HK J Paediatr (new series) 2007;12:86-92

The Use of Bubble CPAP in Premature Infants:

Local Experience

KM CHAN, HB CHAN

Abstract Bubble continuous positive airway pressure (CPAP) was introduced more than 30 years ago for infants
with respiratory distress. With this, there had been reports of decreased incidence of mechanical ventilation
and chronic lung disease among the premature, as well as less failure of extubation. This report described
how this treatment modality was adopted locally and showed it might be associated with less apnoea
among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants post extubation
with improved non-pulmonary outcomes.

Key words Apnoea of prematurity; Bubble CPAP; Chronic lung Disease; ELBW babies; VLBW babies

Introduction device. Pressure can be generated from the following three

ways.4
Continuous positive airway pressure (CPAP) is a method Firstly, the expiratory valve of the ventilator is used to
of delivering positive end-expiratory pressure with a adjust the expiratory pressure. Secondly, the pressure is
variable amount of oxygen to the airway of a spontaneously generated by adjusting the inspiratory flow or altering the
breathing patient to maintain lung volume during expiration, expiratory resistance (e.g. Infant Flow Nasal CPAP system,
so as to reduce atelectasis, respiratory fatigue and to VIASYS Healthcare, Inc. USA). Thirdly, the bubble CPAP
improve oxygenation. It was first reported in 1971 for system produces a positive pressure by placing the far end
supporting breathing of preterm neonates.1 Clinical benefits of the expiratory tubing under water. The pressure is
have been associated with the use of CPAP in the premature adjusted by altering the depth of the tube under the surface
newborn. Even in the pre-surfactant era and when antenatal of the water.
steroid usage was uncommon; there was some evidence In the seventies, Dr. Jen-Tien Wung at the Columbian
that early application of CPAP might reduce subsequent Presbyterian Medical Center, New York developed the
use of mechanical ventilation and the associated adverse bubble CPAP system using short nasal prongs. In 1987,
outcome.2 Infants extubated to nasal CPAP experienced a Avery et al 5 published a retrospective study of 1625
reduction in respiratory failure necessitating assisted neonates at eight tertiary centers. Columbia University,
ventilation.3 where the predominant mode of respiratory support was
CPAP system consists of a source of humidified blended the use of nasal CPAP, had the lowest incidence of chronic
oxygen, the pressure generator and the airway interface lung disease (CLD) without any significant difference in
mortality.
Department of Paediatrics and Adolescent Medicine,
United Christian Hospital, 130 Hip Wo Street, Kwun Tong,
Kowloon, Hong Kong, China The Bubble CPAP System
KM CHAN RN, RM, MSc(Nursing)
HB CHAN MBBS, FHKAM(Paed), FRCPCH
Essentially, the bubble CPAP system consists of three
components: a continuous gas flow into the circuit, an
Correspondence to: Dr HB CHAN
expiratory limb with the distal end submerged into a liquid
Received February 15, 2007 to generate positive end expiratory pressure,6 and the nasal
Chan and Chan 87

