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Discrepancy in the physical dimensions of nose and continuous positive

airway pressure (CPAP) interface: a possible reason for high rates of nasal
injury in Indian neonates

Article  in  BMJ Innovations · September 2020

DOI: 10.1136/bmjinnov-2019-000372

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ORIGINAL RESEARCH

Discrepancy in the physical dimensions

of nose and continuous positive airway
pressure (CPAP) interface: a possible
reason for high rates of nasal injury in
Indian neonates
Jagjit Singh Dalal ‍ ‍ ,1,2 Sanketh Kumar Ajmera,3 Kanika Prajapat,3
Tanushree Sahoo,1 Chander Prakash Yadav,4 P V Madhusudhan Rao,3
Alok Thakar,1 Anu Thukral,1 Mari Jeeva Sankar,1 Ashok Kumar Deorari,1
Ramesh Agarwal1

►► Supplemental material is ABSTRACT resulting in possible erosion of columella and

published online only. To view, distension of nostrils.
Background  Properly fitting continuous positive
please visit the journal online
(http://​dx.​doi.o​ rg/​10.​1136/​ airway pressure (CPAP) interface is critical to

bmjinnov-​2019-​000372).
1 preterm. Unfortunately, there is a perception that
All India Institute of Medical
Sciences, New Delhi, India
2
Pt B D Sharma Post Graduate
Institute of Medical Sciences,
Rohtak, Haryana, India
3
Indian Institute of Technology,
New Delhi, India
4
National Institute of Malaria
Research, New Delhi, India
Correspondence to
Professor Ramesh Agarwal,
All India Institute of Medical
Sciences, New Delhi, India; ​ra.​
aiims@​gmail.​com
Received 3 July 2019
Revised 19 August 2019
Accepted 12 August 2020
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Dalal JS, Ajmera SK,
Prajapat K, et al. BMJ
Innov Epub ahead of
print: [please include Day
Month Year]. doi:10.1136/
bmjinnov-2019-000372
the efficacy and safety of nasal CPAP therapy in
CPAP interfaces being used in Indian neonatal
intensive care units do not fit well and cause a
high rate of nasal injury.
Objectives  To determine the nasal
anthropometric dimensions in preterm (<35
weeks) Indian neonates and compare them with
those of commercially available CPAP interfaces.
Methods  In this cross-­sectional study, relevant
anterior nasal parameters were measured
by three dimensional imaging in 32 preterm
newborn (26+0–34+6 weeks) and compared
with commercially available 17 short binasal
CPAP prongs of multiple sizes made by five
manufacturers. Dimensions for best-­suited
interfaces were generated for Indian neonates.
Results  The mean (SD) gestation and birth
weight of enrolled neonates were 30.6 (3.0)
weeks and 1338 (575) g, respectively. The inter
prong distance was narrower than the upper
bound of the 95% CI of the columellar width in
Hudson type CPAP interfaces in <1250 g weight
category with discrepancy in measurement
varying from 0.2 to 0.5 mm and 0.9–1.4 mm at
midpoint and base of columella, respectively.
Similarly, the lower bound of 95% CI of the
distance between the lateral walls of the nostrils
was narrower than the width of the prongs by
1–3 mm.
Conclusions  There is mismatch between nasal
prongs and nose dimension of Indian neonates
Protected by copyright.
INTRODUCTION
Continuous positive airway pressure
(CPAP) provides constant distending
pressure to a spontaneously breathing
preterm neonate for the alleviation of
mild to moderate respiratory distress due
to a variety of diseases. The optimum use
of CPAP reduces the need for exogenous
surfactant administration, need for inva-
sive ventilation and mortality by half in
preterm neonates.1 Also, it reduces the
need for upward referral by 50% for
advanced respiratory support in neonates
managed at level-2 facilities.2 Given that
CPAP therapy requires much lesser cost
and nursing skills and time than invasive
ventilation, it has emerged as the major
form of respiratory support modality in
low/middle-­ income countries (LMICs).
Accordingly, LMICs have made signifi-
cant investments for scaling up of CPAP
therapy in their level-2 and level-3 centres
in recent years.
CPAP therapy is based on the simple
concept. It involves delivery of heated
and humidified air–oxygen mixture at a
constant pressure of 3–10 cm of water at
the patient end. The CPAP can be gener-
ated using several machines that vary
from a proper ventilator to a simple
bubble CPAP (online supplemental

