Bubbles CPAP is one of the exciting new technologies Dr.Oden and Dr.Machen left with us. Compared to the expensive respiratory devices in the US, bubbles CPAP is a proven cost-effective support for respiratory distress in neonatal intensive care units, especially in developing countries where ventilators are unaffordable. The neonatal special care ward at Queen’s has a CPAP machine composed of a compressor, oxygen concentrator, a fan to keep the compressor from overheating and tangle of tubing. Seeing the CPAP device demonstrated by Dr.Machen, which costs about $150 and is the size of a shoe box, Dr.Rylance and Dr.Molyneux were eager to try out the technology immediately.

However, we have to first figure out which babies would benefit the most from the technology. At this point, it was interesting for me to learn that the success of an implementation does not only depend on the technology itself but also on the initial patient cases. If the first few babies die after being on CPAP, the nurses and families may associate the technology with eventual death. The nurses would be become reluctant to use it even though the deaths may simply be that the babies are too premature. Thus, the first few babies on CPAP must be picked carefully to be babies who can both benefit from the technology and be most likely to survive. Quite a lot of sickly babies come through the neonatal ward; almost every case is related to prematurity which can be caused by malnutrition, HIV/AIDS and infections. We have seen babies weighing around 600 g; however, babies less than 1kg may simply be too difficult for the CPAP to make a difference because the lungs are not developed enough. Liz and I actually collected the mortality data for the ward from January to June of this year for the babies under the weight of 1500g and studied it according to band widths of 100g. It was startling to find that babies under 1 kg had a mortality of 100%. Only starting with the band from 1000-1100g does the mortality percentage start to drop around 50% and lower. Dr.Sarah Rylance was keen to set the initial criteria at weights above 1200g as the survival rate on average hovers around 50%, a percentage which the CPAP may make a big difference.
Training the nurses is the next big step to implementation. There are currently about seven working in Chitinkha (name of the neonatal special care ward) but only three nurses work at any one time. It would be difficult to introduce the device to everyone in one meeting because half works the day shift while the other, the night shift. We were advised to talk to the nurses in groups, checking off the nurses from our list as we go through the week. All of them are experienced with the CPAP machine in the ward, as they have been trained by a Dutch doctor who first introduced the device. However, the current machine is not being used because it is not working properly or in the nurses’ words “making too much noise” and no one knows how to fix it. They were an attentive bunch at our presentations. Some took notes; they were happy to play with the device, connecting the tubes and such. From our interviews, I do not get the feeling that the nurses have any reservation about CPAP or the technology, but everything would be at the discretion of the doctor in charge. Previously, babies on CPAP were put on and off at a doctor’s orders and the nurses have never instigated CPAP based on their own judgment. However, they feel comfortable about CPAP and its benefits, but when asked about how families react to the technology, we received quite interesting responses. One, it seems that the mothers do not trust the device. Some become suspicious when they see that their children have a nasal prong for the CPAP/oxygen and a gastro tube for feeding; they wonder how the baby would breathe. Getting the mother more involved may help belay their fears, which this device has incorporated. The mother can watch over her child to monitor that the water bottle is bubbling. If there is no bubbles, she can alert a nurse or someone in charge that something is wrong and the baby isn’t getting extra help to breathe.

Currently, we have set up the device in the CPAP corner of the ward. All the nurses have been trained on the device and we have a picture protocol of how to use the device on file in the “technology protocol book” and on the wall. We are hopeful that candidate babies will be on CPAP starting next week. There was already a potential baby this week. He was a 1300g neonate three days old who was starting to show chest recession. When we check his oxygen saturation rate, he was at the 86-88 range. The consensus was to put him on the oxygen concentrator and if his saturation doesn’t improve, then he would be put on CPAP. He is currently doing fine on the concentrator, but this may be the procedure we will be using.