interface connecting the infant's airway with the circuit without leakage, it results in continuous bubbling and
(Figure 1). As the gas leaves the circuit via the expiratory the pressure oscillates in the circuit. 9 Leakage is not
limb, it bubbles (Figure 2). obvious in ventilator (Infant Star) CPAP. Though the
Oxygen blender connected to wall oxygen and pressure oscillation was once suggested to facilitate gas
compressed air supply is used for supplying appropriate exchange,10 this postulation was not supported in another
concentration of inspired oxygen. Optimal gas flow is recent report.11
maintained with a flow meter to prevent rebreathing of Short binasal prongs are commonly used for the nasal
carbon dioxide, increased work of breathing related to interface between the circuit and the infant's airway as they
insufficient flow available for inspiration and to compensate are found to have the lowest resistance12 and their use has
for leakage in the CPAP system.7,8 Flow rate of 5 to 10 been supported by a meta-analysis as the better device for
liters per minute is optimal for CPAP delivery in the delivery of effective CPAP.13 Choosing the right prong and
neonates.8 keeping it in place not only increase the effectiveness of
Pressure in the bubble CPAP system is created by placing CPAP support but can also prevent nasal trauma. The
the distal expiratory tubing in water. Designated pressure resistance increases proportionately with increasing length
is determined by the length of expiratory limb being of the prongs and exponentially with decreasing radius.
immersed.8 When the pressure is delivered to the baby Shorter and wider binasal prongs that can fit snugly in the
nares without causing blanching of the skin is a good option.
Hudson (The Hudson RCI infant nasal CPAP cannula
system, Teleflex Incorporated, USA) and Inca (Ackrad
Laboratories, Cranford, N.J., USA) prongs are similar in
design. Similar sized prongs (actual measured size, not
nominal size as designated by the manufacturer) of either
type are likely to have similar resistance. Inca prongs are
straight, whereas Hudson prongs are anatomically curved.
Theoretically, the latter might fit the airway better, directing
the flow more appropriately down the airway.

Nursing Care of Infants on Bubble CPAP

Elaborate nursing care is pivotal for the success for

applying bubble CPAP to premature infants. Proper
Figure 1 The nasal interface positioning of the prongs can be secured by putting on an
appropriate size hat which rests along the lower part of the
infant's ears and across his forehead with the circuit fastened
on it. It has to be snugly fitted and stationed on the infant's
head, otherwise the circuit and the prong will move with
the motion of the loosely fit hat. Tissue necrosis was
observed if one was unable to keep the prong in the nostrils
of an active infant.14
Nasal trauma is common when the prong rests on the
septum of the nose or on the columella.15-17 Application
of a Velcro mustache placed over a piece of Duoderm
on the philtrum can prevent the accidental incarceration
of the prong onto the nasal septum or the columella.
Besides, adequate airway humidification and gentle nasal
suctioning is paramount in maintaining a clear airway
without jeopardising the tissue integrity of the nostrils.
Figure 2 The expiratory limb Lightweight ventilator circuits with dual heated wire
88 Use of Bubble CPAP in Premature Infants

