Table 2. Studies on feasibility and/or effectiveness of CPAP therapy in LMIC settings.
| Author, year | Country | Setting | Study design | Study population | CPAP Strategy | Results | Comments |
|---|---|---|---|---|---|---|---|
| Studies with a control group | |||||||
| Koyamaibole, 200515 | Fiji | Referral hospital (only hospital providing NICU services in Fiji) | Comparison of two time periods—before and after introduction of bCPAP | Median weight 2765 g (1785–3300); 70 (12.6%) were 1000–1500 g | CPAP was considered for neonates with grunting, severe chest indrawing, severe respiratory distress and hemoglobin oxygen saturation <90% despite oxygen | Among the 105 neonates who received CPAP, 24 (22.8%) failed and required mechanical ventilationTrend towards lower mortality in the period when bCPAP was used (OR 0.74; 95% CI 0.52 to1.03; P=0.06) | Not a randomized trial; ventilator assistance was available as backup if required so the findings may not be translated to a scenario where it is used in isolation |
| Ballot, 201016 | South Africa | Tertiary care neonatal unit | Retrospective chart review | All very low birth weight neonates admitted over a one-year period (n=474) | CPAP commenced when the infant showed signs of respiratory failure; exact strategy not given; CPAP use between survivors vs non-survivors was evaluated | Nasal CPAP use was associated with decrease in mortality from 32.8% to 16.7%Use of nasal CPAP resulted in improved survival among very low birth weight infants (OR 4.58; 95% CI 1.58 to 13.31) | No information regarding respiratory support in the control group or other confounding variables |
| Peiper, 200317 | South Africa | Tertiary care neonatal unit | Prospective data collection | All admissions with birth weight<1200 g who were refused admission to the unit | CPAP protocol was initiated with a pressure of 5 cmH2O and then increased to stabilize respiratory movements and achieve target pressure of arterial oxygen (PaO2) | 21 neonates total; 11 received CPAPSurvival of neonates with respiratory distress managed with CPAP was 81.8% (9/11) vs 20% (2/10) with head box oxygenSurvival to discharge 45.4% (5/11) vs 20%(2/10) | Skewed gender distribution, intention to treat analysis was not done; small sample size |
| Kawaza, 201418 | Malawi | Referral hospital | Prospective observational study with two groups – CPAP with Hudson prongs vs standard care (oxygen with nasal cannulae) | Neonates weighing 1000 g and presenting with severe respiratory distress | Low-cost bCPAP system delivered by Hudson nasal prongs | Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls64.6% (31/48) of neonates with RDS receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls | Control group received standard care (oxygen by cannula); they were shifted to CPAP group if CPAP device was available |
| Jeena, 200219 | South Africa | NICU, teaching hospital | Retrospective review of cases seen at King Edward VIII Hospital | Nasal CPAP was required by 85 neonatesMedian weight 1659 g and gestation 34 weeks. | CPAP was considered for neonates with respiratory failure Maximum CPAP 6 cm and maximum FiO2 60% | 63 neonates (74%) were initially successfully supported with nasal CPAP aloneOf these, 50 (79%) required no further respiratory support until discharge and seven received IPPV subsequentlyMortality rate of 25% in the 85 neonates who received CPAPMortality in neonates successfully managed with CPAP 18%Mortality on CPAP was only 9% for those infants who were not offered ventilation | — |
| Studies with no control group | |||||||
| Saxena, 201220 | India | NICU, teaching hospital | Prospective observational study | All preterm neonates diagnosed with RDS Nasal CPAP alone was given to all spontaneously breathing neonates (n=50)Gestational age 31 (25–35) weeks, birth weight 1543 (710–2700) g | Trial of nasal CPAP was given to all spontaneously breathing newborns | Among the neonates who received CPAP alone 46/50 survived (92%)9/24 (37.5%) neonates <28 weeks, 24/35 (68.5%) 29–32 weeks and 17/24 (70.8%) of 33–36 weeks gestational age neonates could be managed successfully with CPAP and did not require mechanical ventilation | No details of CPAP delivery devices, pressures at the time of initiation, whether breastfeeding |
