Hello Friends 👋

Welcome back to the second installment of our mini-series on "Managing Respiratory Distress." Today our guests include Dr. Richard Polin and Dr. Amy Miner. This episode continues the exploration of neonatal respiratory distress, with a specific focus on the effective use of CPAP (Continuous Positive Airway Pressure) in treating newborns.

Dr. Polin, a distinguished expert in neonatology, and Dr. Miner, a Neonatology fellow at Rutgers University, discuss the critical role of CPAP in establishing Functional Residual Capacity (FRC) in neonates. They delve into the advantages of CPAP over invasive respiratory support, highlighting its ability to reduce or avoid the need for mechanical ventilation. The conversation also covers the importance of noise created by bubble CPAP in improving ventilation and oxygenation, as well as its potential role in promoting lung growth.

This episode offers a comprehensive look at the practical aspects of CPAP application. Today's guests discuss the selection of appropriate CPAP levels, the variability in practice across institutions, and the impact of different interfaces on pressure delivery. They also address potential complications of CPAP therapy, such as pneumothorax and nasal damage, providing insights into prevention and management.

Our heartfelt thanks to Fisher & Paykel for sponsoring this series.

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Watch the video below to learn more about how interface design can affect your therapy outcomes, or for further insight into the evidence, download the NIV in NICU Clinical Evidence Summary Booklet.

Fisher & Paykel Healthcare offer a full neonatal care continuum which helps provide the best start possible to our precious babies worldwide.

To help demonstrate the importance of interface, Fisher & Paykel Healthcare have created a neonatal airway simulator (Baby LIV) which is based off a 28–30-week gestational age neonate. The simulator helps visualize pressure and flow therapies. For more information and to book an in-person demonstration, go to https://www.fphcare.com/us/hospital/infant-respiratory/cpap-interface-design/

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Short Bio: Dr. Richard A. Polin is the William T. Speck Professor of Pediatrics at Columbia University, College of Physicians and Surgeons and is the immediate past Director of the Division of Neonatology at Morgan Stanley Children’s Hospital of New York-Presbyterian. From July, 1977 until January 1998, Dr. Polin was a faculty member in the Division of Neonatology at the Children’s Hospital of Philadelphia and Professor of Pediatrics at the University of Pennsylvania. In 1998, Dr. Polin returned to Morgan Stanley Children’s Hospital of NY- Presbyterian as the Director of Neonatology. In the spring of 2006 Dr. Polin received the National Neonatal Education Award from the AAP’s Section on Perinatal Pediatrics and in 2017 he was inducted into the “Legends Hall of Fame”. Dr. Polin is the 2021 recipient of the Apgar Award from the American Academy of Pediatrics. Dr. Polin has published over 200 original papers, 20 books (including Fetal and Neonatal Physiology, Workbook in Practical Neonatology, Pediatric Secrets and Fetal and Neonatal Secrets,) and more than 200 abstracts. Dr. Polin is the Chair of the NICHD Neonatal Research Network executive steering committee, and he is the past chair of the Sub-board of Neonatal-Perinatal Medicine

Short Bio: Dr. Amy Miner is a neonatal-perinatal fellow in the department of Neonatology at

Rutgers Robert Wood Johnson Medical School.

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The transcript for today's episode can be found below 👇:

Ben: 1:06

Dr Richard Polin and Dr Amy Miner. Thank you so much for making the time to be with us today on the podcast. I wanted to continue the discussion that we started yesterday, dr Polin, and now with Dr Amy Miner, in terms of we've discussed a little bit some of the pathophysiology of respiratory distress, we've talked a little bit about some of the therapeutic approaches, and so for the people who are joining us starting today, maybe go back one episode and listen to episode one, as we're going to delve into a little bit of some of the management Now. I guess the first question I wanted to ask you is that we've talked yesterday about the fact that CPAP is very beneficial in the context of RDS. Can we go over some of the basics as to what do you guys see as? Why is CPAP, then, the beneficial treatment and not just like some other form of respiratory support, like a nasal cannula or like a face mask, like they do in the ER? You know, like what is it with continuous positive airway pressure that helps babies who are struggling with RDS?

