RT obtains industry insights on bubble CPAP administration and how technology and best practices are helping to ensure more babies stay successfully on noninvasive support.
Bubble CPAP is designed to provide a safe, protective, and effective method of respiratory support to spontaneously breathing neonates. New developments in bubble CPAP technology enable respiratory therapists to consistently deliver vital care to newborn children and infants.
In this industry Q&A, RT speaks with manufacturers on the state of bubble CPAP technology and how RTs can safely and successfully implement technology. Participating in this month’s discussion are:
Erika Ingbretson, Cert. AT, Sr. Marketing Manager, Respiratory Consumables, Dräger Inc.
Robert Landis, BS, RRT, Co-founder, Director of R&D, DRW Medical Inc.
RT: What’s new with bubble CPAP? Have innovations in bCPAP systems improved clinical outcomes in neonatal populations?
Erika Ingbretson (Dräger): Innovation in bCPAP is happening on two fronts: technology and practice. On the technology side, the Dräger Bubble (Seattle PAP Plus) uses a patented 135o angled submersed tube designed to help reduce the work of breathing, thereby potentially helping to prevent therapy failure from respiratory muscle fatigue.1 Safety and usability improvements such as a self-sealing expiratory water trap, locking CPAP probe, and longer circuits for kangaroo care may further help strengthen therapy delivery.2
At the same time, clinical practice has evolved. Starting bCPAP earlier in the delivery room, combining it with less-invasive surfactant (LISA/MIST), applying automated oxygen control, and using gentler interfaces have been associated with reduced intubations, improve safety, and make CPAP more sustainable for fragile neonates.3-5 Together, technology and practice innovations are helping to ensure more babies stay successfully on noninvasive support.
Robert Landis (DRW Medical): What’s new with bCPAP is that many RTs are using pressure monitors with high/low airway pressure alarms. This has the advantage of alerting us of interface dislodgment before a de-sat or bradycardia alarm. This practice is saving countless amounts of hypoxic events allowing the patient to grow and thrive. It also alerts us when rain-out in the exhalation tubing adds pressure to the CPAP.
RT: What evidence supports the role of bCPAP in reducing the need for ventilation, and how are newer technologies reinforcing that trend?
Ingbretson: There are multiple studies that show the use of bCPAP may help lower oxygen requirements and reduce respiratory decompensation which reduces the need for mechanical ventilation6. This can, in turn, help reduce the incidence of chronic lung disease and decrease the length of NICU stays.6
Respiratory muscle exhaustion is often identified as a major cause of failure in conventional CPAP therapy.7 It occurs in half of babies receiving this therapy and often necessitates endotracheal intubation and mechanical ventilation, both of which carry the risk of tissue damage and inflammation.6
Dräger partnered with leading specialists in the field to help improve the science and technology of bubble CPAP therapy. The goal was to create a bubble CPAP solution that could lessen the load on respiratory muscles, help reduce the chances of CPAP therapy failure due to respiratory muscle exhaustion and help infants with respiratory distress syndrome breathe more easily. To lessen the load on respiratory muscles, Dräger designed Dräger Bubble – Seattle PAP Plus to enhance bubble CPAP therapy and provide an improved option for respiratory support.
RT: What are the most common complications associated with bCPAP, and how can they be mitigated through design or protocol enhancements?
Ingbretson: One common complication associated with bCPAP is unintended changes in CPAP pressure. Such changes can be harmful to the patient and potentially increase the chance of therapy failure. These unintended changes are commonly caused by:
Accidental movement or adjustment of the CPAP probe. This is common with the traditional design of the CPAP probe on the bubble box as it lacks any built-in safeguards to prevent accidental adjustment/movement.
Too much condensate trapped in the expiratory limb of the breathing circuit.
To help mitigate these risks, Dräger’s bubble CPAP offers a solution with a locking CPAP probe designed to help prevent any accidental changes to CPAP pressure. In addition, Dräger’s bubble CPAP features a self-sealing expiratory water trap integrated within the breathing system to help minimize the risk of pressure spikes resulting from condensate.
Landis: The most common complication is the breakdown of nasal tissue. This can be mitigated somewhat by making sure the interface is fitted without restricting tissue perfusion. It is better to error on the loose side rather than fitting too tight.
RT: Compared to other types of respiratory support, bCPAP is generally considered inexpensive. Are product advancements inflating costs or can the industry make improvements while maintaining affordability?
Ingbretson: There isn’t necessarily a correlative relationship between product advancement and cost inflation. Dräger’s Bubble CPAP is an innovative product with enhanced safety features and is offered at a price point considered to be cost-effective.
Landis: Product advancements may appear to inflate costs, but it is more likely due to the rising costs of medical device regulations and gaining access to hospital procurement systems. The small market size for the bCPAP makes it challenging for innovation. Expect bCPAP product advancements to come from smart clinicians who are brave and passionate about improving patient care.
RT: Tell us about your bubble CPAP system. What are some of the features and advantages it offers?
Ingbretson: As a global leader in neonatal and pediatric ventilation, Dräger partnered with leading specialists in the field to improve the science and technology of bubble CPAP therapy. The goal was to create a bubble CPAP solution that could lessen the load on respiratory muscles, minimize the chances of CPAP therapy failure due to respiratory muscle exhaustion, and help infants with respiratory distress syndrome breathe easier.
