#6 Bubble CPAP for Increased Lung Function in Premature Babies


Underweight and frail, babies born prematurely are susceptible to a host of issues. While equally as precious as their full-term counterparts, these early deliveries often require specialized care upon arrival – including ventilation for those with infant respiratory distress syndrome (IRDS).

For IRDS, infants are commonly administered surfactant – medication to lower surface tension – during mechanical ventilation. Although treating IRDS with surfactant improves clinical outcomes, mechanical ventilation can cause lasting lung injury in preterm infants and contribute to the development of chronic lung disease and other devastating conditions like reactive airway diseases and neurodevelopmental delay as the child grows. The incidence of CLD differs significantly among institutions, but after adjusting for centers’ distributions of birth weight, race, and sex, the lowest incidence of CLD in literature has been reported from centers that use the method of bubble CPAP (b-CPAP) as early as possible. Administering b-CPAP rather than surfactant and mechanical ventilation in the delivery room and as the primary mode for respiratory support of all premature infants in respiratory distress is an important advancement in the world of neonatology.

Unlike mechanical ventilation, b-CPAP is a non-invasive ventilation strategy. It is a method by which continuous positive airway pressure is delivered to a spontaneously breathing newborn to maintain lung volumes during exhalation. In b-CPAP, blended and humidified oxygen is delivered via infant-sized  prongs, and pressure in the circuit is maintained by immersing the end of the expiratory tubing in water. The depth to which the tubing is immersed underwater determines the pressure generated in the airways of the infant. As the gas flows through the system, it “bubbles” out and prevents buildup of excess pressures.

The oscillating, rather than constant, pressure provided by b-CPAP plays a role in its safety and efficacy of volume retention in an infant’s lungs. Its physiologic advantages include optimally matched blood and airflow in the lungs, increased functional residual lung capacity, and maintenance of inflation of alveoli – the functional unit of lung tissue. Compared with mechanical ventilation and tracheal intubation, b-CPAP minimizes physical and subsequent biotrauma and induces a favorable strain that stimulates lung growth when administered over a prolonged period. Other advantages over mechanical ventilation include lower cost, ease of application by nursing staff, and lower risk of complications. The method has also been proposed as an inexpensive method of delivering ventilation in developing countries.

In a center with historical 33% CLD development in its population of very low birth weight (VLBW) infants, the implementation of a b-CPAP program was associated with CLD reduction to 6%. The reduction of CLD rates does not occur immediately – it requires significant time to develop staff experience and achieve the full effect of b-CPAP integration into the ventilation workflow. In a follow-up study of the same institution, the consistency of outcomes was demonstrated over 12 years with an even further reduced CLD rate of 5%.

While neonatologists have been exploring with b-CPAP usage for years, its widespread adoption has only just begun, with large children’s hospitals and specialized centers switching to use of this method alone. New research has confirmed its place within premature infant ventilation, given its CLD-reducing capabilities. Allowing for the growth of strong children with lungs full of life, b-CPAP earned its Top 10 spot for 2021.

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