A one hour old baby boy presented to the Special Care Baby Unit (SCBU) of the Ahmadu Bello University Teaching Hospital (ABUTH), Shika, Zaria, on account of respiratory distress noticed from birth. He was a product of supervised pregnancy, delivered at 37 weeks gestation via emergency caeserien section performed due to severe pre eclampsia and fetal distress. APGAR scores were 2 and 7 at one and five minutes respectively.He weighed 1850 grams and was found to be dusky, inactive, hypothermic(T = 35.50C) and in severe respiratory distress (SPO2 ranged between 60 % and 72 %). He was tachypnoeic with respiratory rate persistently above 80 cycles/ min, and had reduced air entry in the mid and lower zonesof the lungs bilaterally with wide spread coarse crepitations. A diagnosis of perinatal asphyxia was entertained with differential diagnoses of pulmonary hypoplasia, hyaline membrane disease and group B streptococcal (GBS) pneumonia. He had a full sepsis screen including chest radiograph and was commenced on supplemental oxygen via nasal cannula, antibiotics and other supportive measures. The patient howevercontinued to have laboured breathing and subsequently had an apnoeic attack. He was resuscitated and commenced on bubble nasal CPAP. He did remarkably well and was weaned off CPAP after a total of 60 hours. A repeat chest radiograph showed remarkable aeration of the lungs asagainst an earlier one which showed a reticulogranular (ground glass) appearance. Key words: Neonates, Respiratory distress, Bubble nCpap, Downesscor

Abdulkadir, I

Abdullahi, F

English

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                 CASE REPORT Niger J Paed 2013; 40 (3) : 303 –306 Abdulkadir I Abdullahi F  Hassan L Purdue S Okpe M Mohammed A Aminu AT Usman N Aliyu H Ogala WN The Use of bubble nasal CPAP in the management of IRDS -A Case  report and literature review Accepted: 27th January  2013  Abdulkadir I,  Abdullahi F, Hassan L, Purdue S, Okpe M, Mohammed A, Aminu AT, Usman N, Aliyu H, Ogala WN Department of  Paediatrics  Ahmadu Bello University Teaching Hospital Shika – Zaria, Kaduna State Nigeria. (      )DOI:http://dx.doi.org/10.4314/njp.v40i3,22 Abstract A one hour old baby boy presented to the Special Care Baby Unit (SCBU) of the Ahmadu Bello University Teach-ing Hospital (ABUTH), Shika, Zaria, on account of respiratory distress noticed from birth. He was a product of supervised preg-nancy, delivered at 37 weeks ges-tation via emergency caeserien section performed due to severe pre eclampsia and fetal distress. APGAR scores were 2 and 7 at one and five minutes respectively. He weighed 1850 grams and was found to be dusky, inactive, hypo-thermic (T = 35.50C) and in se-vere respiratory distress (SPO2 ranged between 60 % and 72 %). He was tachypnoeic with respira-tory rate persistently above 80 cycles/ min, and had reduced air entry in the mid and lower zones of the lungs bilaterally with wide spread coarse crepitations. A di-agnosis of perinatal asphyxia was entertained with differential diag-noses of pulmonary hypoplasia, hyaline membrane disease and group B streptococcal (GBS) pneumonia. He had a full sepsis screen including chest radiograph and was commenced on supple-mental oxygen via nasal cannula, antibiotics and other supportive measures. The patient however continued to have laboured breath-ing and subsequently had an apnoeic attack. He was resusci-tated and commenced on bubble nasal CPAP. He did remarkably well and was weaned off CPAP after a total of 60 hours. A repeat chest radiograph showed remark-able aeration of the lungs as against an earlier one which showed a reticulogranular (ground glass) appearance.    Key words: Neonates, Respiratory distress, Bubble nCpap, Downes score.       Introduction  Newborns who develop respiratory distress may requi respiratory support which could be provided via various methods. Continuous positive airway pressure (CPAP) refers to a mode of respiratory support where positive pressure is provided to a spontaneously breathing neo-nate. This has become a popular and effective therapy in the management of idiopathic respiratory distress syn-drome (IRDS) which remains a common cause of respi-ratory distress in the preterm neonate.1 CPAP can be applied via different types of interface including asal prongs, nasopharyngeal tube and face mask using a con-ventional ventilator, bubble circuit or a CPAP driver as the pressure generating source.1 -6  Bubble CPAP is a low cost nasal continuous positive airway pressure de-livering system which has been in use since the sevn-ties but is regaining popularity due to its gentleness on the fragile lungs of the neonate. Also, it is free of severe complications associated with modern mechanical venti-lator usage in newborns.3- 6 Indications for the use of CPAP include idiopathic respiratory distress syndrome (IRDS), apnoea of prematurity or obstructive apnoea, post-extubation in preterm VLBW infants and transiet tachypnoea of newborn (TTNB)/delayed adaptation. 