Hello Friends 👋

Daphna and I are happy to bring to you another episode from our Giants of Neonatology series. This week we havethe pleasure of hosting Dr. Eduardo Bancalari, from the University of Miami, whose work on bronchopulmonary dysplasia and on neonatal pulmonary pathophysiology has had a tremendous influence on our practice of neonatology and has help improve outcomes for nicu babies around the world. We hope you enjoy this interesting interview and thank you all once again for your continued support.

Bio: Dr. Eduardo Bancalari is the Project New Born Professor of Pediatrics and Obstetrics and Gynecology and Director Division of Neonatology at the University of Miami Miller School of Medicine and the Chief Newborn Service at Jackson Memorial Hospital.

He received his undergraduate and medical degrees from the University of Chile and then completed research fellowships in Respiratory Diseases and Physiology, at the Respiratory Center Maria Ferrer, Buenos Aires and University of Chile and in Pediatric Cardiology at the University of Miami.

He has served in numerous professional organizations including American Board of Pediatrics and Sub-Board of Neonatal-Perinatal Medicine.

Dr. Bancalari is Associate Editor for the Journal of Perinatal Medicine and sits on a number of editorial boards, including Neonatology, Revista Chilena de Pediatria and Jornal de Pediatria.

He has received several national and international awards including the Career Achievement Research Award, the Duane Alexander Award for Academic Leadership in Perinatal Medicine and the Erich Saling Award in recognition for outstanding contributions to the field of Perinatology.

Dr. Bancalari is the recipient of the 2003 Virginia Apgar Award from the American Academy of Pediatrics.

He is the author or co-author of more than 300 papers and book chapters in the areas of neonatal respiratory physiology, lung injury and respiratory care. He is the editor of The Newborn Lung published by Elsevier.

Dr Bancalari and his collaborators have developed one of the largest and most prestigious neonatal programs in the USA based at the University of Miami Jackson Memorial Hospital.

Through his continuous and active participation in educational activities, Dr Bancalari has made major contributions to the improvement of neonatal care in developing countries in Latin America.

Dr. Bancalari and Dr. Charles Bauer have organized “Miami Neonatology”, one of the most successful and longer lasting neonatal conferences in the world – celebrating 44 years in November. This program brings some of the most outstanding neonatal faculty from around the world and is attended by more than 1000 perinatal/neonatal professionals from over 40 countries.

The transcript of today's episode can be found below 👇

Ben 1:00

Hello, everybody. Welcome back to another episode of the incubator. We are Sunday, we have a great interview lined up for you Daphna, how are you?

Daphna 1:09

I'm good. I'm it sounds like you're feeling better. So that's good.

Ben 1:13

It's getting better. I think if I push the voice a bit further up the scales. Yeah, it will break but much better than last week.

Daphna 1:21

Much better. Okay. Well, this is a bit we've been looking forward to this interview for some time. I know especially you have

Ben 1:28

I've been I've been it's mixed emotions, you know, because on the one hand, I'm excited, but a little bit terrified. Right. I mean, Dr. Ben Clary is is both somebody that I admire and somebody who was one of my mentors and my, my one of the people who trained me, so I'm anxious that I don't want to say something stupid today. But now we're very excited. Dr. Ben Clary is definitely a physician that fits in that category of the giants of our field and is he's world renowned. And yeah, and we're very excited to have Dr. Ben Clary on. It's actually quite nice that we're having him on now because it gives us the opportunity to showcase the upcoming conference that the group will be hosting the Miami neonatology Conference, which will take place in November, this November in, in South Florida. And I think the dates of the conference, I'm going to get that for you give me one second because I know I have them written down November 14 to 16th. So it's quite soon, you can still register. Yeah. And so so we're very excited. Okay, so let me go through Dr. I have to start because Dr. Benko, his bio is long, which is the case with all these giants of neonatology. But Dr. Eduardo banchory is the project newborn Professor of Pediatrics obstetrics and gynecology and the Director of the Division of neonatology at the University of Miami Miller School of Medicine. And as the chief of newborn services at Jackson Memorial Hospital. He has served in numerous professional organizations including the American Board of pediatrics and sub board of neonatal perinatal medicine. Dr. Ben Clary is the Associate Editor for the Journal of perinatal medicine and sits on a number of editorial boards, including neonatology revista chilena Deepika Yatra, and Jornal de pediatria sorry if I mispronounced that. He has received several national and international awards including the Career Achievement Research Award, the Dwayne Alexander award for academic leadership and Perinatal medicine and the Eric sailing Award in recognition for outstanding contributions to the field of parasitology. Dr. Ben Clary is the recipient of the 2003 prestigious Virginia Apgar Award from the American Academy of Pediatrics. He is the author, or co author of more than 300 papers and book chapters in the areas of neonatal respiratory physiology, lung injury and respiratory care. He is the editor of the newborn lung published by Elsevier, Dr. Ben Clary and his collaborators have developed one of the largest and most prestigious neonatal programs in the USA based at the University of Miami Jackson Memorial Hospital. Through his continuous and active participation in educational activities, Dr. banglori has made major contributions to the improvement of neonatal care in developing countries in Latin America. Without further ado, please join us in welcoming to the show Dr. Eduardo pink Laurie. Dr. banca Laurie, thank you so much for being on the podcast with us today.

