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Respiratory diseases associated with prematurity continue to be a highly challenging condition to manage globally, even in today's modern medical landscape.[1] Each year, approximately 1 million children die worldwide as a result of complications associated with preterm birth, and a major cause of these deaths is respiratory distress syndrome (RDS).[2][3][4] In the United States, RDS still contributes to infant mortality, accounting for 2.2% of all infant deaths in 2022.[Birth/Infant Death Data] RDS can be managed by various methods, eg, exogenous surfactant administration or supportive respiratory care with mechanical ventilation via endotracheal intubation or noninvasive ventilatory methods like noninvasive positive pressure ventilation (NIPPV), bilevel positive airway pressure (BiPAP), or continuous positive airway pressure (CPAP).[5] The CPAP system was first recognized for neonates in 1971.[6] After multiple revisions and iterations, CPAP is now recommended by the World Health Organization (WHO) as a first-line therapy for respiratory support in premature neonates worldwide.[4] CPAP administered through the nose, ie, nasal CPAP (nCPAP), can be classified into 2 main types based on the method of positive pressure generation. These include the continuous-flow CPAP, which are bubble CPAP (bCPAP) and ventilator-derived CPAP, also known as conventional CPAP, and variable-flow CPAP, which are infant flow driver (IFD) CPAP and Benveniste gas-jet valve CPAP.[7][8] Briefly, bCPAP can be differentiated from other types of CPAPs by its key feature, pressure oscillations (hence the name "bubble" CPAP), which promote airway opening and enhance lung recruitment.[9] Multiple bCPAP studies have shown to lower oxygen requirements, decrease respiratory decompensation, reduce the need for mechanical ventilation, reduce the incidence of chronic lung disease, and decrease the length of NICU stays.[10] This improved efficacy, ease of setup, and minimal equipment needs are reasons for its increased uptake in the NICUs, especially in low- to middle-income countries.[11]

Air Leak Syndromes The use of CPAP in neonates enhances the FRC. Still, with excessive positive pressure, the alveoli can become inadvertently overdistended, causing increased transpulmonary pressures and resulting in air leak syndromes like pneumothorax and pneumomediastinum.[20][61][62] The Continuous Positive Airway Pressure or Intubation at birth (COIN) trial found that nasal CPAP started at a pressure of 8 cm H2O was found to be associated with an increased incidence of pneumothorax in infants with a birth gestational age of 25 to 28 weeks gestation.[63] However, an RCT of infants receiving early surfactant and bCPAP without invasive ventilation showed that these neonates were less likely to develop pneumothorax.[64] Additionally, more recent meta-analyses and Cochrane reviews have shown that bubble CPAP is not associated with an increased rate of air leak syndrome compared to other forms of CPAP.[65][66] Clinicians can prevent such complications by carefully monitoring oxygenation and ventilation and weaning off CPAP quickly when clinical improvement is noted, especially after exogenous surfactant administration. Nasal Septal Injury Both meta-analyses and a Cochrane review showed that bCPAP use is associated with twice the risk of any nasal injury when compared to other forms of CPAP.[65][66][67] Incorrect application of the CPAP device, inappropriate size of the nasal interface, inappropriate application or size of the head-securing device, and inadequate monitoring of skin and surrounding nose tissue are other risk factors for nasal septal injury.[68] Thus, preventing such pressure injuries is imperative through close monitoring during nursing care; a validated scoring system can also be used for an objective assessment.[53]

Both meta-analyses and a Cochrane review showed that bCPAP use is associated with twice the risk of any nasal injury when compared to other forms of CPAP.[65][66][67] Incorrect application of the CPAP device, inappropriate size of the nasal interface, inappropriate application or size of the head-securing device, and inadequate monitoring of skin and surrounding nose tissue are other risk factors for nasal septal injury.[68] Thus, preventing such pressure injuries is imperative through close monitoring during nursing care; a validated scoring system can also be used for an objective assessment.[53] The type of nasal interface also plays a role in the nasal septal injury. Studies report that a nasal mask is associated with a significantly lower risk of nasal injury than binasal prongs.[69][70] While nasal masks can still cause pressure injury to the nasal bridge and philtrum, the binasal prong causes injuries to the columella. Such pressure or friction can eventually result in nasal septal erosion or necrosis. This can be avoided by using appropriately sized, snug-fitting nasal prongs, alternate use of short binasal prongs and nasal mask, applying a protective barrier (eg, hydrocolloid dressing or silicone gel), and correct positioning of the neonate.[45][71][72] Gastric Distension Gastric distention occurs when the infant inadvertently swallows excessive air delivered through the nasopharynx. This is also known as “CPAP belly,” a benign condition that can be differentiated on the plain abdominal x-ray by the polygonal shape of diffusely dilated bowel loops, normal anatomic landmarks such as the central location of the small bowel, and the presence of haustral folds in the large intestine, and the absence of pneumatosis intestinalis or portal venous gas.[73] However, gastric distension from bCPAP can also delay the initiation or advancement of oral feeds by causing feeding intolerance and gastroesophageal reflux, as the positive pressure distends the intestines and stents open the lower esophageal sphincter.[74][75][76]

