694 - Bubble CPAP in Preterm Infants: Evidence from Comparative Cohort Studies.

Publication Number: 4678.694

Amanda Gross, McGill University Faculty of Medicine and Health Sciences, Montreal, PQ, Canada; Emily R. Campbell, Research Institute- McGill University Health Centre, Monteal, PQ, Canada; Guilherme Santanna, McGill University Health Center, MONTREAL, PQ, Canada; Wissam Shalish, McGill University Health Center, Montreal, PQ, Canada

Background: Bubble continuous positive airway pressure (bCPAP) is a simple, low-cost device that generates pressure oscillations as airflow escapes into a water canister, aiding gas exchange and alveolar recruitment. Despite decades of use, meta-analyses have not shown clear superiority of bCPAP over other CPAP modalities in reducing bronchopulmonary dysplasia (BPD), but randomized trials may be limited by heterogeneity, open-label designs, and variable implementation. Comparative cohort studies may better capture the real-world effectiveness of bCPAP.

Objective: To review the effects of bCPAP on BPD and short-term respiratory morbidities in preterm infants using comparative cohort evidence.

Design/Methods: A PubMed search was conducted in June 2025 using ("bubble CPAP" OR "bubble continuous positive airway pressure" OR "bCPAP") AND (neonat* OR newborn* OR infant OR premat*). Additional studies were identified through reference searching. Included studies compared outcomes in preterm infants managed with bCPAP to a historical cohort or benchmark database in high-income countries. Data on population, implementation protocols, and outcomes were extracted. The primary outcome was BPD; secondary outcomes were mortality, delivery room (DR) intubation, surfactant administration, and mechanical ventilation (MV) duration. Effect estimates were calculated as differences between the bCPAP and comparison groups across birth weight and gestational age cohorts.

Results: Of the 192 articles identified, 16 were included (Table 1). Most studies introduced bCPAP in the DR using short binasal prongs and maintained it for prolonged periods, modeling the New York Presbyterian (Columbia University) approach. After implementation, all but three cohorts reported lower BPD, with the greatest reductions in extremely low birth weight (ELBW, < 1000g) and extremely preterm ( < 28 weeks) infants (median -12.5% [IQR -24.3% to -6.5%]), generally accompanied by decreased mortality (median -7.0% [IQR -8.5% to 1.7%]) (Figure 1A-B). DR intubations in the same population dropped markedly (median -36.6% [IQR -49.5% to -27.4%]) as did surfactant administration (median -27.7% [IQR -33.0% to -18.2%]) (Figure 2A-B). Across all cohorts, MV duration decreased from 7.0 [IQR 3.0-16.0] to 4.6 days [IQR 1.5-10.5].

Conclusion(s): Current evidence from comparative cohort studies suggests sustained implementation of bCPAP protocols may be associated with reduced BPD, DR intubations, and surfactant administration, particularly among ELBW infants. This offers valuable insights into the real-world impact and feasibility of integrating bCPAP into routine clinical practice.

Table 1. Study Characteristics
Abbreviations: BW - birth weight, GA - gestational age, bCPAP - bubble continuous positive airway pressure, DR - delivery room, BPD - bronchopulmonary dysplasia, MV - mechanical ventilation, DCC - delayed cord clamping, NIV - non-invasive ventilation.

a Comparisons were made with benchmark values derived from the Australia and New Zealand Neonatal Network.
b Comparisons were made with benchmark values derived from the Vermont Oxford Network.

Figure 1. Impact of bCPAP Implementation on (A) BPD and (B) Mortality
Each point represents a study cohort, coloured by population: Extremely preterm ( < 28 weeks' gestation), very preterm ( < 32 weeks), extremely low birth weight (ELBW, < 1000 g), and very low birth weight (VLBW, < 1500 g). Data points above the diagonal line indicate improvement following bCPAP implementation.

Figure 2. Impact of bCPAP Implementation on (A) Delivery Room Intubations and (B) Surfactant Administration
Each point represents a study cohort, coloured by population: Extremely preterm ( < 28 weeks' gestation), very preterm ( < 32 weeks), extremely low birth weight (ELBW, < 1000 g), and very low birth weight (VLBW, < 1500 g). Data points above the diagonal line indicate improvement following bCPAP implementation.