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Medtronic Ad: This podcast is supported by an unrestricted educational grant provided by Medtronic. Any statements, opinions, findings, conclusions, or recommendations contained in the podcast are strictly those of the host and interviewee, and do not necessarily reflect the views or opinions of Medtronic or any of its affiliates, including Covidien.

This podcast is for educational purposes only and does not constitute medical or professional clinical advice.

Dr Pam Peeke:

Hello and welcome to the Society of Critical Care Medicine's iCritical Care podcast. I'm your host, Dr. Pam Peeke. Today, we'll be talking about noninvasive respiratory support, opinion or evidence-based medicine. I'm joined by Dr. Deepak Jain, who is the Interim Chief Division of Neonatology at Rutgers Robert Wood Johnson Medical School.

Welcome, Dr. Jain. Before we begin, do you have any disclosures to report?

Dr Deepak Jain: Thank you, Pam, for inviting me. Yes, I would like to disclose that I have received funding for speaking engagement from Medtronics.

Dr Pam Peeke: Excellent. Very good. Thank you so very much. And for all of our listening audience, the learning objective today is to discuss aspects of noninvasive ventilation in the pediatric population. So why is this podcast needed? Well, we need to discuss the impact of strategies that optimize noninvasive ventilation. The knowledge gaps that this podcast will address include strategies to optimize noninvasive ventilation, including synchronized modes of noninvasive ventilation, noninvasive positive pressure ventilation, CPAP and more. So first, I'd like to ask you, Dr. Jain, why is this such an important topic right now?

Dr Deepak Jain: Yeah, I think that's a very important question. First of all, we have to start looking at does avoiding ventilation really help, right? So at this point, we have a large number of babies who are born extremely preterm. And at some point of time, we have to decide whether these babies need to be intubated or not. And the use of noninvasive ventilation, whether it's required or not, the answer is not really that straightforward. There is some good evidence from randomized control trials that avoiding intubation in extremely preterm infants is better than invasive ventilation.

There was a recent meta-analysis, which showed reduction in bronchopulmonary dysplasia or death, and had numbers needed to treat of about 35. But one of the concerns, which many of us neonatologists have is would giving these babies noninvasive ventilation increase the risk of short-term morbidities, like intraventricular hemorrhage? As many of these patients, when we start them on noninvasive ventilation feel they would have higher carbon dioxide levels increasing the risk of IVH. But good part of that meta-analysis was that it did not show any significant difference in rate of IVH between two groups.

Dr Pam Peeke: Is there an age issue here? I know that you shared with us an excellent analysis, trends in care practices, morbidity and mortality of extremely preterm neonates. And the study took place between looking at the span of 1993 to 2012. And in this study, they were looking specifically at babies that were very preterm and morbidity and mortality. Could you explain a little bit about what this study revealed?

Dr Deepak Jain: Yeah. So the study revealed that over a time period, so this was looking at the data from 1990s to recently, how morbidities and mortalities has changed over this period of time. It clearly showed that most of the morbidities actually have decreased in extremely preterm infants, but only morbidity, which has not changed much or actually has gone up a little bit is bronchopulmonary dysplasia. And that is where the question which is always coming up is why are we not able to decrease bronchopulmonary dysplasia in this group of patients.

Dr Pam Peeke: All right. And what is the answer to that? Because at this point in time, you know, it is an interesting trending. Were you surprised to see that?

Dr Deepak Jain: I think most of us were not really that surprised. And I think there are multiple reasons for that. One, I think is that more extremely preterm infants are surviving. So the babies in maybe 1990s, normal mean gestational age of these babies will be 28 weeks. Now we have babies surviving at 23, 24 weeks. So it's likely that these babies will have more bronchopulmonary dysplasia.

Dr Pam Peeke: Oh, so basically, you're suffering from your own success, and that is the babies are now very preterm and, of course, then you will see something like this. Does that make sense?

Dr Deepak Jain: Yes, exactly. And, in addition to that, how we define bronchopulmonary dysplasia also could be one of the factors. And we have to start thinking of what actually we should look as our outcome. Maybe we should look at more longer term respiratory health on these babies.

Dr Pam Peeke: What do you mean by that?

Dr Deepak Jain: What I mean by that is for parents, let's say, I have a baby. Most of them, that would not matter much to me that whether my baby's classified as bronchopulmonary dysplasia or not. What would matter more for me is, "Is my baby going to have more asthma or some issues with respiratory health when he is a child? Would he be able to do exercises?" I think those might be more important outcomes for me as a parent.