Amy Miner: 2:11

So CPAP is important to establish the FRC, and studies have shown that earlier that we can start that we can establish FRC, the better. And then, of course, the huge benefit is that using CPAP, you can either reduce the time that you're on mechanical ventilation with invasive respiratory support or avoid it altogether. So that's really the biggest advantage is avoiding or reducing the time of invasive, invasive support.

Rich Polin: 2:51

So for me CPAP is wonderful because it can be delivered noninvasively, it does not require intubation. There are other strategies like it but in comparison with other noninvasive strategies I think the literature would say CPAP is more effective. Cpap has several advantages. It deliver through the bubble. People have shown that the noise created by bubble CPAP helps to keep the terminal airways open and promotes better ventilation and oxygenation. And CPAP in human trials has been showing to promote lung growth. The longer babies you want to CPAP, the better pulmonary physiology they develop.

Ben: 3:35

What do you mean by the noise of CPAP? Like the noise the machine makes.

Rich Polin: 3:38

Yeah, the noise. If you put your set scope on a baby who has bubble CPAP on, you can't listen to the harder lungs where you hear the bubble. And people on the West Coast I'm blocking on the name now Cindy McAvoy has done studies and shown that the longer CPAP is on, the better improvement pulmonary function occurs, and Jane Pilla has shown studies in animals that that noise probably helps to keep terminal airways open and again promotes better ventilation and oxygenation.

Ben: 4:15

Amy, I'm curious to know, when you are managing patients with RDS, what is your standard sort of CPAP level that you're beginning with for babies with RDS?

Amy Miner: 4:26

So I think that's a very interesting question, one that has always intrigued me, because it has it differs significantly by the institution you're in and even the area of the country. I did my residency on the West Coast and now fellowship on the East Coast, and on the West Coast we generally would start at higher peaks or feel more comfortable going to higher peaks, and then in the institution I'm at right now, we start at five and go to six, and that's our limit. So that has been very interesting to me, because we don't have a lot of evidence, we can't truly measure what people we are delivering, and so you know what is the maximum amount of peep that we should be giving and where should we be starting. I think that's a great question.

Ben: 5:23

Dr Polin, and do you have an opinion as to the starting positive and expiratory pressure? Yeah, we should start.

Rich Polin: 5:31

As you may know, the religion at Columbia is placed all our live born babies on CPAP within doing respiratory distress and our nurses routinely choose five. It's a made up number. I don't know whether five delivering noninvasively is better than six or seven or eight. What we do know is that many centers around the country, and especially in Canada, are using higher levels of CPAP and studies done by the group in Melbourne, australia, Stuart Hooper and others have shown that higher levels of CPAP and they've looked at actually peep grid and they want five up to 10 can promote better air entry to longer. The method they use is electroimpedance tomography. The bottom line is they can show that things improve dramatically by using higher pressures. I would always say if five works, use five. If it's not working and you were limited every technical reason why CPAP is not working the mouth is closed, the nares are suction then for me I go up to eight as a routine in my management of babies, but it's probably most effective when you do that early on in RDS Once they've developed atelectasis. I think Dr Marlowe said that this it's not going to be as effective.

Ben: 6:50

So, when you're putting a baby on CPAP, my question to you is what are some of the side effects of the intervention? Yesterday, on the first episode, we discussed how every intervention has its own inherent side effects, and so for you, when you're thinking of CPAP, what are the things you keep in the back of your head as potential complications of that therapy?

Amy Miner: 7:07

Yeah, great, I think that's really important. So certainly early studies had shown that CPAP has an increased incidence. Using CPAP has an increased incidence of pneumothorax. So we always keep that in mind, with, of course, the caveat that the initial studies they did not give surfactant to those infants on CPAP, whereas the ones who were intubated did receive surfactant. So then the question is you know how much of a, how much should our concern for pneumothorax color our use of CPAP and how high of a pressure we're willing to go? And I say that because I think we have to have to think about the association between pneumothorax and CPAP. Is it, is it truly because of over distention or is it because of atelectasis and the sheer trauma of inadequate pressure, initially right, because animal studies have shown us that really more of the lung injury is due to atelectasis that sheer trauma. So pneumothorax, of course we always think about that. And then we also know that septal erosion and, you know, nasal damage is is a risk of CPAP, something that that we need to watch carefully, that we should monitor closely, and there are options we can change the interface to mask if necessary. Certainly that's important to to think about. And the other thing is that CPAP really is labor intensive. I would say from a nurse's perspective. They really have to be aware of how that, how the interface is sitting with the, with the infant Infants typically are uncomfortable with, with those and they don't always stay in place. So do you have trained your nurses, you know, are they very comfortable always making sure that you have an advocacy? You know those kind of things.

