With advances in neonatal care, the survival rate of infants less than 1500 g has increased. However, there is a disparity in neonatal outcomes between high-income and low- and middle-income countries. Among the greater than 2.6 million neonatal deaths worldwide each year, more than 98% occur in low- and middle-income countries.¹ Among the 8 sustainable development goal (SDG) regions, sub-Saharan Africa had the highest neonatal mortality rate in 2018 at 28 deaths per 1000 live births, followed by Central and Southern Asia with 25 deaths per 1000 live births.² In South Africa, the most common cause of death in the neonatal period is prematurity (35% – 48%), followed by intrapartum-related events.³

Primary respiratory distress syndrome (RDS) from surfactant deficiency in the newborn is the most prevalent respiratory disorder among preterm infants. Respiratory distress syndrome-specific mortality in low- and middle-income countries is high. Survival among neonates less than 32 weeks of gestation is below 50% in resource-limited settings;⁴ however, this has increased over the years to around 70% because of increased access to health care. Improving access to facilities capable of delivering quality neonatal care for small and sick newborns has been identified as a target of the Early Neonatal Action Plan (ENAP), which aims to have 80% of districts with available care for small and sick newborns.⁵ Respiratory distress syndrome is treatable with continuous positive airway pressure (CPAP).

Continuous positive airway pressure has been used extensively since the 1970s for managing respiratory disease in premature infants and is no longer limited to regional and tertiary hospitals. It is now advocated and widely implemented in district hospitals. It is considered the initial mode of respiratory support for spontaneously breathing preterm infants and is being increasingly used in low- and middle-income countries. It is a relatively low-cost therapy shown to improve neonatal and infant outcomes across a wide range of healthcare settings.⁶ Early use of CPAP in neonates with RDS reduces mortality, the need for mechanical ventilation (MV) and transfer to a tertiary centre.^7,8 Continuous positive airway pressure has shown a 50% reduction in the need for MV.⁹ Bubble CPAP is cost effective and can be used in district hospitals for neonates with RDS. Continuous positive airway pressure improves lung volume, especially functional residual capacity. The increased positive distending airway pressure improves oxygenation, decreases apnoea and reduces the work of breathing with a reduction in the need for MV and mortality.^10,11 However, there is an increase in the rate of pneumothorax with CPAP.¹¹

One of the challenges in district hospitals (a hospital that receives referrals from and provides generalist support to clinics and community health centres with health treatment administered by general health care practitioners or primary health care nurses) is the lack of early radiological diagnosis and blood gas analysis. There is now less emphasis on radiographic diagnosis and grading of RDS, such as ‘ground glass with air bronchograms’. Definitions based on blood gas analyses are also redundant, as management has moved towards an approach of pre-emptive treatment with surfactant based on clinical assessment of work of breathing and inspired oxygen requirement to avoid worsening RDS.

Work of breathing can be determined using a scoring system that is simple, non-invasive, inexpensive and has shown both prognostic value and good inter-rater reliability. Some of the scoring systems include the Downes scoring system¹² (Table 1) or the Silverman Andersen respiratory severity scoring system¹³ (Figure 1).

Silverman Andersen score in the range of 4–6 is commonly used as a threshold for initiation, and titration of CPAP therapy given it can be serially repeated at the bedside as a type of vital sign. A score of ≥ 6 on the Downes score can be used to initiate CPAP. Surfactant therapy using the intubate, surfactant and extubate technique (INSURE) can be administered, based on the expertise of the healthcare worker.¹⁴ Less invasive surfactant administration (LISA) has also proven to be effective; however, more studies are required.¹⁵ A mechanical ventilator should be available with these techniques, in the event of the neonate failing extubation. Surfactant therapy should be considered if the fraction of inspired oxygen (FiO₂) is more than 30% and if CPAP pressure of ≥6 cm of water is required. The oxygen target should be between 90% and 94%.

There is a lack of consensus regarding the optimal method of weaning neonate off CPAP. Criteria used in various studies to wean a neonate off CPAP are described in Box 1.¹⁷ This can be determined by the work of breathing. It is variable in different centres.

The criteria that can be used to determine the failure of CPAP are as stated in Box 2.¹⁸

Ensuring the proper setup and utilisation of nasal CPAP (nCPAP) is contingent upon various requirements. One needs to emphasise delivering safe and effective respiratory support to neonates.

Evaluating the feasibility of implementing nCPAP in district hospitals is essential for successful integration, sustained operation and positive health outcomes for patients in need of respiratory support. In resource-limited settings, diagnostic tests such as laboratory and radiographic assessments are not consistently available. This is compounded by the lack of medical doctor supervision, leading nurses to take the initiative in medical interventions.^30,32 Initiating nCPAP is an easy process; however, for optimal effectiveness, it requires continuous usage for hours or days, involving a consistent supply of electricity and medical gases, along with ongoing clinical monitoring.³³ Nasal continuous positive airway pressure stands out as a promising and reliable technology for delivering respiratory support to neonates facing respiratory distress.^29,31 Its potential for extensive adoption, especially in addressing respiratory distress in developing nations, is emphasised by its lower initial costs. Challenges such as the cost and availability of consumables, the need for additional equipment like humidifiers and the presence of skilled staff may hinder the widespread implementation of nCPAP therapy.³¹

By addressing these key aspects, healthcare facilities can pave the way for the successful implementation of nCPAP, ultimately improving respiratory support for infants in resource-limited settings.

Respiratory distress syndrome stands out as a significant contributor to neonatal mortality and morbidity. Utilising non-invasive CPAP emerges as a safe and efficient approach in mitigating both mortality and morbidity among preterm neonates. Its applicability within district hospitals proves advantageous, as it minimises the necessity for neonatal transfers to regional and tertiary care centres, thereby alleviating strain on the healthcare system. Nonetheless, substantial training is imperative before implementing CPAP at lower levels of care.