Dr Pam Peeke: I see. Okay. Very good. And what we're seeing now is survival that is increased most markedly for infants born at 23 and 24 weeks and survival without major morbidity increase for infants 25 to 28 weeks. And so what you're really seeing here is trending toward more and more survivability during this time. Does this inform at all about the issue of ventilation? These young infants, were they more likely to be ventilated earlier, say the 1990s and the early 2000s versus now? Are there different ways of thinking this through?

Dr Deepak Jain: Yes, definitely. There are different ways to thinking this through. And I think it's very difficult to compare a patient population, which is born at 28 weeks as compared to a patient population, which was born at 24, 25 weeks. And there is good amount of data suggesting that almost majority, almost 90% of babies that are born at 24, 25 weeks, even if we try to give them noninvasive ventilation initially, they fail and they require invasive ventilation. So it is quite clear that the babies who fail noninvasive ventilation, they actually do worse as compared to babies who succeed.

Dr Pam Peeke: Okay. And why is that?

Dr Deepak Jain: Well, the one thing is that the babies who failed, there's a high risk that these babies will have more CO2, more carbon dioxide levels, and they can increase their incidents of intraventricular hemorrhage and also we may be delayed in finding out that these babies are failing.

Dr Pam Peeke: Okay. Very good. And so really, it's interesting, we're looking at a variety of different nuances with regard to the morbidity and mortality of these preterm babies over the years. So although the survival of extremely preterm infants has actually increased over the past two decades, including survival without major morbidity, let's consider the individual and societal burden of preterm birth, which remains substantial. By last estimate, approximately 450,000 neonates born prematurely in the United States each year. What do you have to say about that?

Dr Deepak Jain: Yes. I fully agree. I think that's a very important aspect of it. And we do have to look at all of these factors and see what is the impact of the survival is also on individual and society. I fully agree with that. But I think what we have to also figure out is how we can actually improve our noninvasive ventilation strategies so that we can take care of these extremely preterm infants in a better way so that we can decrease their long-term morbidities.

Dr Pam Peeke: Can you describe that then? Basically, you are looking at the issue of noninvasive ventilation. Walk us through the decision-making process there.

Dr Deepak Jain: Yeah. So the decision-making process, like let's say if I have a 24 weeks infant who gets delivered and those babies can essentially be divided into three types. A group of babies will be the ones who would require intubation right in the delivery room and they will be mechanically ventilated. And a group of babies will be what we can say as good babies who will stay on CPAP and do well. The problem comes with the babies who are started on CPAP, but they started requiring more and more oxygen. And then we have to start thinking, "Okay, at what point do I need to start intubating this kid and escalate his respiratory support?" I think that is where we have not really been good about, what is the time when we have to really have to intubate?

We know that babies who are born at lower gestational age are more likely to fail. And there is some data suggesting that oxygen requirement could be a marker of predicting some failure. So those are the things which we have, but we really haven't set out like a clear cut idea when do these babies fail.

Dr Pam Peeke: And so this is a very critical point here. Let's look, for instance, I mentioned earlier about the noninvasive positive pressure ventilation versus say CPAP. What can you say about the difference between the two as research has borne this out, if you were to compare either of those?

Dr Deepak Jain: So there is a reasonable quality of randomized control data suggesting that the noninvasive ventilation in terms of providing positive pressure with the rate. Using it as an initial respiratory support or also as a post-extubation respiratory support does have improved short-term outcomes in terms of risk of re-intubation. But there's not really good data in terms of whether it improves long-term respiratory outcomes like bronchopulmonary dysplasia or later term respiratory health. So that data is lacking and there are several caveats to that. And one of them is that we really don't have a good number of studies and some of the reasoning behind that could be that many of these modes we are using is nonsynchronized as compared to synchronized.

Dr Pam Peeke: Could you describe that, synchronized and nonsynchronized?

Dr Deepak Jain: What usually happens is when we have a kid intubated, the ventilator detects a breath taken by the baby and tries to provide the rate at the same time when the baby is inspiring. The problem with noninvasive ventilation comes with the usual ways of ventilator to detect the breath. They don't work because there's a huge amount of leak from the patient interface and that causes ventilator to not being able to detect those breaths.

So that's why traditionally the noninvasive ventilation used to be given by nonsynchronized. So the babies can be breathing out, but the ventilator will try to give a breath. So there will not be any effective delivery of positive pressure when actually it's needed.

Dr Pam Peeke: Gotcha. Okay. Technologically, what do we have today that didn't exist say five or ten years ago that could help us in terms of tools? Not only to assess what type of decision to make, but also in terms of ventilation.