  
Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372 1
MEDICAL DEVICES
figure 1). The CPAP pressure is delivered to the
patient using a nasal interface (ie, most commonly
by short binasal prongs) that fit in neonate’s nostrils.
Despite the simplicity of design and ease of use, the
CPAP is associated with significant nasal injury in a
large proportion of neonates. In developed nations,
the incidence of nasal injury has been reported
to vary from 20% to 60% with 10%–30% being
moderate to severe.3–6 The incidence and severity
of this injury is higher in lower gestation neonates
and with prolonged use. The nasal injury is asso-
ciated with significant pain, bleeding, crusting and
healthcare-­associated infection and is perceived to
be a major hindrance in its wide-­scale use.
The problem of nasal injury with CPAP use is much
worse in Indian (and other LMICs) neonates than
their Caucasian counterparts in developed nations.
The reported incidence in Indian neonates is 2–3
times higher (60%–80%) with one-­third of them being
moderate to severe in nature (17%–31%) compared
with their Caucasian counterparts.7–9 The high inci-
dence of nasal injury in LMICs is likely due to multiple
factors including low nurse–patient ratio, suboptimal
nursing skills, malnutrition of the neonate, humidifica-
tion issues and the design of the nasal interface. While
the clinicians and policymakers try to address other
issues, the one related to CPAP interface design has
largely remained unaddressed despite being critical to
the pathogenesis of the nasal injury.
The commonly available short binasal prongs in
Indian markets (Argyle (Covidien Healthcare, USA)
and Hudson type (manufactured by four firms: (a)
Phoenix Medical System, India, (b) Hudson Respira-
tory Care, USA, (c) GaleMed, Taiwan and (d) Respi-
care Solutions, Great Group Medical Co, Taiwan))
have been designed using nasal anatomical measure-
ment of Caucasian neonates.10 There are fundamental
differences between the nasal dimensions of Indian
and Caucasian neonates, for example, the columella
(middle septum of the nose) is thicker in former.11
Consequently, the space provided between two prongs
of these nasal interfaces is lesser for the thickness of
columella causing its impingement and erosion—the
most common type of injury.12–14
Despite these concerns, there is no systematic inves-
tigation assessing the appropriateness of the design of
commonly available CPAP interfaces with the anatom-
ical nostril dimensions of Indian neonates. In this
study, we systematically measured nostril dimensions
of Indian neonates and tried to determine if the design
of the currently available CPAP interfaces is appro-
priate for them.
METHODS AND MATERIAL
This cross-­sectional study was conducted between
June 2015 and December 2015 at the Division of
Neonatology, Department of Paediatrics, All India
Institute of Medical Sciences (AIIMS), New Delhi in
2 Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372
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collaboration with Indian Institute of Technology,
Delhi. The study was approved by the institutional
ethics committee of AIIMS, New Delhi. In this study,
we aimed at comparing nostril dimensions of preterm
Indian neonates with the relevant dimensions of the
commonly available CPAP nasal prongs.
Measurement of nostril dimensions
Participant recruitment
Preterm neonates of 26+0–34+6 weeks of gestation
were enrolled after written informed consent from
one of the parents. We excluded neonates with major
congenital malformation affecting the nose, cleft of
lip and palate, dysmorphic facies or suspected genetic
syndromes.
Imaging procedure
We performed photography of the mid-­facial structures
of enrolled neonates from different directions using a
three-­dimensional (3D) camera with blue light (ATOS
Core 5M Multiple distributors with APM technology,
GOM mbh, Braunschweig, Germany). The procedure
was carried out when the neonates did not require any
nasal respiratory support. We did not use any sedation
and carried out the procedure under strict asepsis and
1 hour post-­feeding when neonates were calm. It took
approximately 30 min for imaging a neonate.
Protected by copyright.
Analysis of the images
Some basic assumptions in measurement process for
our study were: every neonate’s face is symmetrical
about a plane that divides the face into an enantio-
meric pair which has a total 12 df (degree of freedom):
six translational and six rotational. By setting two
mutually perpendicular planes passing through the
line connecting the outer most point of the nose the
df can be restricted to 4. Further, one of these two
planes is set parallel to the philtrum, which constricted
the remaining two rotational df. Finally, these three
mutually perpendicular planes acted as a coordinated
system for all facial measurements (online supple-
mental figure 2).
The raw images consisted of surface mesh recon-
structed from 3D scanning of baby facies. From the
raw digital images, we selected images that depicted
complete mesh with clearly identifiable three coordi-
nates of important facial landmarks. The images with
incomplete meshes or indistinct coordinates were
discarded. Using the optimum quality of digital images
(online supplemental figures 3–5), we extracted X, Y
and Z coordinates of the important facial landmarks
and measured nasal and other relevant facial dimen-
sions with the help of Rhinoceros V.5.0 software
(Robert McNeel & Associates, North America, Seattle,
USA). All the parameters were measured with the
precision of 0.01 mm.
Measurement of anterior nasal parameters
We measured the following structures of the colu-
mella: width at upper, mid and lower point (base)
 MEDICAL DEVICES

