"Effectiveness of Delivery Room Bubble CPAP in Preterm Infants With Respiratory Distress

Preterm birth remains one of the most significant contributors to neonatal morbidity and mortality worldwide. Globally, an estimated 15 million infants are born prematurely each year, with the majority occurring in low- and middle-income countries (Blencowe et al., 2013; WHO, 2018). Complications related to prematurity account for over one million deaths annually, and in Bangladesh, prematurity is responsible for nearly one-third of neonatal deaths. Effective respiratory support strategies are therefore critical in improving outcomes in this population.

Continuous Positive Airway Pressure (CPAP) is a well-established mode of non-invasive respiratory support that has been shown to reduce ventilator dependence and the risk of chronic lung disease in preterm infants with respiratory distress. By providing a continuous distending pressure, CPAP stabilizes the alveoli, reduces atelectasis, conserves endogenous surfactant, improves lung compliance, and decreases the work of breathing. These physiological benefits reduce the need for intubation, mechanical ventilation, and exogenous surfactant therapy, all of which are associated with short- and long-term complications.

Bubble CPAP (bCPAP) represents a simple, low-cost, and effective CPAP system particularly suitable for use in resource-limited settings. The system can be assembled using readily available components, and healthcare workers can be trained in its use with relative ease. Compared to ventilator-driven CPAP, bCPAP requires less technical infrastructure and is associated with a lower risk of complications. Previous studies have demonstrated that early initiation of bCPAP is associated with reduced need for intubation and surfactant therapy, shorter duration of respiratory support, and improved weight gain, without increasing adverse outcomes such as pneumothorax (Narendran et al., 2013; Bahareh et al., 2013).

There is increasing evidence that the timing of CPAP initiation plays an important role in determining outcomes. Early initiation of CPAP in the delivery room, before the onset of severe atelectasis, appears more effective than delayed initiation. A systematic review and meta-analysis comparing early versus late CPAP demonstrated that early initiation significantly reduced subsequent use of mechanical ventilation (RR 0.55; 95% CI 0.32-0.96), though effects on mortality, bronchopulmonary dysplasia (BPD), and pneumothorax were not significant (Gupta et al., 2015).

Despite this evidence, there is limited research evaluating the efficacy of immediate delivery room initiation of bCPAP in low-resource countries such as Bangladesh, where the burden of prematurity is high and access to advanced ventilatory support is limited. This randomized controlled trial aims to address this gap.

Study Design and Setting

This is a single-center, randomized controlled clinical trial conducted at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, involving both the Department of Neonatology and the Department of Obstetrics \& Gynecology. The study duration is 18 months, following approval by the Institutional Review Board (IRB).

Eligible preterm neonates (\<34 weeks gestation) presenting with respiratory distress at birth will be randomized within 10 minutes of delivery to one of two intervention arms:

Delivery Room bCPAP Group - neonates will receive bubble CPAP initiated in the delivery room.

Control Group - neonates will receive standard oxygen therapy in the delivery room.

Block randomization will be used to ensure equal distribution of participants. Following stabilization, all neonates will be transferred to the Neonatal Intensive Care Unit (NICU) with their assigned respiratory support continued. Subsequent management will follow institutional protocols.

Study Procedures

Upon delivery, eligible neonates will be placed under a radiant warmer. A pulse oximeter will be applied, and respiratory distress will be assessed using a standardized scoring system. In the intervention arm, bCPAP will be initiated using nasal prongs, with pressures titrated according to clinical need. In the control arm, supplemental oxygen will be administered via standard delivery methods.

Daily monitoring will include clinical assessment, oxygen saturation, need for escalation of respiratory support, episodes of apnea, and complications such as pneumothorax, necrotizing enterocolitis, intraventricular hemorrhage, and patent ductus arteriosus. Data will be collected for the first 7 days of life or until discharge, whichever occurs earlier.

Sample Size

Based on prior studies (Desai et al., 2017), an outcome rate of 30% was assumed in the intervention group and 67% in the control group. With α = 0.05 and 80% power, the calculated sample size was 25 participants per group. Allowing for 20% attrition, the final estimated enrollment is 60 neonates.

Statistical Analysis

Data will be analyzed using SPSS version 25. Continuous variables will be summarized as mean ± standard deviation or median (interquartile range) depending on distribution. Categorical variables will be presented as frequencies and percentages. Between-group comparisons will be made using the Student's t-test or Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. Logistic regression will be used to adjust for potential confounders. Statistical significance will be set at p \< 0.05. Additional analyses will include correlation testing and ROC curve analysis for predictive variables.

Ethical Considerations

The study will adhere to the principles of the Declaration of Helsinki. Written informed consent will be obtained from parents or guardians prior to enrollment. Data will be de-identified, securely stored, and used exclusively for research purposes. No additional risks are anticipated beyond standard neonatal care.

Significance

This trial is designed to provide robust evidence on the role of early delivery room initiation of bubble CPAP in improving respiratory outcomes for preterm infants in a resource-limited setting. By evaluating both efficacy and safety, the findings are expected to inform national and regional neonatal care strategies, promote scale-up of bCPAP technology, and contribute to reductions in neonatal morbidity and mortality associated with prematurity.