How to set up a bCPAP program in your unit

Starting a bubble CPAP program at your unit

The foundational steps used to initiate a bubble CPAP program are similar to other ‘Quality Improvement’ projects. These steps include:

  • the buy in of stakeholders
  • a developed consensus of the benefits of the new intervention and its impact on outcomes
  • preset algorithm to handle potential side effects and setbacks
  • clear implementation plan with common vision and achievement parameters
  • user friendly communication platform
  • detailed policy and procedures
  • consistent monitoring with predetermined check points and regular follow up to assess progress, identify challenges and maintain success

Step 1: Team establishment

The very first step in starting a bCPAP program is to identify team members. The team leader should aim to select and engage a multidisciplinary standing committee that will spearhead the change. The bCPAP team should consist of:


At least one lead physician


All levels are necessary: a nurse manager, charge and clinical nurses, however, one lead nurse should be identified

Feeding specialists

If they are part of NICU staff, it is better to engage feeding specialists at an early stage in the development of the bCPAP program. They will feed those who require bCPAP by mouth when developmentally ready

Nurse practitioners

At least one lead neonatal nurse practitioner

Respiratory therapists

At least one lead respiratory therapist

Quality team

At least one lead member from the quality improvement team for proper design of the implementation program and optimal follow up and monitoring

Step 2: Education

Educating the implementing team about bubble CPAP (the why, how, and what) is the most important step for a successful bCPAP program. Proper education, orientation and familiarity of bCPAP leads to early success of the program and improved outcomes compared to prior entrenched methods. This visualization of positive change in the unit leads to change in the team’s attitude.


The team needs to properly become aware of the benefits of bCPAP as a unique non-invasive respiratory tool that improves outcomes. Neonatal ICUs that primarily use bCPAP in the management of preterm infants have been shown to have less chronic lung disease (CLD)1-4. The team needs to understand the conceptual foundation behind it and how it compares to other non-invasive and invasive respiratory interventions.

See educational modules

It is crucial for the team to have a thorough understanding of bCPAP and its effects on lung mechanics of preterm infants, full term infants or older children. This is an essential step to appreciate the indications and contraindications of bCPAP; when to consider starting infants on bCPAP; how to escalate your intervention using other non-invasive strategies or when to intubate these infants; how to wean from mechanical ventilation to bCPAP and when and how to wean off bCPAP to room air.

See educational modules

At a later phase, the team needs to discuss and finalize the implementation plan, training schedule, bubble CPAP equipment to be introduced into the unit (nasal interface, bubbler system, air/oxygen blenders and humidifiers, cannulaide, chin straps, etc.), a bedside checklist, a monitoring plan (items to be monitored), sharing monitoring results, educational intervention to correct implementation course, etc.

To further educate your team about bCPAP, you may use our available online materials, attend our Bubble CPAP and Neonates Annual Conference or invite our team to run a bCPAP workshop at your institution. You will find appropriate educational materials under “Educational Modules” including written chapters, recorded lectures, and demonstration videos.

A suggested introductory course should include:

Step 3: Implementation Plan

This step includes developing and finalizing a multi-phasic implementation plan

Bubble CPAP, although a simple bedside tool, is relatively labor intensive and requires gradual implementation and time for the team members to absorb and master the required steps. The bedside team needs time to go through the educational curve while learning how to assemble respiratory circuit, apply nasal interface, comply with bedside check list, troubleshoot, monitor quality, etc.

The implementation team needs to agree on a gradual transition plan where certain parts of the unit or a dedicated nursing team will start implement bCPAP (provided that they provide 24/7 coverage of the assigned beds). After success with a small cohort, the team should gradually adapt bCPAP usage to the remainder of the unit.

It is always better to start bCPAP on infants who are less sick in order to focus on learning and mastering technique, building skills and growing the confidence among staff members. Confidence in bubble CPAP needs to be built gradually to avoid setbacks of unexpected failure caused by lack of experience.

The following is a suggested schedule of a multiphasic gradual implementation plan:

Guidelines to step-wise bCPAP program implementation

Phase Gestational age or birth weight* Duration
1 ≥ 32 weeks / ≥ 1500g 4-6 months
2 ≥ 28 weeks / ≥ 1000g 4-6 months
3 ≥ 26 weeks / ≥ 750g 4-6 months
4 ≥ 24 weeks / ≥ 500g 6 months
5 Any GA or BW thereafter

*Suggested birth weight and/or gestational age categories

The table above suggests to start with infants who weigh 1500 grams or more at birth, for 4-6 months. It is recommended that you should not start using bCPAP on any infant less than 1500g during the initial phase. Advance gradually to infants 1000-1499g after 4-6 months for a period of another 4-6 months. Continue progressing according the above guidelines until your team is comfortable using bCPAP on all infants, regardless of birth weight or gestational age, by 18-24 months from your bCPAP program initiation. Alternatively, gestational age categories may be used.

Regular evaluation and follow up meetings need to be in place. In the first 2-3 months, it should be every week to discuss obstacles and setbacks. Meeting frequency may space out gradually based on the team’s comfort level and success of implementation. However, at least once a month, a meeting should be conducted to assure quality and monitor outcomes.

Create a bCPAP Standing Committee
Educate team about bCPAP
Approve equipment, policy and procedures
Complete training and assure competency
Monitor for proper implementation
Discuss outcomes and identify challenges
Continue educational plan for staff

Step 4: Platform preparation

  • Discuss and approve the type of nasal interface, bubbler, chin strap, cannulaide, etc.
  • Provide training for the startup team on equipment to be used and assure competency
  • Discuss and approve ‘Policy and Procedures’ with your staff

Discuss and approve type of nasal interface, bubbler, chin strap, cannulaide, etc.