Speaker 3 4:30

So big pleasure to be here. And see you again.

Ben 4:33

Yes. So for the audience members who I've mentioned my, my my training at the University of Miami and people may know this already because I mentioned it all the time. But you you were you are the Division Chief at the at the University of Miami and I trained under your guidance and under your mentorship which I am extremely thankful. So thank you for everything. And yeah, it's it's it's really great to have you on the Podcast, I were always very honored to be able to speak to what we've now called the giants of neonatology. And what we usually like to start with is the inception of what led you to pick the field of neonatology. Especially considering that, at the time where you made this commitment, the field looked very different from what it does today. And so we're interested in the motivation that prompted you to establish yourself in this field that was not established. So can you tell us a little bit as to what was that like?

Speaker 3 5:35

Okay, well, that's a, that's a good question. And he say, interesting story. I think I I'm from Chile, originally, and I did my pediatric training in Chile. And then I did training in respiratory physiology. And actually, I was a pediatric pulmonologist. So I came to Miami in the early 70s, to do a research fellowship in pediatric cardiology, because I never understood why we were splitting the line in the heart were intimately related, and they have a common function. So anyways, I was here really doing a fellowship trying to learn hemodynamics and neonate, and really cardiology, pediatric cardiology, not neonatal care. And then I, I had skills in Respiratory Care, because that was my area of interest in at that time, and most of the extreme premature infants didn't make it. And they didn't make it because the way we were supporting their respiratory function was very primitive. They were pediatric ICU, they were certainly adult ICUs, where they were using newer modalities, mechanical ventilation, better monitoring, blood gas monitoring, etc. In newborn really at that point, was mainly care of the preterm infant. And that was basically nutrition and temperature control, in avoidance of infection. In the unit where I did my neonatal experience in Chile, the nurses had to shower every morning before going into the unit, to make sure that they didn't carry any bugs, because that was one of the main issues, infections. And as I mentioned, nutrition, obviously, like it is today, but those were the focus. So essentially, I started then, working here in cardiology, and they had a small neonatal unit. That was, again, mainly focusing on the basics of premature care. But there were some attempts already for at respiratory support. So they essentially asked me for consultations, can you knew that they were deleting all their kids? So they start asking me can you help us with this or the other, and then gradually, I drifted into that area, because obviously was for the needs were in in pediatric ICU things were much more established. And they were much more similar to what is done in adults, you can say that they pediatric, a patient in a pediatric ICU, it's a small adult, you cannot say that from a neonate.

Ben 8:44

We want to have our PICU friends about that.

Speaker 3 8:49

When I tell you that we were taking care of premature infants, I'm telling you that we're taking care of babies that were 1213 1500 grads, yeah, bear roll. A Jackson when I started here was no baby under a kilo should be given any support, no integration, no mechanical ventilation, because essentially, there were no survivors when those things were attempted. So it was a different population. It was a they were larger babies, but in a way they were sicker because we didn't have antenatal surfactin excuse me, antenatal steroids, within our surfactant. In the ventilators we were using were essentially adult ventilators that were adapted to be used in the neonate. And the adaptation was simply take smaller tubes. So you read but nothing else. So that's that's really how the sensor started for me here. That's how I drifted from pediatric pulmonology into neonatology. And then we start having fellow was at that point there were no training programs that were edited by the board of Pediatrics. So they, they were just people that were interested in learning a little bit more about neonatology. And then, so that's how the Unit here at Jackson began. And at that point, yes, there were no boards, no training programs for neonatology. Although there were a few units here and there. So I have to tell you that at that time, we had 16,000 deliveries a Jackson per year. So Jackson was just incredible. There were no rooms for the mothers, many times we had moms laboring in the hallways, right on stretchers on the hallway. So it was they were challenging times.

Ben 10:49

Yep. And the history of Jackson Memorial Hospital is a very interesting one as as it as it aims to serve the Miami community. It really became the center where everybody converged. So So I think it's great that you're mentioning that I think in the story that you're describing, there's something that you're skipping over, which I think would be interesting. So what started as a research fellowship ended up being a permanent move was the decision to to stay in Florida and leave Chile, was that a difficult decision for you?

Speaker 3 11:20

Well, I have not made that decision. That's what I love it. I came here for one year, pediatric cardiology. And after three years, I was becoming a neonatologist by default, and I was asked to lead the group, taking care of this 16,000 births here at Jackson, in I really never made the decision, I came here with my family, we left everything in a garage store in Chile. And my intentions were always to go back after one or two years of, of training here. So I always say, if somebody had asked me, Listen, come here and make a decision, tell me are you staying or you're not going to stay? Probably, or to say no, I not want to stay. But this many opportunities opening up here. In Chile, there were rough times at that time because of political situation. So the academics really were not priority. And my interest was always research combined with clinical care. So I said, I'm going to stay one more year, and then I'm going to stay more one one more year. And here I am, performing

Daphna 12:43

things, two things that are always striking to me when we get to do these interviews, you know, for this series, is that there's always this, this acceptance of opportunities, right? And then somehow your opportunities where you ended up just create this domino effect of, of more opportunities. And you really have to just be willing to say, Well, I'm not sure but but let's see how it turns out. And the other thing I love, which you've described perfectly is in in your lifetime in your career, I mean, neonatology went from basically non existent to, to what we are such a, you know, a tech savvy. Every year, we're pushing more and more boundaries. It's really incredible. And one thing I, you know, I like to ask is, you know, how, how were, you know, how was the feeling of taking on this specialty that really wasn't even a specialty, right and saying, you know, we're going to do this and we're going to push boundaries. And you know, we talk right now especially, we were just talking earlier this week on the all of the ethical and moral moral situations in the NICU. And I mean, you guys, were dealing with that from day one, right. It's something that has always both been a pillar of neonatology and a burden of neonatology. So I'd love to hear you talk a little bit about that.

