In low resource-countries, the mortality of critically-ill children remains high. Severe pneumonia remains one of the leading causes of death. Malaria and intercurrent bacteraemia adversly affects survival in this setting. Low cost bubble continuous positive airway pressure (bCPAP) set-ups are used in some reference centres in sub-Saharan Africa. More evidence for use beyond the neonatal period is needed. We evaluated the role of bCPAP for the care of critically-ill children in Lilongwe, Malawi.

This observational study was conducted between 26 February-15 April 2014, in a busy, urban paediatric unit with >20,000 admissions/year (in-hospital mortality ~ 3%). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. The inclusion criteria was a convenience sample of non-neonates initiated on bCPAP at the discretion of a clinician. BCPAP failure was defined as; death during bCPAP treatment, within 48 h of bCPAP weaning, or escalation to intubation. Ethical approval was from the Malawi National Health-Sciences Research-Committee.

116 children with symptoms of WHO defined very severe pneumonia (VSPNA) were included. Median age: 8 months. Median duration of bCPAP treatment: 2.5 days. Malaria rapid-tests were positive in 36 (31%) cases. 34 (29%) had severe anaemia (Hb <7.0 g/dL). 58 (50%) children had > 1 organ-failure (MOF). 23 (20%) children were HIV-positive/exposed. 24 (21%) were malnourished. The over-all survival was 74/116 (64%). 33/34 (97%) with signs of uncomplicated VSPNA survived and HIV infection/exposure did appear to affect survival in this group. Treatment failure rates rose with the presence of respiratory depression, MOF or signs of shock (delayed capillary refill time etc.)

The higher survival rates among children with uncomplicated VSPNA indicates that bCPAP could be used in resource-limited, malaria-endemic settings with a high HIV prevalence. This is important to explore, as Malawi has been reported as doing well to reduce under 5 mortality. This success has been attributed to following and implementing new evidence based interventions and policies. The time may have come when critical care skills and technologies from developed settings can be used to benefit those suffering the inordinate burden of disease in the developing world.