Table 4

Case series and case reports

Author and year of publicationCountry and settingStudy design SelectionOutcomeComparisonSample sizeOutcomesQuality assessment
Bassiouny 199443Oman
Tertiary neonatal unit
No definition of mild/ moderate/ severe respiratory distress
MV available
Currently a high-income country but considered ‘developing country’ at the time of data collection
Case series
Retrospective review of premature infants managed with jet CPAP
‘Preterm infants’ (no definition)
Cases stratified according to severity based on clinical grounds (mild, moderate, severe)
Not bubble CPAP
Very small subgroups so not possible to draw conclusions re: differences in outcomesNo controlled comparison
CPAP failure vs CPAP success
44 in total
27 CPAP success
17 CPAP failure
Overall 6/44 (14%)
2/27 CPAP success (7%)
4/17 CPAP
failure (24%)
Very low
Brown 201345Malawi
National referral centre
No MV available
Case reports
(management with bubble CPAP)
Representative of other very low-income settings
Only 2 cases
One was a neonate with respiratory distress
Technical report rather than true case seriesNo comparison2 in totalBoth cases survivedVery low
Hendrik 201031South Africa
District hospital
No MV available locally but transfer was possible
Case series
(management with bubble CPAP)
All consecutive cases (none excluded)
Separated into:
Infants >1800 g with respiratory distress
Infants <1800 g with respiratory distress
Transfer was primary outcome
All infants >1800 g requiring transfer had conditions unlikely to be resolved by CPAP (cardiac and other structural anomalies)
No comparison>1800 g: 17 neonates
4 CPAP failure (required intubation)
<1800 g: 34 neonates
11 CPAP failure
4 died
Vague mortality data for neonates >1800 g
30 CPAP recipients <1800 g survived
Very low
Kirsten 201246South Africa
Tertiary hospital
Very limited MV available for this cohort
Case series of patients managed with CPAP alone vs intubate, surfactant, extubate protocol (‘InSurE’)
83% received antenatal steroids
Observational study of surfactant use, not randomised
ELBW newborns (500–1000 g) with respiratory distress requiring respiratory support in birth suite
Primary outcome was mortalityNo comparison212 treated with CPAP onlyMortality 42 (19.8%)
Required MV:
Koti 201032India
Tertiary neonatal unit
Surfactant and MV available
Case series
GA28–34/40 infants admitted to nursery with symptoms and CXR changes consistent with RDS
91% received antenatal steroids
Clear exclusion criteria inc exclusion of those intubated in the delivery suitePublication bias unlikely
Outcomes of interest were mortality, CPAP failure/ requirement for IPPV
No controlled comparison
CPAP failure vs CPAP success
56 in total
14 CPAP failure
42 CPAP success
6/56 overall (11%)
1/42 CPAP success (2.4%)
5/14 CPAP failure (35.7%)
Rojas 200947Columbia
Multicentre trial in tertiary neonatal units
Surfactant and MV available
Relatively low mortality
High rate of antenatal steroids
Case series of CPAP only arm of randomised trial (early InSurE vs early CPAP)Randomised to early CPAP group
27–32 weeks, with O2 requirement or respiratory distress at 15–60 min of age
Publication bias unlikely (not device/product based)
Outcomes: MV and mortality/morbidity
No comparison relevant to this review (comparison treatment included surfactant)137 babies treated with CPAPMortality: 13/137 (9%)
53 (39%) required MV
Pneumothorax: 12 (9%)
Shrestha 201034Nepal
Secondary neonatal unit
No MV available locally but transfer was possible
Very low income setting
Case series
Prospective data collection for 3/12 post-introduction of bubble CPAP
Similar to other low-income settings
Inclusion criteria were clear—all cases with respiratory distress
Exclusion criteria not described
Small numbers overall
Clear description of causes of death for babies that died
No group to group comparison15 in totalMortality:
4/15 (33%)
Pneumothorax x1
Causes of death: sepsis, apnoea
Very low
Singh 199344India
Tertiary neonatal unit
MV available
Case series
Retrospective review of neonates requiring respiratory support with clear indications for CPAP vs MV and clear description of failure
Stratified by birth weight
Inclusion and exclusion criteria clearly described
Ventilator CPAP, not bubble CPAP
Small subgroups so impossible to draw conclusions within stratifications (inadequate power)No group-to-group comparison33 CPAPMortality:
8/33 CPAP (24%)
Very low
Urs 200942India
Tertiary neonatal unit
MV available
Case series/ audit
Prospective observational study
GA <37 weeks
Clear indications for CPAP and for MV (ie: CPAP failure)
Clear exclusion criteriaSmall subgroups so inadequately powered for subgroup analysis
No cases of pneumothorax in either group
Mortality not mentioned
No non-CPAP comparison
CPAP success vs CPAP failure
50 overall
CPAP success 40
CPAP failure 10
CPAP success: higher rate of antenatal steroids, higher BW and greater GALow
Van den Heuvel 201148Malawi
National referral centre
No access to MV
Very low-income setting
Case series
1–2.5 kg neonates with respiratory distress at 4 h of age
Simple circuit to set up
Clear exclusion criteriaTiny sample size
High background mortality in the population but sample size too small to see reduction in mortality
No controlled comparison11 babies, only 5 actually met inclusion criteria3/5 who met inclusion criteria survived
1/6 others survived
Very low
  • Assessment based on the Newcastle-Ottawa Quality Assessment Scale.

  • BW, birth weight; CPAP, continuous positive airway pressure; GA, gestational age; MV, mechanical ventilation; RDS, respiratory distress syndrome; IPPV, intermittent positive pressure ventilation; ELBW, extremely low birth weight, CXR, chest X-ray.