wright CJ, Roehr CC. Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis. EClinicalMedicine. 2023 Aug:62():102097. doi: 10.1016/j.eclinm.2023.102097. Epub 2023 Jul 20 [PubMed PMID: 37538537]
Level 1 (high-level) evidenceKidman AM, Manley BJ, Boland RA, Malhotra A, Donath SM, Beker F, Davis PG, Bhatia R. Higher versus lower nasal continuous positive airway pressure for extubation of extremely preterm infants in Australia (ÉCLAT): a multicentre, randomised, superiority trial. The Lancet. Child & adolescent health. 2023 Dec:7(12):844-851. doi: 10.1016/S2352-4642(23)00235-3. Epub 2023 Oct 27 [PubMed PMID: 38240784]
Level 1 (high-level) evidencede Carvalho Nunes G, Barbosa de Oliveira C, Zeid M, Leone M, Mardakis S, Remmer E, Boyer J, Hailu E, Altit G, Beltempo M, Shalish W, Sant'Anna G. Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD. Pediatrics. 2024 Jul 1:154(1):. pii: e2023065373. doi: 10.1542/peds.2023-065373. Epub [PubMed PMID: 38887808]
Anne RP, Murki S. Noninvasive Respiratory Support in Neonates: A Review of Current Evidence and Practices. Indian journal of pediatrics. 2021 Jul:88(7):670-678. doi: 10.1007/s12098-021-03755-z. Epub 2021 Jun 1 [PubMed PMID: 34075532]
Heath Jeffery RC, Broom M, Shadbolt B, Todd DA. CeasIng Cpap At standarD criteriA (CICADA): Implementation improves neonatal outcomes. Journal of paediatrics and child health. 2016 Mar:52(3):321-6. doi: 10.1111/jpc.13087. Epub [PubMed PMID: 27124841]
Amatya S, Rastogi D, Bhutada A, Rastogi S. Weaning of nasal CPAP in preterm infants: who, when and how? a systematic review of the literature. World journal of pediatrics : WJP. 2015 Feb:11(1):7-13. doi: 10.1007/s12519-014-0535-4. Epub 2014 Dec 29 [PubMed PMID: 25557597]
Level 1 (high-level) evidenceRastogi S, Wong W, Gupta A, Bhutada A, Deepa Rastogi, Maimonides Neonatal Group. Gradual versus sudden weaning from nasal CPAP in preterm infants: a pilot randomized controlled trial. Respiratory care. 2013 Mar:58(3):511-6 [PubMed PMID: 22906960]
Level 1 (high-level) evidenceJardine LA, Inglis GD, Davies MW. Strategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants. The Cochrane database of systematic reviews. 2011 Feb 16:(2):CD006979. doi: 10.1002/14651858.CD006979.pub2. Epub 2011 Feb 16 [PubMed PMID: 21328289]
Level 1 (high-level) evidenceAmatya S, Macomber M, Bhutada A, Rastogi D, Rastogi S. Sudden versus gradual pressure wean from Nasal CPAP in preterm infants: a randomized controlled trial. Journal of perinatology : official journal of the California Perinatal Association. 2017 Jun:37(6):662-667. doi: 10.1038/jp.2017.10. Epub 2017 Feb 23 [PubMed PMID: 28230835]
Level 1 (high-level) evidenceJensen CF, Sellmer A, Ebbesen F, Cipliene R, Johansen A, Hansen RM, Nielsen JP, Nikitina OH, Petersen JP, Henriksen TB. Sudden vs Pressure Wean From Nasal Continuous Positive Airway Pressure in Infants Born Before 32 Weeks of Gestation: A Randomized Clinical Trial. JAMA pediatrics. 2018 Sep 1:172(9):824-831. doi: 10.1001/jamapediatrics.2018.2074. Epub [PubMed PMID: 30039171]
Level 1 (high-level) evidenceAbdel-Hady H, Shouman B, Nasef N. Weaning preterm infants from continuous positive airway pressure: evidence for best practice. World journal of pediatrics : WJP. 2015 Aug:11(3):212-8. doi: 10.1007/s12519-015-0022-6. Epub 2015 Apr 6 [PubMed PMID: 25846068]
