P2B077: Reported Complications of Bubble CPAP Systems in Low-resource Settings: An International Survey

Background: Lower respiratory tract infections (LRTIs) are the leading cause of death in young children globally. Most of this mortality occurs in low-resource settings (LRS) with limited access to respiratory support devices. Fortunately, modified low-cost respiratory support devices have been designed, such as the WHO-style bubble CPAP (bCPAP) circuit. Recently however, the safety of this design has been called into question. The described concern for the side effects of high circuit-generated pressures noted in these lab-based studies were incongruent with our team’s clinical experience with WHO-style bCPAP. We sought feedback via a survey from practitioners in LRS who use WHO-style bCPAP exploring clinical complications encountered.

Methods: The survey explored frequency of complications (nasal irritation, gastric distension, and pneumothorax) based on patient age, size of expiratory limb tubing, and type of circuit – “homemade” –with a narrow (WHO-style) or wide expiratory limb or commercial bCPAP. The survey was designed and validated by the authors, and distributed via email to international academic and clinical contacts of the University of Minnesota Global Health Program. Responses were collected on Google Forms, and analyses were performed with StataSE 16 and XLMiner Analysis ToolPak. Descriptive analyses were performed. Results are exploratory in nature.

Results: 25 hospitals were surveyed, and the response rate was 64%. In neonates, 14 hospitals used homemade bCPAP (7 narrow expiratory limb); and 10 used commercial bCPAP. In children >28 days, 10 used homemade bCPAP (6 narrow expiratory limb); and 3 used commercial bCPAP. Countries represented included Tanzania, Nepal, Cambodia, Nigeria, Haiti, Somaliland, Togo, Pakistan, Laos, and Kenya. Across both age groups, the most reported complication was nasal irritation and the least commonly reported was pneumothorax. Among neonates, nasal irritation was frequently reported in association with use of commercial bCPAP. In contrast, nasal irritation among older children was recalled occurring equally as often between use of homemade versions of bCPAP with a wide limb and commercial bCPAP. Gastric distention among neonates using homemade bCPAP with a wide expiratory limb was reported as occurring equally or less commonly compared to the other device types. In contrast, gastric distention in older children was the least common when using homemade bCPAP with a narrow limb. Pneumothorax was mostly reported as “Never” or “Rarely” in both age groups.

Conclusion: In a qualitative international survey of hospitals that use commercial and homemade WHO-style bCPAP, respondents recall that the side effects were similar. In homemade WHO-style bCPAP in children, pneumothorax was largely reported as a “rare” or “never” event based on recall and clinical experience.