Speaker 3 14:13

Yeah, I think that that has always been a big challenge, and will continue to be a challenge in terms of what is the balance between what we want to accomplish in one side and on the other? What are the consequences of what we're doing? And, again, I told you, we didn't ventilate babies under one kilo, but the eight weeks, but the nine weeks. And the reason was simple was was mainly because it was a futile effort because most babies die that they want to survive late today, and didn't do well. Always. So I think that, that it's an it's an interesting issue because we keep talking about the border of viability What are their viability and whether it's this week or this week? Well, the same discussions we're having today for 22 weekers is the discussion we had 50 years ago for 2829 weekers was pretty much the same thing. So if this is obviously a moving target, and it's it's, the movement is slows down as we make more progress, so it's unlikely that we're going to be going much lower. But I may be wrong again, I don't know. In other words with this artificial uterus, and you never know how, how lower we're going to go, I hope we don't go to the extremes. But it is a it is a it is one of the biggest challenges and we keep revisiting these questions. Fortunately, now we have our colleagues in the MFM. side, with whom we work much closer than before. So we are always in to make sure that we give a a unison, a message to the family, especially in these very difficult situations.

Ben 16:09

But I think what's what's interesting is that when you start this early on in the field, as Daphna was mentioning that it's not fully established, you don't have the luxury that we today as trainees have in terms of having and having evidence. I mean, sometimes the evidence isn't great, but when I when I was a fellow, there was a lot of publications out there you start and and I'm assuming they're not I actually no, there's not a lot of there's not a lot of trials that have been done on these babies. And so you look for evidence where you can find it in the immediately adjacent populations, whether it is the pediatric or even sometimes the adult. And I think my perspective, you tell me, if I'm wrong is that your generation developed a very keen sense of assessing the evidence critically, because you really had to. And today, we, I think my generation is a bit biased, because we are in the same position when it comes to 22 weekers. And I think sometimes we're making a few mistakes here and there by transferring evidence that is applicable to 32 weekers. And that's going to work for 22 years, when in truth, they're very different populations. And so I'm wondering if you could talk a little bit about the importance of critically assessing the evidence and how that can have a dramatic impact as regarding the evolution of our field and where we go from there?

Speaker 3 17:26

Yeah, no, you are absolutely right at the beginning, we were just applying principles from the adult and from the pediatric critical care areas to the newborn, realizing that we were dealing with completely different physiologies Completely different consequences, good and bad, from anything we were doing. So there were many, many mistakes done. And, and I think that it's very interesting because if you analyze backwards, you will see that the progress has been in the last 1015 years in neonatology has been more related to less doing less and being more conservative and be is less been less invasive than really introducing new things. So I think we have we have learned a lot and fortunately, we have learned from our mistakes that had negative consequences on many of our patients. And I think that that because of the lack of evidence is that neonatology became such a wonderful field for those of us who are interested in moving forward in knowledge in doing research, clinical and basic research. This is a a human subject that is evolving very quickly. And as you say, you cannot apply the principles that you apply to a 28 or certainly weaker to a 22 or 23 weaker because then again, that physiology is completely different. And the response is completely different. In that in Yeah, and you can see if you go if you read any pediatric journal, even OB journals today, or if you go to SPR O P ies or the European meetings, now, at least half of the things that are being discussed and presented are related one way or another to neonatal medicine. So there is a tremendous amount of new knowledge coming out every day, that essentially is, is filling this big gap in knowledge in the management of this population. And obviously, the other thing is that we have a pediatric patient in the ICU. Yes. What you do is very important for that kid in terms of how it's going to come out of the ICU and what are the chances for survival and so on. But there is no other stage during a human development that where a Everything we do can have such a huge impact on long term survival but long term outcome, and this is becoming more and more evident on a daily basis. And you know this event because you were interested in, in follow up in the it's, it's crucial. In other words, in every day we are discovering new things we use antenatal steroids, marvelous intervention improves survival decreases are the as the critically busy now there is everyday more and more evidence that if you give antenatal steroids to a baby who is born at term later on, because preterm labor is stopped, that baby has negative consequences for two doses of steroids. So everything we do, always can have a benefit, but very frequently has also a downside. It so in everything we do, we have to be very careful and always look at this balance between what what we are doing to improve the situation, what is the negative side of it, the dark side of it?

Ben 21:11

Yeah, we actually reviewed that paper on the podcast not too long ago, it's fascinating that you have to be very careful, even when giving the you shouldn't be giving steroids willy nilly. I guess, since we're talking about evidence, and you are the biggest name in the field of neonatology when it comes to bronchopulmonary dysplasia. And I wanted to ask you a little bit about the original definition of BPD that this famous paper that you wrote with our job, and and wanting to find out exactly what prompted the need to define BPD in the first place, right? I mean, we know that there was this radiographic assessment of bronchopulmonary dysplasia, and then the first clinical decision, the first clinical I'm sorry, definition was was published, what was the incentive to clinically defined BPD at the time?

