Table 4 Implementation factors
Topic | Facilitators | Barriers |
|---|---|---|
Device | • Simple to use, affordable and low maintenance for low-resource settings. • A temperature-controlled gas circuit may reduce the risk of hypothermia especially in extremely low-birthweight babies. | • Efficacy may be limited to mild to moderate respiratory distress and less effective with severe cases. |
Training and staffing | • Regular and interactive training with intermittent refresher trainings. • Clinical mentorship with training on how to train others to use bubble CPAP. • Investing in nurses dedicated to the nursery. • Clinicians that stay longer term in the nursery. • Combination of external consultant with local clinicians as trainers. • Health facility management that prioritized neonatal care. | • Understaffed neonatal units limit the capacity for care. • Staffing shortages exacerbated by healthcare provider strikes in some locations. • High turnover of nurses and doctors necessitated repeated training of new staff. • Lack of motivation and accountability. • Gaps in training as many nurses and doctors are untrained in bubble CPAP. • Communication barriers between doctors and nurses. |
Initiation | • Decision-making aided by clinical algorithm that is clearly posted by the machine. | • Gaps in correct identification of early and mild signs of distress. • Reluctance of nurses to initiate while short-staffed at night and without consulting a clinician. • Overtightening the chin strap can lead to facial swelling. |
Monitoring | • Appropriate and regular monitoring. • Monitoring with pulse oximetry. • Monitoring respiratory distress with respiratory severity score. | • Complications such as CPAP belly syndrome and mucosal drying require regular monitoring and actions to prevent. |
Weaning | None discussed. | • Knowing when to wean, especially when resources are limited. • A need to monitor closely after weaning to ensure the infant is not desaturating. |
Caregivers | • Peer support from caregivers with positive experiences with bubble CPAP use on their own newborns. | • Local beliefs that the oxygen led to poor outcomes. • Poorly providing information to caregivers and gaps in consenting parents before starting bubble CPAP. • Bubble CPAP may complicate mother-infant interaction as mothers were afraid to hold babies, unable to see their infant’s faces and interrupted skin-to-skin contact. |
Supplies and equipment | • Appropriate snug-fitting nasal prongs. • Soft nasal prongs. • Use of locally available materials. | • Cost of disposable nasal prongs. • Oxygen concentrators not always available. • CPAP machines not always available. • Different machines cause challenges in training, set up and maintenance. • Poor equipment maintenance once donors withdraw support. |