Ben: 9:19

Dr Polin and I wanted to ask you about bubble CPAP specifically because I know we've talked about it for the people who are curious about, like, let's say, let's say people don't know what we mean when we say bubble CPAP and why. Why do we have this little bubbly apparatus at the bedside of the baby? How is that different? Can you tell us a little bit how bubble CPAP generates pressure and and, and how did it come about? I guess?

Rich Polin: 9:44

So how did it come about? I it came. Cpap came about from an observation from South Africa that when babies with RDS were intubated without positive air pressure, their oxygenation fell and and when the tube was taken out they were allowed to groin and generate their own positive pressure, oxygenation improves. That was the original observation about CPAP and in the 1970s at Columbia we decided to use a very simple system for CPAP. We didn't originate bubble CPAP, which was used in other places around the country. It means that the expiratory limb off the nasal prongs is inserted into a volume of water, can be diluted acetic acid and it's inserted to a depth of five centimeters and the bubbles continually see come out as the baby excels and the pressure is generated is affected by the depth that the expiratory limb is inserted, and so, for people who don't realize, that's why it's measured into, that's why it's measured in centimeters of water. That is it's?

Daphna: 10:54

literally, it's literally centimeters of water. Um, so to that point, I mean, I have my own ideas about practice, but I'd love to hear from the two of you about why you would use bubble CPAP over conventional CPAP. What sorts of physiologies or pathologies would make you choose one over the other? And my second question, maybe Dr Polin and you can answer this when we started, when we started really using CPAP as a kind of historical note, why did we start at five? Why not four?

Rich Polin: 11:31

Uh, tradition is a simple answer to your last question, it's. It's a made up number. And again, whether you choose five or six or four in your nursery, I don't think it matters very much, they're all low pressures. There's some inaccuracy in the measurements. So I think all those numbers are okay. And just to point out the differences in CPAP ventilator CPAP, at least in the small randomized clinical trials, has not been as effective as blood bubble CPAP in preventing respiratory failure. And then in the second instance of bubble CPAP versus infant flow driver, which is the other major technology used for RDS, bubble CPAP had some advantages in terms of the uh decreased duration of CPAP use and, again in babies were ventilated for less than 14 days, decreased incidence of respiratory failure. So it's not a lot of data uh supporting one type of CPAP over another, but I think that bubble CPAP is better than infant flow driver it was a pretty large study out of Millsboro which demonstrated that and probably significantly better than ventilator derived CPAP.

Ben: 12:47

I wanted to then touch on the point that Amy brought up, which relates to interfaces, because I think that today, when we're looking at the number of interface, that interfaces that are available for us to deliver CPAP, we have a wide choice from nasal masks to large nasal prongs, to small nasal prongs, and so I am wondering, amy, or Dr, or or Richard, if you, if you can, comment a little bit as to what benefit does having a multitude of option brings about, but also what are some of the risks in terms of how it can effectively change the intended intervention.

Amy Miner: 13:30

I think it is important to recognize that each interface is different. I think that certainly, each hospital system will, you know, choose the ones that they use and um, and there are others that they don't use. I think that you can, um, you can get a, uh, a good effect from you know most of of the interfaces, but I think the important thing is to understand the specific interface that you're using and understand what is the minimum and maximum um pressure delivery that you can expect and um how it needs to be used effectively. Yeah, I guess. Yeah, I guess that's it.

