Article Text

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design
  1. Sonja Baldursdottir1,2,
  2. Markus Falk1,3,
  3. Snorri Donaldsson1,2,
  4. Baldvin Jonsson1,2,
  5. Thomas Drevhammar3,3
  1. 1 Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
  2. 2 Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
  3. 3 Department of Anesthesiology, Östersund Hospital, Östersund, Sweden
  1. Correspondence to Dr Thomas Drevhammar, Department of Anesthesiology, Östersund Hospital, 831 83 Östersund, Sweden; thomas.drevhammar{at}


Background The original bubble continuous positive airway pressure (bCPAP) design has wide-bore tubing and a low-resistance interface. This creates a stable airway pressure that is reflected by the submersion depth of the expiratory tubing. Several systems with alterations to the original bCPAP design are now available. Most of these are aimed for use in low-income and middle-income countries and have not been compared with the original design.

Objective We identified three major alterations to the original bCPAP design: (1) resistance of nasal interface, (2) volume of dead space and (3) diameter of expiratory tubing. Our aim was to study the effect of these alterations on CPAP delivery and work of breathing in a mechanical lung model. Dead space should always be avoided and was not further tested.

Methods The effect of nasal interface resistance and expiratory tubing diameter was evaluated with simulated breathing in a mechanical lung model without interface leakage. The main outcome was delivered CPAP and imposed work of breathing.

Results High-resistance interfaces and narrow expiratory tubing increased the work of breathing. Additionally, narrow expiratory tubing resulted in higher CPAP levels than indicated by the submersion depth.

Conclusion Our study shows the significant effect on CPAP delivery and imposed work of breathing when using high-resistance interfaces and narrow expiratory tubing in bCPAP systems. New systems should include low-resistance interfaces and wide-bore tubing and be compared with the original bCPAP. Referring to all systems that bubble as bCPAP is misleading and potentially hazardous.

  • intensive care
  • neonatology
  • respiratory

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  • Contributors All authors (SB, MF, SD, BJ and TD) had full access and were active in writing and reviewing the manuscript. Data collection and analysis were mainly performed by MF.

  • Funding The research was funded by the Swedish government and independent research funds.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The trial did not involve humans and no ethical review was needed.

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

  • Data availability statement All data are available from the authors on request.

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