(e.g. Airlife , Allegiance Healthcare Corp., USA) and October, 2000 and end of March, 2002 (Period 1) were
servo-regulated humidification system is necessary for compared with those born between October, 2002 and end
the delivery of warm and humidified inspired gas to the of March, 2004 (Period 2). Babies with major congenital
CPAP supported infant. 18 "Rain-out" (condensation) anomalies such as cranio-facial cleft or requiring transfer
affects the gas flow and resistance. It should be checked to other centres for various reasons were excluded.
and drained regularly. The probe and chamber This study aimed to evaluate the following respiratory
temperature and the positioning of the temperature probe outcomes after the change:
can be manipulated to minimise the "rain-out". 1. duration of mechanical ventilatory support
Consistent bubbling is important to recruit alveoli, 2. number of infants who required mechanical ventilation
maintain functional residual capacity, and reduce airway within 24 hours after extubation (failed extubation)
resistance and work of breathing, especially in the early 3. duration of CPAP support
acute phase of respiratory distress. If the bubbling stops 4. number of days with significant apnoea (cessation of
it means that there is a pressure leak in the system, respiration 15 seconds with SaO2 <50% and associated
usually around the nostrils. It has been reported that the with bradycardia, heart rate <100 beats per minute)
pharyngeal pressure drops markedly when the CPAP during CPAP
supported infant opens his mouth. 19 Recent study 5. duration of oxygen therapy
demonstrated that the prong pressure, though not totally 6. the postmenstrual age (PMA) of the infants when
transmitted to the pharynx, was more effectively oxygen therapy was terminated
transmitted when the mouth was closed.20 The use of chin 7. number of infants requiring FiO2 >30% at PMA of 36
strap or pacifier has been recommended to reduce mouth weeks.
leak for effective CPAP support. 20 However, it should
not be so tight as to prevent the infant from yawning or The non-respiratory outcomes were also reviewed which
crying but tight enough to prevent leaking at rest. included:
The infant's respiratory status has to be assessed at 1. duration on total parenteral nutrition (TPN)
regular interval to evaluate effectiveness of the treatment 2. postnatal age of the infants when full enteral feeding
and plan for subsequent care. CPAP has to be temporarily was tolerated
interrupted during chest auscultation as the bubbling sound 3. number of infants with necrotising enterocolitis (NEC)
may interfere. However, caution has to be taken as the infant 4. number of infants with grade 3 to 4 intraventricular
may present with apnoea and bradycardia when CPAP hemorrhage (IVH)
support is suspended for just a brief period. 5. body weight at PMA of 36 weeks
Gastric distension is common in the CPAP supported
infant (CPAP Belly Syndrome).21 Frequent decompression During both study periods, there was no major change
of the stomach with an oro-gastric tube is necessary to in technology and medical management of the premature
promote comfort, preventing the distended stomach from infant in the unit. The only difference was the use of bubble
splinting the diaphragm and compromising respiration. CPAP in Period 2 which substituted for the ventilator (Infant
The bubble CPAP system and practice of the Columbia Star, Tyco Healthcare) CPAP support in Period 1. All of
University were introduced to the Neonatal Intensive Care the study population except 6 very low birth weight
Unit of United Christian Hospital, Hong Kong in October, (VLBW) infants, 3 in each period, required intubation. They
2002. A retrospective survey with historic control was were extubated and maintained on CPAP when their
carried out after the change to evaluate the effects of bubble synchronised intermittent ventilator (SIMV) settings were
CPAP on the respiratory and non-respiratory outcomes in <10 breaths per minute, peak inspiratory pressure (PIP) was
premature infants in the unit. <15 cmH2O, positive end-expiratory pressure (PEEP) was
5 cmH2O, fractional inspired oxygen (FiO2) was <0.3 with
no respiratory acidosis and minimal respiratory distress.
Patients and Methods Apnoea, cessation of respiration for 15 seconds or more
with or without desaturation (SaO2 <90%), and cardio-
The short term outcome of CPAP supported premature respiratory status of the subjects were monitored
infants who were delivered in United Christian Hospital continuously with physiological monitors (Spacelab
with birth weight less than 1499 gram born between Healthcare). During the study periods, caffeine citrate was
Chan and Chan 89

given to infants with repeated apnoea (i.e., more than three groups of premature infants between the two study periods
apnoea episodes per hour) with SaO2 <50% or they required (Table 1). Around 85% of the VLBW infants and all of the
frequent bag and mask ventilation. Reintubation was ELBW infants were initially intubated in both study periods.
considered when infants on CPAP developed marked The infants in Period 2 were extubated to bubble CPAP
retraction, FiO2 requirement >0.6 with PaO2 <50 mmHg, and those in Period 1 were given ventilator (Infant Star)
PaCO2 >65 mmHg with intractable metabolic acidosis, nasal CPAP post extubation.
prolonged apnoea with SaO2 <50% and required bag and In the VLBW group, there was no difference in duration
mask ventilation, frequent apnoea not responsive to drug of mechanical ventilatory support or extubation failure in
therapy or at the discretion of the attending clinician both study periods. Though the duration of CPAP was
depending on the infant's clinical status. Infants without significantly shorter in babies in Period 1, the number of
significant retractions would be weaned off from CPAP days with significant apnoea during bubble CPAP was
when their FiO2 requirement <0.3, free from apnoea for 24 significantly less (Table 2). There was no difference in
hours and tolerated gentle nasal-pharyngeal suctioning duration of oxygen support in both periods and the infants
without increasing FiO2 requirement with CPAP removed. were weaned off oxygen at the mean PMA of 35 weeks.
Two babies, one with cranio-facial cleft in Period 1 and Around 20% of the VLBW infants required oxygen support
one baby required interhospital transfer in Period 2 were greater than 30% at PMA of 36 weeks. However, all of
excluded in the study. A total of 80 infants were analysed them survived and could successfully wean off oxygen
and they were further stratified into the very low birth therapy before PMA of 40 weeks.
weight (VLBW) group with birth weight between 1000 Similar results were obtained in the ELBW group (Table
gram to 1499 gram and the extremely low birth weight 3). There was no significant difference in failed extubation
(ELBW) group with birth weight less than 1000 gram. The and duration for mechanical ventilation. Again, there was a
outcomes of 45 VLBW and 35 ELBW premature infants significantly longer duration of CPAP support in Period 2.
were reviewed. Results were analysed by the independent The number of days with significant apnoea during bubble
sample t-test for normally distributed continuous variables, CPAP was significantly less during Period 2. There was no
Chi Square analysis for dichotomous variables and difference in duration of oxygen support in both periods
Mann-Whitney U-test for non-parametric data at the 5% and the neonates were weaned off oxygen at the mean PMA
significance level. of 39 weeks. Thirty percent of ELBW infants in both study
periods require oxygen therapy greater than 30% at PMA
of 36 weeks. The majority of them could be weaned off
Results oxygen successfully at PMA of 44 weeks. The longest
duration of oxygen therapy in ELBW in Period 1 and 2 were
There was no difference in the characteristics of both PMA of 64 weeks and PMA of 54 weeks respectively.