Rich Polin: 14:14

So I would add, the interfaces are used very differently. If you're using the RAM channel, we know that the prongs occupy about 68% of the nares. We're using CPAP. The prongs are sort of fit and include 100% of the of the nares. Uh, you try to choose an interface which has a relatively low resistance. If it has a high resistance, you may not be delivering the pressure that you intend to do, and I'm not going to get into arguments about which kind of interface is better, but you're choosing one with a low resistance that allows you to deliver the pressure you intend to do. I think it's very important.

Ben: 14:55

And that's the point I'm trying to get at, because I think that, um, the point here is probably not to say which interface should you use. I think the interface is at the discretion of the of the clinician and the team. However, um, I think that there's that there's a an important misconception sometimes where, um, we will change interface for quote, unquote comfort, so we'll say, oh, this baby doesn't really like to have the, the mask on its nose and prefers those, those thin silicone prongs in the nose, and, and we do this based on comfort, because the baby will be more comfortable, but yet we set the people level at the same number and we assume that the delivery will be identical, when in truth, by making that change, it was, uh, maybe driven for comfort, but you've effectively changed the therapy. And I think, is there, is there any data, or do you have any, have any experience as to how changing the interface can really change the amount of pressure being generated and, effectively, what you've intended to do with these infants?

Amy Miner: 15:56

We actually did a study, and I say we with the group at the University of Utah, we did a study where we took a variety of interfaces. We did both with CPAP interfaces, ram CAN, high flow nasal cannula, and we measured the pressure delivered on a model. So it was a 750 gram model of a neonate, so it wasn't in an infant right. Obviously there are some limitations with that, but what we were really looking at was not the specific pressure delivered but the changes in pressure delivery. So using the same set-peeps, the same flow, and we used a variety of the set-peeps and flows we looked at how the delivered pressure changed between interfaces. It was significant and it was interesting and it a lot depended on the internal diameter. But I think with the RAM CAN it was really important to note the difference between having it non-occlusive because how they recommend, 80 percent or less occlusion versus full occlusion, because sometimes we use the we it is used. I should say the RAM-CAN is used as a way to deliver CPAP and if it's used how the manufacturer recommends, you're not delivering very much pressure at all. So there certainly is a difference and I think that, even though we can't quantify exactly how much pressure we are delivering. I think the important point is that when you change interfaces, being aware that you are changing your pressure delivery.

Rich Polin: 17:51

The Invitro study Amy's talking about. It is great, but there have also been In vivo studies that show that the RAM-CAN delivers less pressure to the order of firing. Send us standard binasal prongs. I think they use Hudson prongs in their trials. I think it's pretty clear that the RAM-CAN, with a high resistance, is not going to be delivering the same kind of pressure as standard binasal prongs. Does that mean you can't use it in some babies? Well, some babies don't require much pressure if their airways open and probably the RAM-CAN is fine. But if you have a sick baby, I think you want to choose an interface like binasal prongs which can deliver effective pressures. The pressure you said is the pressure you're delivering to the airways of the babies. I think for sick babies it does make a big difference.

Ben: 18:43

I think that's an interesting point because at the end of the day, like we said in the beginning, people can choose the interface that they please. But I think there's room in certain cases, especially when the babies are not that sick, where you could make some adjustment on your end to try to compensate for any leakage or any loss of pressure, to actually generate something closer to what you had originally attended. But, like you said, in babies that are quite sick that need this consistent delivery of pressure that we can rely on to make further clinical decisions, then that's when the send gets a little bit wetter and it's a bit more difficult to know what you're doing.

Rich Polin: 19:17

To me. The RAM-CAN is used like a high-flow nasal cannula.

Ben: 19:21

Right, and we'll have a whole episode dedicated to high-flow nasal cannula, a minga, yeah, so we're excited about that as well. Yes, daphna, go ahead.

Daphna: 19:30

Yeah well, we talked about alternating interfaces for a certain scenario, but many units are routinely alternating interfaces, for example, to minimize breakdown. What you talked about is a potential adverse effect or perceived comfort for the infant. So me we could talk a little bit about the pros and cons of using an alternating method, especially with the risk of losing the FRC during the swap each time.

