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Doing more with less: The use of non-invasive ventilatory support in a resource-limited setting
Heloise Buys1,2,3, Tamara Kerbelker1,2,3, Shirani Naidoo1,2,3
1Red Cross War Memorial Children's Hospital, Cape Town, Western Cape Province, South Africa.
Insights
Bubble CPAP (bCPAP) effectively reduced the need for intensive care admission in children with respiratory illnesses in a low-resource setting. This non-invasive ventilation method is a viable alternative to mechanical ventilation, improving outcomes for pediatric patients.
Area of Science:
- Pediatric critical care
- Respiratory medicine
- Public health in low-resource settings
Background:
- Bubble CPAP (bCPAP) is a non-invasive ventilation technique that can decrease pneumonia-related mortality in children in resource-limited environments.
- Understanding the utilization and outcomes of bCPAP in such settings is crucial for optimizing pediatric care.
Purpose of the Study:
- To describe a cohort of children who received bCPAP in the Medical Emergency Unit (MEU) of Red Cross War Memorial Children's Hospital between 2016 and 2018.
- To analyze demographic data, clinical characteristics, management, and outcomes, including PICU admission, invasive ventilation, and mortality.
Main Methods:
- Retrospective review of a randomly selected sample of paper-based patient records.
- Inclusion criteria: children initiated on bCPAP at the MEU.
- Data collected: demographics, clinical details, management, PICU admission, invasive ventilation, and mortality. Statistical analysis included descriptive statistics, percentages, medians, and IQRs.
Main Results:
- 500 children received bCPAP; 53% were male, median age 3.7 months. 34% were underweight-for-age, 2% were HIV-infected, 24% exposed to tobacco smoke.
- Common admissions: acute respiratory illness, gastroenteritis, cardiac failure, sepsis, seizures. 82% had no underlying conditions.
- 8% required invasive ventilation, 2% died. 75% did not require Pediatric Intensive Care Unit (PICU) admission.
Conclusions:
- Bubble CPAP is an effective non-invasive ventilation strategy in low-resource settings, with 75% of patients avoiding PICU admission.
- This modality should be more widely adopted in African settings with limited access to pediatric intensive care.
- bCPAP offers a valuable alternative to invasive ventilation, potentially reducing mortality and improving resource allocation in pediatric critical care.
Objectives:
Bubble CPAP (bCPAP), a non-invasive ventilation modality, has emerged as an intervention that is able to reduce pneumonia-related mortality in children in low resourced settings. Our study primarily aimed to describe a cohort of children who were started on CPAP in the Medical Emergency Unit (MEU) of Red Cross War Memorial Children's Hospital 2016-2018.
Methods:
A retrospective review of a randomly selected sample of paper-based folders was conducted. Children started on bCPAP at MEU were eligible for inclusion. Demographic and clinical data, management, and outcomes regarding admission to PICU, need for invasive ventilation and mortality were documented. Descriptive statistical data were generated for all relevant variables. Percentages depicted frequencies of categorical data while medians with interquartile ranges (IQR) were used to summarise continuous data.
Results:
Of 500 children started on bCPAP, 266 (53%) were male; their median age was 3.7 (IQR 1.7-11.3) months and 169 (34%) were moderately to severely underweight-for-age. There were 12 (2%) HIV-infected children; 403 (81%) had received appropriate immunisations for their age; and 119 (24%) were exposed to tobacco smoke at home. The five most common primary reasons for admission were acute respiratory illness, acute gastroenteritis, congestive cardiac failure, sepsis and seizures. Most children, 409 (82%), had no underlying medical condition. Most children, 411 (82%), were managed in high care areas of the general medical wards while 126 (25%) went to PICU. The median time on CPAP was 1.7 (IQR 0.9-2.8) days. The median hospitalisation time was 6 (IQR 4-9) days. Overall, 38 (8%) children required invasive ventilatory support. Overall, 12 (2%) children with a median age of 7.5 (IQR 0.7-14.5) months died, six of whom had an underlying medical condition.
Conclusions:
Seventy-five percent of children initiated on bCPAP did not require PICU admission. This form of non-invasive ventilatory support should be considered more widely in the context of limited access to paediatric intensive care units in other African settings.
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