Team needs to discuss available options with hospital administration and agree on tools and equipment that the unit will commit to. Starter ups are encouraged to use nasal interfaces that have been associated with better outcomes in units that have shown consistently low chronic lung disease rates. The respiratory team needs to be comfortable with the respiratory equipment (humidifier, blender, circuits, bubbler, etc.) The team may use one of the commercially available bubblers or make their own as shown in our “Respiratory Circuit” under educational modules.

Provide training for the startup team on equipment to be used

All staff selected for initial implementation (physicians, nurses, respiratory therapists, etc.) must have hands-on training on the selected equipment to be used. Competency must be assured in all members of the pioneering team, as they will be the super-users who will teach and train the remainder of the staff.

Discuss and approve ‘Policy and Procedures’ with the staff

Bubble CPAP policy and procedures need to be in a readily available file during the initiation phase until bCPAP is routinely used in your unit. The following policies are suggest:

Indications, contraindications, and potential side effects

Read More

Applying nasal interface

How to properly and safely apply nasal prongs and secure respiratory circuit on infant’s head

Read More

Setting up respiratory circuit

How to set up respiratory circuit using in-house made bubbler and available equipment

Read More

Protecting nasal septum

How to avoid nasal erosion and how to manage it if it occurs

Read More

Trouble shooting

Trouble shooting if bubbler is not bubbling.

Read More

Bedside check list

A check list of suggested items to be completed by the bedside nurse every shift

Read More

LMA for surfactant administration procedure guidelines

Read More

Implementation should start as planned and team members should meet weekly to assess. Super-users should always be identified and available as main references for the implementation staff.

Step 5: Quality Monitoring

Implement a continuous and systematic education schedule for all staff members

All staff in the neonatal ICU need to be fully educated on the proper application, assembly, and use of bCPAP. Their competency in applying the nasal interface, setting up the bCPAP circuit, protecting the nasal septum, implementing the bedside checklist and troubleshooting should be verified and documented. The bCPAP team should modify this plan according to unit policies and culture. In certain units, all staff would be trained to perform all the steps. In others, RTs will take care of the circuit; nurses will handle the nasal interface and review bedside check list while quality personnel will assure standardization and monitoring.

New staff members need to have formal education, which includes foundational concepts, clinical scenarios, and periodic hands on sessions (i.e. every three months). Based on monitoring and quality assurance results as described below, existing staff may need to have refreshing courses or attend full educational program as designed by the bubble CPAP Committee. The quality assurance team should identify educational materials to be used as a refresher course. See different materials under “Educational Modules”: written chapters, recorded lectures by renowned bCPAP educators, along with demonstration videos.

A suggested course is:
  • Nuts and bolts of bCPAP by Jen Wung, MD
  • Reproducibility of bCPAP by Hany Aly, MD
  • bCPAP clinical scenarios by Mohamed A. Mohamed, MD
  • Nasal Interface application (demonstration video)

Set up a monitoring plan with your quality assurance team

A new quality improvement project may lead to an initial excitement that gradually dissipates if it is not supported by a strong quality assurance and monitoring program. Bubble CPAP is no exception and without meticulous monitoring, staff may not see its full impact on outcomes and revert to old intervention methods.

All aspects of bCPAP, from the circuit to the patient, should be assessed periodically. The following list includes suggested items to be monitored at least once a week. Monitoring rounds should be unannounced and include all infants on bCPAP at the time.

Item for evaluation Response
1 Prongs are the appropriate size for nares Yes or No
2 Prongs are positioned correctly (i.e. bridge is not touching nasal septum) Yes or No
3 Cannulaide is the correct size and properly adherent to skin Yes or No
4 Velcro mustache is correct shape (i.e. corners rounded, thin) Yes or No
5 Velcro mustache is properly positioned (i.e. not touching septum/nares) Yes or No
6 Chin strap is used as indicated Yes or No
7 Respiratory tubes are properly placed (i.e. not touching the eyes) Yes or No
8 Water in bubbler is at the correct level Yes or No
9 Water in bubbler is continuously bubbling Yes or No
10 Flow meter is set at 5-7 liters/min Yes or No
11 Oxygen saturation is at desired range (i.e. 90-93%) Yes or No
12 Daily Bedside CPAP Checklist is complete for current shift? Yes or No

Data should be compiled and reviewed by the team on a monthly basis to promptly identify any deviation in implementation. Results could be displayed and shared as follow:

Overall Compliance Rate
Overall Compliance Rate

The graph above illustrates the overall compliance rate by month. The dotted line represents a compliance rate goal of at least 80%. The overall compliance rate per month is an average score of the evaluated items above.

Download Excel version
Correct Cannulaide Size
Correct Cannulaide Size
Continuous bubbling
Continuous bubbling
Prongs position
Prongs position
Correct prong size
Correct prong size


  • Aly H and Mohamed M: An experience with a bubble CPAP bundle: is chronic lung disease preventable? Pediatr Res. 2020 Jan 17.
  • Aly, H., Mohamed, M. A. & Wung, J. T. Surfactant and continuous positive airway pressure for the prevention of chronic lung disease: history, reality, and new challenges. Semin. Fetal Neonat. Med. 22, 348–353 (2017).
  • Schmolzer, G. M. et al. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ 347, f5980 (2013).
  • Aly, H., Massaro, A. N., Patel, K. & El-Mohandes, A. A. E. Is it safer to intubate premature infants in the delivery room? Pediatrics 115, 1660–1665 (2005).