Speaker 3 22:05

Yeah, I told you the original definition of BPD is not the 2001 nih definition. There were other definitions before in the 90s. And when I was just a few years here, we had a meeting sponsored by NIH, I think was in California at that time, to try to come up with some sort of consensus. Now at that time, the BPD that we saw was the original BPD described by Northway. And there was no question, but that was because were very severe. These were kids who had severe HMD, as I mentioned before, very severe respiratory failure because of no steroids, no antenatal steroids, no surfactant. So these babies, all of them require 100% oxygen for days or weeks. And they require very high peak inspiratory pressures, because if not, you couldn't just move, move those legs. Most of you have never seen a kid like that, that has such a stiff line, because of HMD. You may have seen other lung pathologies, hyperplastic, lungs, and so on. So it was a terrible disease, very severe respiratory failure in the only way of getting these babies out of there. This severe hypoxemia and hypercapnia was ventilating them very aggressively. So we really ripped those lungs apart, essentially, with the ventilator. And that's why the mortality was very high. And the babies that survived after that type of respiratory support, they had horrible lungs very severe. So there was no mystery in the diagnosis there. So we had custom consensus, and we decided that we were going to establish some criteria of chronicity. So we required oxygen to the 28th day, it was continuous oxygen from birth until 20 a day. Well, what changed everything was the introduction of steroids and surfactant because that made initial respiratory failure due to RDS much milder, much easier to control and to support to assist. And the type of disease then changed. And it's not that we don't see a few patients with severe BPD. But most of them are relatively mild. So essentially, BPD changed from the original Northway BPD that was a lung that was immature and was totally messed up in its development, because of what we had to do to get those babies to survive to a disease disease today, but it's mainly a developmental issue where a baby is born. They haven't mature lungs, we can use this marvelous setup is antenatal studios and surfactant. So we don't have to use very aggressive settings. And in fact, you'll see most of these babies went to room air or very low fire twos, as soon as we give surfactant, and we can ventilate them many times with lower settings or even with non invasive modes of support. So, but these babies still don't have normal length in flight or they have normal length. And we keep thinking that is because of what we are doing nasal CPAP, or, or high flow nasal cannula, or this or the other. And the truth is that and we have we have written several commentary with Alan Jove about this. The truth is, this babies, again, have abnormal lungs because they are born in mature and because they are exposed to air breathing with a higher fit than for the receiving uterus. So no matter what we do, those lungs will not develop normally, unfortunately. And it's not only the lungs, there is everyday more and more evidence that the kidney, the gut, the brain, unfortunately, they don't develop normally when a baby was supposed to be in utero for 10 or 15 more weeks, is exposed to this completely different environment. So today, again, BPPV I think it's it's more a developmental disease. It doesn't help when we use a mechanical ventilation. But I don't think that that plays a major role in that's why we keep trying different modalities CPAP and high frequency and volume targeted ventilation. And further we finding my note changes advantages. We keep trying things, and we don't find anything that has a a striking effect because of that, because I think that the issue is that if you have a 2324 weaker, no matter what we do, that baby will will have consequences because of his prematurity. This episode

Ben 27:05

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Daphna 27:23

Yeah, I think that's such a difficult concept for like trainees to understand until they really until we can really discuss the history of neonatology that the BPD definition is changing, not just because we've changed the definition, it's changing because the disease itself is different. The histopathology is different. Our interventions are different. And we're just trying to keep up the definition is trying to keep up really with the with the disease changing. And I wonder as you've watched this progression over time, what do you think will be like the next iteration of the definition? Because I'm not sure we're quite, we're quite there yet.

