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#222 - 🫁 Mastering the Mechanics, A Deep Dive into Neonatal Ventilation Strategies (ft Bryan King)

Hello friends 👋

In this episode of the Incubator podcast, Ben interviews Bryan King, an experienced respiratory therapist and educator in neonatal and pediatric care. Bryan shares his journey into respiratory therapy, which began unexpectedly after initially pursuing x-ray technology. He discusses his passion for working in the NICU and the challenges of treating increasingly smaller premature infants.

The conversation delves into the evolution of neonatal respiratory therapy, focusing on the impact of surfactant and antenatal steroids in improving infant lung compliance. Bryan emphasizes the importance of avoiding lung hyperexpansion in nano-premies and discusses various ventilation strategies, including volume-targeted ventilation, high-frequency ventilation, and pressure support.

Bryan shares insights on selecting appropriate ventilation modes and settings, stressing the need to adapt strategies based on individual patient responses. He advocates for having a diverse set of tools and modalities available in Level 4 NICUs to provide comprehensive care and education.

The interview also touches on the challenges of weaning patients from ventilators and the importance of considering long-term outcomes rather than focusing solely on immediate blood gas results. Bryan discusses his experience as a non-physician educator teaching physicians and emphasizes the value of lifelong learning in the medical field.

Throughout the conversation, Bryan shares valuable tips for respiratory care, including the importance of encouraging spontaneous breathing, understanding ventilator feedback, and being open to trying different approaches when standard methods aren't effective. He also mentions his current project of writing a book about his experiences as an educator in the field of neonatal ventilation.

The episode provides a wealth of knowledge for healthcare professionals working in neonatal and pediatric respiratory care, emphasizing the importance of adaptability, continuous learning, and patient-centered approaches in this rapidly evolving field.


Short Bio: Bryan A. King was the Education Coordinator for Bunnell Incorporated and Clinical Specialist for International Accounts from 2020-2023. Bryan spent the first 15 years of his career in the Neonatal Intensive Care Unit at Forsyth Medical Center in Winston-Salem, NC and also worked for five years in the NICU, PICU and as an ECMO specialist at Wake Forest University. Bryan previously was the Regional Clinical Specialist for Bunnell in the Southeast region and was a clinical consultant for Dräger medical. Bryan has a bachelor's degree in history from the University of North Carolina at Greensboro and currently resides in Asheville, North Carolina. He has two children who are both currently in college.


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

Ben Courchia MD (00:00.826)

Hello everybody, welcome back to the Incubator podcast. It is Sunday. We are back with another interview. Actually, I am back with another interview. Daphna is off today. She is on a family retreat and it is my great pleasure to bring to you today our guest for this Sunday, who is none other than Brian King. Brian, good morning and thank you for joining the show.


Bryan A King (00:26.766)

Good morning, I appreciate you guys having me.


Ben Courchia MD (00:29.324)

Of course, for the people who are not familiar with who you are, you were the education coordinator for Bunnell Incorporated and clinical specialist for international accounts from 2020 to 2023. You spent the first 15 years of your career in the NICU at, I'm not sure if I'm pronouncing this correctly, Forsyth Medical Center in Winston -Salem, North Carolina. And Forsyth, sorry. My French roots are showing now.


Bryan A King (00:52.046)

Yeah, Forsyth, yeah, but yeah, that's North Carolinians. We have, hey, North Carolinians are pronunciations.


Ben Courchia MD (00:59.022)

You've also worked for five years in the NICU, in the PICU, and as an ECMO specialist at Wake Forest University. You were previously the regional clinical specialist for Bunnell in the Southeast region, and you were the clinical consultant for Draeger Medical. You have a bachelor's degree in history from the University of North Carolina at Greensboro, and you currently residing in Asheville, North Carolina with your two children who are both in college.