Ho JJ, Subramaniam P, Davis PG. Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants. The Cochrane database of systematic reviews. 2020 Oct 15:10(10):CD002271. doi: 10.1002/14651858.CD002271.pub3. Epub 2020 Oct 15 [PubMed PMID: 33058208]
Level 1 (high-level) evidenceMilner AD, Saunders RA, Hopkin IE. Effects of continuous distending pressure on lung volumes and lung mechanics in the immediate neonatal period. Biology of the neonate. 1977:31(1-2):111-5 [PubMed PMID: 321039]
Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB, COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. The New England journal of medicine. 2008 Feb 14:358(7):700-8. doi: 10.1056/NEJMoa072788. Epub [PubMed PMID: 18272893]
Rojas MA, Lozano JM, Rojas MX, Laughon M, Bose CL, Rondon MA, Charry L, Bastidas JA, Perez LA, Rojas C, Ovalle O, Celis LA, Garcia-Harker J, Jaramillo ML, Colombian Neonatal Research Network. Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive airway pressure: a randomized, controlled trial. Pediatrics. 2009 Jan:123(1):137-42. doi: 10.1542/peds.2007-3501. Epub [PubMed PMID: 19117872]
Level 1 (high-level) evidencePrakash R, De Paoli AG, Davis PG, Oddie SJ, McGuire W. Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants. The Cochrane database of systematic reviews. 2023 Mar 31:3(3):CD015130. doi: 10.1002/14651858.CD015130. Epub 2023 Mar 31 [PubMed PMID: 37009665]
Level 1 (high-level) evidenceBharadwaj SK, Alonazi A, Banfield L, Dutta S, Mukerji A. Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis. Archives of disease in childhood. Fetal and neonatal edition. 2020 Sep:105(5):526-531. doi: 10.1136/archdischild-2019-318165. Epub 2020 Jan 22 [PubMed PMID: 31969457]
Level 1 (high-level) evidenceMathai SS, Rajeev A, Adhikari KM. Safety and effectiveness of bubble continuous positive airway pressure in preterm neonates with respiratory distress. Medical journal, Armed Forces India. 2014 Oct:70(4):327-31. doi: 10.1016/j.mjafi.2013.08.003. Epub 2014 Sep 26 [PubMed PMID: 25382905]
Squires AJ, Hyndman M. Prevention of nasal injuries secondary to NCPAP application in the ELBW infant. Neonatal network : NN. 2009 Jan-Feb:28(1):13-27 [PubMed PMID: 19176303]
Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. 'Nasal mask' in comparison with 'nasal prongs' or 'rotation of nasal mask with nasal prongs' reduce the incidence of nasal injury in preterm neonates supported on nasal continuous positive airway pressure (nCPAP): A randomized controlled trial. PloS one. 2019:14(1):e0211476. doi: 10.1371/journal.pone.0211476. Epub 2019 Jan 31 [PubMed PMID: 30703172]
Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial. European journal of pediatrics. 2017 Mar:176(3):379-386. doi: 10.1007/s00431-017-2851-x. Epub 2017 Jan 13 [PubMed PMID: 28091776]
Level 1 (high-level) evidenceCasey JL, Newberry D, Jnah A. Early Bubble Continuous Positive Airway Pressure: Investigating Interprofessional Best Practices for the NICU Team. Neonatal network : NN. 2016:35(3):125-34. doi: 10.1891/0730-0832.35.3.125. Epub [PubMed PMID: 27194606]
Level 3 (low-level) evidenceXie LH. Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants. World journal of emergency medicine. 2014:5(3):218-22 [PubMed PMID: 25225588]
Gu H, Seekins J, Ritter V, Halamek LP, Wall JK, Fuerch JH. Characterizing continuous positive airway pressure (CPAP) Belly Syndrome in preterm infants in the neonatal intensive care unit (NICU). Journal of perinatology : official journal of the California Perinatal Association. 2024 Sep:44(9):1269-1275. doi: 10.1038/s41372-024-01918-2. Epub 2024 Mar 6 [PubMed PMID: 38448640]
