Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa

Abstract

Background: Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality.

Methods: We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions.

Results: Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109).

Conclusion: This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.

Keywords: continuous positive airway pressure (CPAP); interventions; invasive mechanical ventilation; low-and-middle income countries (LMIC); preterm (birth); respiratory; respiratory distress syndrome (RDS); surfactant.

Figure 1

A pyramid composed of levels of interventions to illustrate the modeling methodology. Interventions are removed in a stepwise manner and the number of additional deaths is calculated at each subsequent step. MV, invasive mechanical ventilation; SRT, surfactant replacement therapy; CPAP, continuous positive airway pressure.

Figure 2

Mortality rate stratified by weight band. The total number of infants in each weight band has been depicted to illustrate the relative burden of admissions per weight band and deaths is depicted as a proportion of the total number of admissions.

Figure 3

Kaplan-Meier graph depicting day of death stratified by birth weight. Total number of deaths was 78 infants of which 39 infants (50%) were <1,000 g and 39 infants (50%) were ≥1,000 g. There was no significant difference in the time to death between groups (p = 0.242).

Figure 4

Respiratory interventions at any time during admission stratified by weight band. Due to resource constraints, infants born <800 g are not eligible for many of the interventions usually given for RDS in well-resourced areas. However, should they survive until they are more mature, they may become eligible to receive CPAP or MV later. CPAP, continuous positive airway pressure; MV, invasive mechanical ventilation.

Figure 5

A model of the additional deaths and mortality rates of the study should respiratory interventions be sequentially removed. (A) All interventions available (baseline). (B) MV removed. (C) SRT removed. (D) CPAP removed. MV, invasive mechanical ventilation; SRT, surfactant replacement therapy; CPAP, continuous positive airway pressure.