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Provider Perceptions of Bubble Continuous Positive Airway Pressure and Barriers to Implementation in a Level III Neonatal Unit in South India

Atreya, Mihir R., MD, MPH; Lorenz, John M., MD; Narendran, Vivek, MD, MRCP, MBA

Section Editor(s): Dowling, Donna PhD, RN; ; Thibeau, Shelley PhD, RNC-NIC;

doi: 10.1097/ANC.0000000000000510
Original Research

Background: Bubble continuous positive airway pressure (bCPAP) is a simple, safe, and cost-effective strategy to provide respiratory support to newborns with respiratory distress syndrome in resource-limited settings.

Purpose: To understand whether implementation of bCPAP, relative to other modes of respiratory support in the care of newborns with respiratory distress syndrome, increases positive attitudes about its potential for consistent and widespread use among providers in neonatal intensive care units (NICUs) of lower middle-income countries.

Methods: Semistructured qualitative interviews with 14 healthcare providers, including 5 neonatal nurses, 2 respiratory therapists, 5 postgraduate trainees in pediatrics, and 2 attending physicians, were conducted at a level III NICU in south India where bCPAP had been in consistent use for 6 years. Interviews were transcribed and then coded and categorized using NVivo 10 Software (QSR International, Victoria, Australia).

Findings: Categories that emerged from our data include (1) perceived indications, (2) learning curve, (3) perceived costs, (4) perceived shortages, and (5) barriers to use. Providers believed that bCPAP was easy to learn and that it helped empower neonatal nurses in decision-making process. Participants provided a nuanced perspective of cost-benefit associated with bCPAP and that it helped make optimal use of limited resources. Participants identified several barriers to the implementation of bCPAP.

Implications for Practice: Providers of a level III NICU in a lower- to middle-income country viewed the use of bCPAP favorably. Addressing context-specific barriers will be important for the successful widespread implementation of bCPAP.

Implications for Research: Further research will need to focus on whether bCPAP can be safely implemented at level II NICUs.

Video Abstract Available at

Department of Pediatrics (Dr Atreya) and Division of Neonatology (Dr Narendran) Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and Division of Neonatology, College of Physicians and Surgeons, Columbia University, New York, New York (Dr Lorenz).

Correspondence: Mihir R. Atreya, MD, MPH, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 (

This study was conducted at Kasturba Medical College, Madhav Nagar, Manipal, Karnataka, India.

The study was supported by a stipend awarded by the Mailman School of Public Health, Columbia University, New York.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

© 2018 by The National Association of Neonatal Nurses