Speaker 3 28:07

I don't think we will ever have a a perfect definition. In a way, I don't know why we are stuck on the we don't know, we don't talk so much about definition of issues of intracranial hemorrhage. And I think that those definitions are much worse. Or in the gradations are much worse, if you call grade four ivh, a Panenka. Mobility, that can be a little minut thing, or a baby who has any sphere blown by a hammer, they're both great for ivh. And we know that the consequences couldn't be more different wildly apart in those two situations. with BPD. I think that, again, it's a it's an evolving target. We want to I think that if you as clinicians, we all know what the BPD for the patient with BPD is. So I think that the problem is that as we have milder and milder forms, then it's it's more difficult to know how much of this is related to again, the developmental the alteration of development of the lung versus damage induced by oxygen ventilator and this and the other in I think what we're what really is it's interesting to me is that we are fixated on having a definition that predicts outcome. One year other people want to predict outcome at four years. In I ask, why are we asking about the diagnosis of sepsis or the diagnosis of any C or ivh in also use some criteria that will predict what happened what will happen LinkedIn? Not only were asking to predict for the language Bitcoin, but we are asking now a EPB definition to predict neurodevelopmental outcomes is totally crazy. Yes, in normal, that BPPV is associated with poor neurodevelopmental outcome, we don't understand exactly why they must, they may just be coincidental. Or they may be related to the fact that the baby was bad, they believe, as hypercapnia and episodes of hypoxemia, and this is the other in eight hours, they will never be the ability to predict what happens with the brain or the gut or the kidney, based on what the lung is doing at 36 or 40 weeks. So I think that, again, will be beautiful. If we could tell the parents yes, because of this criteria, and this degree of lung disease, your baby will be doing this and this and the other that, again, I'm not even sure how useful that is. Because unless you have an intervention that will change the course of that disease. I don't know whether we want to tell the parents exactly what will be happening with their kid or two or four or five years of age. So I think that we are we are grossly overdoing this. Every week, I am asked to participate in some discussion about how can we change? How can we improve the definition of BPD? In at the end? Yes, we don't have and we will probably never have a specific definition. Because the length like many other organs, it has been a number of, of factors that can evolve in the development, and also in function. So I don't think that we will ever have a specific that IV le should be a pulmonary function test that will be able to tell us how severe lung function is affected? Well, unfortunately, you can measure resistance, you can measure compliance, you can measure diffusion, those are not all nonspecific measurements, any disease will alter to a different degree, these functions, but I don't think there is any specific about BPV that will allow you to do that. So, again, I don't think that we're going to make much progress, I think we're going to waste a lot of time for something that is meaningless for clinicians, because we all know, what we're dealing with. And I think that for research is important, but I think that they're the most important thing is to to be consistent. And to be and to agree, we cannot have one center doing research on BPD and calling BPD need for mechanical ventilation in the other centers calling BPD in need of high flow nasal cannula. So I think that we have to agree on on what parameters we are going to use to define PPV those parameters have to be simple to obtain, because every time we try to complicate things, things fall apart, because people they know we cannot collect all this data. So it has to be simple. It has to reflect the again, the degree of lung disease, I think that that is very important because of what we said before. Today. BPPV is a broad range of alterations in lung function. So we have to be able to define a baby who has a very mild alteration in lung function in the Finnish say that from a one that has a moderate or, or a more severe alteration in lung function. And yeah, people criticizes a need for oxygen. And I agree there are many limitations to use of oxygen as a criteria for BPD. But I asked what else can we use? And people tell me Well, maybe if we add P co2 PCs to is the integration is much more related to respiratory control than to lung disease? Or now well, all let's call the PD only the wastewater mechanical ventilation. Yeah, sure, that will have a much better predictability of long term outcome because we are selecting a very small group of people who are very sick at 36 weeks, so sure, those babies will be sicker. And we will know that it's likely that those babies will have more neurodevelopmental issues and more, again, associated complications. But that doesn't make it a better definition, because we are leaving out many babies that are not on mechanical ventilation at 76 weeks, and they have very bad lungs. So it's it's a complicated issue. And I but I don't think I think we are over overdoing it. And we are complicating it much more than what it should be.

Ben 34:46

And so I think it's very, I mean, everything you said is phenomenal. I could not agree with you more and I think as a as a as for Daphna and I who are new attendings when you start in the practicing in the real world At a fellowship, then you start understanding that people are collecting metrics. And and I wanted to get your opinion on whether like right now, hospitals, depending on which network you're part of, and I'm not talking about any specific network, or there's there's multiple networks around the globe. But like you said, if you assess whether your unit is doing well or less well, based on the need for oxygen at 36 weeks, is it how do you how as a young attending, how do you deal with this, because you're like, if I have a baby on a nasal cannula, and it's 27%, my, my baby is doing much worse than a baby that is on CPAP of eight, but isn't 21%? That makes no sense. And it gets everybody confused? Because it's completely moving away from the academic discussion about what is like you said, What is the physiology of this disease? And yet we're now being confined to these boxes. I'm wondering, what is your your take on that? Yeah, this

Speaker 3 35:59

is a very interesting point. And it's exactly, I think it's at the center of all this discussions and conflicts. The, you know, it's, I think that that most neonatologist would agree that a baby who needs 40% Oxygen has, without shunt without extra polymerization, has worse lung disease that the baby who is receiving who requires 25 or 30% Oxygen. And then I think that that there is no question that the amount of oxygen is related to diffusion is related to be a cue, that are two of the functions that are characteristically altered by bronchopulmonary dysplasia. Now, the problem is first targets. And there was a huge difference from among centers. So obviously, if if you say, I'm going to give my variable saturations of over 85, you will have a lower BPD incidence defined by oxygen requirement than a unit that says no, I'm going to keep my saturations overnight. So that was a big issue. And that's why the physiologic definition of BPD came up, where essentially you had to prove that the baby really needed such amount of oxygen or needed oxygen at all, at 36 weeks, we after the oxygen trials that has narrowed considerably, I don't think that there is the amount of difference that we had before for oxygen therapy. I think most most units have tried to keep between 90 and 95. That again, we don't know that really the ideal because nobody has compared different targets with except the very low and the higher. And we know that again, 90 to 95 is better than 85 to 90, but we don't know anything more. We don't know if this applies to different gestational ages to different natal ages so on. But anyways, I think that you will agree that that the the the use of oxygen has become much more consistent and uniform across units. So I think that Dan, in a way has made has has added value to the use of oxygen as a criteria to define degree of lung alteration of lung damage. The other problem is that once we have said that, we have to know how much oxygen were given to the babies. If you're using a ventilator a oxygen hood, or nasal CPAP. You pretty much know for the oxygen that baby not only what oxygen you are giving but what oxygen the baby's getting. Now we go into nasal cannulas. And this falls through the clerk's doesn't have any idea how much oxygen the baby is receiving. Because you may be giving Yeah, 100% Oxygen point one liter and I see that some places. How much oxygen is the baby getting? Is it getting 100%? Or is it getting 22%? It all depends on the flow and depends on the peak inspiratory flow of the baby and depends on the size of the cannula and the size of the nostrils. So the problem with nasal cannulas is that they are effective, not as effective I think as nasal CPAP. But they are effective because they generate some pressure that we don't know how much it is. And they generate and they add supplemental oxygen or the concentration that we know is above Romania, but we don't have any idea how much it is. So there is no way of quantifying that. And there are many papers not many But there are a few papers where they have measured nasal pharyngeal, effective FIU to which different flows and different concentration for inspiral. Oxygen delivered through the nasal cannula in the range is huge, huge. So we really don't know. And then yeah, everything. You know, it's how, what do we do? We can do. So we, we, we had this other meeting I think was 2018, also sponsored by NIH to try to come up with a solution for this nasal cannula thing. And we propose there is a definition that complicates much more thing because you have to consider the flow of the cannula in the inspires oxygen that we are delivering in the cannula. And it's an approximation is just something to get a little bit closer to for the effective and fire to the baby getting. But it's nothing that is very precise. So that is that is a significant problem.