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Protected by copyright.
Figure 1  Various dimensions of nose and CPAP prongs, (A) a: horizontal diameter, b: vertical diameter, c: diameter of major (long)
axis, d: diameter of minor (short) axis, e: cross-­sectional area of nostril, f: circumference of nostril opening, g: nose width, h: nose
height. (B) i: columella width upper point, j: midpoint, k: lower point (base), l: wider lower point, m: distance between lateral walls of
the nostrils at midpoint of columella. (C) columella philtrum angle, (D) width of the prongs (distance between outer wall of the two
prongs) and (E) distance between inner wall of the prongs (inter-­prong distance). CPAP, continuous positive airway pressure.

and at lower wider point (figure 1, online supple-
mental figure 3), height and its angle with philtrum.
The other structures of the nose measured were:
horizontal and vertical diameters, major and minor
axes, cross-­sectional area, circumference and rota-
tion of nostrils (angle between major axis and hori-
zontal diameter) (online supplemental figure 4) and
angulations of anterior nares and columella (angle
between philtrum and axis of nostril aperture, angle
of frustum and angle of columella with lateral ala of
nostril) (online supplemental figure 5). The defini-
tion of each parameter as well as graphical measure-
ment of each dimension has been provided in online
supplemental table 1.
(for weight categories of <700 g, 700–1249 g, 1250–
1999 g and 2000–3000 g) while Argyle prongs have
three sizes (<1000 g, 1000–1500 g and >1500 g). We
measured two dimensions of these nasal interfaces:
‘width of the prongs’ (distance between outer walls
of the prongs, figure 1D) and ‘inter-­prong distance’
(distance between two nasal prongs, figure 1E).
Commercially available 17 short binasal CPAP prongs
of multiple sizes made by five manufacturers were
measured. The short binasal prong measurements
were taken using a Vernier Calliper with precision of
0.01 mm. We also assessed the physical properties of
the interfaces namely the degree of softness, transpar-
ency and whether the margins were rounded or sharp.

