October 2021 Newsletter

October 2021 Newsletter

Hello, Would you know where I can get a video going through all indications and contraindications for Bubble CPAP? I saw the ones linked in the “resources” tab but am wondering if one goes in more depth.

The lecture by Jen Wung discusses in details relevant indications and contraindications of bubble CPAP. You will find it under the “educational modules” at (www.bcpap.org/modules/). Let me know if you need help listening to it!

Which nasal interface to use with bubble CPAP?

The answer to your question ‘which nasal interface to use with bubble CPAP’ has recently been a matter of debate. Early in the history of the evolution of bubble CPAP, only Hudson prongs were available. Currently we have several options and with the aggressive marketing techniques of the manufactures, it is a challenge to health care providers planning to start a bubble CPAP program to decide which nasal interface to chose.

To be able to decide on this matter, you need to consider several factors:

– Outcomes: which nasal interface has proven its association with better outcomes

– Usability: which nasal interface is easier to use

– Safety: which nasal interface is associated with least adverse effects

– Costs: financial consideration in your unit and the prevailing providers in your hospital

To our knowledge there were few publications that compared nasal interfaces either on mannequin models or live infants. These studies looked at immediate physiological changes such as changes in oxygen supplementation, physical implications such as resistance to flow and hypo-pharyngeal pressure generated, or complications such as association with nasal septal injury1-10.  None of them compared the association of the nasal interface with the primary outcome of interest which is reduction in chronic lung disease.

To our knowledge, centers who have been adopting bubble CPAP for long time and achieved significant reduction in the incidence of chronic lung disease (<10% among infants <1500g) have been using the traditional short curved nasal prongs that radiate from a transverse cylindrical tube. However, one may claim that there are several other factors that are associated with the ultimate outcome of chronic lung disease11.

So, our answer is, we are awaiting a randomized controlled trial that examine the use of specific nasal interface with the incidence of chronic lung disease while standardizing other factors that lead to better outcomes such as strict control of supplemental oxygen, transfusion policies, feeding and nutrition, extra.


  1. Bushell T, McHugh C, Meyer MP. A comparison of two nasal continuous positive airway pressure interfaces – a randomized crossover study. J Neonatal Perinatal Med. 2013;6(1):53-9. (PMID: 24246459).
  2. Singh N, McNally MJ, Darnall RA. Evaluating the Effect of Flow and Interface Type on Pressures Delivered With Bubble CPAP in a Simulated Model. Am J Perinatol. 2019 Jul;36(8):849-854. PMID: 30396227
  3. Green EA, Dawson JA, Davis PG, De Paoli AG, Roberts CT. Assessment of resistance of nasal continuous positive airway pressure interfaces. Arch Dis Child Fetal Neonatal Ed. 2019 Sep;104(5):F535-F539. PMID: 30567774
  4. 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. Cochrane Database Syst Rev. 2008 Jan 23;2008(1):CD002977. PMID: 18254011
  5. King BC, Gandhi BB, Jackson A, Katakam L, Pammi M, Suresh G. Mask versus prongs for nasal continuous positive airway pressure in preterm infants: a systematic review and meta-analysis. Neonatology. 2019;116(2):100-114.
  6. 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.
  7. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018;103(1):F29-F35.
  8. Sharma D, Murki S, Maram S, Pratap T, Kiran S, Venkateshwarlu V, Dinesh P, Kulkarni D, Kamineni B, T A, Singh G. Comparison of delivered distending pressures in the oropharynx in preterm infant on bubble CPAP and on three different nasal interfaces. Pediatr Pulmonol. 2020 Jul;55(7):1631-1639. PMID: 32237275.
  9. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates Cochrane. Available from: https://www.cochrane.org/CD002977/NEONATAL_devices-and-pressure-sources-for-administration-of-nasal-continu-ous-positive-airway-pressure-ncpap-in-preterm-neonates
  10. Miller MJ, DiFiore JM, Strohl KP, Martin RJ. Effects of nasal CPAP on supraglottic and total pulmonary resistance in preterm infants. J Appl Physiol. 1985;68(1):141-146.
  11. Aly H, Mohamed MA. An experience with a bubble CPAP bundle: is chronic lung disease preventable? Pediatr Res. 2020 Sep;88(3):444-450. PMID: 31952073

Do you offer any training courses? Online or in person 

Since 2011, we have been organizing an in-person one day workshop in Washington DC on the first weekend in December every year. In this “Bubble CPAP and the Non-Invasive Respiratory Management of the Neonate” we invite Dr, Jen Wung, Dr. Hany Aly, Dr. Robert Kari and our experienced nurses and respiratory therapists to teach the foundations and essentials of bubble CPAP application

Due to continued COVID19 challenges, we plan to offer a virtual conference this year. You may find more information at (https://smhs.gwu.edu/bubble-cpap/). Virtual attendance is free. There will be an administrative fee if you need CME or MOC certification.

In addition, we offer an on-site training module where our team visits your institution to provide the training to your staff in person. This is a full day of lectures, hands-on training, and interactive discussion.

Hello Dr Mohamed – is there a target gestational age (33, 34 weeks?) where you consider a first trial off of CPAP, for a preterm baby who has been on CPAP for weeks or since birth?

The main idea behind the best time to start weaning off bubble CPAP is when the infant’s lung has reached enough maturity. Using postmenstrual age makes sense if you are sure about the dates. Gained weight also reflects maturity if it is a healthy weight gain and not fluid overload. Using either one as your mark to start the weaning process should eventually lead to similar results.

We recommend using a mixture of postmenstrual age and weight. We typically consider weaning the ELBW infants who have been on CPAP since birth (or after a brief intubation period) off CPAP when they reach 32 weeks postmenstrual age and at least 1200-1400 grams in weight. 

Weaning off bubble CPAP would be considered if these infants have been down to CPAP of +5 cmH2O and 21% supplemental oxygen for at least 48 hours while fulfilling above age and weight criteria before starting weaning trials.

The weaning process is like training for competing in a marathon, where weaning off time starts with 30-45 minutes once a day that can continue as long as the infant can tolerate RA trial without significant desaturation, bradycardia or obvious distress. The infant needs to be put back on bubble CPAP as soon as signs of distress ensue. Trial off time is to be repeated daily starting on the same time and to extend everyday as much as the infant can tolerate. It is not unusual for these infants to initially do well and gradually increase their off time to several hours (8-12 hours) then get exhausted and fail to keep up after a few days. This is not uncommon, and these infants need to be given a rest (not to be weaned off bubble CPAP) for 24-48 hours before restating the weaning off trials. Usually, the whole process may take several days up to 2 weeks before the infant is stable on room air. 

Successful weaning off bubble CPAP is considered when these infants are off CPAP for at least 48-72 hours. Occasionally, after a few days off bubble CPAP, some of these infants will gradually lose their recruited functional residual capacity and may start to show signs of distress or hang on at lower baseline peripheral oxygen saturation (low 90s to high 80s). At this point, they need to be put back on bubble CPAP for 24-48 hours to re-recruit their alveolar space before weaning them off again. On such occasions, no gradual weaning is required.

Start exploring our learning modules in bCPAP.

The Bubble CPAP Institute is an interactive educational platform aiming to make the knowledge and skill set of Bubble CPAP accessible to practitioners who care for neonates and young infants across the globe. This platform will primarily focus on the know-how and will offer educational modules on issues like when to consider bCPAP in managing infants with respiratory distress, how to assemble the bCPAP circuits, how to apply the nasal interface and how to troubleshoot bedside issues.

Read modules