Ben 41:05

I remember you love to ask that question to incoming fellows about how much oxygen is the baby receiving one on a nasal cannula. And I remember even myself as a first year fellow, we're trying to think, what is the correct answer? And you wanted us to get to the right answer, which was you have no idea No, no.

Daphna 41:23

The hardest thing for first year fellow to say,

Ben 41:26

I want since we're talking about oxygen. I wanted to ask you specifically about this because I know that you were involved in the trials, looking at this, but automated FIU to control how come it's taking so long in the US to have this technology. And we're seeing in Europe that they're using it and they're even innovating on different algorithms there. There is this, it seems, from looking at the literature that Europe is Europe and the rest of the world is moving is moving along on this. And we're still stuck in the US in terms of rolling this out to our units. Can you tell us a little bit more about that?

Speaker 3 41:57

Yeah, well, this is one of the big frustrations for Nelson Lowry, my collaborator and myself here. Because we have been working in this, I think, close to 20 years now. And we have a system that is commercially available is made here in the US, and is commercially available in many parts of the world and has been used now for more than 1015 years. And then we developed it here and we cannot use it because it's not FDA approved. And I, again, I don't want to get into the details of why it's not approved. But I think that it again, the approval processes is tricky and requires a lot of steps. I think that there is a lot of data on these systems. And it's very clear that they are not perfect, but they simplify things for the nurses. And they control and they avoid essentially the extremes better than a clinical nurse taking care of a baby. So they do what they are supposed to do. I think that the big problem is that so far, there are no studies that have shown long term differences, you know, so we know that the baby will have less hypoxemia and less hypoxemia. So we can deduct that that probably is better for the baby is good. But it's amazing. There are still no studies showing that there is less ROP, less BPPV or less brain damage, that may be the most important effect of these systems. Studies are going on now in Europe multicenter trials using different controllers. And so hopefully in the near future, we will have data on that. And I think that that will apply a lot of pressure on industry and FDA and everybody else to approve the system. So I think that that, again, I think that these systems will will help. I don't think that they will eliminate the problem because these babies are incredibly unstable. Some of you are always reacting with change in saturation, it always takes some time, from the time the controller increases or decreases the Fit until the saturation in the blood changes will never be perfect. I think artificial intelligence may improve the performance in the future and learn essentially how to predict this hyperoxia or hypoxemic episodes. But it's going to be a challenge. And I am pretty sure that that this again the trials will be finished in the next couple of years. We'll have data and hopefully that will help us get those systems in in our units here in the States.

Daphna 44:51

Yeah, I am. I want to make sure we can get you hit. There's so much more to your career than BPD right so I want to make sure we get to that but Before we do, you've already alluded to some of the upcoming trials. I wonder in your perspective, what you know, what are the next research imperatives? And in terms of, you know, neonatal lung disease, you

Ben 45:13

were mentioning off air, some work. You're you're you're conducting on the respiratory control in preterm infants, I think I think that's something that not everybody may be aware of.

Speaker 3 45:22

Yes, I think that this is interesting. And it relates to the issue of definition of PPE, because we are using oxygen to define lung disease. But unfortunately, a another complicated complex, a complicating issue is that many babies I think, in our units are receiving oxygen, not so much because they have lung disease, but because they have unstable respiratory control system. And this is all related to the immaturity, they have periodic breathing, they have apnea, they have these hypoxemic episodes, many times are more behavioral than respiratory in the so there are many of the things that will make us give oxygen to babies that may have relatively normal lungs. So this is something that has become to focus now, at many centers. And at this point, NHLBI, from NIH is funding a very interesting study prospective study, where more than 700 babies have been enrolled already. And they have been monitored from the first days of life or hours of life until they are 36 weeks, collected age, and all this monitoring signals are being kept and analyzed in each of these institutions, trying to describe exactly what is happening with these babies in terms of apnea, periodic breathing, intermittent hypoxia, etc, etc. So some of these data was already presented in the last day PHS in Denver, and at this point, the data has been prepared for publication. And I think that that it will substantially add to our knowledge in terms of what's going on in these babies again, not not only with the lungs, but with their, their respiratory control. And there are other interesting studies going on also the Miami involve with a with a DSMB, where they are showing that we are discharging many babies home, on room air who have significant hypoxemic episodes related to apnea after discharge. So this is another this work is in the spirit of a book, Dr. Hunt, who has spent all his life evaluating respiratory control in preterm infants. So also, I think that we will have a new information coming up from those of those trials.