Table 1 Characteristics of the study infant

VLBW (N=45) ELBW (N=35)
Period 1 (N=21) Period 2 (N=24) P Period 1 (N=19) Period 2 (N=16) P
Gestation in weeks (meanSD) 30.361.87 30.441.89 0.89 26.72.69 27.31.78 0.45
Birthweight in gram (meanSD) 1243.71162.29 1226.79155.94 0.72 765.63136.13 828.44102.61 0.14
Number of males (%) 12 (57%) 13 (54%) 0.84 9 (47.37%) 7 (43.75%) 0.83
Antenatal steroids
None (%) 1 (4.76%) 1 (4.17%) 1 (5.26%) 1 (6.25%)
Partial (%) 7 (33.33%) 6 (25%) 0.54 8 (42.11%) 5 (31.25%) 0.61
Complete (%) 13 (61.9%) 17 (70.83%) 10 (52.63%) 10 (62.5%)
Apgar score 1 minute (meanSD) 7.142.67 7.251.68 0.87 5.672.17 6.192.14 0.49
Apgar score 5 minute (meanSD) 8.621.6 8.790.88 0.65 7.561.46 8.251.07 0.13
No. with intubation (%) 18 (85.71%) 21 (87.5%) 0.86 19 (100%) 16 (100%) NS
No. given surfactant (%) 18 (85.71%) 19 (79.17%) 0.79 19 (100%) 16 (100%) NS
NS, not significant
90 Use of Bubble CPAP in Premature Infants

The non-respiratory outcome of both groups of enteral feeding as measured by gastric residue less than
premature infants was similar (Tables 4 & 5). As soon as half of the feeding volume with no vomiting or gastric
the infants were medically stable, trophic feeding was distention, total enteral feeding was gradually advanced by
instituted. In both study periods, when the infants tolerated 10 ml to 20 ml/kg/day. Both groups of infants who were

Table 2 Respiratory outcome of the VLBW infant (N=45)

Period 1 (N=21) Period 2 (N=24) P
Duration of mechanical ventilation in days (meanSD) 2.172.44 3.4311.47 0.6
No. of failed extubation (%) 0 (0%) 0 (0%) NS
Duration of CPAP support in days (meanSD) 7.9710.21 18.3414.93 0.009
No. of days with significant apnoea during CPAP (meanSD) 2.293.52 0.541.32 0.029
Duration of oxygen therapy in days (meanSD) 32.4522.15 28.237.47 0.48
PMA off oxygen (meanSD) 35.042.61 34.552.14 0.496
No. required FiO2 > 0.3 at PMA 36 weeks (%) 5 (23.81%) 5 (20.83%) 0.88
NS, not significant; PMA, postmenstral age

