Every breath you take…
Authors: Elizabeth Molyneux
Journal: The Lancet Global Health (2017)

Breathing can be hard work, especially for an infant with immature lungs or one who has an acute respiratory infection. The effort of breathing can lead to exhaustion, respiratory failure, and death. But with respiratory support—often for a relatively short period of time—death can be averted. Respiratory illnesses are common, and they are the reason for 13·1 million hospital admissions annually worldwide in children younger than 5 years.1Rudan I Tomaskovic L Boschi-Pinto C Campbell H Global estimate of the incidence of clinical pneumonia among children under five years of age.Bull World Health Organ. 2004; 82: 895-903PubMed Google Scholar Most of these admissions occur in low-income or middle-income countries (LMIC), in small health units with basic laboratory and radiology services and only a few, non-specialist staff. These hospitals might be able to provide oxygen therapy but they do not have the equipment nor the expertise to provide mechanical ventilation. If a child is breathing spontaneously continuous positive airway pressure (CPAP) ventilation is a simple, relatively safe method of supporting respiration. Since nurses often initiate and manage ongoing care, it is important for them to be able to deliver effective and appropriate CPAP. In The Lancet Global Health, Patrick Wilson and colleagues2Wilson PT Baiden F Brooks JC et al.Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an open-label, cluster, crossover trial.Lancet Glob Health. 2017; 5: e615-e623Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar report on their trial of children younger than 5 years with respiratory distress admitted in two small hospitals in Ghana.2Wilson PT Baiden F Brooks JC et al.Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an open-label, cluster, crossover trial.Lancet Glob Health. 2017; 5: e615-e623Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar They compared giving CPAP (with oxygen) to keep the peripheral blood oxygen saturation (pSaO2) above 92% to standard oxygen therapy with nasal prongs, or a face mask, titrated to keep the pSaO2 above 92%. Nurses initiated and provided respiratory care. Research nurses were in continuous attendance and sufficient CPAP machines were available to provide for any child who needed it. This was a pragmatic study that included any child aged 1 month to 5 years with a raised respiratory rate or laboured breathing. Inevitably, these criteria meant that children with non-primary respiratory diseases such as malaria, anaemia, sepsis, or cardiac disease were included. The 2 year study recruited over 2000 children; there were very few refusals (40 patients) or withdrawals (five patients), although 47 (5%) of 1021 children in the CPAP group did not tolerate the CPAP prongs. The few adverse events were distributed equally, more or less, between the two groups of the study. The number of deaths in each group was similar (26 [3%] deaths in the CPAP group and 44 [4%] in the control group); but in the infants less than 1 year old the results were significantly better in the CPAP group (ten [3%] deaths) than in the control group (24 [7%] deaths; RR 0·40, 95% CI 0·19–0·82; p=0·010). Most children only required 12 h of CPAP support, which was stopped when the respiratory rate normalised. We are not told if they were then put onto oxygen therapy, nor if any children relapsed and had to be put back onto CPAP support. CPAP pressure was fixed at 5 cm H2O and oxygen was adjusted to keep the pSaO2 above 92%. Some children might have benefitted from higher pressures, some might not have needed CPAP. The children in the control group received oxygen at flow rates governed by pSaO2 readings. WHO recommends fixed rates of oxygen delivery of 0·5, 1·0, or 2 L/min according to age.3WHOPocket book of hospital care for children: Second edition. Guidelines for the management of common childhood illnesses.http://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/Google Scholar It would have been interesting to compare WHO-recommended oxygen rates against CPAP therapy. The study was not powered to demonstrate if CPAP was beneficial in non-respiratory diseases; only studies with a larger number of patients can answer this question. The group of infants younger than 1 year for whom CPAP did reduce deaths probably had less cases of malaria and other non-primary respiratory diseases than did the group of infants older than 1 year. Each hospital was supplied with CPAP machines and consumables, extra nurses, and a generator should the electricity supply fail. It would be interesting to know how often the generators had to be used. Most medical equipment used in LMICs is not built for hot, dusty climates and unreliable power supplies. These CPAP machines appear to have been robust. Importantly the study shows that nurses working in small hospitals can provide a CPAP service with minimal supervision and that most parents are willing for their children to receive CPAP support. Younger children benefitted from CPAP and, given the huge number of children requiring admission for respiratory problems, CPAP machines, supported by training, mentoring, and supervision, should be made available at all hospitals. Embedding the use of new medical devices into routine care takes training, ongoing mentoring of clinical staff and maintenance of equipment. Costing analyses should be done—the consumables in this study were expensive (US$32 per child)—making it essential to be able to prioritise CPAP use or to find a way of cleaning and safely re-using tubing. The study nurses received bi-annual refresher training; nurses in public hospitals are moved frequently from one department to another and will rapidly lose expertise. The CPAP machines and generators have been left in the hospitals after the close of the study. It would be very interesting to go back to those hospitals and see if the machines still function and if, and how, they are still being used. I declare no competing interests. Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an open-label, cluster, crossover trialIn the unadjusted analysis the use of CPAP did not decrease all-cause 2-week mortality in children 1 month to 5 years of age with undifferentiated respiratory distress. After adjustment for study site, time, and clinically important variables, 2-week mortality in the CPAP group versus the control group was significantly decreased in children 1 year of age and younger. CPAP is safe and improves respiratory rate in a non-tertiary setting in a lower-middle-income country. Full-Text PDF Open Access