Bubble CPAP in Low-Resource Settings

Bubble CPAP may be a useful and affordable tool that can save lives in low-resource settings (LRS).

Health care providers (HCP) in LRS can use bCPAP to treat many of the conditions that require respiratory support in the absence of high-end technology such as ventilators, respirators or even oxygen sources. In addition, HCP may find alternative parts of the bCPAP circuit in their own environment that are more available and cost-effective than those used in developed countries (see links1-4 below).

The world health Organization (WHO) recommendations regarding the use of CPAP for preterm infants in low-resource settings environment states that:

Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with respiratory distress syndrome. (Strong recommendation based on low-quality evidence) The Guideline Development Group (GDG) felt strongly that the technological context of care, including the ability to monitor oxygen saturation and cardiorespiratory status, must be considered prior to instituting any respiratory intervention (supplemental oxygen, continuous positive airway pressure [CPAP] or ventilator support) to critically ill neonates in less-developed medical settings, as these interventions have the potential to lead to more harm than benefit. This recommendation should be implemented in health-care facilities that can provide quality supportive care to newborns. If oxygen therapy is to be delivered with CPAP, low concentrations of blended oxygen should be used and titrated upwards to maintain targeted blood oxygen saturation levels. Where blenders are not available, air should be used; 100% oxygen should never be used because of demonstrable harms. Respiratory distress syndrome can be diagnosed on the basis of clinical or radiological criteria.

Indications of bCPAP

In addition to the common indications for bCPAP discussed in the educational modules, health care providers in low-resource settings may use bCPAP as a non-invasive and affordable respiratory intervention in older infants. Infants 1 months – 5 years were managed successfully with bCPAP (some reports describe use of bCPAP in children up to 12 years old):

Conditions that may be managed with bCPAP in the neonatal period include:
  1. Transient tachypnea of newborn
  2. Meconium aspiration syndrome
  3. Laryngomalacia and Tracheomalacia
  4. Respiratory distress syndrome of prematurity
  5. Apnea of prematurity
  6. Bronchopulmonary dysplasia
  7. Infants with cardiac lesions that require moderate respiratory support
Conditions that may be managed with bCPAP beyond the neonatal period:
  1. Pneumonia (viral or bacterial)
  2. Pneumonitis
  3. Bronchiolitis
  4. Infants with cardiac lesions that require moderate respiratory support
  5. Other mild to moderate respiratory conditions

If available and affordable, it is always recommended to use the proper equipment that is approved by USA-Food and Drug Administration (FDA), European Medicines Agency (EMA) or similar country-specific or local health authorities. Health care providers in low-resource settings are encouraged to use similar parts or components of the bCPAP circuit as described in the set-up section of our educational modules. However, there have been a few reports that produced bCPAP with satisfactory results using a simple set-up.

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Air/Oxygen mixture

If no air or oxygen sources are available, air compressors that work through electric supply or automotive battery may be sufficient to produce required air flow (no oxygen, though!). It may be lifesaving in some conditions to use bCPAP with room air to recruit the alveoli and support the airway in cases that may require pressure support but not a high oxygen requirement or until professional help arrives or transfer to higher care center achieved. Bennett et al. from Massachusetts describes a simple set-up for a bCPAP apparatus with room air (FiO 2 21%) (see link below 6) . If oxygen tanks are available but not air source, Daga et al. from India describes a way of mixing air with oxygen using an air pump to avoid using 100% oxygen (see link below 7 ). In both arrangement above, a flow meter is needed to ensure that infants are receiving proper flow.


If humidifiers that deliver warm and humidified air/oxygen mixture to the patients are not commercially available, the air/oxygen mixture can be humidified by passing through a bottle of sterile water. Bennett et al. further described the set-up (see link below 6 ). Nasal interface Ideally, air/oxygen mixture should be delivered to the infants via nasal prongs as described in nasal interface chapter under educational modules. In the absence of such prongs, a large infant-size nasal cannula that fits well in the nostrils can be used. If not available, a shortened endotracheal tube (ETT) or a large french nasopharyngeal (NP) catheter may be used. Either one should be inserted into the nose to a depth equal to the distance from the nose to the ear. This will put the lower end of ETT or catheter in the pharynx below the soft palate and above the tracheal opening. (See link below for more description 8)


The bubbler is the part of the bCPAP circuit where the expiratory end of the tubing immerses under the water seal. There are several commercially available bubbler systems that are currently used in both developed and developing countries. However, many institutions make their own bubblers. The Set-up section found in the bCPAP respiratory circuit chapter describes how to make a bubbler system from sterile water or acetic acid standard sterile bottles that are commonly used in hospitals and clinics worldwide. In the case of using sterile water or normal saline bottles, 5 ml of 0.25% vinegar needs to be added to the water to make it an acidic medium and suppress bacterial growth. In the absence of sterile water or normal saline bottles, water boiled for at least 30 min with the same vinegar amount and concentration of 5 ml of 0.25% can be used.


A manometer is used to ensure that the pressure applied to the infants’ lungs via bCPAP is within the target range. Some units do not routinely use manometers as long as they have full control of the airflow and the pressure generated in the bubbler. A manometer would be beneficial to test bCPAP circuits prior to usage to assure accuracy of the bCPAP circuit. Sterilization is very important. Health care providers should always use sterile equipment or sterilize the equipment using standard practices.

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Quality and monitoring

Under the Quality page, a detailed description of how to plan for a successful bCPAP program is described. This includes how to train staff, prepare the environment and choose equipment. Monitoring for standardized practice and improved education using policies and procedure with bedside checklist and regular auditing are also described. Health care providers in low-resource settings may adopt measures that best fit their environment and their patients’ needs. For editable versions of the policy and procedure or checklists please visit the. Quality Page


All educational modules (written chapters, audio presentations and demonstration videos) are free on the Bubble CPAP Institute website. If in-house training by experts in bCPAP is desired for faculty and staff please contact training@bcpapinstitute.org