Nasal CPAP protocol reduces intubation and improves mortality in a resource-poor setting.

Presenting Authors: Yos Pagnarith, M.D., Jason Reynolds, M.D. Contributing Authors: Ngoun Chanpheaktra, M.D., Varun Kumar, M.D.

Purpose: Decrease mortality of children

Decrease the mortality of children presenting to the PICU at Angkor Hospital for Children in Siem Reap, Cambodia.

Background: Angkor Hospital for Children

Angkor Hospital for Children (AHC) is a privately-funded pediatric facility that serves as the provincial referral medical center for children aged birth to 15 years for Siem Reap Province in Cambodia.

UNICEF Data AHC Data

Under 5 Mortality Rank / 25
Under 5 Mortality Rate, 1990 / 115
Under 5 Mortality Rate, 2005 / 143
Infant Mortality Rate (Under 1), 1990 / 80
Infant Mortality Rate (Under 1), 2005 / 98
Neonatal Mortality Rate, 2000 / 40
Total popul.ation (thousands), 2005 / 14,071
Annual No. Births, 2005 / 429,000
Annual No. Under 5 Deaths, 2005 / 61,000
% Under 5 w/pneumonia / 20
GNI per capita (US$), 2005 / 380
% of population below $1/day, 1004-2004 / 34
Location / Dec-07 / YTD / Total
Outpatient / 9,311 / 107,732 / 508,736
Emergency / 694 / 11,925 / 81,633
Inpatient / 255 / 3,829 / 22,537
PICU / 56 / 787 / 3,272
LAU / 68 / 826 / 6,885
Surgery / 112 / 1,345 / 8,108
Home Care / 224 / 2,731 / 10,315
ARV (new) / 10 / 85 / 432
Dental / 2,746 / 25,201 / 87,416
Eye Care / 262 / 2,865 / 9,943
Lab Tests / 4,005 / 56,177 / 256,689

Intubation & Mortality

Critical care is difficult to do well in the best of circumstances. Previous studies have shown that invasive procedures may worsen mortality in developing countries.

Hypothesis: Nasal CPAP improves mortality

We hypothesize that nasal CPAP, used aggressively, will decrease intubation and improve the mortality of critically ill patients with a primary diagnosis of pneumonia presenting to the Angkor Hospital for Children in Siem Reap, Cambodia.

Methods

The PICU log was reviewed for the year 2005 and all patients were placed in a database according to diagnosis, intubation, and mortality. The available evidence was reviewed and a protocol for nasal CPAP was developed by the local Cambodian staff through a process of journal club review and senior medical staff meetings. The protocol was implemented and data was collected prospectively on diagnosis, intubation, CPAP use, and mortality.

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CPAP Protocol

Results

Conclusions

A minimally invasive, low-cost, evidence-based nasal CPAP protocol reduces intubation and improves mortality in patients with a primary diagnosis of pneumonia presenting to a community hospital in a resource-poor setting.

Possible Explanation:

CPAP supports ventilation

Intubation increases mortality

Other factors

Areas of Current Investigation:

Time to initiation of CPAP

Time on CPAP

Maximal CPAP Support