Rich Polin: 20:04

So I'm going to respond. We do not routinely alter our ways of delivering CPAP. If a baby has no nasal septal erosion and is tolerating CPAP, well, we leave the baby on bubble CPAP until the point where the illness becomes a lot less and we might use high-flow nasal cannula. At that point, if a baby has nasal septal erosion and we recognize there's redness of the nasal septum or hopefully not depression of the nasal septum, we'll take nasal prongs off and deliver CPAP through nasal mask.

Amy Miner: 20:39

Yeah, so that's essentially our practice as well. Where I did my residency, however, it was different. We routinely every shift would change the interface. So I think one of the things that has come up in our conversation here where I'm at now is how much are we risking losing our FRC, and that I don't know that there's really been any evidence to guide on that.

Rich Polin: 21:13

Amy, would you give us an evidence-based practice from your West Coast experience or an experience-based practice of alternating different interfaces?

Amy Miner: 21:25

So I believe it's experience-based. I honestly am not aware of any evidence on that.

Rich Polin: 21:32

I agree.

Daphna: 21:34

Since we've touched a little bit actually on some of those adverse events and some of the breakdown associated with all really of the interfaces, maybe we can talk a little bit about some of the preventative measures that we can be taking to make sure that we can provide the interface we had intended to use and not have some of those adverse events.

Rich Polin: 22:02

Amy, how do you practice it where you are?

Amy Miner: 22:06

I think the most important preventative is regularly monitoring how the interface is applied to the infant and what affects. I think if it's very closely monitored and everybody is really aware of that, it's much easier to make some changes in how it's applied or reduce pressure points early on and not ever get to the point where you have to completely remove the infant from nasal CPAP because of an erosion. That's kind of. Our process is just very close monitoring and making sure that the interface is applied as it was designed to be applied.

Rich Polin: 22:55

Yeah, I think that's the right answer. I would just add that it's how you apply the prongs and how you can fixate the prongs to the head determines how much movement occurs in them. Our nurses are great at making sure that the prongs are fixed and are always above the nasal septum. There are different ways of applying CPAP, different systems. The music Columbia is very simple and it's done with a cap and tape and it works extremely well.

Ben: 23:26

Yeah, there are some babies that are very much movers and you find themselves dangling off their respiratory support somewhere in the vicinity of their isolates, I agree. So now I wanted to really introduce some complexity after we've talked about all this, in terms of how we've talked about CPAP, we've talked about interfaces, and I feel like some babies are going to do well, as Amy and Dr Polin have said, and you know, there are some babies who are not going to do so well and they're going to need more. And our reflex, I think, as clinicians and you tell me if you have the same which is that if a baby fails CPAP, we go to non-invasive ventilation, we go to an IMD, and I feel like, when we are moving to an IMD, first of all, that decision in and of itself is something that I think we should discuss, because you touched on this yesterday, dr Polin, but like and you've touched on this also today in terms of CPAP thresholds, but is there a criteria that, to you guys, you say okay, now we need to rely on an IMD in order to support this infant? Some people are also questioning whether surfactants should come after a trial of CPAP, or maybe after a trial of CPAP and an IMD, because a lot of people are talking about FIU2 thresholds, saying, oh, if a baby requires 30, 40% of FIU2, then we should provide surfactant, but does that mean on CPAP, does that mean on an IMD? I'm very curious about what is your individual approach to these infants and do you have a stepwise approach to escalating care for both an NIMV and surfactant?

Rich Polin: 25:04

Let me just make a comment. NIMV, is a great idea Theoretically. You're giving a breath through the prongs, getting rid of CO2, helping with ventilation, helping with oxygenation. But the studies that have been done out of Melbourne have clearly shown that most of the NIMV breaths are not transmitted to the airways. The title of the line doesn't change and the reason is because the vocal cords are docked during the use of NIMV. For me, the primary benefit of NIMV is not so much you're going to ventilate the baby more effectively, but you're going to be delivering a higher mean air pressure. Every time you give a breath the mean air pressure is going to go up because you're giving a higher peak inspiratory pressure, but it has little to do with delivering more effective ventilation to the lower airways. So I'm not a big believer of NIMV prior to intubation and surfactant Post-extubation. I think the data are pretty clear that NIMV has benefited in decreasing post-experts, both ventilatory respiratory failure, but pre-intubation. I do not use it very much. I guess if you think you need a higher mean air pressure, why not just give it through bubble CPAP instead of resorting to something like NIMV? That's my prejudice based on a little bit of data.

