Efficacy of Delivery Room Bubble Continuous Positive Airway Pressure in Preterm Neonates <34 Weeks Having 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.