Measurement of dimensions of CPAP interfaces
Two types of CPAP short binasal prongs are commer-
cially available in Indian market: (1) Argyle prongs
(Covidien Healthcare, USA) and (2) Hudson type
prongs manufactured by four firms ((a) Phoenix nasal
prongs by Phoenix Medical System, India, (b) Hudson
prongs by Hudson Respiratory Care, USA, (c) Baby
Plus by GaleMed, Taiwan and (d) Respicare prongs
by Respicare Solutions, Great Group Medical Co,
Taiwan). They are of different sizes meant for different
weight categories. Hudson type prongs have four sizes
Comparison of dimensions of CPAP interfaces with nasal
structures’ dimensions
The following comparisons were done: (1) columella
width at the midpoint as well at its base versus inter-­
prong distance and (2) the actual distance between
lateral walls of two nostrils at the level of midpoint of
columella versus width of the prongs.
Quality control
Two independent observers took different measure-
ments and average of the two was finally taken. A third

Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372 3

 MEDICAL DEVICES
observer rechecked the measurements if there was a
discrepancy between or unreliable measurements (too
high or too low). The observers were blinded to the
weight and gestation of neonates.
Sample size
From a previous study by Ghosh et al15 in healthy
term neonates reported mean width of columella as
0.25 cm with SD of 0.1, precision of 0.02 and CI of
90% calculated sample size was 11. But because of
limited feasibility, we planned to take five neonates
in each gestation group (26–27 weeks, 28–29 weeks,
30–31 weeks, 32–33 weeks, 34 weeks gestation group)
for uniformity of the data and finally enrolled 36
neonates. Each neonate was enrolled only once in our
study.
Statistical analysis
Statistical analysis was carried out using Stata V.11.2
(Stata Corp). Categorical variables between the
groups were compared by χ2 or Fisher Exact Test.
Continuous variable was compared by Student’s t-­test
(if normally distributed) or Wilcoxson rank-­sum test
(if skewed).
RESULTS
Of 37 neonates approached, 36 consented to partici-
pate in the study and 32 were successfully imaged. The
mean (SD) gestation and birth weight of the neonates
were 30.6 (3.0) weeks and 1338 (575) g, respectively
(table 1). Nearly half (n=17; 53.1%) were males and
one-­third of them were small for dates (n=11; 34.5%).
The median postnatal age at imaging was 8.0 (IQR
3.0–11.0) days.
Table 1  Baseline characteristics of the enrolled neonates
Variable n=32
Gestation (week), mean (SD)
Birth weight (g), mean (SD) 1338 (575)
Postnatal age* at the time of measurement, days,
median (IQR)
Time of measurement, n (%)
 <72  hours
 4–7  days
  8–14 days
 15–30 days
Weight for gestation
 Less than 10th centile, n (%)
 10th to 90th centile, n (%)
 More than 90th centile, n (%)
 Male gender, n (%)
Mode of delivery, n (%)
 Caesarean
 Vaginal
*Postnatal age is calculated by taking birth as zero point. The
postmenstrual age refers to gestation age at birth plus postnatal age.
4 Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372
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Physical dimensions of nose and other relevant mid-facial
structures
Columella
The columella was wider at the ends and narrower
at the middle giving it the shape of an hourglass. The
width at all points and height of columella progres-
sively increased with an increase in birth weight
(online supplemental table 2) and gestation (online
supplemental table 3). However, the magnitude of
difference in dimensions between weight categories of
<750 g and 750–999 g, and between 1000–1249 g and
1250–1499 g was not clinically substantial. The colu-
mella–philtrum angle was higher at lower birth weight
categories compared with that in higher birth weight
categories.
Nostrils
Nostril dimensions are depicted by birth weight (online
supplemental table 4) and gestation (online supple-
mental table 5) categories. The nostrils were oval with
an inclination towards upper end of the columella such
that the major axis of nostrils makes an angle of approx-
imately 40° with the horizontal axis of the nostrils.
The distance between lateral walls of the nostrils at the
midpoint of columella also increased with increase in
birth weight categories. Angulations of anterior nares
and columella relevant to prong design are provided
Protected by copyright.
as supplementary file (online supplemental table 6).
We also measured some other parameters relevant to
construction of appropriate nasal mask and facemask
(not included in current manuscript).
Dimensions of CPAP interfaces (short binasal prongs)
versus nostril dimensions
Inter-prong distance of CPAP interfaces versus columella width at
midpoint and lower point
The inter-­prong distance of CPAP interfaces (short
binasal prongs) of most of the five manufacturers did
not match that of columella width at midpoint or at
base of the neonates nose in different birth weight
30.6 (3.0) categories—being either less (in <1250 g weight cate-
gory) or more (in higher weight category) (table 2).
8.0 (3.0–11.0) The distance between upper bound of 95% CI of the
columellar width and inter-­prong distance varied from
0.2 to 0.5 mm and 0.9–1.4 mm at midpoint and base
9 (12.5) of columella, respectively. Nasal prongs during CPAP
8 (25.0) remain at midpoint or more commonly at the base of
11 (34.4) columella, hence lower point (base) dimensions were
4 (12.5) considered for inter-­prong distance while constructing
best fitting measurements from our study. Argyle
11 (34.5) prongs had better fit for the inter-­prong distance in
18 (56.2) different weight categories (table 2).
3 (9.4)
17 (53.3) Distance between lateral walls of the Nostrils versus maximum width of
the prongs
22 (68.7) The width of the prongs was greater than the distance
10 (31.3) between lateral wall of nostrils in Argyle prongs in all
weight categories and it was lower in rest four prongs
(Phoenix, Hudson, Baby Plus and Respicare) in lower
 MEDICAL DEVICES

