Bubble CPAP for Prevention of Chronic Lung Disease in Premature Infants

Surfactant’s discovery was one of the most important events in the history neonatology. Surfactant saved the lives of premature infants otherwise considered unviable. Surfactant saved the lives of premature infants who were otherwise considered non-viable. 1

Even after accounting for birth weight, race, and sex distributions at the centers, CLD incidence is significantly different between institutions. This wide variation could not be explained biologically. Therefore, respiratory management was deemed key to creating or stopping CLD. CLD incidences that are low in literature have been found in centers that use bubble CPAP, b-CPAP, as soon as possible. This is preferentially in the labor room.

I have demonstrated previously the reproducibility and effectiveness of b-CPAP. A b-CPAP program resulted in a decrease of CLD from a center where 33 percent of the very low birth weight (VLBW), infants developed CLD. The reduction in CLD rates didn’t happen immediately. It took considerable time to train staff and achieve the full impact of b-CPAP. A follow-up study showed that the CLD rates were consistent over 12 years. 3

How the apparatus works

The bubble CPAP apparatus consists of a simple breathing circuit that includes an inspiratory limb that delivers heated humidified gas mixtures to infants and an expiratory limb that is submerged in water to create the desired pressure. Gas flow creates bubbles beneath the water, which cause oscillations in the water level and the pressure that is delivered to the patient. The patient receiving b-CPAP has an oscillating pressure rather than a constant one. The oscillation effect can increase the effectiveness of b-CPAP for volume recruitment.

CPAP offers many physiologic benefits. It reduces the effort required to breathe in premature infants who are spontaneously breathing. It keeps the alveoli inflated, improves the functional residual capacity of your lung, and matches ventilation with perfusion. CPAP is less harmful than mechanical ventilation or tracheal tube intubation. CPAP creates a favorable strain in the lungs that stimulates lung growth when it is administered over a long period of time. 4

Multiple randomized controlled trials were conducted to evaluate the effectiveness of nasal CPAP compared to mechanical ventilation. The trials did not use b-CPAP but used any type of CPAP. They also did not provide details about competency-based training to make sure its effectiveness. Despite these reservations and other concerns, trials proved that CPAP can be applied early to premature infants. This includes those who are extremely premature at 24-25 weeks.

These trials were analyzed together in a recent meta analysis. They showed that CPAP early use had a marginal advantage for survival without CLD compared to prophylacticsurfactant with intubation. These results do not agree with recurring reports that b-CPAP significantly reduced CLD in neonatal units.

Two factors could account for the lower CLD in bCPAP units. The first factor is the type and type of CPAP. The second is caregiver competency in using b-CPAP at bedside. The b-CPAP strategy requires a comprehensive bundle of care. This includes clear guidelines and training. We offer a hands-on training program to familiarize staff with bCPAP components, indications, methods of application, maintenance procedures, troubleshooting techniques, and criteria for bCPAP failure.

CLD rates in infants with bCPAP have not been compared to infants with other CPAP devices. Short-term data are lacking, including information on oxygenation and work of breathing that favored bCPAP. Nevertheless, many studies have compared the short-term results of CPAP, biphasic CPAP and nasal intermittent positive pressure ventilation.

Recently, the American Academy of Pediatrics Committee on Fetus & Newborn acknowledged that there was a lack of data on safety and efficacy of these modalities. Notably, none of these noninvasive modalities can replicate the success of bCPAP in reducing CLD. 1


  1. Aly H., Mohamed MA, Wung TT. Continuous positive airway pressure and surfactant for the prevention and treatment of chronic lung diseases: History, reality and new challenges. Semin Fetal Neonatal Med. 2017;22(5):348-353.
  2. Aly H, Mohamed MA. Continuous positive airway pressure bubble. In: MacDonald MG and Ramasethu J. Eds. Atlas of Procedures in Neonatology. 5 th Philadelphia. Lippincott Williams & Wilkins 2012.
  3. Aly H, Milner DJ, Patel K and El-Mohandes AAA. Is there a difference in the results of continuous positive airway pressure nasally for extremely low birthweight infants? Pediatrics. 2004;114(3):697-702.
  4. Aly H. Nasal prongs continuous negative airway pressure: A simple but powerful tool. Pediatrics 2001;108(3), 759-761.
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