An Audit of the Use of Nasal Continuous Positive Airway Pressure in Neonates With Respiratory Distress, Admitted to the Newborn Units of Four County and Sub-county Hospitals in Kenyatta - (a Cross-sectional Observational Study)

Abstract

Background: Neonatal respiratory distress is the most frequent indication for admission to the newborn unit (NBU). International and Kenyan guidelines advocate for the early use of Continuous Positive Airway Pressure (CPAP) as a standard of care. CPAP machines have been introduced in several county and sub-county hospitals in Kenya but implementation of CPAP therapy has not been well documented in these less-resourced facilities. We set out to audit the use of CPAP in neonates with features of respiratory distress in these hospitals. Specifically, we sought to describe the criteria used to initiate, wean, and stop CPAP therapy, patient monitoring, patient outcomes, and factors associated with adverse outcomes. Methodology: A hospital-based, retrospective, cross-sectional observational study conducted in the NBUs of four purposively selected secondary-level public referral facilities. We included all neonates admitted with features of respiratory distress, and among them, those managed on CPAP from January 2020 to December 2022. Data were obtained from the Clinical Information Network (CIN) database, patient files, and facility CPAP records. Variables of interest were descriptively reported in proportions, medians, and interquartile ranges. Measures of associations were summarized as odds ratios. The outcomes of interest were survival to discharge, need for mechanical ventilation, death, and chronic lung disease. Factors associated with these adverse outcomes were analyzed using a multivariate regression model. Results: A total of 23,119 neonates were admitted to the selected NBUs from January 2020 to December 2022. 6,469 (28%) had features of respiratory distress, with CPAP use in 1,211/6469 (18.7%). For those managed on CPAP, all 259 available patient records were audited. 160/259 (62%) were male, 136/259 (53%) had a low birth weight < 2500 grams, 178/259 (69%) were premature and 184/259 (71%), had a diagnosis of RDS. 193/259(75%) were discharged alive, 61/259 (24%) died and 5/259 (1.9%) were referred for mechanical ventilation. The median time to initiation of CPAP from admission was 13.8 hours (IQR: 3.8-35.6 hours) with a median duration of 18 CPAP use of 2 days (IQR: 1.0-3.0 days). The median number of monitoring observations in the first 24 hours while on CPAP were 4 (IQR: 2-8) respiratory rate, 5(IQR: 3-8) heart rate, and 5(IQR: 3-8) oxygen saturation (SpO2) observations. Only 10 /259(3.9%) had documented weaning of FiO2 by 10% up to 30% and 8/259 (3.1%) had documented weaning of CPAP pressure by 1 cm to a minimum of 5 cm of water before cessation of CPAP. Silverman Anderson Score (SAS) was only indicated in 17/259 (6.6%) of the records. Male gender, prematurity, low birth weight, hypothermia, and maternal diabetes were associated with higher odds of death in patients on CPAP but these were not statistically significant. Neonates with neonatal sepsis had a 67% reduction in the odds of death (OR 0.33, 95% CI [0.12, 0.79]), after adjusting for other confounders at multivariate analysis likely due to antibiotic use. Conclusion: Use of CPAP was low with only 18.7% (95% CI [17.8, 19.7]) of neonates with features of respiratory distress managed on CPAP. There was delayed initiation, inadequate monitoring, improper titration, weaning, and cessation of CPAP therapy. There was understaffing as well as lack of adequate monitoring equipment in the study sites. Concerted efforts need to be put into training health workers, guideline implementation, and adequate monitoring and staffing