Thank you so much for making the time. I have to say, I'm very excited to speak to you because it is not every week that we get to speak to respiratory therapists. And we know that as in the NICU, you guys play such a crucial role in the care of our neonates that it almost feels like we should have more respiratory therapists on the show. But you know, like we always begin...


some of our interviews, I would like to ask you a little bit about what prompted you to pursue this career, to become a respiratory therapist. And specifically once you did become a respiratory therapist, what was the incentive to work with kids specifically in the NICU and the PICU? I'm wondering if you can share the inception story.


Bryan A King (02:10.926)

Yeah. So I backed into becoming a respiratory therapist. I was actually working retail. I was managing an American Eagle Outfitters. I knew I wanted to do something in medicine and I had friends who were x -ray techs. They seem to have lots of money and they seemed very happy. So I decided that I would become an x -ray tech and actually got into x -ray tech school. But the very first day it seemed incredibly boring.


Ben Courchia MD (02:14.522)



Ben Courchia MD (02:18.586)



Ben Courchia MD (02:33.658)



Bryan A King (02:38.798)

So I went to the allied health Dean and said, I, I don't think I can do this for the next 30 years. So do you have anything else in, in healthcare? I don't really care what it was. They said, we have one opening in respiratory therapy. And I said, I'll take it. What's that? So I put no thought into my career. All right. So that's, that's an important part here, but I have fit into this career, like around PEG and around whole.


Ben Courchia MD (02:50.49)



Ben Courchia MD (02:57.37)



Bryan A King (03:09.07)

It has been, it's opened lots of doors for me. Again, I grew up in the mountains of North Carolina. I didn't grow up traveling. I didn't grow up thinking I would end up in education. And so as far as how I ended up becoming more neonatal and pediatric focused, I knew immediately the very first time I stepped into a NICU, I was like, this is what I want to do. I think there are two groups of folks when they see that.


When they see a NICU and this was at Wake Forest University, they are either completely turned off or Enthralled and I was in the latter care category. I Loved it. I like the pace. I liked the excitement. I like that the fact that these children it's like reading a mystery They can't share with you. What's wrong. You have to deduce it and I loved that


Ben Courchia MD (03:45.882)

That's right.


That's right.


Ben Courchia MD (04:00.674)

It's almost a philosophical message of everybody wants to go into something they're passionate about, but it tends to be lost on us that there's a place to find passion in something unexpected. And I think you're the example of that. So I think that's very cool. And do you think, I mean, I'm going to share a little bit of my journey as well that...


Bryan A King (04:14.958)

Yeah. Yeah.


Ben Courchia MD (04:25.946)

I love working with events. I love neonatal pulmonary medicine. And I must say that a lot of the things that I've learned, I've learned from respiratory therapist. I would go at the bedside and I would tell my respiratory therapist, Joe, tell me like, how does this work? How do you set this up? How, what does this do? What does this not do? And, and I must say that every respiratory therapist that I've I guess bothered slash annoyed was always very keen on teaching me.


Bryan A King (04:50.03)



Ben Courchia MD (04:53.626)

And so I wanted to ask you, because you really took on this role as an educator, do you think that's something that's inherent to you? Or do you think that in every respiratory therapist, there is a portion that just wants to teach and explain how all of this works, whether it is the machine or the patient.


Bryan A King (05:11.918)

so I think that's a twofold question for me personally, my parents were teachers and I worked my entire life. I majored in history, minor in English. I worked my entire life to not become a teacher, even though that looked like the track I was going to be on. But I think I've got the soul of a teacher and I think it's probably ingrained from my parents and it's the family business. My brother is a teacher. His wife's a teacher. It's the family business.


Ben Courchia MD (05:16.954)



Bryan A King (05:40.558)

So that for me is how I think I was eventually drawn to it. My father was a coach. My brother was a coach. I enjoyed teaching and coaching, even though I didn't do that in the, necessarily in the public school realm, like they did, as far as other respiratory therapists you've run across, I think that the best respiratory therapists, and this is going to be a bias showing the best respiratory therapists.


are teachers at heart because we remember being students and we remember the physicians, the nurses, the other respiratory therapists who taught us. And one thing I've always said about knowledge, it's not yours. Not one bit of the knowledge that you have is yours. It was given to you by someone else. So it's incumbent upon you to share it because if you don't own it, then it's just this thing that you've borrowed that you definitely should give to other folks.


