Low Cost Bubble CPAP Machine with Pressure Monitoring and Controlling System

Background Africa contributed to one-third of the world’s neonatal mortality burden. In the Sub-Saharan region, preterm birth complications are the leading, in which a neonate is a higher risk of developing respiratory distress syndrome that will require extra oxygen and help with breathing. When compared to other respiratory supportive methods for treating infants in respiratory distress, bubble continuous positive air pressure (CPAP) is a safe, and effective system that is appealing to many resource-limited neonatal units in low and middle income countries. However, despite of its benefit, the accumulation of condensate in the patient's circuit's exhalation limb during a bubble CPAP can significantly increase pressure delivered to the serious physical consequences that can potentially lead to respiratory failure. Currently, existing technology in developing nations is expensive, and they will not control the accumulation of condensate in the exhalation limb. This quietly increases the mortality rate of neonates. Therefore, the objective of this project was to design, and develop a bubble CPAP device that able to monitor and control pressure delivered to the infant. Methods In this project, a low-cost bubble CPAP machine with a pressure monitoring and controlling system has been developed. When the neonate expires, the pressure sensor inserted into the expiratory tube reads the instant positive end expiratory pressure (PEEP) and sends it to the microcontroller. The microcontroller decides whether to turn the relay (controls the electric power to the 2 - solenoid valve) to switch the way of expiration between the two expiratory tubes connected to the valves of two outlets. This depends on the pressure reading and the cutoff pressure value manually inserted by the physician. Results The prototype was built and subjected to various tests and iterations to determine the device's effectiveness. The developed prototype was tested for accuracy, safety, cost, ease of use, and durability. The prototype was accurate in 10 iterations that had been made to monitor and control the pressure. It was safe and provided accurate pressure for the neonate, and it was built for less than 193 USD. Conclusion The proposed design allows physicians, especially those in low resource settings, to easily monitor and control the accumulation of condensate in the exhalation limb of the CPAP machine accurately and safely. This helps to reduce the neonate mortality rate that may occur due to respiratory distress syndrome.

Cue-Based Feeding as Intervention to Achieve Full Oral Feeding in Preterm Infants Primarily Managed with Bubble CPAP

Objective Cue-based feeding aims at matching introduction of per oral (PO) feeding with physiological readiness of preterm infants to facilitate PO intake and avoid oral aversion. It was claimed that cue-based feeding may lead to delay in the initiation or achieving full PO feeding in clinical setting primarily using bubble nasal continuous positive airway pressure (CPAP). The study aimed to examine the association of cue-based feeding with time of introduction and completing oral feeding in infants primarily managed with bubble CPAP. Study Design A retrospective analysis where outcomes of preterm infants ≤32 weeks' gestational age (GA) and ≤2,000 g birth weight (BW) were compared after a practice change from volume-based feeding advancement to cue-based feeding. Continuous variables were compared by using t-test and multilinear regression analysis to control for confounding variables. Results Of the 311 preterm infants who met inclusion and exclusion criteria, 194 were in the cue-based feeding group and 117 were in the volume-based advancement historical comparison group. There were no differences between groups regarding demographic or clinical variables. 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 with 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. Similar results were obtained when examining subcategories of infants ≤1,000 g and 1,001 to 2,000 g. Conclusion Cue-based feeding may not be associated with a delay in achieving full oral feeding or prolongation of the length of stay in preterm infants managed with CPAP. Key Points