To lessen the load on respiratory muscles, Dräger designed the Dräger Bubble – Seattle PAP Plus to enhance bubble CPAP therapy and provide an improved option for respiratory support. (See Table 1.)
Table 1. Features & Benefits of Drager Bubble
| Dräger Bubble Features | Dräger Bubble Benefits |
|---|---|
| CPAP probe locks in place | • Helps prevent unwanted pressure spikes that can occur in systems without built-in safeguards—a benefit because unintended changes in CPAP pressure can harm the patient and increase the risk of therapy failure |
| Proprietary 135° angle in the submersed tubing | • Increases the amplitude of oscillations • Provides effects similar to high frequency oscillatory ventilation • Proven to reduce the patient’s work of breathing |
| Long and flexible circuits | • Helps reduce the risk of accidental disconnection from patient during transition / transport and parental kangaroo / skin-to-skin care |
| Self-sealing expiratory water trap | • Mitigates risk of pressure spikes resulting from condensate in tubes – a common issue with tubes lacking attached expiratory valves that, if not constantly monitored, increases the chance of therapy failure |
| 24/7 technical / clinical support | • Gives customers 24/7 live access to clinicians familiar with Dräger Bubble who can help troubleshoot situations |
RT: How does interface selection and fit impact the efficacy and safety of bCPAP in NICU infants? What advancements have interfaces seen in recent years?
Ingbretson: Interface choice and fit can directly affect delivered pressure, tolerance, and skin integrity. A noninvasive respiratory support system can be designed to help maximize performance and patient comfort.
The Dräger BabyFlow Plus respiratory support system was designed using state-of-the-art technology (Computational Flow Analysis) to help reduce the imposed work of breathing for the patient. Every single component, including individually sized masks and nasal prongs, have been designed with the goal of supporting optimal performance and patient comfort. In addition, the streamlined adapter head is intended to enhance flow distribution.
We want your patients to feel comfortable. The less discomfort a patient experiences, the greater the opportunity the patient may have for healthy growth and development during this critical time in the patient’s recovery.
The adjustable angle on the BabyFlow Plus interface enables you to fit the prongs and masks properly on the patient, thus helping to reduce leaks and provide more stable CPAP levels. More stable CPAP levels can reduce noise levels, making BabyFlow plus a low noise level respiratory support system, therefore, supporting Developmental Care practices and offering excellent therapy for tiny patients. The flexible, kink resistant hoses help enable suitable positioning of the patient. Swivel connectors can help minimize unnecessary disconnections of the breathing circuit, thereby helping to ensure stable CPAP pressures.
Landis: Interface selection is often driven by patient comfort and tissue damage avoidance rather that bCPAP efficacy. For example, choosing a high flow RAM cannula for comfort and adding an underwater bubbler is not bCPAP. With this setup, the depth of the tube bubbling under water is not the pressure in the patient’s airway, which is unknown. Patients exhale around high flow cannula not into them. Bubble CPAP is defined by having the nasal cannula fitted sealingly into the nares requiring the patient to inhale from the cannula and exhale back through the cannula against the depth of water in the bubbler to generate the CPAP. Interfaces will continue to be refined, since avoiding tissue breakdown is a primary goal.
RT: What other advancements in technology, or expanded clinical indications, do you foresee in the next five years and beyond? (If any)
Ingbretson: As part of Dräger’s commitment to enhance patient outcomes while reducing overall care costs, Dräger sees this as an opportunity to investigate patient-ventilator synchrony to help enhance noninvasive modalities, advance safety measures to minimize human error, as well as improve workflow processes to accommodate the varying clinical demands of these tiny patients.
Landis: The next advancement is using upper airway pressures to manage high flow therapy. After that we are looking at noninvasive tidal volume for bCPAP and high-flow therapy.
RT
For more information, contact [email protected]
References
- Kamlin CO, et al. Bubble CPAP with Seattle-PAP vs conventional bubble CPAP: a multicenter randomized controlled trial. Journal of Pediatrics. 2023;254:62-69.e2. doi:10.1016/j.jpeds.2022.11.035
- Draeger, Inc. Seattle PAP: Product Overview and Technical Features. Lübeck, Germany: Draeger Medical Systems; 2022.
- DeMauro SB, et al. Impact of delivery room continuous positive airway pressure on outcomes in extremely preterm infants. Journal of Pediatrics. 2013;163(1):144-149.e1. doi:10.1016/j.jpeds.2012.12.017
- Aldana-Aguirre JC, et al. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2017;102(1):F17-F23. doi:10.1136/archdischild-2015-309216
- Claure N, et al. Automated adjustment of inspired oxygen in preterm infants with frequent episodes of hypoxemia. J Pediatr. 2011;159(4):512-518.e1. doi:10.1016/j.jpeds.2011.04.011
- Sujakhu E, et al. Bubble CPAP in Infants. [Updated 2025 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK613282/
- Welty S, et al. Short term evaluation of respiratory effort by premature infants supported with bubble nasal continuous airway pressure using Seattle-PAP and a standard bubble device. Plos One. 2018 Mar 28. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193807.