3-9 Other indications include pneumonia, mild meconium aspiration or other aspiration syndromes, pulmonary edema, pulmonary hemorrhage and  laryngomalacia.3-9 The bubble CPAP system essentially consists of three components: a continuous gas flow into the circuit, an expiratory limb with the distal end submerged into a liquid to generate positive end expiratory pressure (PEEP) and the nasal interface connecting the infant's airway to the circuit.1,4  It was developed and first used by Dr. Jen-Tien Wung at the Columbian Presbyterian Medical Center, New York.1 Subsequently the use of bubble CPAP has been associated with a reduction in the number of newborns requiring mechanical ventila-tion.5 A retrospective study of neonates at Columbia University, where the predominant mode of respiratory support was the use of nasal CPAP, revealed that tre ted babies had the lowest incidence of chronic lung disease (CLD) without any significant difference in mortality. 6   Other studies have also shown that the use of bubble CPAP is not associated with increase in short or long term morbidities.7-12 In Nigeria, management of new-borns with respiratory distress continues to pose chal-lenge to neonatal care providers and experience with the use of bubble CPAP remains very low. The use of bub-ble CPAP was introduced in our centre in June 2012. We present the case of a neonate who was admitted and successfully managed for IRDS using bubble CPAP to highlight the practicability of providing this mode of respiratory support to neonates with respiratory distress in resource - poor setting like ours.   Case report  An hour old baby boy, who was delivered via emer-gency caesarien section to a 31 yr old Para 3 mother was admitted to the Special Care Baby Unit of Ahmadu Bello University Teaching Hospital (ABUTH) due to respiratory distress. An early obstetric scan revealed a normal singleton pregnancy which was subsequently booked at the 28th week of gestation with normal booking parameters at aprivate hospital in Zaria. She had a total of three visits at 4-weekly intervals before she presented to the Obstetric unit of ABUTH at about the 37th  week of gestation where she was evaluated and subsequently delivered of a live male neonate via emergency caesarien section performed on account of complications of hypertensio  in pregnancy, severe oligohydramnios and fetal distres . APGAR scores were 2 and 7 at one and fiveminutes respectively, and the baby was dried, covered, kept warm, suctioned and oxygen administered via face mask before he was transferred to the SCBU.  In the SCBU he was found to be dusky, in severe respi-ratory distress and moderately hypothermic (T = 35.5 0C). He weighed 1850 grams and was adjudged small for gestational age (SGA). He was floppy, tachypnoeic with respiratory rate of 80 cycles/ min and had reduced air entry in the mid and lower zones of the lungs with widespread coarse crepitations. His Downes’ score5 was 6 (cyanosis = 1, retraction =1, respiratory rate = 2, air entry = 1, grunting = 1) and oxygen saturation ranged between 60% and 72% but rose to 80% with commence-ment of oxygen supplementation via nasal cannula at  flow of 2L/ min. He had a heart rate of 142 beats/min and heart sounds were normal. Other systems were es-sentially normal.   A diagnosis of perinatal asphyxia was made with differ-ential diagnoses of pulmonary hypoplasia, hyaline mem-brane disease, GBS pneumonia, early onset neonatal sepsis and cyanotic congenital heart disease.  Investigations including Full Blood Count (FBC) and differential, blood culture, RBS, serum urea and electro-lytes, chest radiograph and intermittent oxygen satura-tion monitor were conducted.     Results   Packed cell volume (PCV) of 0.40 L/L, total white cll count of 4.7 x 109/L, with differential white cell count of 56.4% neutrophils and 34.6% lymphocytes and platelet count of 167 x 109/L. Serum urea and electrolyte were normal and blood culture was negative. He was commenced on parenteral antibiotics - crystal-line penicillin, gentamicin; intravenous fluids and subse-quently upgraded to partial parenteral feeding with addi-tion of amino acids after 24 hours. Respiratory distress worsened and he eventually had an episode of apnoea at about the 24th hour of life. The baby was resuscitated using bag and mask ventilation and after resumption of spontaneous breathing he was commenced on bubble nasal CPAP at a PEEP of 5cmH2O and a flow of 7 L/ min (Fig 1).  