Amy Miner: 26:34

So I would say that our practice is very much the same philosophy. I do think I've been intrigued at a couple of studies that have come out recently. I think just in, a 2022 study came out about non-invasive high frequency oscillatory ventilation, and I don't have experience with that, but I think that that will be interesting to see if that shows a good response or a good outcome, I should say so that'll be interesting to watch.

Ben: 27:09

Any of you have experienced. Since the point you made, dr Polin, about the vocal cords during an IMV, have you guys had any experience with newly adjusted ventilatory assist, nava, or NIVNVA as it is known in terms of maybe synchronizing with the baby a bit better?

Rich Polin: 27:28

We have, but usually in babies that are very complex, so babies with gastroschisis. So we've used NAVA New Early Assisted Ventilatory Assistance in those circumstances, but not as a routine way of ventilating babies or using it non-invasively.

Amy Miner: 27:47

Yeah, same with us. We've used it infrequently, but when we do get to that point and we use it, it is successful.

Daphna: 27:59

And Ben, just as an alternate perspective. We use quite a bit of NAVA, so I don't know if you want to give your opinion.

Ben: 28:05

No, I mean, that's an interesting point. I think we fall in line with what the practice at Columbia is in terms of using it in more medically complex babies. I have not. It's maybe something interesting to try, but we have not really tried non-invasive NAVA on a baby that's a full-term, late pre-term baby with respiratory distress or the afterbirth and I think, because Dr Polin said, most of our babies do very well with C-Pap. We rarely have to go to an IMV, so it's really a small sample. I wanted to ask you a little bit about this new recommendation and what you guys thought about this. Since we're talking about C-Pap and since we're talking about RDS, where the WHO came out in the Lancet not too long ago this was something that was discussed at a webinar with Dr Roger Sol from Von that we should try C-Pap empirically on any baby that is presenting with RDS, and I am wondering if to you there is a gestational or age cutoff, like they recommended by the WHO, where you just have to try C-Pap and you don't have to think about it and almost make it a blanket intervention.

Rich Polin: 29:12

That'll be very simple and say is there a religion at Columbia that our nurses say any baby with respiratory distress, preterm term, all those babies get placed on CPAP. If they're doing well, cpap is removed pretty quickly. I guess I agree with Dr Soul that there's a wide range of babies, even during the transitional phase after the birth, who benefit from short-term use of CPAP.

Amy Miner: 29:39

I absolutely agree as well. I think that very quickly establishing FRC has been shown to be beneficial and I do think that it's warranted. It certainly is how we practice as well very quickly using CPAP, yeah.

Ben: 29:57

So I think we'll post that. I guess it's an article. It's kind of short, it's listed under a comment, which is a bit more than a comment, but the WHO's 11 new recommendation and good practice statement for care of preterm or low birth weight infant and it recommends CPAP immediately after birth for infants that are born before 32 weeks with or without respiratory distress, and it recommends CPAP and parentheses bubble CPAP for preterm infants who are less than 37 weeks who need CPAP therapy. And so I am wondering if maybe this is driven by also a global health perspective of trying to find a relatively cheap and effective method of supporting infants with RDS. But yeah, I thought that was very interesting.

Rich Polin: 30:48

Yeah, as you know, bubble CPAP is so low-tech. I like to call bubble CPAP no check because it can be done anywhere in the world, in any country, to support babies with respiratory distress.

Ben: 31:02

I'm tubing a bucket of water and you're good.

Rich Polin: 31:05

Right, basically a bottle of water, some tubing. You can create a bubble CPAP device pretty simply, so I like the thought of using it in. We use it very liberally here at Columbia.

Daphna: 31:20

In addition to the recommendations, you've alluded actually a little bit to some of the theory behind that about improved lung growth on CPAP. Maybe you can speak a little bit about that as well.