Table 3 Respiratory outcome of the ELBW infant (N=35)

Period 1 (N=19) Period 2 (N=16) P
Duration of mechanical ventilation in days (meanSD) 21.5124.66 15.6716.48 0.097
No. of failed extubation (%) 1 (5.26%) 0 (0%) 0.81
Duration of CPAP support in days (meanSD) 20.2915.85 38.4418.08 0.004
No. of days with significant apnoea during CPAP (meanSD) 66.18 2.12.9 0.028
Duration of oxygen therapy in days (meanSD) 87.4157.92 87.3848.35 0.778
PMA off oxygen (meanSD) 39.886.91 39.216.62 0.616
No. required FiO2 >0.3 at PMA 36 weeks (%) 7 (36.84%) 5 (31.25%) 0.736
PMA, postmenstral age

Table 4 Non-respiratory outcome of the VLBW infant (N=45)

Period 1 (N=21) Period 2 (N=24) P
Duration on TPN in days (meanSD) 28.29.7 15.64 <0.01
Age when full enteral feeding tolerated in days (meanSD) 28.310.4 16.44.6 <0.01
Necrotising enterocolitis (%) 2 (9.52%) 0 (0) 0.23
No. with IVH grade 3-4 (%) 0 (0) 0 (0) NS
Body weight at PMA 36 weeks in gram (meanSD) 2061.24317.04 2232.71443.21 0.14
TPN, total parenteral nutrition; PMA, postmenstral age; IVH, intraventricular haemorrhage; NS, not significant

Table 5 Non-respiratory outcome of the ELBW infant (N=35)

Period 1 (N=19) Period 2 (N=16) P
Duration on TPN in days (meanSD) 47.722.8 31.613.2 0.018
Age when full enteral feeding tolerated in days (meanSD) 46.420.2 31.111.7 0.012
Necrotising enterocolitis (%) 1 (6.25%) 0 (0) 0.29
No. with IVH grade 3-4 (%) 2 (10.53%) 0 (0) 0.17
Body weight at PMA 36 weeks in gram (meanSD) 1734.83 406.57 1935.63 394.17 0.154
TPN, total parenteral nutrition; PMA, postmenstral age; IVH, intraventricular haemorrhage
Chan and Chan 91

on bubble CPAP had shorter duration of TPN support and A recently published retrospective case-control study
they could tolerate full enteral feeding sooner. Most from the Netherlands also suggested that a trial of early
important of all, there was no increase in incidence of IVH. nasal CPAP, using nasopharyngeal tube or the Infant Flow
No baby on bubble CPAP suffered from NEC. These were system, at birth might reduce the incidence of moderate to
consistent with the findings reported in 2001 at New severe CLD and did not seem to be detrimental in very
Zealand.22 preterm infant. Thirty-three percent of the very preterm
No infant had any injury or trauma to the nose. No infants (25-32 weeks) were successfully managed with
significant airleak was encountered in both study periods. CPAP alone.24 Whether bubble CPAP in the delivery room
management of the premature babies will demonstrate
differences in chronic lung disease or death at 36 weeks
Discussion adjusted age may be addressed in multi-centers randomised
trials such as the one by the Vermont Oxford Network.
When bubble CPAP was used after extubation in our With our experience, we conclude that there was no
unit in Period 2, the neonates had significantly less number increase in adverse respiratory outcome in the unit after
of days with significant apnoea, although they were on the change from ventilator CPAP to bubble CPAP. Bubble
CPAP for longer duration. There was no significant CPAP is safe to use and it appeared to be associated with
difference in other respiratory outcomes in the VLBW and less apnoea and more favorable non-respiratory outcome.
ELBW babies in the two time periods. The bubble CPAP However, because of the small sample size, a larger scale
supported premature infants achieved full enteral feeding prospective study is warranted to determine the long term
earlier, thus the duration for TPN was significantly reduced. benefits.
This might be related to the decrease in significant apnoea,
which is a sign of medical instability for which the attending
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