A study by researchers at Columbia University Medical Center and the Mailman School of Public Health found that applying continuous positive airway pressure (CPAP), a form of non-invasive ventilation, decreased mortality in children with respiratory distress. Findings from the trial in Ghana indicated that the procedure especially benefitted children less than one year of age. Results of the study are published online in The Lancet Global Health.
CPAP can improve respiratory rate and survival in children with primary pulmonary diseases. The latest findings confirmed that no serious adverse events were associated with the treatment, it is safe and effective to use in district level hospitals, and a step forward in treating children with respiratory distress in resource-limited settings.
Sites for the Columbia study were two non-tertiary hospitals in Ghana where invasive mechanical ventilation was not routinely available, and nurses initiated and managed care with once or twice daily physician rounds. A sample size of 1025 participants in the CPAP group and 1175 in the control group was studied.
Two-week all-cause mortality in children 1 year of age and younger significantly decreased when non-invasive positive airway pressure was continuously applied -- 3 percent of patients in the CPAP group versus 7 percent of patients in the control group who were not given the therapy. In children of all ages - one month to 5 years, respiratory rate was significantly lower in the CPAP group at 4 hour, 8 hour, 12 hour, and 24 hour time points.
"In addition to demonstrating the safety of CPAP and the children's improved survival rates, our study is unique in that CPAP was initiated and managed at the first hospital level by emergency ward nurses who work much of the day without direct supervision by a physician," said Rachel T. Moresky, MD, MPH, Mailman School of Public Health associate professor of Population and Family Health, associate professor of Medicine, Emergency Medicine at Columbia University Medical Center, and senior author.
Dr. Moresky continued, "Other CPAP studies in low resource settings have been demonstrated at tertiary hospitals (or university hospitals) and with physician specialists applying the CPAP treatments. Our study demonstrates that by task sharing this skill to nurses, that lifesaving care can be brought closer to the community."
Pneumonia, sepsis, and severe malaria kill more than 2 million children younger than 5 years every year. These treatable illnesses can progress to respiratory failure. Most of these deaths occur in low-income and middle-income countries, where diagnostic and therapeutic interventions are often severely scarce.
The World Health Organization recommends redistributing health-care tasks to less highly trained individuals. With a nurse to doctor ratio of 8:1 in many African nations, successful training of nurses to effectively and safely apply CPAP will be crucial for its proliferation in non-tertiary hospitals.
"We aimed to evaluate the effectiveness of CPAP in a setting where nurses care for patients with limited physician oversight, and where certain sophisticated diagnostic tests are not routinely done which added value to our study," said Dr. Moresky, who is also director of the International Emergency Medicine Fellowship program at Columbia.
"Our findings coupled with the results from two smaller studies in Bangladesh and Malawi support the use of non-invasive ventilation for children presenting with acute respiratory distress in low-resource settings and are a step forward in codifying best practices for treating them," noted Patrick T. Wilson, MD, MPH, Columbia University Medical Center assistant professor of Pediatrics, Mailman School of Public Health assistant professor of Population and Family Health, and lead author.
The results also suggest that the use of CPAP in young children with respiratory insufficiency is appropriate in other parts of the developing world, where diagnostic capabilities are similarly limited. The study showed that for every 25 children under the age of 1 year treated with CPAP, one life can be saved and most patients will have improved respiratory rates for at least 24 hours.
Dr. Wilson concludes "The results of the study are remarkable in that it included children with a wide range of disease processes, making it more generalizable to real life settings in low- and middle-income countries around the world."
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