Daphna 48:02

I think that's a really good reminder, right? We're so we're a little siloed in the in the NICU admittedly, and we forget how much of the work right if this developing person happens once they leave the NICU? Right, and how important our you know, transitions of care are to their next, you know, medical home would agree with

Speaker 3 48:24

this. And that's why it's so important to to involve parents earlier. And I think we are I don't know, I say we here in Miami specifically. And I think what we're all here in the US, we are lagging behind Europe and Canada, in terms of having a family integrated care in our neonatal ICUs. It may have to do with styles of life and the fact that many women here work and they cannot spend as much time as they would like and we would like them spending with their kids. But I think that this is yes, this is this should be a much easier transition and should not be from one day to make the baby goes home in literally different hands because moms here don't become that involved in the care of their infants.

Ben 49:20

I wanted to switch gears a little bit and talk about like Daphna said, You've done so much work on BPD but your career is more than that. And particularly I wanted to talk a little bit about mentorship and training because you have you have trained many, many amazing neonatologist who went on to have great careers. I wanted to know what is your secret sauce to to successfully training young physicians in the field of neonatology?

Speaker 3 49:49

Well, I guess the most important thing is that we feel that this is the key The essence of what we are and what we do in academic institutions and institutions where there are training programs. What we do here is important. But it becomes much more meaningful if we are multiplying this by having other people, or many people who will do the same things, or maybe better things when they move to other institutions, either academic institutions or private practice. So you probably heard me saying this many times, but in I just said it to our new fellows. The training program really is the core of our division. And everything circles around, you know very well Ben, because you were here for three years that they care in our unit is intimately related to our fellows, they are you are you were in our fellows are the people who are there day and night at the bedside. And they clearly define and determine the quality of care in our unit. So if we want to provide good care, we have to make sure that our fellows learn as quickly as possible to provide the care that these babies need. Our research efforts are all fertilized and enhanced by the presence of fellows, we wouldn't do half of what we do, if it was not because of your because again, we we not only coach you and mentor you, but you give us feedback. And it's a cross again, fertilization of discussions and knowledge and so on from from our research activities. So I do help us train the residents, the residents spend much more time with you in the unit than with the attendings that, unfortunately, we cannot spend as much time as we would like many times in the in the ICU, or in the rest of the unit. So I think I think that the the fellowship, it's really the heart and soul of any academic I think program. And we are very proud of our fellows. And we want them to be successful and enjoy neonatal neonatology as much as we have enjoyed taking care of, of newborns. And

Ben 52:33

I think I think you're selling yourself a bit short because you make it sound as if there's this delegation of power. When for the people who may not know the you make a point yourself to check in with the incoming fellow every morning and the postcard Fellow at like, seven o'clock, 730 in the morning. And unless you're out of town, you are in the fellows office, just finding out how the night went, what are the difficult cases and you do this every single day. And so you are putting in a tremendous amount of time and effort to and consistency. And so I think it's it's, it's it's this support that you're almost taking for granted because you didn't mention it but you do make it involves waking up and involves, it involves coming to the office at a certain time to catch both the postcard lender and the oncoming fellow. And I think that speaks volumes to I think the training that's provided at your institution and and to the success of your of your trainees. How do you keep the stamina to keep to like, that's what I was wondering as a fellow is like, how do you have the energy to that you're doing this in the first few years after you become the division chair? Fine. But you are an established you're a great of the field and yet you still come in every morning at 777 30 in the morning to check in how do you have the energy and the passion to keep doing this?

Speaker 3 53:59

Yeah, by the way, this is one of the things I really hate that has changed now during the pandemic because our presence in the unit clearly decreased not now it's we're coming back again to normal but so I did this on Zoom was good and bad because I could do it sometimes even when I was traveling for meetings, and she could still log in at 730 or 745 and spend some time. And the the truth there is that I think this this is an important activity for the fellows and for the kid in the unit because I think it's important to keep some standardization and and and try to to, again, give a consistent message to young people who are in training. But I have to tell you that this benefited me also a lot because it allowed me to stay fresh even when I was attending less It allowed me to know what is going on in the unit, not only with the fellows, but in the interaction with the other specialties and with nurses and therapists. So, like, like everything else I told you from the beginning, this is a two way street, I was giving something but I was getting probably more. And I am getting more every time that I meet with the, with the fellows in their, in their office in the morning.

Daphna 55:27

I love though I and it's obvious that you have a great relationship, you know, with your fellows, and you have this balance of this autonomy and super advisory role, but I think you've described something very important that I think is becoming less and less talked about and it's really about how much of medicine is both the clinical care and the propagation of discipline? Certainly, neonatology is no exception comes on the work of trainees. And so my question is really, you know, what do you think are some of the vital components that programs should be doing to really support trainees, both their professional development, their, you know, emotional, you know, mental health needs, their work life balance? What are the things we have to do to keep to keep the people who run, you know, so much of our so many of our units, you know, fulfilled and happy and coming back every day?

