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Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis
  1. Shruti K Bharadwaj1,
  2. Abdullah Alonazi1,
  3. Laura Banfield1,
  4. Sourabh Dutta2,
  5. Amit Mukerji1
  1. 1 Pediatrics, McMaster University, Hamilton, Ontario, Canada
  2. 2 Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  1. Correspondence to Dr Amit Mukerji, McMaster University, Hamilton, ON L8S 4K1, Canada; mukerji{at}


Background Use of bubble continuous positive airway pressure (CPAP) has generated considerable interest in neonatal care, but its comparative effectiveness compared with other forms of CPAP, especially in developed countries, remains unclear.

Objective To systematically review and meta-analyse short-term clinical outcomes among preterm infants treated with bubble CPAP vs all other forms of CPAP.

Methods Prospective experimental studies published from 1995 onward until October 2018 comparing bubble versus other CPAP forms in preterm neonates <37 weeks’ gestational age were included after a systematic review of multiple databases using pre-specified search criteria.

Results A total of 978 articles were identified, of which 19 articles were included in meta-analyses. Of these, 5 had a high risk of bias, 8 had unclear risk and 6 had low risk. The risk of the primary outcome (CPAP failure within 7 days) was lower with bubble CPAP (0.75; 95% CI 0.57 to 0.98; 12 studies, 1194 subjects, I2=21%). Among secondary outcomes, only nasal injury was higher with use of bubble CPAP (risk ratio (RR) 2.04, 95% CI 1.33 to 3.14; 9 studies, 983 subjects; I2=42%) whereas no differences in mortality (RR 0.82, 95% CI 0.47 to 1.92; 9 studies, 1212 subjects, I2=20%) or bronchopulmonary dysplasia (BPD) (RR 0.8, 95% CI 0.53 to 1.21; 8 studies, 816 subjects, I2=0%) were noted.

Conclusion Bubble CPAP may lead to lower incidence of CPAP failure compared with other CPAP forms. However, it does not appear to translate to improvement in mortality or BPD and potential for nasal injury warrants close monitoring during clinical application.

Trial registration number CRD42019120411.

  • continuous positive airway pressure
  • CPAP failure
  • infant flow CPAP
  • ventilator CPAP
  • meta-regression

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  • Contributors SKB co-conceived the project, conducted data acquisition and analysis, and drafted the initiated manuscript. AA contributed to data acquisition and analysis, and provided feedback on manuscript draft. LB devised the search strategy for data acquisition. SD provided methodological input for data analysis, including the conduct of meta-regression, and provided critical feedback on manuscript draft. AM devised the study concept, oversaw data analysis and finalised the manuscript. All authors approved the final manuscript version.

  • Funding AM is supported by a Research Early Career Award from Hamilton Health Sciences Foundation (2019–2021).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplementary information. Data were garnered from review of studies included in this meta-analysis.