Fig 1: Neonate under Bubble Nasal CPAP With the commencement of bubble nasal CPAP he pro-gressively stabilized. Respiratory rate declined from 86 to 54 cycles/ min over 36 hours, his Downes’ score im-proved to < 3, oxygen saturation rose from 70% to 98% almost immediately while heart rate and temperature remained within normal limits (Fig 2). Warmth was pro-vided from a radiant warmer before he was transferred to an incubator.  304 Fig 2: Line Plot Showing Parameters of Neonate on Bubble Nasal CPAP He was weaned off CPAP after 36 hours when all pa-rameters were normal. He however began to desaturate eight hours later with SPO2 dropping from between 88 – 94% to 80 – 86% and respiratory rate rose from 54  cycles/ min to above 80 cycles/ min. He was recom-menced on CPAP for a further 24 hours before weaning. He maintained normal oxygen saturation on supplemen-tal oxygen at 1.5 L/min for another 18 hours before he was completely weaned off oxygen. Nasogastric tube feeding was gradually introduced and intravenous flids gradually withdrawn.  Results of chest radiograph revealed a uniform reticulo-granular (ground glass) appearance of the lung fields suggestive of grade IV IRDS (Fig 3A. taken within the first 24 hours of life) which subsequently became clear with management (Fig 3B taken on the fifth day of life).  Fig 3A: Chest radiograph showing reticulogranular  (ground glass) appearance                       Fig 3B: Chest radiograph showing normal findings after CPAP Discussion  This is the first report of the use of CPAP in the man-agement of IRDS in our centre. The patient presented with features of respiratory distress from birth which progressively worsened, with a falling oxygen saturtion pressure, apnoea and a Downes’ score of 6 suggestin the requirement of respiratory support and heralding a  impending respiratory failure. The chest radiograph lso showed reticulogranular (ground glass) appearance sug-gestive of a grade IV idiopathic respiratory distres of the newborn. These factors were indications for the us  of CPAP. Though IRDS is thought to be uncommon among SGA neonates due to the common assumption that intrauterine stress led to accelerated pulmonary maturation of such neonates and decreased incidence of IRDS, recent published studies however have not been supportive of this concept.12 - 15  In addition impaired maturation of type II alveolar epithelial cells and re-duced surfactant content and activity have also been reported  in infants with IUGR possibly resulting from the effect of  chronic hypoxia and acidosis on surfactant synthesis.13 - 15  Oligohydramnious a known cause of pulmonary hypoplasia, which was a presentation in the index case, has also been shown to increase the  risk of IRDS.16 Conversely meconium aspiration syndrome and polycythaemia which are other possible causes of respi-ratory distress in a small for gestational age neonate were less likely in this patient with no history ofme-conium stained liquor and a packed cell volume of 0. 40 L/ L.   Initiation of CPAP resulted in a sharp rise in oxygen saturation, a decline in respiratory rate and an improve-ment in his Downes score. The improvement followed well known principles. By maintaining positive pressure in the airway during spontaneous breathing, alveoli are prevented from collapsing, functional residual capacity is increased, gaseous exchange is enhanced and oxygen saturation is improved.1 - 4 After initial discontinuation of CPAP, our patient experienced deterioration which we attribute to excessive airway secretions or inadequate recruitment of alveoli. However, recommencement of CPAP for a further 24-hour period resulted in sustained improvement. Management of IRDS sometimes in-volves the use of exogenous surfactant. However, this potentially useful agent was not available to us and was thus not employed. This modality of treatment may or may not have influenced the course of illness in the in-dex case because some studies1, 17 have compared the use of early CPAP alone to the use of a combination of surfactant and intubation and did not find superiority of either technique. Similarly the initiation of CPAP also prevented the recurrence of obstructive apnoea in this patient, a benefit which is a known indication of CPAP use.  