August 2022 Newsletter

Healthcare Professionals

• October 17, 2022

Welcome to Bubble CPAP Updates, A periodic newsletter from the Bubble CPAP Institute General Editor: Mohamed A. Mohamed, MD

In this release:

What’s new?

- Should less invasive surfactant administration (LISA) become routine practice in US neonatal units?
- Aerosol delivery of lung surfactant and nasal CPAP in the treatment of neonatal respiratory distress syndrome
- The efficacy of CPAP in neonates with meconium aspiration syndrome: a systematic review and meta-analysis

Frequently asked questions

What is your experience with non-invasive surfactant administration using laryngeal masks in preterm infants?
Can we feed preterm infants while on bubble CPAP?
How to start a CPAP program in your unit?

Should less invasive surfactant administration (LISA) become routine practice in US neonatal units?

In this article, Kakkilaya et al, explore the benefits of the routine use of less invasive surfactant administration (LISA) instead of endotracheal intubation and ETT surfactant installation. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States yet. This article discusses the accumulated body of evidence supporting LISA, justifies its use as an alternative to intubation for surfactant administration, offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy Read more … Kakkilaya V, Gautham KS. Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res. 2022 Aug 19:1–11. doi: 10.1038/s41390-022-02265-8. Epub ahead of print. PMID: 35986148; PMCID: PMC9389478.

Aerosol delivery of lung surfactant and nasal CPAP in the treatment of neonatal respiratory distress syndrome

In this article, Walther et al, claims that non-invasive surfactant nebulization is the next Holy Grail in neonatology after the shift that occurred in recent years from invasive mechanical ventilation toward non-invasive ventilation in preterm infants with respiratory distress syndrome. The authors review the characteristics of different types of lung surfactants (animal derived and synthetic) and the improvements in nebulization technology required to secure optimal lung deposition and effectivity of non-invasive lung surfactant administration. Studies have demonstrated the safety and potential of non-invasive surfactant administration, implementation of breath-actuated nebulization and optimization of nasal CPAP, nebulizer circuit and nasal interface. Read more … Walther FJ, Waring AJ. Aerosol Delivery of Lung Surfactant and Nasal CPAP in the Treatment of Neonatal Respiratory Distress Syndrome. Front Pediatr. 2022 Jun 15;10:923010. doi: 10.3389/fped.2022.923010. PMID: 35783301; PMCID: PMC9240419.

The efficacy of CPAP in neonates with meconium aspiration syndrome: a systematic review and meta-analysis

Toro-Huamanchumo et al, conducted a literature review to examine the safety and benefits of using non-invasive CPAP in managing infants with meconium aspiration syndrome (MAS) to avoid the need for intubation and mechanical ventilation (ETI). In their analysis, three RCTs were included (n = 432). No significant difference was found in mortality (RR=0.82; CI=0.54–1.25; p=0.36), need for ventilation (RR=0.49; CI=0.15–1.56; p=0.57), and incidence of pneumothorax (RR=1.24; CI=0.30–5.12; p=0.77) in the CPAP group compared to the ETI group. Similarly, no significant differences were found in APGAR at one minute (MD= −1.01; CI −2.97 to 0.94; p=0.31), APGAR at 5 min (MD= −1.00; CI −2.96 to 0.95; p=0.32), days of hospitalization (MD= −0.52; CI −1.46 to 0.42; p=0.28), and cord pH (MD= 0.003; CI −0.01 to 0.02; p=0.79). Authors concluded that in infants with MAS, there is no significant difference between using non-invasive CPAP compared to invasive ETI on primary (mortality, need for ventilation, or the incidence of pneumothorax), and secondary outcomes. These findings suggest the safety and efficacy of non-invasive ventilation approach to avoid invasive mechanical ventilation while managing infants with MAS. Read more … Toro-Huamanchumo CJ, Hilario-Gomez MM, Diaz-Reyes N, Caballero-Alvarado JA, Barboza JJ. The Efficacy of CPAP in Neonates with Meconium Aspiration Syndrome: A Systematic Review and Meta-Analysis. Children (Basel). 2022 Apr 21;9(5):589. doi: 10.3390/children9050589. PMID: 35626765; PMCID: PMC9139540

Frequently asked questions

What is your experience in using laryngeal masks for surfactant administration in preterm infants on bubble CPAP?

