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      A pilot study of improvised CPAP (iCPAP) via face mask for the treatment of adult respiratory distress in low-resource settings

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          Abstract

          Background

          Continuous positive airway pressure (CPAP) is a mode of non-invasive ventilation used to treat a variety of respiratory conditions in the emergency department and intensive care unit. In low-resource settings where ventilators are not available, the ability to improvise a CPAP system from locally available equipment would provide a previously unavailable means of respiratory support for patients in respiratory distress. This manuscript details the design of such a system and its performance in healthy volunteers.

          Methods

          An improvised CPAP system was assembled from standard emergency department equipment and tested in 10 healthy volunteers (6 male, 4 female; ages 29–33). The system utilizes a water seal and high-flow air to create airway pressure; it was set to provide a pressure of 5 cmH2O for the purposes of this pilot study. Subjects used the system in a monitored setting for 30 min. Airway pressure, heart rate, oxygen saturation, and end-tidal CO2 were monitored. Comfort with the device was assessed via questionnaire.

          Results

          The system maintained positive airway pressure for the full trial period in all subjects, with a mean expiratory pressure (EP) of 5.1 cmH2O (SD 0.7) and mean inspiratory pressure (IP) of 3.2 cmH2O (SD 0.8). There was a small decrease in average EP (5.28 vs 4.88 cmH2O, p = 0.03) and a trend toward decreasing IP (3.26 vs 3.07 cmH2O, p = 0.22) during the trial. No significant change in heart rate, O2 saturation, respiratory rate, or end-tidal CO2 was observed. The system was well tolerated, ranked an average of 4.0 on a 1–5 scale for comfort (with 5 = very comfortable).

          Conclusions

          This improvised CPAP system maintained positive airway pressure for 30 min in healthy volunteers. Use did not cause tachycardia, hypoxia, or hypoventilation and was well tolerated. This system may be a useful adjunctive treatment for respiratory distress in low-resource settings. Further research should test this system in settings where other positive pressure modalities are not available.

          Electronic supplementary material

          The online version of this article (10.1186/s12245-019-0224-0) contains supplementary material, which is available to authorized users.

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          Most cited references 13

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          Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis.

          Non-invasive positive pressure ventilation (NIPPV), using continuous positive airway pressure (CPAP) or bilevel ventilation, has been shown to reduce the need for invasive mechanical ventilation in patients with acute cardiogenic pulmonary oedema. We assessed additional benefits of NIPPV in a meta-analysis. Meta-analysis comparison in acute cardiogenic pulmonary oedema was undertaken to compare (1) CPAP with standard therapy (oxygen by face-mask, diuretics, nitrates, and other supportive care), (2) bilevel ventilation with standard therapy, and (3) bilevel ventilation with CPAP, incorporating randomised controlled trials identified by electronic and hand search (1966-May, 2005). In 23 trials that fulfilled inclusion criteria, we assessed the effect of NIPPV on hospital mortality and mechanical ventilation, estimated as relative risks. CPAP was associated with a significantly lower mortality rate than standard therapy (relative risk 0.59, 95% CI 0.38-0.90, p=0.015). A non-significant trend towards reduced mortality was seen in the comparison between bilevel ventilation and standard therapy (0.63, 0.37-1.10, p=0.11). We recorded no substantial difference in mortality risk between bilevel ventilation and CPAP (p=0.38). The need for mechanical ventilation was reduced with CPAP (0.44, 0.29-0.66, p=0.0003) and with bilevel ventilation (0.50, 0.27-0.90, p=0.02), compared with standard therapy; but no significant difference was seen between CPAP and bilevel ventilation (p=0.86). Weak evidence of an increase in the incidence of new myocardial infarction with bilevel ventilation versus CPAP was recorded (1.49, 0.92-2.42, p=0.11). Heterogeneity of treatment effects was not evident for mortality or mechanical ventilation across patients' groups. In patients with acute cardiogenic pulmonary oedema, CPAP and bilevel ventilation reduces the need for subsequent mechanical ventilation. Compared with standard therapy, CPAP reduces mortality; our results also suggest a trend towards reduced mortality after bilevel NIPPV.
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            Efficacy of a Low-Cost Bubble CPAP System in Treatment of Respiratory Distress in a Neonatal Ward in Malawi

            Background Respiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care. Methods We conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups. Findings 87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived. Interpretation Use of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.
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              Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review.

              Forty per cent of global child deaths occur in the neonatal period. Low and middle income countries need effective and simple methods to improve hospital-based neonatal care. Bubble continuous positive airway pressure (CPAP) may have a role in improving the quality of respiratory support in hospitals in low and middle income countries.
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                Author and article information

                Contributors
                Brendan.milliner@gmail.com
                Suzanne.bentley@mssm.edu
                jducanto@mac.com
                Journal
                Int J Emerg Med
                Int J Emerg Med
                International Journal of Emergency Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1865-1372
                1865-1380
                5 March 2019
                5 March 2019
                2019
                : 12
                Affiliations
                [1 ]ISNI 0000 0001 2193 0096, GRID grid.223827.e, Division of Emergency Medicine, , University of Utah, ; 30 N 1900 E 1C026, Salt Lake City, UT 84132 USA
                [2 ]ISNI 0000 0004 0453 0340, GRID grid.414488.5, Simulation Center at Elmhurst and Department of Emergency Medicine, , Elmhurst Hospital Center, ; Elmhurst, NY USA
                [3 ]ISNI 0000 0001 0670 2351, GRID grid.59734.3c, Departments of Emergency Medicine and Medical Education, , Icahn School of Medicine at Mount Sinai, ; 3 East 101st Street, Box 1620, New York, NY 10029 USA
                [4 ]GRID grid.427152.7, Department of Anesthesiology, , Aurora St. Luke’s Medical Center, ; 2900 W Oklahoma Ave, Milwaukee, WI 53215 USA
                Article
                224
                10.1186/s12245-019-0224-0
                6399909
                © The Author(s). 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                Categories
                Practice Innovations in Emergency Medicine
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                © The Author(s) 2019

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