Dr Deepak Jain: There has been quite a significant improvement in our ventilator technology in the last few years. And one of them is what we call a leak compensation by the ventilator. So there are automated algorithms by the ventilators where they detect the leak and try to compensate for it. And by compensating for it, they can try to get an effective synchronization, even though the baby is on noninvasive ventilation. Now, that's one of the ways to do it. And there is some early promising data to suggest that in preterm babies, some degree of synchronization can happen with it. But we really don't have any good clinical data to suggest that it improves outcomes. So we're still waiting for those results to come.

Dr Pam Peeke: Okay. So why is there a knowledge gap, as it relates to strategies to optimize noninvasive ventilation, synchronized modes, et cetera? Why is there this knowledge gap? What is going on with practitioners like yourself, leaders in the field in terms of the ability to grab that new knowledge base that you're describing and utilize it? What is happening, what is not happening here that is feeding into this knowledge gap?

Dr Deepak Jain: I think there are several reasons for that. One is definitely we as neonatologists have been very careful in terms of adapting new technology. And that's good. And so we're still waiting for some data to actually show that it actually improves meaningful clinical outcomes before it can be adapted. So that's one of the reasons.

And second thing is that to do large randomized control trials in the field of neonatology is always very difficult because the field is so small and it's expensive. And we really don't have good clinical outcomes to use. So all of those are actually the challenges which neonatologists are facing day in and day out.

Dr Pam Peeke: Gotcha. And I completely understand, and I know that our listeners empathize with this too. You have a very, very unique demographic to say the least. So we've already discussed now aspects of noninvasive ventilation in the pediatric population, and really addressing some of the challenges about the knowledge gap in these strategies that optimize noninvasive ventilation. As we're concluding this podcast, what pearls of wisdom do you have that you would like to impart to listeners out there, your peers who are considering ways to improve and enhance their own ability to impact positively upon outcome in this patient population?

Dr Deepak Jain: A couple of points I think we have to be a bit careful about. So we do know that noninvasive ventilation is a viable alternative to mechanical ventilation. I think that's quite clear from the data. And I think we also know that the smaller the baby and the most at risk baby is likely to fail more. And these are the infants we have to be very careful when we select respiratory support and do close monitoring with early correction of worsening respiratory status. I think we all have this challenge just to find right respiratory support for the right patient at the right time.

Dr Pam Peeke: Excellent. Fantastic. And what do you consider to be, as our last point here, one of the biggest challenges to be able to achieve the goal of enhanced patient care in this population?

Dr Deepak Jain: I think the biggest challenge for us will always be to find a suitable balance in terms of looking at finding a right respiratory support, which actually does not just look at the short-term outcomes, but also at longer term outcomes.

Dr Pam Peeke: Excellent. Okay. I don't think there's any question about that. I can't thank you enough for being able to really address non-invasive respiratory support in this very challenging demographic as well as the trends over time in both technology and understanding of how our knowledge base, as it applies to ventilation and to optimal care in this demographic, has changed over time and has been beneficial to this demographic.

So thank you very much, Dr. Deepak Jain, for being our expert in this particular podcast. Dr. Jain again is Interim Chief Division of Neonatology at Rutgers Robert Wood Johnson Medical School. And we've been talking about noninvasive respiratory support, opinion or evidence-based medicine.

And I know that our listeners have benefited greatly from this, and this concludes another edition of the iCritical Care Podcast. For the iCritical Care podcast, I'm Dr. Pam Peeke.

Medtronic Ad: This podcast is supported by an unrestricted educational grant provided by Medtronic. Any statements, opinions, findings, conclusions, or recommendations contained in the podcast are strictly those of the host and interviewee, and do not necessarily reflect the views or opinions of Medtronic or any of its affiliates, including Covidien.

This podcast is for educational purposes only and does not constitute medical or professional clinical advice.

Peeke Bio: Pamela M. Peeke, MD, MPH, FACP, FACSM is a nationally renowned physician, scientist, expert and thought leader in the field of medicine. Dr. Peeke is a Pew Foundation scholar in Nutrition and Metabolism, Assistant Professor of Medicine at the University of Maryland, holds dual master's degrees in Public Health and Policy, and is a fellow of both the American College of Physicians and the American College of Sports Medicine.

Dr. Peeke has been named one of America's top physicians by the Consumer's Research Council of America. She is a regular in-studio medical commentator for the National Networks and an acclaimed TEDx presenter and national keynote speaker.

Dr. Peeke is a three-time New York Times Bestselling Author and is a science and health advisor for Apple.

SCCM Disclaimer: The iCritical Care Podcast is the copyrighted material of the Society of Critical Care Medicine and all rights are reserved. Statements of fact and opinion expressed in this podcast are those of authors and participants, and do not imply an opinion or endorsement on the part of the Society of Critical Care Medicine, its officers, volunteers, or members, or that of the podcast commercial supporter.