Speaker 3 56:35

Yeah, again, I think that it goes back to what I just said before, I think this is a two way street. I think that churches all over enjoy teaching, because what they are giving, but they are also receiving a tremendous amount. And sometimes we don't even realize how much we get from our interactions with with trainees. So I think that it's not a difficult task. And yeah, I'm a little bit worried actually, about the future of training. Because I think that many other things in life are getting much more bureaucratic, there is less flexibility. There are more rules that are implemented with good intentions, I think, to protect the trainees and this and the other. But I think that some of these things are, are taking away sub some of this contained 80 of the training programs and some of the interaction. And some also have the common sense. In other words, I understand that, that fellows should have their time off and should not be abused in terms of how much they have to do in the unit, to provide care and this and the other. But I think that we may be losing a little bit, especially those of us who are intensivist, I don't think that you can be a good intensivist if you have to stick to these pain rules and that you cannot do more of these in the unit. And I think that that I am a little bit worried about that. And again, this has nothing to do with neonatology have to do much more with what's happening in general with the world. And it's not only affecting medicine, but it's affecting many other disciplines also. But again, I think it's it's essential to put to, essentially to realize that how much our trainees are contributing. And this again, I talked about Ross's famous and everybody else, it's a it's a, it's it. I think it's teaching is a wonderful activity for humans, in general, in medicine, I think adds a huge additional dimension. So I really think that we are extremely privileged to be able to do both things to take care of sick people, in this case, sick, tiny infants that are totally dependent on what we do, in at the same time, give our knowledge and our experience or at least give part of our knowledge and experience to Chinese I cannot imagine of anything more fulfilling and more again, rewarding than then be able to do those two things simultaneously.

Ben 59:35

My last question to you Dr. Bank, Laurie, is you've seen the field of neonatology evolve and you've seen so many advances so many things being taken away introduced, what is the one thing that gets you the most excited about? It's it's future use in the field and doesn't have to be specific, but I'm curious if there's one aspect of current research that really gets you I'm excited about what it could bring to the NICU and how much it could improve outcomes down the road.

Speaker 3 1:00:07

That's a difficult question. Because I think that there are many different things. You know, I have, I am, at this point very excited about, I think, the new frontier in Perinatology. That is fetal interventions. I think that the rest of the things in the unit are relatively stable. I don't think that they will be I don't see major breakthroughs. In the near future, I hope I am wrong. And there are some major breakthroughs. But I, I think that we are settling in as I mentioned before, in many ways, we are settling and we are improving by doing less by being more conservative by making sure that we do less harm. On the other hand, I think that the field of fetal surgery is has a great potential, it will affect a relatively small number of kids, but make such a big difference, you know, you have a fetal tracheal occlusion, secondary to a membrane. And just to know that the, the fetal surgeon can go into that trachea and with laser, open that membrane and change completely the expectation of that kid from certain death immediately after birth to a baby who may have absolutely nothing. And I think that that is really amazing. And I am writing a book now anything that the newborn Lamba use, you know, this will be the fourth edition. And so I asked our Maternal Fetal Medicine chief here, the third one to write a chapter. So he wrote a chapter. And then he describes these techniques, and he puts minimally invasive techniques. I'm leaving something and I write a comment. This is really minimally invasive. inside and then a band aid laryngoscope in a tube, and go into the trachea of the baby and do laser, they're

Daphna 1:02:14

in many less invasive.

Speaker 3 1:02:17

This is non invasive invasive would be if we put the mother to sleep, we open the abdominal wall, we open the uterus, and we take the fetus, airway out, we expose it that will be invasive, this other thing is less invasive, less invasive, or non invasive, he said,

Ben 1:02:36

The Body of humans and it remains minimally invasive. And then

Daphna 1:02:41

relative, I said,

Speaker 3 1:02:42

Tell me and we do this in 15 minutes. So I am excited about about the audit. This fetal interventions in some of them are medical, some of them are surgical, but I think it's it's just fantastic that that can be done and go on with the pregnancy and have a baby who's normal afterwards.

Ben 1:03:06

That's amazing. Well, Dr. Bank, Laurie, thank you very, I mean, we're coming to the end of the hour. It was it was phenomenal. I really appreciate you sharing with us your experiences, your your your your advice, and thank you for all the work that you do. Thank you, again for for all the training and all the guidance. I think people will get a lot out of this episode. Daphna, thank you very much as well.

Daphna 1:03:28

Yeah, Ben's really been looking forward to speaking with you. So I'm just so pleased that we got to have you on. So the one

Ben 1:03:35

thing is that all the things I usually say to Daphna is usually things I repeat that I learned from you. So now she

Daphna 1:03:40

say, you know, Dr. Benkler used to always says and this so just know that your passion for teaching has paid its dividends and it's staying with your trainees for sure.

Speaker 3 1:03:55

This is what I was saying before. So it's not only the fellows, but the fellows past some of that knowledge to other people, to other colleagues. And in that that's a nice thing of, of being one of the

Daphna 1:04:07

best teachers in our unit. Thank you.

Speaker 3 1:04:11

Thank you very much. Thank you both. It has been a pleasure to have this conversation about the most interesting field of medicine by far.

Ben 1:04:20

That's correct. That's correct. Thank you for listening to the incubator podcast. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot the dash incubator.org. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care professional. Thank you

Transcribed by https://otter.ai