Seattle, Nalgenes and CPAP

I'm back in Winston now after a pretty long trip a week and a half ago that started out in Fort Portal on a Thursday morning around 8AM and ended in Winston on Friday night around 9PM with some extended layover time in Entebbe (where I filled my time by swimming at the Lake Victoria pool and jumping off their 30 ft high dive along with a quick visit to the zoo) and in London-Heathrow (occupying my time by staring bleary-eyed out the airport windows, reading Wind, Sand and Stars and finally giving in and lying down on two chairs). Now it's back to life in the South and almost excessively hot weather already despite only being the middle of March.                                          Picture taken with permission of the mother

After the last post which was pretty heavy, I figure I ought to post a more uplifting post about things I saw in Kiwoko to help balance things out a bit. My last two days at the hospital were spent in the NICU which has the capacity to care for around 30 infants or so. It's actually a pretty modern unit with incubators for all the neonates thanks to support from the ISIS Foundation in Seattle. I hadn't spent much time in the NICU at Wake so it was good to get some exams of these really small babies under my belt. The babies ranged pretty broadly in their acuity and prematurity with the really small ones checking in at under 1 kg and hanging somewhat precariously to life while the ones on the other end of the spectrum were basically hanging out and eating and adding weight every day while they waited to hit the minimum weight needed to be discharged.

There were 22 babies there the first day I was there so examining and writing up the plans along with Jill who was the physician in charge took a while. About the time we had 3 or 4 babies remaining to see, a baby in respiratory distress who had just been born was brought in from Maternity. The baby wasn't particularly premature but had clear signs of respiratory distress (fast rate of breathing, increased work of breathing, nasal flaring, intercostal retractions, supraclavicular retractions). Initially we bulb suctioned his mouth and nose and got a O2 monitor on him which showed sats in the 70's if I remember right (normal would probably be >93% at Kiwoko's altitude.)

He didn't show much improvement so Jill broke out the CPAP (continuous positive air pressure) machine which had just been given to the hospital by the ISIS folks and had only been used once before. It had been developed by some people in the US I believe as a low cost alternative to expensive CPAP machines found in the West. CPAP is designed to help open up and keep open the alveoli that can be collapsed in these little babies. It basically consisted of a Y valve that split the flow from the O2 concentrator and one side went into a 1L Nalgene bottle filled with water and the other side went into the nasal cannula in the baby's nose. The pressure that the baby received was regulated by how deep the tubing was lowered into the water in the Nalgene which had markings that indicated the relation of the depth to the air pressure the infant received. Once the back pressure in the nasal cannula exceeded the marked water pressure, the excess air would flow into the Nalgene and bubble out which operated essentially as a pressure release valve and helped maintain a constant pressure. If more pressure was needed the tubing could be lowered farther down into the water and vice versa.

After only a few minutes of CPAP the baby showed marked improvement, began breathing much more comfortably and had much better O2 saturation. We finished our rounds and went to lunch and when we checked back in after a couple hours he was doing so good that we were able to take him completely off CPAP and off oxygen and he did fine.

It was great to see how such a simple adaptation for the third world could make such a big difference and get the baby over that critical hump in the first few hours of his life. So big props to ISIS and Seattle and the people who designed that basic Nalgene CPAP machine. The one part of the equation that wasn't cheap was the O2 concentrators which are quite spendy and which many poor hospital wouldn't necessarily have. Since this NICU was well supplied, there were a number of them available to use and we actually had to use two in tandem to get the desired pressure. However I just read about a CPAP that uses aquarium pumps that are much cheaper and may be a more affordable solution for many of the third world hospitals out there. http://www.nytimes.com/2011/09/27/health/27breathe.html