The procedure has six stages, shown in Figure 1 as a cycle because the protocol is expected to be revised after use. It is carried out by a small working group that should include the nurse in charge of the newborn unit, a clinician responsible for newborn care, the person who maintains equipment and, where possible, a representative of the referral hospital that receives transfers.
The proposed adaptation cycle for a district bubble CPAP protocol
The group starts from an existing document and not from a blank page. The most suitable source is the national newborn guideline or the protocol of the referral hospital to which the unit sends infants, since shared definitions make transfer and feedback easier. WHO guidance on oxygen therapy and on care of the preterm infant supplies the clinical principles against which the source is checked (WHO, 2016; WHO, 2022). The group lists every instruction in the source protocol as a separate line so that each can be examined.
Readiness is assessed by walking through the unit at different times of day with the list in hand. The questions are concrete. How many hours of electricity are lost in an ordinary week, and is there a backup? Is oxygen supplied by concentrator, cylinder or pipeline, and can its concentration be reduced? How many pulse oximeters with neonatal probes work today? How many nurses are on duty at night, and for how many infants? Which sizes of nasal prongs are in stock, and who orders them? How long does a transfer to the referral hospital take, and what support can be given on the way? The answers define the limits within which the protocol must operate.
Each line of the source protocol is then placed in one of three groups: kept as written, rewritten to achieve the same purpose by other means, or removed with a matching restriction on eligibility. Table 1 sets out the elements that most often fall into the second group. The principle throughout is that the adapted instruction must be something a nurse working alone at night can carry out.
Elements of a bubble CPAP protocol that commonly need adaptation for a district newborn unit
| Element | Assumption in the source protocol | Adaptation to consider |
|---|---|---|
| Eligibility | Gestation and radiograph define the diagnosis | Weight band plus a bedside respiratory severity score |
| Gas source | Blended air and oxygen at any concentration | Document what the device delivers; titrate to oximetry |
| Monitoring | Continuous oximetry for every infant | Scheduled observations with shared oximeter; fixed observation chart |
| Nasal interface | Full range of prong sizes always available | Stock list with reorder level; nasal inspection at every observation |
| Failure | Blood gas criteria; ventilation on site | Clinical criteria; early call to referral hospital |
| Weaning | Stepwise reduction guided by blood gases | Clinical stability over a set period, then trial off |
| Family | Parents visit at fixed hours | Mother present; feeding and skin-to-skin contact planned |
Eligibility is the element with the greatest consequences. Referral-centre protocols define candidates by gestational age and radiographic findings. A district unit often knows neither with confidence. A weight band and a bedside score are workable substitutes: the retraction score of Silverman and Andersen (1956) and the clinical score of Downes et al. (1970) were both designed to grade neonatal respiratory distress by observation. The group must also state who is not treated in the unit. Infants who are apnoeic or gasping, those with major congenital anomalies of the airway or gut, and those below a weight at which the unit has no realistic prospect of success are examples for discussion, and the lower limit should be agreed with the referral hospital.
The oxygen source needs explicit attention. Preterm infants are vulnerable to oxygen toxicity, and retinopathy of prematurity is a recognised consequence of unrestricted oxygen. Some low-cost and improvised systems deliver whatever concentration the concentrator or cylinder supplies, while others entrain room air. The protocol should record what the unit's device does, require pulse oximetry whenever supplemental oxygen is given, and state the saturation range to be maintained according to national guidance (WHO, 2016). If oxygen concentration cannot be reduced and oximetry is not available, that is a reason to limit eligibility and not a detail to be passed over.
Starting pressure and its upper limit are normally kept as in the source protocol, which will usually begin at about 5 cm H2O and allow modest increases. What changes is the instruction for checking that the pressure is delivered: continuous bubbling, a water level topped up to the mark, prongs that fit the nostrils without blanching the skin, and a closed mouth or chin support. Nursing care is written as a short bundle performed at each observation. It includes inspection of the nasal septum, because pressure injury from prongs is common and largely preventable (Fischer et al., 2010), an open orogastric tube to vent the stomach, attention to humidification, and positioning.
Failure and referral complete the adapted protocol. Without blood gases, failure has to be defined clinically: rising respiratory score, saturation that cannot be held in range, recurrent apnoea, or exhaustion. The protocol should name the point at which the referral hospital is telephoned, and that point should come before the infant is in extremis, because transfer takes time and an infant on CPAP is difficult to move. Pneumothorax is a known complication of CPAP (Ho et al., 2020) and the protocol should say what the unit will do if sudden deterioration suggests it.
The draft is tested first on a manikin. Each nurse and clinician assembles the circuit, selects and fixes prongs, starts treatment, completes the observation chart and responds to scripted problems: the bubbling stops, the saturation falls, the power fails. Simulation exposes instructions that are ambiguous or cannot be followed with the equipment as stored, and the draft is corrected. Implementation reports describe turnover and rotation of trained staff as a persistent threat to competence (Kinshella et al., 2020), so the plan should include new staff and periodic refreshers.
The protocol is introduced for a defined period with a register that records, for every infant started on CPAP, the weight, the respiratory score at the start, whether oximetry was used, the duration of treatment, nasal injury, suspected pneumothorax, the outcome and whether the protocol was followed at each decision point. The register serves safety and learning. It is not a research dataset, and it should be short enough to be completed.
At the end of the pilot the group reviews the register and the experience of staff and mothers. Departures from the protocol are treated as information about the protocol before they are treated as failings of individuals. Small changes are made and tested in turn, in the manner of the plan-do-study-act cycle used in quality improvement (Langley et al., 2009). The revised document is dated, shared with the referral hospital and scheduled for review.