BMJ Innov: first published as 10.1136/bmjinnov-2019-000372 on 16 September 2020. Downloaded from http://innovations.bmj.com/ on September 17, 2020 at India:BMJ-PG Sponsored.
Table 2  Comparison of columella width at midpoint and at its base versus inter-­prong distance of commonly available CPAP short
binasal prongs in India
Inter-­prong distance
Columella width at Columella width at its
Hudson type nasal prongs
Birth weight midpoint base
Size categories, g (mean (95% CI)) (mean (95% CI)) Phoenix Baby Plus Hudson Respicare
0 <700 1.99 (1.38 to 2.6) 2.67 (2.11 to 3.27) 2.41 1.97 – 2.17
1 700–1249 2.33 (2.08 to 2.58) 3.22 (2.92 to 3.51) 2.08 2.68 2.91 2.47
2 1250–1999 2.81 (2.48 to 3.14) 3.67 (3.34 to 3.99) 4.20 3.86 4.48 4.62
3 2000–3000 3.09 (2.58 to 3.6) 3.73 (3.23 to 4.24) 5.0 4.26 4.6 –
  Argyle nasal prongs
Extra small <1000 2.01 (1.92 to 2.11) 2.90 (2.64 to 3.15) 3.31
Small 1000–1500 2.65 (2.38 to 2.93) 3.50 (3.20 to 3.78) 3.74
Large >1500 3.01 (2.74 to 3.29) 3.76 (3.45 to 4.10) 4.48
All measurements are in mm.
CI, Confidence interval; CPAP, continuous positive airway pressure.

birth weight group (<700 g and 700–1249 g) sugges-
tive of mismatch to the size of nostril (table 3). The
difference between lower bound of 95% CI of the
distance between lateral wall of nostril and width of
the prongs varied from 1 to 3 mm.
We also studied the physical properties of available
interfaces and found that most of them have sharp
margin, angulations variability is very high and some
orifice was circular which is also not in co-­inside with
oval nostrils.
DISCUSSION
In our study, we measured the nasal dimensions rele-
vant to CPAP interfaces in preterm (<35 weeks) Indian
neonates using a novel 3D photogrammetry technique
and compared it with the dimensions of CPAP inter-