| Singh, 199321 | India | Tertiary care teaching hospital | Uncontrolled observational study | Not available | Clearly delineated CPAP protocol | 25/33 (75.8%) neonates who received CPAP and 25/57 (44%) neonates who received ventilation survived | No control group, details of patient population and illness not available |
| Rojas, 200922 | Colombia Multicenter trial | Tertiary care center | Randomized trial of INSURE vs CPAP only arm | Preterm infants 27–32 weeks, with O2 requirement or respiratory distress at 15–60 min of age were randomized into INSURE or early CPAP | — | Of the 137 babies treated with CPAP, mortality was 13/137 (9%), mechanical ventilation was needed in 53 (39%),12 (9%) babies had pneumothorax | Case series of only CPAP arm included |
| Hendrik, 201023 | South Africa | Secondary level unit | No comparison | Mean birth weight: 1166 g Mean gestational age: 31 weeks Male: 22/34 (65%) | CPAP protocol clearly delineated, case series | >1800 g: 4/17 neonates had failure<1800 g: 11/34 neonates had failureSurvival 80% | Case series |
| Shrestha, 201024 | Nepal | Secondary level unit | Uncontrolled observational study | All babies with respiratory distress Gestational age 28- 37 weeks Weight 800-2700 g | — | 15 babies; mortality was 33% (4/15) | Case series |
| Heuvel, 201125 | Malawi | Secondary care unit | Case series of 11 babies | Weight 1000-2500 g | CPAP considered for babies with respiratory distress | 5 babies received CPAP and 3 survived (60%) | Case series |
| Kirsten, 201226 | South Africa | Tertiary care NICU | Observational study | Preterm neonates 500 -1000 g⩾25 weeks were included | Clear protocol; started at 4–6 cm of water. FiO2 titrated based on oxygen concentration | 80% survival until discharge for neonates who received only CPAPNasal CPAP was associated with an improved survival at day 3, day 7 and at dischargeBirth weight less than 750 g identified as independent risk factor for failed CPAP | Observational study |
| Boo, et al. 200027 | Malaysia | NICU | Case–control study | 97 preterm infants<37 weeks | CPAP started for infants with respiratory distress; given with either bubble or ventilator CPAP | 37 infants (38.1%) failed CPAPOverall mortality rate not reported | |
| Urs, 200929 | India | NICU, teaching hospital | Prospective observational study | All neonates diagnosed with RDS (n=50) CPAP failure (n=10) CPAP success (n=40) Overall 33 neonates (1000-1500 g), 4 (⩽999 g), 13 (1501-2000 g) | CPAP considered for neonates with FiO2 requirement >0.40 to maintain PaO2 >60 mm Hg with pH <7.25, PaCO2 >50 mm and Downe's score >4 | BCPAP proved to be effective in 40/50 (80%) neonates.Success rate of bCPAP in mild, moderate and severe RDS was 100%, 93.1 and 46.6% respectivelyMortality rate not reported | No details on safety of CPAP delivery, outcome of neonates enrolled in study |
| Pillai, 201129 | India | NICU, teaching hospital | Prospective observational study | Very low birth weight infants <36 weeks eligible for enrollment (n=62) | CPAP considered for neonates with any respiratory distress Initiating pressure: 4-5 cm water, FiO2: 0.4 to 0.5; Target saturations 88-93% | 16 neonates (25.8%) failed CPAPMortality not reported | No details on safety of CPAP delivery, outcome of neonates enrolled in study |
| Koti, 200930 | India | Level III NICU | Prospective observational study | 56 Inborn preterm infants (gestation 28 to 34 weeks) with respiratory distress and chest x-ray suggestive of RDS | BCPAP with bi-nasal prongs started at 5 cm of water and adjusted to minimize chest retractions. FiO2 was adjusted to maintain SpO2between 87 and 95% | Fourteen (25%) babies failed CPAP.Of the 14 infants who failed CPAP, in 4 (28.5%) ventilation was started after an initial recovery from CPAP.Six (6/64; 9.4%) babies died during hospital stay | |
| Bassiouny, 199431 | Oman | NICU | Prospective observational study | 44 preterm infants with RDS enrolled | CPAP delivered using Beneveniste's valve and silastic nasal prongs | 27/44 cases successfully treated with CPAP (61%) and 17 cases (39%) failed to respond | Full text could not be retrieved |
Abbreviations: CPAP, continuous positive airway pressure; INSURE, intubate-surfactant-and-extubate; IPPV, intermittent positive pressure ventilation; LMIC, low- and middle-income countries; NICU, neonatal intensive care unit; RDS, respiratory distress syndrome.