Phthalate Exposures in the Neonatal Intensive Care Unit

Background: Di-2-ethylhexyl phthalate (DEHP), a phthalate compound found in medical devices, may cause toxic effects in premature infants. In this study, the objective is to quantify DEHP exposures from various intravenous and respiratory therapy devices, and to use these values to predict typical exposure for an infant in a neonatal unit. Methods: Common IV products used on infants are directed through various types of IV tubing (IVT) and analyzed for DEHP content. DEHP exposure for infants receiving respiratory therapy was determined indirectly through analysis of urine DEHP metabolites. By deriving these values for DEHP we calculated the daily exposure to DEHP from common IV fluids (IVF) and respiratory devices during hospitalization in a neonatal unit. Results: IVF labeled DEHP-positive showed very high concentrations of DEHP, but when passed through IVT, substantial amounts were adsorbed. DEHP was undetectable with all DEHP-negative IVF tests, except when passed through DEHP-positive IVT. The DEHP leached from most respiratory devices was relatively modest, except that detected from bubble CPAP. In 14 very low birthweight infants, the mean DEHP exposure was 182,369 mcg/kg over 81.2 days of the initial hospitalization. Ninety-eight percent of the exposure was from respiratory devices, with bubble CPAP accounting for 95% of the total DEHP exposure in these infants. Conclusions: The DEHP exposure in our neonatal unit can be reduced markedly by avoiding or modifying bubble CPAP equipment and avoiding IV tubing containing DEHP.

Bubble CPAP (Continuous Positive airway pressure) therapy as a primary mode of respiratory support in preterm newborns with mild to moderate respiratory distress syndrome

Background: Respiratory distress syndrome (RDS) is an important cause of morbidity and mortalityin preterm infants. Bubble CPAP when used appropriately, is more cost-effective, non-invasive,requires less training and has a lower risk of complications. However, not all preterm infants withRDS respond to CPAP. Aims: To study the immediate outcome of preterm infants with mild tomoderate respiratory distress syndrome on Bubble CPAP. To study the safety and effectiveness of B-CPAP and to identify the risk factors associated with its failure. Setting: NICU, Department ofpediatrics, Mamata general hospital and medical college, Khammam. Design- Prospectiveobservational study Material and Methods: This duration bound study was conducted fromFebruary 2018 to February 2020. Based on the inclusion criteria 73 Preterm babies with mild tomoderate respiratory distress syndrome requiring respiratory support were included in this study.Details of birth history, use of antenatal steroids, gestational age, type of delivery, birth weight,Downes score and chest X-ray were recorded. And the effectiveness and outcome of bubble CPAPwere studied. Results: Out of the total of 73 cases, 53(72.60%) were treated successfully, while20(27.40%) failed bubble CPAP. Conclusion: Bubble CPAP is the safe primary mode of respiratorysupport in Preterm newborns with mild to moderate RDS, more effective with early Initiation and inPreterm babies born to mothers with the use of antenatal steroids.

In vitro comparison of performance including imposed work of breathing of CPAP systems used in low-resource settings

Respiratory distress due to preterm birth is a significant cause of death in low-resource settings. The introduction of continuous positive airway pressure (CPAP) systems to treat respiratory distress significantly reduced mortality in high-resource settings, but CPAP was only recently introduced in low-resource settings due to cost and infrastructure limitations. We evaluated pressure stability and imposed work of breathing (iWOB) of five CPAP systems used in low resource settings: the Fisher and Paykel bubble CPAP, the Diamedica baby CPAP, the Medijet nCPAP generator, and the first (2015) and second (2017) generation commercially available Pumani CPAPs. Pressure changes due to fresh gas flow were evaluated for each system by examining the relationship between flow and pressure at the patient interface for four pressures generated at the bottle (0, 3, 5, and 7 cm H2O); for the Medijet nCPAP generator, no bottle was used. The slope of the resulting relationship was used to calculate system resistance. Poiseuille’s law of resistance was used to investigate significant contributors to resistance. Resistance ranged from 0.05 to 1.40 cmH2OL/min; three CPAP devices had resistances < 0.4 cmH2OL/min: the Fisher and Paykel system, the Diamedica system, and the second generation Pumani bubble CPAP. The other two systems, the Medijet nCPAP generator and the first generation Pumani bCPAP, had resistances >1.0 cmH2OL/min. Imposed WOB was measured using an ASL5000 test lung to simulate the breath cycle for an infant (5.5 kg), a term neonate (4.0 kg), and a preterm neonate (2.5 kg). Imposed WOB ranged from 1.4 to 39.5 mJ/breath across all systems and simulated infant sizes. Changes in pressure generated by fresh gas flow, resistance, and iWOB differ between the five systems evaluated under ideal laboratory conditions. The available literature does not indicate that these differences affect clinical outcomes.