Bamat N, Jensen EA, Kirpalani H. Duration of continuous positive airway pressure in premature infants. Seminars in fetal & neonatal medicine. 2016 Jun:21(3):189-95. doi: 10.1016/j.siny.2016.02.005. Epub 2016 Mar 3 [PubMed PMID: 26948885]
Jadcherla SR, Gupta A, Fernandez S, Nelin LD, Castile R, Gest AL, Welty S. Spatiotemporal characteristics of acid refluxate and relationship to symptoms in premature and term infants with chronic lung disease. The American journal of gastroenterology. 2008 Mar:103(3):720-8. doi: 10.1111/j.1572-0241.2007.01748.x. Epub [PubMed PMID: 18341491]
Sokou R, Grivea IN, Gounari E, Panagiotounakou P, Baltogianni M, Antonogeorgos G, Kokori F, Konstantinidi A, Gounaris AK. Gastric Volume Changes in Preterm Neonates during Intermittent and Continuous Feeding-GRV and Feeding Mode in Preterm Neonates. Children (Basel, Switzerland). 2021 Apr 15:8(4):. doi: 10.3390/children8040300. Epub 2021 Apr 15 [PubMed PMID: 33920800]
McGill VE. Neonatal abdominal support to address CPAP belly: Two cases report and literature review. Journal of neonatal-perinatal medicine. 2022:15(4):831-836. doi: 10.3233/NPM-221047. Epub [PubMed PMID: 36031911]
Level 3 (low-level) evidenceAbdel-Hady H, Matter M, Hammad A, El-Refaay A, Aly H. Hemodynamic changes during weaning from nasal continuous positive airway pressure. Pediatrics. 2008 Nov:122(5):e1086-90. doi: 10.1542/peds.2008-1193. Epub [PubMed PMID: 18977958]
Hsu HS, Chen W, Wang NK. Effect of continuous positive airway pressure on cardiac output in neonates. Zhonghua Minguo xiao er ke yi xue hui za zhi [Journal]. Zhonghua Minguo xiao er ke yi xue hui. 1996 Sep-Oct:37(5):353-6 [PubMed PMID: 8942029]
Moritz B, Fritz M, Mann C, Simma B. Nasal continuous positive airway pressure (n-CPAP) does not change cardiac output in preterm infants. American journal of perinatology. 2008 Feb:25(2):105-9. doi: 10.1055/s-2008-1040341. Epub 2008 Jan 31 [PubMed PMID: 18240105]
Beker F, Rogerson SR, Hooper SB, Wong C, Davis PG. The effects of nasal continuous positive airway pressure on cardiac function in premature infants with minimal lung disease: a crossover randomized trial. The Journal of pediatrics. 2014 Apr:164(4):726-9. doi: 10.1016/j.jpeds.2013.10.087. Epub 2013 Dec 15 [PubMed PMID: 24345453]
Level 1 (high-level) evidenceBahman-Bijari B, Malekiyan A, Niknafs P, Baneshi MR. Bubble-CPAP vs. Ventilatory-CPAP in Preterm Infants with Respiratory Distress. Iranian journal of pediatrics. 2011 Jun:21(2):151-8 [PubMed PMID: 23056781]
Nowadzky T, Pantoja A, Britton JR. Bubble continuous positive airway pressure, a potentially better practice, reduces the use of mechanical ventilation among very low birth weight infants with respiratory distress syndrome. Pediatrics. 2009 Jun:123(6):1534-40. doi: 10.1542/peds.2008-1279. Epub [PubMed PMID: 19482765]
De Klerk AM, De Klerk RK. Nasal continuous positive airway pressure and outcomes of preterm infants. Journal of paediatrics and child health. 2001 Apr:37(2):161-7 [PubMed PMID: 11328472]
Narendran V, Donovan EF, Hoath SB, Akinbi HT, Steichen JJ, Jobe AH. Early bubble CPAP and outcomes in ELBW preterm infants. Journal of perinatology : official journal of the California Perinatal Association. 2003 Apr-May:23(3):195-9 [PubMed PMID: 12732855]
Urs PS, Khan F, Maiya PP. Bubble CPAP - a primary respiratory support for respiratory distress syndrome in newborns. Indian pediatrics. 2009 May:46(5):409-11 [PubMed PMID: 19179737]