Rich Polin: 31:32

Yeah, I mean there's not a lot of data. There's data in experimental animals that CPAP promotes lung growth, but animals are not babies and there's been a couple of studies randomizing babies to continuing on CPAP when they meet criteria for discontinuing it, showing better FRCs, better lung function, if they're maintaining on CPAP for a two-week time period after they meet criteria for normal removal. That's the studies of Cindy McAvoy from about, I guess, a couple of years ago. So there's a lot of theory that CPAP promotes lung growth, but not a lot of data. That's the one clinical study that I often refer to.

Ben: 32:16

As we're getting close to the end of this conversation, I wanted to go back to 2008 where, when the coin trial is published in the New England Journal of Medicine so for people who need a refresher, write the article. It's called nasal CPAP or intubation at birth for very preterm infants, and this is really a paper that looked at intervention for respiratory distress in babies that were born between 25 and 28 weeks and really it showed that for these infants, early nasal CPAP really did not significantly reduce the rate of death or BPD, and making a strong case for nasal CPAP at birth for some of our smaller preemies. I am wondering if you guys can share both your experiences but also what has changed since that paper has come out and where do we fall in terms of the management of RDS of our micro preemies right after birth.

Rich Polin: 33:17

I can make a comment. The CPAP looks deceptively simple. You put some prongs to the nose, you have an expiratory limb going to a bottle of water to create pressure. But CPAP is not simple. If you look at the experience of Hanali, who is at GW, it took them about four years in their NICU and he came from Columbia until it started to get marked decreases in bronchopulmonary dysplasia. Cpap I heard Dr Miner say it requires a lot of nursing intervention. It absolutely does. In any study that uses a new technology like CPAP it's going to be very difficult over the course of one or two years to show that CPAP is going to have a benefit to reducing death or chronic lung disease. But clearly the meta-analysis of all the trials, which were very similar, the five trials show that death or BPD is decreased by use of CPAP. The same analogy when we started to use the hummingbird ventilator for RDS. You probably knew that. None of you were probably old enough to remember the hummingbird ventilator, but it was a high-frequency, oscilatory ventilator and it did not show any benefit. I think the problem was centers were not very good at managing babies with using that ventilator. And see if it's true about CPAP If you're not using CPAP. You start using it and you say tomorrow we're going to have great outcomes. That's probably unrealistic. It's going to take you a while until you start to see the benefits of CPAP. In my mind there's no question that death or chronic lung disease is lower if you look at all the trials compared to intubation and surfactant.

Ben: 34:55

So then I wanted to then get your opinion on what we often are responsible for in unitology, which is that we take some evidence and we let it trickle down to other patient populations that were not tested in the trials that influenced our current practice. So in that sense, we brought up the coin trial, which looked at maybe 25 to 28 weeks. Is there reason to attempt nasal CPAP even in smaller gestation, as we are dealing with them more and more frequently?

Rich Polin: 35:26

Amy, what do you have to say about that?

Amy Miner: 35:28

That's a great question, right, and certainly always important to look at how we're applying the evidence and if it's appropriate to generalize, especially to smaller gestational ages. And that's very, very difficult. But I would say that in the absence of a trial, I still would use CPAP. I would do a trial of CPAP if it's deemed appropriate in that instance. Right. If the infant has spontaneous respirations and is otherwise looking okay, I think that I would certainly do a trial of CPAP because we know that the benefits are great in the older gestational ages.

Rich Polin: 36:15

I totally agree, and we say we would even the smallest gestational age babies, we would try CPAP. So even at 22 and 23 and 24 weeks, knowing that the number of babies you're going to be successfully maintaining on CPAP is probably not more than about 30%, but still 30% who don't need ventilation will probably never need surfactant, that seems to be a reasonable approach. I may avoid more injurious practices like ventilation and surfactant.

Daphna: 36:48

As we're talking about. Like you all said, sometimes our success with any given device is really about the user and what we do outside of the interface for success. So that brings me to a point that I think some people either really really love or really really hate. But about the chin strap is it a way to provide more peep or is it evidence that maybe we're just on the wrong interface or a modality for the baby?