have prongs of equal length for all weight group babies
(Baby Plus prongs, Fisher and Paykel prongs and so on)
Hudson also had same prong length for lower birth
weight categories (sizes 0, 1 and 2).
The inter-­prong distance of Argyle and Hudson
short binasal prongs had good correlation to mid-­
columella width (narrowest part of columella), it
was not so with at upper end and lower end (base)
of columella due to hourglass shape of columella
(table 2, online supplemental tables 2 and 3, online
supplemental figure 3). Angulations of nostril were not
taken in to consideration in the design of most of the
interfaces. The surface area of contact of prongs was
less leading to more displacement; the shape of prong
Protected by copyright.
faces commercially available. We found mismatch
between dimensions of available CPAP interfaces in
market and actual nose parameters of Indian preterm
neonates. The inter-­prong distance of CPAP devices of
Hudson type binasal prongs (Phoenix, Hudson, Baby
Plus, Respicare) was lesser as compared with columella
width at midpoint of the babies of lower birth weight
categories (<700 g and 700–1249 g), thus resulting in
high rate of impingement injury. However inter-­prong
distance was good in Argyle prong. Similarly, measured
distance of lateral walls of two nostrils was wider as
compared with the maximum width of the four out
of five commercially available prongs in lower weight
category (<700 g and 700–1249 g) resulting higher

Table 3  Comparison of the ‘distance between lateral walls of nostrils’ with ‘maximum width of the prongs’ of commonly available CPAP
short binasal prongs in India
Maximum width of prongs
Distance between lateral walls
Hudson type nasal prongs
Birth weight of nostrils at midpoint of
Size categories, g columella (mean (95% CI)) Phoenix Baby Plus Hudson Respicare
0 <700 10.35 (8.58 to 12.17) 7.27 9.01 – 8.85
1 700–1249 11.77 (10.79 to 12.72) 9.64 10.3 10.81 9.51
2 1250–1999 12.93 (12.12 to 13.74) 12.38 12.82 13.58 12.94
3 2000–3000 14.29 (11.91 to 16.46) 15.1 14.42 15.56
  Argyle nasal prongs
Extra small <1000 10.73 (9.88 to 10.78) 10.81
Small 1000–1500 12.77 (12.01 to 13.53) 13.58
Large >1500 13.56 (12.48 to 14.65) 15.56
All measurements are in mm.
CI, Confidence interval; CPAP, continuous positive airway pressure.

Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372 5

MEDICAL DEVICES
rate of displacement in these neonates. Moreover, it
is hypothesised that the Argyle and Hudson prongs
significantly widened the nose in larger neonates
as maximum prong width was more for nose size in
larger weight infants .
We found that the columellar width in neonates is
more compared with that in Caucasian neonates, a
finding that is consistent with that made by Khandekar
et al.11 Hence, there is an urgent need for design modi-
fication of the CPAP interfaces that is more suitable
for Indian infants. Among all parameters (birth weight,
gestation and postmenstrual age), we found birth
weight is best correlated with nasal dimensions. Also,
birth weight is more readily known to clinicians than
the gestation of neonates. Therefore, it makes sense
to design prongs for different weight categories than
those based on gestation. Our nasal anthropometric
data can be used to improvise existing interfaces as
well as designing new prongs that is more suitable for
Indian neonates.
Most CPAP prongs used in developing countries like
India have been designed for use in developed coun-
tries. As a result, these imported prongs do not fit well
in the nostrils of Indian neonates.16 17 An ideal nasal
prong should not be so big that it distends the nostrils
and nor it is so small to the point that it lets extra
space or leak between the prong and nostrils.18 Disfig-
urement of the size and shape of the nostrils has been
described in multiple studies with use of nasal inter-
faces and it was most commonly associated with the
Hudson prongs.12 19
Our study measured all necessary parameters for
designing an appropriate CPAP interface in the preterm
neonate using a device with high precision (3D photo-
grammetry) in contrast to previous studies which
measured the limited nasal dimensions in healthy term
or older infants11 15 20–23 using less accurate manual
technique. For example, Zanki et al22 measured the
nose length, philtrum and nasal protrusion with the
help of rigid transparent calliper in term and older
infants. Ghosh et al15 measured columella width, phil-
trum and length of nose in normal and low birthweight
neonates at 37–40 weeks gestations.
We used 3D photogrammetry technique for
obtaining measurement of nasal parameters due to
following advantages: non-­ invasiveness, fast image
capturing speed, high precision (up to 0.01 mm), good
reproducibility and ability to measure the angles. Also,
compared with other methods, it does not distort the
images from parallax (measurement error secondary to
variations in camera angle relative to the subject). The
accuracy of this technology has been documented on
mannequin heads, on normal adults and on children
and adults with non-­cleft facial dysmorphology as well
as in infants.24 25 However its use in preterm neonates
has not been reported in literature so far.
Strengths of the study are: (1) Use of high preci-
sion (with precision of 0.01 mm) 3D photogrammetry
6 Dalal JS, et al. BMJ Innov 2020;0:1–7. doi:10.1136/bmjinnov-2019-000372
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to measure nasal parameters instead of less accu-
rate manual measurement in preterm neonates. (2)
Measurement of a vast set of nasal parameters that
would be needed to design an appropriate nasal inter-
face for Indian preterm neonates. However, our study
had few limitations too which include small sample
size. We did not compare angulations of devices
with the nasal angulations of preterm babies. Simi-
larly, we did not study the appropriateness of nasal
mask. Hence confirmation of these studies focusing
on preterm infants with larger sample size is essen-
tial before manufacturers can proceed for design
modification.
From current study, it appears Argyle prong has better
fit for nose of Indian preterm infants out of currently
available short binasal prongs in Indian market. Based
on our data, we suggest that there should be three sizes
of binasal prongs: size 1 (for less than 1 kg), size 2 (for
1–1.5 kg) and size 3 for >1.5 kg babies. The proposed
best-­suited dimensions for the different sizes are: inter-­
prong distance of 3.15 mm, 3.78 mm and 4.10 mm and
maximum prong width of <10.78 mm, <13.53 mm
and <14.65 for sizes 1–3, respectively. For each size,
the prong inclinations/angulation inside nose should
be around 30° and prong outer diameter should be
around 3.5 mm.
Protected by copyright.
CONCLUSION
The currently available CPAP binasal prongs are not
suited to the Indian neonates which is likely to be
significant contributory factor to the high rates of nasal
injuries seen in these neonates receiving CPAP. Due to
small size of our study, there is a need to generate data
in a larger cohort of Indian neonates especially those
less than 1200 g. As an interim measure, our nasal
anthropometric data can be used for design modifica-
tion of CPAP interfaces for a better fit and reduced
nasal injury.
Contributors  JSD conceptualised and designed the study,
developed the protocol, recruited the patients, also wrote the
first draft of the manuscript. PVMR, SKA and JSD performed the
measurements. SKA, KP, PVMR and JSD analysed the data. TS,
JSD, CPY, AlT and AnT contributed to statistical analysis and gave
critical inputs in performing the study, reviewed the manuscript
for intellectual content. AKD helped in protocol development
and critically reviewed the manuscript. RA conceptualised and
designed the study, developed protocol and reviewed and finalised
the manuscript. He was the guarantor of the manuscript. All the
authors approved the final manuscript as submitted and agree to be
accountable for all aspects of the work
Funding  The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Ethics approval  Institutional ethical clearance from All India
Institute of Medical sciences, New Delhi, Ethics committee was
obtained before initiation of study. We obtained informed consent
from either of parents/legally accepted representative before
enrolling study subjects.

Provenance and peer review  Not commissioned; externally peer
reviewed.
Data availability statement  Data are available upon reasonable
request. All data relevant to the study are included in the article or
uploaded as supplementary information.
ORCID iD
Jagjit Singh Dalal http://​orcid.​org/​0000-​0002-​3005-​4531
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