The editors of the Bubble CPAP Institute have no firsthand experience in using LMA for surfactant instillation in preterm infants on bubble CPAP or other non-invasive respiratory interventions. This is due to the current unavailability of LMA that fits very small preterm infants <1000g, while in their experience, most infants larger than 1 kg will not need surfactant instillation and will be successfully managed with bubble CPAP alone. However, In our annual conference “Bubble CPAP and the Non-Invasive Respiratory Management of the Newborns”, we have a dedicated session and a hands-on demonstration on surfactant instillation using LMA in infants > 1250g to those who like to administer surfactant to infants > 1 kg. Currently, there is a new LMA under development that is designed to fit infants <1000g. In this article, authors discuss the success of using LMA for non-invasive surfactant instillation in infants on CPAP in low- and middle-income countries (LMICs). Read more… Zapata HA, Fort P, Roberts KD, Kaluarachchi DC, Guthrie SO. Surfactant Administration Through Laryngeal or Supraglottic Airways (SALSA): A Viable Method for Low-Income and Middle-Income Countries. Front Pediatr. 2022 Mar 16;10:853831. PMID: 35372140; doi: 10.3389/fped.2022.853831.

Can we feed infants while on bubble CPAP?

We received several questions about feeding preterm infants while on bubble CPAP. This topic has recently attracted the attention of several practitioners who started to adopt strategies allowing long term use of CPAP prongs instead of premature switching to nasal cannula. Our experience is derived from centers who are well-experienced in using bubble CPAP and familiar with its aerodynamics. They feed stable preterm infants on bubble CPAP but not other types of non-invasive respiratory intervention and this has been their regular practice for decades. They usually start feeding infants on bCPAP when they reach about 34 weeks postmenstrual age and has been stable on bCPAP +5 cmH2O and 21% FiO2 supplement. They start with small volumes and advance gradually till reaching full feeding. Unfortunately, there are paucity of publications from these centers describing their experience in randomized controlled trials. In this study, Mohamed et al, describe their results in oral feeding while on bubble CPAP after introducing cue-based feeding in a historical comparison cohort. In 311 preterm infants, 194 infants were managed with cue-based feeding techniques while 117 infants were in the volume-based standard advancement historical comparison group. They found no differences between groups regarding demographic or clinical characteristics. Postmenstrual age (PMA) of initial feeding assessment was less in the cue-based feeding group. Age of first PO feeding and when some PO was achieved every feed was mildly delayed in the cue-based feeding compared to comparison group, 34 (±1.3) versus 33.7 (±1.2) weeks, and 36.2 (±2.3) versus 36.0 (±2.4) weeks, (p < 0.01) respectively. However, the age of achieving full PO did not differ between groups, 36.8 (±2.2) versus 36.4 (±2.4) weeks (p = 0.13). There was no difference between groups regarding growth parameters at 36 weeks’ PMA or at discharge. Read more… Mohamed M, Teumer K, Leone M, Akram N, Rahamn M, Abdelatif D, Condie K. Cue-Based Feeding as Intervention to Achieve Full Oral Feeding in Preterm Infants Primarily Managed with Bubble CPAP. Am J Perinatol. 2021 Jun 15. doi: 10.1055/s-0041-1731046. PMID: 34130317. In their review article, Canning et al, retrieved 1684 studies but included only 16 of hem that were relevant to the analysis. Methods of non-invasive ventilation included CPAP (n = 6), CPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. Authors found that findings are insufficient to conclude whether commencing oral feeding whilst on CPAP or HFNC facilitates transition to full oral feeding without adverse effects. Read more… Canning A, Clarke S, Thorning S, Chauhan M, Weir KA. Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review. BMC Pediatr. 2021 Feb 17;21(1):83. doi: 10.1186/s12887-021-02531-4. PMID: 33596866; PMCID: PMC7887825. In conclusion, feeding preterm infants who show signs of readiness for per mouth feeding while on nasal CPAP depends on several factors including type of CPAP: HFNC, machine generated, or bubble CPAP, circuit design: flow dependent open circuits or snuggly-fit closed/sealed circuits, and type of nasal interface: cannula, prongs or masks. Our experience is specific to bubble CPAP design, using snugly fit short and curved nasal prongs.

How to start a bCPAP program at your unit

Any Neonatal ICU can replicate the successful experience of starting and mastering the us eof bubble CPAP in caring for preterm infants similar to the IC units who have been successful in implementing bubble CPAP programs for decades. The process follows the same rules used in implementing quality improvement projects including:

Apply the golden rules of establishing a multidisciplinary team and invest in educating your team about this new intervention and its impact on outcomes.
Know the WHY, the HOW, and the WHAT in bubble CPAP.
Set a clear plan of implementation and create visuals of each milestone.
Prepare the platform for launching and ensure sustained quality through monitoring, feedback and reeducation.

Step 1: Putting together the right team The first step in starting a bCPAP program is to identify proper team members. The team leader should aim to select and engage a multidisciplinary team who will spearhead the change. The bCPAP team should consist of:

More than one physician should be on the team to get both sides of the coin.
All levels of nurse specialists are a must: nurse managers, clinical nurses, and nurse practitioners.
Respiratory therapist and related expertise
Quality officer to engage in the planning of the implementation and monitoring from the start.

To be continued…

Learn more about Bubble CPAP implementation at www.bcpap.org/quality. Subscribe to our newsletter, YouTube channel, and follow our LinkedIn page to receive regular updates.