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. 2025 Apr 23;17(1):e1-e14.
doi: 10.4102/phcfm.v17i1.4742.

Optimising neonatal bubble continuous positive airway pressure: A Somaliland quality initiative

Hawa D Mahmoud  1 , Sarah C Kent, Fatima E Ibrahim, Najma Mohamed, Fatima A Abdulahi, Meagan N O'Neal, Priya Kanajam, Ellen K Diego
Affiliations

Optimising neonatal bubble continuous positive airway pressure: A Somaliland quality initiative

Hawa D Mahmoud et al. Afr J Prim Health Care Fam Med. .

Abstract

Background: Continuous positive airway pressure (CPAP) therapy is the standard of care for neonatal respiratory distress and improves survival when implemented in low-resource settings. Clinical audits at the Borama Regional Hospital (BRH) Neonatal Intensive Care Unit (NICU) revealed multiple barriers to effective CPAP, including insufficient pressure, a lack of neonatal-sized nasal prongs, and patient interface challenges.

Aim: Improve respiratory distress by increasing effective CPAP delivery for neonates 30 days of age from 52% to 90% in 6 months.

Setting: Single-centre referral hospital in the Awdal region of Somaliland.

Methods: Quality improvement (QI) initiative with outcomes displayed using statistical process control (SPC) charts.

Results: Eleven residents, three medical interns and seven NICU nurses completed the educational training. Forty-five patients were initiated on the locally designed bubble CPAP (bCPAP) device with a 47% (122/261) CPAP safety checklist completion rate for the three daily nursing shifts. We achieved our study aim by increasing the adherence rate to the 7-item bCPAP device set up from a baseline of 52% to 91%. The rate of infants weaned or discontinued from bCPAP for improved respiratory severity score (RSS) increased from 0% to 18% but did not demonstrate process change. There was no increase in adverse event rates (air leak, nasal columella breakdown and nasal irritation).

Conclusion: We demonstrated increased effective bCPAP delivery and decreased respiratory distress.Contribution: This study outlines low-cost, customisable QI strategies to address commonly encountered gaps for effective bCPAP delivery in low-resource settings without access to commercially available CPAP devices or speciality-trained providers.

Keywords: bubble continuous positive airway pressure; low- and middle-income countries; neonatal intensive care unit; neonatal mortality; neonatal respiratory distress; quality improvement.

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Conflict of interest statement

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Figures

FIGURE 1
FIGURE 1
Cause and effect diagram and key driver diagram developed by the multidisciplinary quality improvement team to identify key drivers of change: (1) education; (2) equipment; (3) communication; (4) staffing.
FIGURE 2
FIGURE 2
Borama Regional Hospital neonatal intensive care unit clinical guideline for continuous positive airway pressure management.
FIGURE 3
FIGURE 3
Statistical process control u-chart demonstrating the process measure for rate (%) of adherence to the 7-item continuous positive airway pressure device setup.
FIGURE 4
FIGURE 4
Statistical process control u-chart demonstrating the process measure for rate (%) of continuous positive airway pressure audit form completion by the bedside nursing staff.
FIGURE 5
FIGURE 5
Statistical process control p-chart demonstrating the outcome measure for rate (%) of infants weaning or discontinuing continuous positive airway pressure for improved respiratory severity score.
FIGURE 6
FIGURE 6
Statistical process control u-chart demonstrating the balancing measure for rate (%) of adverse events (nasal irritation, columella breakdown, pneumothorax).
See this image and copyright information in PMC

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