Gastric distention occurs when the infant inadvertently swallows excessive air delivered through the nasopharynx. This is also known as “CPAP belly,” a benign condition that can be differentiated on the plain abdominal x-ray by the polygonal shape of diffusely dilated bowel loops, normal anatomic landmarks such as the central location of the small bowel, and the presence of haustral folds in the large intestine, and the absence of pneumatosis intestinalis or portal venous gas.[73] However, gastric distension from bCPAP can also delay the initiation or advancement of oral feeds by causing feeding intolerance and gastroesophageal reflux, as the positive pressure distends the intestines and stents open the lower esophageal sphincter.[74][75][76] Gastric distension is typically managed by intermittent aspiration, “venting,” of stomach contents in between feeds using an orogastric/nasogastric tube. Prone positioning may also help.[73] When such measures fail, adjustments to bCPAP therapy by decreasing PEEP can also help reduce gastric distension, but respiratory status must be closely monitored while doing so. Some case reports exist of abdominal support with a flexible belly band as effective.[77] However, caution must be exercised for its use while awaiting further clinical trials with such devices. Cardiovascular Compromise High levels of CPAP can increase intrathoracic pressure, resulting in decreased venous return and impaired cardiac output.[33][78][79] This is especially true in preterm infants whose lung compliance is variable. Serial echocardiography done in preterm infants with resolving respiratory distress syndrome on CPAP showed a reduction in superior vena cava and right ventricular blood flow with an accompanying increase in inferior vena cava diameter.[78] However, this was not associated with changes in systemic arterial pressure, similar to other published trials.[80][81] Even though the evidence is not clear one way or the other, clinicians must still be vigilant about the potential adverse effects of CPAP on cardiovascular markers, especially when making adjustments. Impaired Ventilation-Perfusion Mismatch

High levels of CPAP can increase intrathoracic pressure, resulting in decreased venous return and impaired cardiac output.[33][78][79] This is especially true in preterm infants whose lung compliance is variable. Serial echocardiography done in preterm infants with resolving respiratory distress syndrome on CPAP showed a reduction in superior vena cava and right ventricular blood flow with an accompanying increase in inferior vena cava diameter.[78] However, this was not associated with changes in systemic arterial pressure, similar to other published trials.[80][81] Even though the evidence is not clear one way or the other, clinicians must still be vigilant about the potential adverse effects of CPAP on cardiovascular markers, especially when making adjustments. Impaired Ventilation-Perfusion Mismatch Similar to systemic effects, impaired venous return from excessive distending pressure of bCPAP can also compromise the pulmonary blood flow. This may lead to increased pulmonary vascular resistance (PVR), worsening ventilation-perfusion (V-Q) mismatch, and impaired oxygenation.[62][33] Moreover, overdistension of alveoli can also compress extra-alveolar blood vessels, leading to increased PVR. At the same time, collapsed alveoli may also have similar effects on PVR. Thus, close attention to ventilation and oxygenation parameters is essential for achieving an optimal PVR to avoid such adverse effects. Nasal Obstruction Obstruction occurs from secretions or the improper position of the NCPAP prongs. To avoid this, the nares should be suctioned at adequate intervals, and the prongs should be checked for proper placement with every nursing assessment.[52][67]

The successful implementation of bCPAP for neonates experiencing respiratory distress relies on a well-coordinated, interprofessional team approach. Physicians and advanced practitioners play a key role in determining the appropriateness of bCPAP therapy, setting initiation parameters, and supervising patient progress. They must ensure that each institution follows established guidelines, including criteria for initiation, escalation, and weaning. Nurses, particularly those with specialized neonatal training, are essential in monitoring infants on bCPAP, ensuring equipment is functioning correctly, and recognizing early signs of complications. Respiratory therapists provide additional expertise in managing ventilatory strategies, optimizing pressure settings, and troubleshooting technical issues, making their role indispensable in effective bCPAP delivery. Beyond clinical roles, effective interprofessional communication and care coordination are vital for achieving optimal patient-centered outcomes and safety. Frequent team discussions allow for real-time supervision, timely adjustments, and collaborative decision-making, which reduces the need for invasive mechanical ventilation and improves survival rates. Pharmacists contribute by ensuring safe and effective medication management, particularly for neonates requiring surfactant therapy or sedation. The availability of reliable equipment, cost-effective solutions, and ongoing mentorship programs further enhances bCPAP implementation. Additionally, hospital administration support and interactive training sessions covering respiratory physiology and bCPAP principles empower healthcare professionals to work as a cohesive unit, ultimately improving neonatal care and team performance.