Mwatha AB, Mahande M, Olomi R, John B, Philemon R. Treatment outcomes of Pumani bubble-CPAP versus oxygen therapy among preterm babies presenting with respiratory distress at a tertiary hospital in Tanzania-Randomised trial. PloS one. 2020:15(6):e0235031. doi: 10.1371/journal.pone.0235031. Epub 2020 Jun 30 [PubMed PMID: 32603380]
Level 1 (high-level) evidenceDewez JE, van den Broek N. Continuous positive airway pressure (CPAP) to treat respiratory distress in newborns in low- and middle-income countries. Tropical doctor. 2017 Jan:47(1):19-22 [PubMed PMID: 26864235]
Jobe AH, Kramer BW, Moss TJ, Newnham JP, Ikegami M. Decreased indicators of lung injury with continuous positive expiratory pressure in preterm lambs. Pediatric research. 2002 Sep:52(3):387-92 [PubMed PMID: 12193673]
Rauschendorf P, Bou Saba G, Meara GK, Roodaki N, Conde-Agudelo A, Garcia DEC, Burke TF. Effectiveness of a novel bubble CPAP system for neonatal respiratory support at a referral hospital in the Philippines. Frontiers in pediatrics. 2023:11():1323178. doi: 10.3389/fped.2023.1323178. Epub 2023 Dec 15 [PubMed PMID: 38161434]
Liptsen E, Aghai ZH, Pyon KH, Saslow JG, Nakhla T, Long J, Steele AM, Habib RH, Courtney SE. Work of breathing during nasal continuous positive airway pressure in preterm infants: a comparison of bubble vs variable-flow devices. Journal of perinatology : official journal of the California Perinatal Association. 2005 Jul:25(7):453-8 [PubMed PMID: 15858606]
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. Biology of the neonate. 1998:73(2):69-75 [PubMed PMID: 9483299]
Dumpa V, Bhandari V. Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021? Children (Basel, Switzerland). 2021 Feb 11:8(2):. doi: 10.3390/children8020132. Epub 2021 Feb 11 [PubMed PMID: 33670260]
Behrman RE, Butler AS, Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Preterm Birth: Causes, Consequences, and Prevention. 2007:(): [PubMed PMID: 20669423]
Level 3 (low-level) evidenceAvery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, Epstein MF, Fitzhardinge PM, Hansen CB, Hansen TN. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics. 1987 Jan:79(1):26-30 [PubMed PMID: 3797169]
Level 3 (low-level) evidenceSahni R, Schiaratura M, Polin RA. Strategies for the prevention of continuous positive airway pressure failure. Seminars in fetal & neonatal medicine. 2016 Jun:21(3):196-203. doi: 10.1016/j.siny.2016.02.008. Epub 2016 Feb 28 [PubMed PMID: 26936186]
Subramaniam P, Ho JJ, Davis PG. Prophylactic or very early initiation of continuous positive airway pressure (CPAP) for preterm infants. The Cochrane database of systematic reviews. 2021 Oct 18:10(10):CD001243. doi: 10.1002/14651858.CD001243.pub4. Epub 2021 Oct 18 [PubMed PMID: 34661278]
Level 1 (high-level) evidenceBamat N, Fierro J, Mukerji A, Wright CJ, Millar D, Kirpalani H. Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants. The Cochrane database of systematic reviews. 2021 Nov 30:11(11):CD012778. doi: 10.1002/14651858.CD012778.pub2. Epub 2021 Nov 30 [PubMed PMID: 34847243]
Level 1 (high-level) evidenceBuckmaster AG, Arnolda G, Wright IM, Foster JP, Henderson-Smart DJ. Continuous positive airway pressure therapy for infants with respiratory distress in non tertiary care centers: a randomized, controlled trial. Pediatrics. 2007 Sep:120(3):509-18 [PubMed PMID: 17766523]
Level 1 (high-level) evidence