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Introduction: Bubble continuous positive airway pressure (bCPAP) is a low-cost respiratory support device that has demonstrated different safety and effectiveness outcomes for children with severe pneumonia in different settings, some of which may be attributable to implementation factors (e.g., patient monitoring and feeding practices). We aimed to characterize bCPAP implementation and clinical outcomes for children with severe pneumonia in Pakistan. Methods: Prospective cohort study at the private Aga Khan University and the public Abbasi Shaheed Hospitals from February through April 2025. We enrolled children 1–59 months who met WHO criteria for severe pneumonia within 24 hours of presentation to the emergency department (ED). Participants were followed daily via chart review, caregiver survey, and physical exam through discharge, transfer, death, or day 30. We used descriptive statistics to report the following outcomes: Adoption (proportion of children receiving bCPAP); Fidelity (incidence rate of unplanned disruptions to bCPAP, use of continuous pulse oximetry, child location in the ED, step-down unit (SDU), or intensive care unit (ICU), and oral feeding); Safety (risk of aspiration events and pneumothorax); risk of bCPAP failure (death, respiratory support escalation, or leaving against medical advice) and in-hospital mortality. Results: We enrolled 165 children with severe pneumonia; 88 (53.3%) received bCPAP. Over 141 bCPAP patient-days, 46 (32.6%) had unplanned disruptions to bCPAP and 78 (55.3%) were continuously monitored. Children on bCPAP were in ED, SDU, or ICU settings on 119 (84.4%) patient-days and received oral feeds on 79 (56.0%) patient-days. On 17 (12.1%) patient-days, caregivers fed children additional oral feeds against doctors’ orders. Of 88 children who received bCPAP, 9 (10.2%), 1 (1.1%), 19 (21.6%), and 1 (1.1%) experienced an aspiration event, pneumothorax, bCPAP failure, and death, respectively; 14 (15.9%) children left against medical advice while on bCPAP. Conclusions: We identified several gaps in bCPAP adoption and implementation fidelity. These may be modifiable by individual- and team-targeted strategies to reduce bCPAP-related complications and pneumonia-related child deaths.