title: Impact of the systematic introduction of low-cost bubble nasal CPAP in a NICU of a developing country: a prospective pre- and post-intervention study.
abstract: BACKGROUND
  The use of Nasal Continuous Positive Airway Pressure Ventilation (NCPAP) has begun to increase and is progressively replacing conventional mechanical ventilation (MV), becoming the cornerstone treatment for newborn respiratory distress syndrome (RDS). However, NCPAP use in Lower-Middle Income Countries (LMICs) is poor. Moreover, bubble NCPAP (bNCPAP), for efficacy, cost effectiveness, and ease of use, should be the primary assistance technique employed in newborns with RDS.
  
  
  OBJECTIVE
  To measure the impact on in-hospital newborn mortality of using a bNCPAP device as the first intervention on newborns requiring ventilatory assistance.
  
  
  METHODS
  
  
  
  METHODS
  Prospective pre-intervention and post-intervention study.
  
  
  METHODS
  The largest Neonatal Intensive Care Unit (NICU) in Nicaragua.
  
  
  METHODS
  In all, 230 (2006) and 383 (2008) patients were included.
  
  
  METHODS
  In May 2006, a strategy was introduced to promote the systematic use of bNCPAP to avoid intubation and MV in newborns requiring ventilatory assistance. Data regarding gestation, delivery, postnatal course, mortality, length of hospitalisation, and duration of ventilatory assistance were collected for infants assisted between May and December 2006, before the project began, and between May and December 2008, two years afterwards.
  
  
  METHODS
  The pre- vs post-intervention proportion of newborns who died in-hospital was the primary end point. Secondary endpoints included rate of intubation and duration of NICU stay.
  
  
  RESULTS
  Significant differences were found in the rate of intubation (72 vs 39%; p < 0.0001) and the proportion of patients treated exclusively with bNCPAP (27% vs 61%; p <0.0001). Mortality rate was significantly reduced (40 vs 23%; p < 0.0001); however, an increase in the mean duration of NICU stay was observed (14.6 days in 2006 and 17.5 days in 2008, p = 0.0481). The findings contribute to the evidence that NCPAP, particularly bNCPAP, is the first-line standard of care for efficacy, cost effectiveness, and ease of use in newborns with respiratory distress in LMICs.
  
  
  CONCLUSIONS
  This is the first extensive survey performed in a large NICU from a LMICs, proving the efficacy of the systematic use of a bNCPAP device in reducing newborn mortality. These findings are an incentive for considering bNCPAP as an elective strategy to treat newborns with respiratory insufficiency in LMICs.
authors.affiliation: NICU Rho Az. Ospedaliera "G. Salvini" Garbagnate Milanese, Milan, Italy. rossano.rezzonico@libero.it.|Department of Public Health, Laboratory for Mother and Child Health, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy. rossano.rezzonico@libero.it.
authors.forename: Rossano
authors.initials: R
authors.lastname: Rezzonico
authors.affiliation: Az. Ospedaliera Universitaria L. Meyer, Florence, Italy. mletizia.caccamo@tin.it.
authors.forename: Letizia M
authors.initials: LM
authors.lastname: Caccamo
authors.affiliation: NICU Rho Az. Ospedaliera "G. Salvini" Garbagnate Milanese, Milan, Italy. mannj81@yahoo.it.
authors.forename: Valeria
authors.initials: V
authors.lastname: Manfredini
authors.affiliation: Department of Public Health, Laboratory for Mother and Child Health, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy. massimo.catarbia@marionegri.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Cartabia
authors.affiliation: UCIN Hospital Bertha Calderon Managua, Managua, Nicaragua. niessan@yahoo.com.
authors.forename: Nieves
authors.initials: N
authors.lastname: Sanchez
authors.affiliation: UCIN Hospital Bertha Calderon Managua, Managua, Nicaragua. zorpar@yahoo.com.
authors.forename: Zoraida
authors.initials: Z
authors.lastname: Paredes
authors.affiliation: AMCA, Aiuto Medico Centro America, Giubiasco, Switzerland. patrizia.froesch@eoc.ch.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Froesch
authors.affiliation: AMCA, Aiuto Medico Centro America, Giubiasco, Switzerland. franco.cavalli@eoc.ch.
authors.forename: Franco
authors.initials: F
authors.lastname: Cavalli
authors.affiliation: Department of Public Health, Laboratory for Mother and Child Health, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy. maurizio.bonati@marionegri.it.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Bonati
mesh_terms: D045422:Continuous Positive Airway Pressure / Q000191:economics* / Q000379:methods*; D003362:Cost-Benefit Analysis; D036861:Delivery, Obstetric; D003906:Developing Countries; D005260:Female; D005865:Gestational Age; D017052:Hospital Mortality; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D007902:Length of Stay; D008297:Male; D009527:Nicaragua; D011446:Prospective Studies; D012127:Respiratory Distress Syndrome, Newborn / Q000401:mortality / Q000628:therapy*