Rich Polin: 37:21

That we use chin straps routinely. Our nurses use them. I think they keep the mouth gently closed. You can buy commercial chin straps which I don't use. They use paper tape going underneath the baby's jaw and doesn't prevent the baby from opening its mouth but keeps it gently closed. And if you don't keep the mouth closed, whatever pressure you're giving through the nostrils into the oropharynx is going to find its way out of the mouth. So I think it's a reasonable way. Have I ever studied the success of CPAP with or without chin strap? I'm not. I'm not sure there are studies like that. There could be. I miss. It's part of our culture to use chin straps for our baby's one CPAP.

Amy Miner: 38:04

Yeah, and I would just add we don't routinely use them, but we certainly use them whenever it's necessary. And I would definitely say, though, if a baby needs a chin strap is certainly not a reason to to change your interface right. It's not saying, oh, this failed, but certainly you have to monitor closely. If you have a chin strap on, make sure that the baby can still throw up. If they're going to throw up, right, and it has to be gentle, but absolutely it's just an important part of making sure that the interface is working appropriately.

Ben: 38:38

I just like chin straps, so much.

Daphna: 38:41

I knew it was a point of contention. For you it's like chin straps.

Ben: 38:45

I dislike chin straps. I feel like I feel like there's too much at stake and and like, like I think it goes back to the point you both said you still need to. Now you have one more thing that you need to monitor because, again, the chin strap is not allowed to go past the chin, obviously, and then because then you're effectively choking a baby, and so that's, that's yet another thing. And, like Dr Polinin said, you rarely create a seal, which is quite good. You don't want to create a full seal, but I mean. So anyway, I don't, I don't, I'm not a big fan of chin straps, but that's my, that's my two cents.

Rich Polin: 39:17

And I just want other comments. The secret team, cpap. Effectively, it doesn't reside with physicians, it resides with nurses. So true, there are. Nurses know a million secrets about that. I could never, ever learn. I know what the CPAP is good for babies can have lots of benefits but our nurses know the secret, the practical application of CPAP. So if a new center is thinking of using it, I think going and learning from an established centers like Dr Miners or ours and others is a reasonable way to use that modality effectively.

Ben: 39:54

The last point that I wanted to make and then we can probably, we can probably call it a day is is really related to entrainment, and that's something that I learned in fellowship and that's something that I believe we often don't take into account when it comes to respiratory management of our babies, and I'm wondering if you can, maybe one of you, explain what, first of all, is entrainment, especially when we're using a device that allows outside air to come in, and how do we take that into account in assessing what we are giving babies who are on some form of respiratory support? Dr Miner, she's letting you go first. It looks like.

Amy Miner: 40:34

Well, I mean, I'll just say, you know, entrainment is just, you just have to be aware that you're counting on a room air as well. Entering that it's just not the flow that you're actually giving. And how do you assess it? Like how you assess with any other noninvasive device, looking at your, at the infant, how is the work of breathing? And once you are using this device, is the work of breathing decreasing, is your FiO2 decreasing or are you going in the wrong direction? So, I think, always looking at your patient and assessing their response to the therapy that you're giving.

Daphna: 41:15

I think that's such a good reminder about Dr Polin's comment yesterday that we can't just put it on the baby and then forget about them that we have to keep and walk away, you know. Move on to the next thing that we have to just keep assessing Is this working for the baby? Can we take it off sooner than we'd hoped, or was this the wrong choice? Or is the baby, you know, is the baby not being successful on the management Dr Polin.

Ben: 41:43

what are your thoughts on entrainment?

Rich Polin: 41:45

It's not. I don't see it as a significant variable with use of CPAP, so it's not a concern in the use of bubble CPAP, at least noninvasively. So.

Ben: 41:57

I think that's all the questions I had for you guys today. Dr Polin, dr Miner, thank you so much for making the time to be with us today to chat about CPAP and RDS and Management of Respiratory Distress in the neonates. And, dr Miner, I think we will see you on one of our upcoming episodes. And Dr Polin, thank you again so much for making the time to be with us on the incubator podcast. It's been fun.

Rich Polin: 42:21

Yeah, as always.

Amy Miner: 42:23

It's been a pleasure. Thank you so much. Thank you.