Article Text

Evaluation of ‘TRY’: an algorithm for neonatal continuous positive airways pressure in low-income settings
  1. Caroline Crehan1,
  2. Tim Colbourn1,
  3. Michelle Heys1,2,
  4. Elizabeth Molyneux3
  1. 1Institute of Global Health, University College London, London, UK
  2. 2Great Ormond Street Institute of Child Health, University College London, London, UK
  3. 3Paediatric Department, College of Medicine, Blantyre, Malawi
  1. Correspondence to Dr Caroline Crehan, Institute of Global Health, University College London, London WC1N 1EH, UK; carolinecrehan{at}


Background Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm—‘TRY’ (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)—has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi.

Objective To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital.

Methods Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses’ assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician’s clinical decision.

Results Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively.

Conclusions District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation.

  • continuous positive airways pressure
  • infant
  • newborn
  • algorithms
  • developing countries
  • respiratory
  • sensitivity and specificity
  • malawi

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  • Contributors CC helped conceptualise and design the study, and carried out all field work, data collection, statistical analysis and write-up. TC was UK supervisor based at UCL who assisted in statistical analysis, critical review and editing of manuscript. MH provided further advice, critical review and editing of manuscript. EM supervised all aspects of the project in Malawi, overseeing fieldwork, data collection, data analysis and write-up, including initial conceptualisation of the study design.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent This project was an audit within a programme to roll out CPAP, which is approved by NHSRC. Guardians and staff were fully informed and gave verbal permission.

  • Ethics approval Ethical approval was obtained from both the Malawi College of Medicine and University College of London ethics committees (UK).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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