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CPAP helps improve respiratory, survival rates in children in low-resource settings

Pearl Toh
31 Jul 2017

Continuous positive airway pressure (CPAP), a noninvasive ventilation, may help improve respiratory rate and reduce mortality in children with respiratory distress, particularly in those younger than 1 year, a recent study showed. CPAP intervention was initiated by nurses with minimal physician supervision in the study, supporting the use of noninvasive ventilation in low-resource settings where laboratory diagnostic tests are not readily available.   

The open-label crossover trial enrolled 2,181 children (aged 1 month–5 years), whose respiratory rate was >50 breaths/min in children 1–12 months old, or >40 breaths/min in children >12 months old, in two nontertiary hospitals in Ghana where invasive mechanical ventilation was often unavailable. Children who presented to one of the hospitals received oxygen through CPAP (n=1,025) while those in the other control hospital received oxygen via a nonrebreather facemask (n=1,160). [Lancet Glob Health 2017;5:e615-623]

Although the rates of all-cause mortality were similar at 2 weeks between the CPAP and the control groups (3 percent vs 4 percent, relative risk [RR], 0.67; p=0.11), the rate was significantly lower with CPAP in children younger than 1 year (3 percent vs 7 percent, RR, 0.40; p=0.01). The most common causes of death reported were malaria, pneumonia, sepsis, and anaemia, and most patients were diagnosed with multiple conditions.

Analyses adjusted for time, study site, and clinically important variables showed that the younger the child’s age, the lower the risk of death at 2 weeks, with the odds ratios in the CPAP versus the control groups being 0.4 in children aged ≤6 months, 0.5 for those aged 1 year, 0.7 for those aged 2 years, and 1.0 for those aged 3 years.

“In addition to demonstrating the safety of CPAP and the children’s improved survival rates, our study is unique in that CPAP was initiated and managed at the first hospital level by emergency ward nurses who work much of the day without direct supervision by a physician,” said senior author Dr Rachel Moresky of Mailman School of Public Health at Columbia University in New York, New York, US. 

“Our findings suggest that the use of CPAP in young children with respiratory insufficiency is appropriate in other parts of the developing world, where diagnostic capabilities are similarly limited,” said Moresky and co-authors.

Across all ages, significant improvement in respiratory rate was seen in the CPAP vs the control groups at 4 h, 8 h, 12 h, and 24 h (p<0.001 for all timepoints).

CPAP-related adverse events, including aspiration, vomiting, and skin, nasal, or eye trauma occurred in 3 percent of CPAP-treated patients vs 2 percent in the control group. Nasal trauma occurred more frequently with CPAP vs control, although the difference was not statistically significant. There were no reports of serious adverse events.

“CPAP significantly lowered respiratory rate throughout the 24-h monitoring period in all age groups, showing a prolonged physiological benefit,” observed the researchers. “For every 25 children under the age of 1 year treated with CPAP, one life will be saved and most will have improvements in their respiratory status.”

Noting the WHO recommendation to “redistribute healthcare tasks to less highly trained individuals”, Moresky said, “our study demonstrates that by task sharing this skill to nurses, that lifesaving care can be brought closer to the community.”

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