A new study published in the Lancet Global Health by a team of Yale researchers examines the implementation of bubble continuous positive airway pressure (bCPAP) in children 1-59 months old with lower respiratory tract infections (LRTIs) in low- and middle-income countries (LMICs). Globally, LRTIs are the leading cause of death among children in this age group – an estimated 537,000 child deaths were attributed to this in 2021, with the majority occurring in LMICs.
A low-cost and commonly used treatment for children in respiratory distress, bCPAP has been shown to reduce mortality in this patient population in many contexts but also increased mortality in one large trial in 2019. In their new study, the Yale team aimed to understand the reasons behind why different implementation contexts might lead to different outcomes.
The team integrated a literature review with surveys, focus groups, and interviews of interdisciplinary bCPAP stakeholders, including researchers, doctors, nurses, therapists, engineers, and technicians from 14 countries to better understand how and in what contexts bCPAP can be implemented safely and effectively in LMICs. They described 18 factors — from healthcare worker training and supportive supervision to community perceptions regarding oxygen therapy to local institutional processes and infrastructure — interacting at multiple levels to influence bCPAP safety and effectiveness.
In the implementation theory they propose, they describe five levels of factors that might influence bCPAP implementation feasibility, fidelity, and sustainability: (1) the bCPAP device, (2) local partnerships and infrastructure, (3) clinical and technical teams, (4) caregivers and the community, and (5) institutional practices. They suggest that their theory could be leveraged to enhance the rigor of future bCPAP implementation trials, increasing its safety and effectiveness when used in this pediatric population in LMICs.
Lead author and instructor of pediatrics at Yale School of Medicine Nadir Ijaz, MD MHS, said, “Building on previous bCPAP trials, our work emphasizes the need to examine not only bCPAP effectiveness but also its implementation. We propose a theory that might explain why bCPAP improves survival in children with pneumonia in certain contexts but causes harm in others, and we hope our theory can help researchers measure bCPAP implementation and design context-relevant implementation strategies for future trials.”
Read the full piece, “Contextual factors influencing bubble continuous positive airway pressure implementation for pediatric respiratory distress in low-income and middle-income countries: a realist review”, in the Lancet Global Health here.