International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
Centre for International Child Health, Royal Children`s Hospital, The University of Melbourne, Melbourne, Australia.
J Glob Health. 2023 May 26;13:04040. doi: 10.7189/jogh.13.04040.
Effective management of hypoxaemia is key to reducing pneumonia deaths in children. In an intensive care setting within a tertiary hospital in Bangladesh, bubble continuous positive airway pressure (bCPAP) oxygen therapy was beneficial in reducing deaths in this population. To inform a future trial, we investigated the feasibility of introducing bCPAP in this population in non-tertiary/district hospitals in Bangladesh.
We conducted a qualitative assessment using a descriptive phenomenological approach to understand the structural and functional capacity of the non-tertiary hospitals (Institute of Child and Mother Health and Kushtia General Hospital) for the clinical use of bCPAP. We conducted interviews and focus group discussions (23 nurses, seven physicians, 14 parents). We retrospectively (12 months) and prospectively (three months) measured the prevalence of severe pneumonia and hypoxaemia in children attending the two study sites. For the feasibility phase, we enrolled 20 patients with severe pneumonia (age two to 24 months) to receive bCPAP, putting in place safeguards to identify risk.
Retrospectively, while 747 of 3012 (24.8%) children had a diagnosis of severe pneumonia, no pulse oxygen saturation information was available. Of 3008 children prospectively assessed with pulse oximetry when attending the two sites, 81 (3.7%) had severe pneumonia and hypoxaemia. The main structural challenges to implementation were the inadequate number of pulse oximeters, lack of power generator backup, high patient load with an inadequate number of hospital staff, and inadequate and non-functioning oxygen flow meters. Functional challenges were the rapid turnover of trained clinicians in the hospitals, limited post-admission routine care for in-patients by hospital clinicians due to their extreme workload (particularly after official hours). The study implemented a minimum of four hourly clinical reviews and provided oxygen concentrators (with backup oxygen cylinders), and automatic power generator backup. Twenty children with a mean age of 6.7 (standard deviation (SD) = 5.0)) months with severe pneumonia and hypoxaemia (median (md) SpO = 87% in room air, interquartile range (IQR) = 85-88)) with cough (100%) and severe respiratory difficulties (100%) received bCPAP oxygen therapy for a median of 16 hours (IQR = 6-16). There were no treatment failures or deaths.
Implementation of low-cost bCPAP oxygen therapy is feasible in non-tertiary/district hospitals when additional training and resources are allocated.
有效管理低氧血症是降低儿童肺炎死亡的关键。在孟加拉国一家三级医院的重症监护环境中，气泡持续气道正压通气（bCPAP）氧疗有益于降低该人群的死亡率。为了为未来的试验提供信息，我们调查了在孟加拉国非三级/地区医院引入 bCPAP 的可行性。
我们采用描述性现象学方法进行定性评估，以了解非三级医院（儿童和母婴健康研究所和库什蒂亚综合医院）在临床使用 bCPAP 方面的结构和功能能力。我们进行了访谈和焦点小组讨论（23 名护士、7 名医生、14 名父母）。我们回顾性地（12 个月）和前瞻性地（3 个月）测量了在两个研究地点就诊的严重肺炎和低氧血症儿童的患病率。在可行性阶段，我们招募了 20 名患有严重肺炎（2 至 24 个月大）的患儿接受 bCPAP 治疗，并采取了保障措施以识别风险。
回顾性地，虽然 3012 名儿童中有 747 名（24.8%）被诊断为严重肺炎，但没有脉搏血氧饱和度信息。前瞻性地评估了在两个地点就诊的 3008 名儿童的脉搏血氧饱和度，其中 81 名（3.7%）患有严重肺炎和低氧血症。实施的主要结构挑战是脉搏血氧仪数量不足、发电机备用电源不足、患者人数众多，医院工作人员不足，以及氧气流量计不足且无法正常工作。功能挑战是医院临床医生的快速更替，由于工作负荷过重（特别是下班后），医院临床医生对住院患者的常规治疗有限。该研究实施了至少每四小时一次的临床检查，并提供了氧气浓缩器（带备用氧气罐）和自动发电机备用电源。20 名患有严重肺炎和低氧血症的儿童（平均年龄 6.7（标准差（SD）= 5.0）个月，中位数（md）SpO 在室气中为 87%，四分位间距（IQR）= 85-88%），咳嗽（100%）和严重呼吸困难（100%）接受 bCPAP 氧疗，平均时间为 16 小时（IQR=6-16）。没有治疗失败或死亡。
当分配额外的培训和资源时，非三级/地区医院可以实施低成本的 bCPAP 氧疗。