Complications like pneumothorax, nasal septal erosion or necrosis and gastric distention (CPAP belly syn-drome) may arise with use of bubble CPAP. However, our patient did not suffer any such complication possibly because care was taken to use appropriate snug–fitting 305 nasal prongs among other measures. The patient also did well on CPAP even on a low PEEP of 5cmH2O. Occa-sionally some babies may require higher PEEP and yet are not able to maintain saturation suggesting the re-quirement of more respiratory support in form of me-chanical ventilation.  The provision of optimal newborn care and adequate management of hypothermia, an important contributor to neonatal morbidity and mortality which aggravates IRDS, would have contributed the outcome in this pa-tient.  Similarly the use of antibiotics and provision of optimal fluid and electrolytes are important. While anti-biotics were employed as possible treatment for group B streptococcal pneumonia, an important differential d g-nosis which may be clinically and radiographically in-distinguishable from IRDS, the optimal fluid and elec-trolytes management provided adequate caloric requi-ments and prevented fluid overload, all of which are essential determinants of outcome in newborn care. Conclusion  The successful use of nasal bubble CPAP, a simple and inexpensive respiratory support in the management of this case of idiopathic respiratory distress syndrome in our unit promises an improved care to newborns who may require respiratory support particularly in our poor socio economic setting where there is paucity of nena-tal intensive care units with ventilator support and i ade-quate skilled manpower to provide such care. We  recommend therefore, that neonatal care providers b trained and acquainted with the use of bubble CPAP to improve newborn care in the country.   Conflict of interest: None Funding: None References  1.     Medha W. Non invasive respira-tory support in the neonate: Con-tinuous positive airway pressure (CPAP). Sri Lanka Journal of Child Health 2011; 40:172- 6 2.     Neil NF, Waldemar AC, Michele CW, Wade R, Marie GG et al. Early CPAP versus Surfactant in Extremely Preterm Infants.  N Engl J Med 2010; 362 (21):1970- 9  3.     Prashanth SU, Firdose K, Maiya PP. Bubble CPAP - A Primary Respiratory Support for Respira-tory Distress Syndrome in New-borns. Indian Pediatr 2009; 46: 409 – 11. 4.     Chan KM, Chan HB. The Use of Bubble CPAP in Premature In-fants: Local Experience. HK J Paediatr 2007; 12:86-92. 5.     Mathai SS, Raju U, Kanitkar M. Management of Respiratory Dis-tress in the Newborn. MJAFI 2007; 63( 3) : 269 – 72. 6.     Nowadzky T, Pantoja A, Britton JR. Bubble Continuous Positive Airway Pressure, A potentially better practice reduces the use of mechanical ventilation among very low birth weight infants with respi-ratory distress syndrome. Pediat-rics 2009;123(6):1534-40 7.     Avery ME, Tooley WH, Keller JB, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 1987; 79:26-30.   8.     Bahareh BB, Arash M, Pedram N, Mohammad RB. Bubble–CPAP vs. Ventilatory–CPAP in Preterm Infants with Respiratory Distress. Iran J Pediatr 2011; 21 (2):151- 82), 9.     Roehr CC, Schmalisch G, Khak-ban A, Proquitté H, Wauer R.R. Use of continuous positive airway pressure (CPAP) in neonatal units – A survey of current preferences and practice in Germany Eur J Med Res 2007; 12: 139 – 44 10.   Roberts CL, Badgery-Parker T, Algert CS, Bowen JR, Nassar N. Trends in use of neonatal CPAP: A population-based study. BMC Pe-diatrics 2011, 11:89 11.   Vidyasagar D, Velaphi S,  Bhat VB. Surfactant Replacement Ther-apy in Developing Countries. Neo-natology 2011; 99: 355 – 66 12.   Narang A, Chaudhuri MK, Kumar P. Small for gestational age babies: Indian scene. Indian J Pediatr 1997; 64(2): 221-4. 13.   Regev RH, Reidman B. Prematur-ity and intrauterine growth retarda-tion – double jeopardy. Clin Peri-natol 2004; 31: 453 – 73  14.   Torrance HL, Derks JB, Scherjon SA, Wijnberger LD, Visser GH. Is antenatal steroid treatment effec-tive in preterm IUGR fetuses? Acta Obstet Gynecol Scand 2009; 88(10):1068-73.  15.   Morrison JL, Botting KJ, Soo PS, McGillick EV, Hiscock J, Zhang S, McMillen IC, Orgeig S. Antenatal Steroids and the IUGR Fetus: Are Exposure and Physiological Effects on the Lung and Cardiovascular System the Same as in Normally Grown Fe-tuses? J Pregnancy 2012 Published online 2012 November 22. doi: 10.1155/2012/839656 Epub 2012 Nov 22. 16.   Abbasalizadeh SH, Abbasalizadeh F, sharifan Z. Pulmonary Matura-tion in Preterm Rupture of Mem-branes with Oligohydramnious  JMed Sci 2007 7: 203- 9. 17.   Colin JM, Peter GD, Lex WD, Luc PB, Jean-Michel H, John BC. Na-sal CPAP or Intubation at Birth for Very Preterm Infants N Engl J Med 2008; 358:700 - 8  306 

The Use of bubble nasal CPAP in the management of IRDS -A Case report and literature review

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