Disclosure(s): No relevant financial relationship(s) to disclose.
First Author: Nadir Ijaz, MD, MHS – Instructor, Department of Pediatrics (Critical Care Medicine), Yale School of Medicine Co-Author: Perah Bachal, MBBS – Research Associate, Paediatrics and Child Health, Aga Khan University Co-Author: Sadaqat Ali, MSN, BSN, DCN – PhD Scholar, School of Nursing and Midwifery, Aga Khan University Co-Author: Haania Rizwan, MBBS Co-Author: Hajra Malik, MBBS – Pediatrics Resident, Pediatrics Institute at Cleveland Clinic Foundation Co-Author: Noor Ul Ain, MBBS, FCPS – Senior Instructor, Emergency Medicine, Aga Khan University Co-Author: Zareen Qasmi, MBBS, FCPS – Senior Clinical Instructor, ChildLife Foundation, Karachi, Pakistan Co-Author: Sana Samreen, MBBS, FCPS – Senior Clinical Instructor, ChildLife Foundation, Karachi, Pakistan Co-Author: Ibrahim Shakoor, MBBS, FCPS – Professor and Head, Department of Pediatrics, Abbasi Shaheed Hospital, Karachi, Pakistan Co-Author: Nathan Wright, MA – Research Associate, Yale University School of Nursing Co-Author: Deena Costa, PhD, RN – Associate Professor, Yale University School of Nursing Co-Author: J. Lucian Davis, MD, MAS – Associate Professor, Epidemiology of Microbial Diseases, Yale School of Public Health Co-Author: Fyezah Jehan, MBBS, FCPS, MPH – Professor, Paediatrics and Child Health, Aga Khan University Co-Author: Qalab Abbas, Physician – Aga Khan University
Introduction: Bubble continuous positive airway pressure (bCPAP) is a low-cost respiratory support device that has demonstrated different outcomes for children with severe pneumonia in different settings. We previously developed an implementation theory describing how these differences may be partially attributable to variable clinical team availability, workload, and communication, and we proposed familial caregiver education and participation in bCPAP care as a potential strategy to improve outcomes. To evaluate the acceptability and feasibility of this strategy, we sought to assess the knowledge, attitudes, and practices of caregivers of children receiving bCPAP therapy in Pakistan.
Methods: We conducted semi-structured qualitative interviews employing a phenomenological approach at three tertiary care hospitals (one private and two public) in Karachi, Pakistan, from November 2024 through May 2025. We included familial caregivers present at the bedside of children aged 1-59 months who were either receiving or had received bCPAP within the preceding 24 hours. Interviews were audio recorded, and two bilingual analysts independently conducted inductive thematic analysis.
Results: We interviewed 29 caregivers, including 22 (75.9%) mothers, 4 (13.8%) fathers, and 3 (10.3%) other relatives. We conducted 19 (65.5%) interviews in emergency department and 10 (34.5%) in inpatient settings; interview durations ranged from 8 to 29 minutes. Caregivers had limited knowledge of bCPAP or oxygen therapy; those with more knowledge based their understanding on past family health-related experiences. Caregivers expressed deference to the medical team, fear about asking questions of doctors, dissatisfaction with staffing in some settings, and anxiety about their child’s condition that resolved with clinical improvement. Many caregivers replaced dislodged nasal interfaces and alerted nurses about bCPAP water reservoirs needing to be refilled, informed by informal observation of nursing practices. Most caregivers stated they would participate in bCPAP training if available; few felt they were too anxious about their child’s illness to do so.
Conclusions: Despite limited knowledge and training, caregivers already participate in bCPAP care. bCPAP implementation strategies that include caregivers may be acceptable and feasible.