Ben Courchia MD (06:11.002)



Ben Courchia MD (06:39.226)

Yeah, yeah, that's so true. That's so true. I think and I think that's the biggest gift an educator can give to students is giving back what was like we're only the custodian of that knowledge in transits to someone else. So I think I think that's really cool. Your career is full of experiences. And I think you've had the opportunity to really.


Bryan A King (06:54.19)

Right. Yeah.


Ben Courchia MD (07:05.498)

dip your hand into a lot of different parts. I'm just curious as to over the years, what is your outlook on how the field of neonatal respiratory therapy has evolved in terms of how we manage patients, but also the tools that have come to market where really there's opportunities to ventilate a patient using so many different ventilators, different modes of ventilation, different interfaces as well. Can you speak a little bit about that?


Bryan A King (07:29.006)

Yeah. Yeah. Right.


Yeah, so I was fortunate. So I started in 2000. So I came in at what is what I would call the tail end of the early surfactant and a natal steroid revolution. I'm toying around with a book right now about my career in neonatal ventilation and talking about mostly nano preemies and how to how to treat those guys.


Ben Courchia MD (07:54.714)

I was going to ask you about that later on in the conversation.


Bryan A King (07:57.838)

Yeah. Yeah. Yeah. So thinking about that, it's the thing that I've generally focused on in my career is how do we avoid damaging these children? the thing that the antenatal steroid and surfactant revolutions did for us is it improved the compliance of the baby at the bedside. Right. So, and that was the goal. The goal was to improve compliance. So we give these kids antenatal steroids and surfactant. We improve compliance.


Ben Courchia MD (08:17.05)

Mm -hmm.


Bryan A King (08:27.15)

All right, so the baby you see, assuming that they're getting those treatments, the baby that you see at the bedside today, the first few hours of life is better than the child you would have seen in 1995 or 1985. Now the upshot of that law of unintended consequences is it means we can treat smaller and smaller children, right? And so the issue that we run into,


The original studies for all of these treatments were on like say 28 to 32 weekers. What patient population no longer exists. So now how do you treat, you know, 22 to 25 weekers when you don't necessarily have the same data points that you got for those 28 to 32 weekers and they're not the same kid. Right. And so in my career, that has been the biggest change.


we've had to figure out how to treat smaller and smaller children. And no one's perfect. There are places that do things the right way or what I would call the right way. But it's incredibly difficult. I mean, these are challenging children. I've been fortunate in my career. So I've taught volume targeted ventilation. I've taught high frequency jet ventilation, but I've lectured on the oscillator. I've lectured on noninvasive ventilation. Thinking about all of those,


inputs thinking about all of those modalities. If you stick to I don't necessarily I say this when I would lecture at huge NICUs. I don't necessarily care where you start all right with any of those. I don't. I want to know that you've got a cogent theory right for a starting point. If you're a bubble CPAP how's your goals to get to bubble CPAP? If you're volume targeted ventilation how's your goal is to start a volume targeted?


If you're an early high frequency, whether it's oscillator or jet, then that's where you start. And that's fine. I think that's perfectly reasonable. I don't care where you start. I care that you recognize if your strategy is working or not. You know what I mean? It's not where you start, it's where you end. And I think that that's the way, and how you adapt to the changing patient environment in front of you. I do think that's where people struggle the most.


Bryan A King (10:48.846)

but that's okay and we can work through that that's the goal of education


Ben Courchia MD (10:52.922)

Do you think that the way we've been looking at our patients specifically I think if I can be very general here and maybe I'm wrong But most people think of their babies in terms of gestational age saying this is a 28 week or this is a 22 weaker But in truth from a pulmonary standpoint, it's a very it's a very inadequate way of thinking of our patients some of them have Prolonged premature rupture of membrane. They have pulmonary hypo. They have some degree of pulmonary hypoplasia. They have a much more


the maternal history makes these patients so much more complex than what can just be summarized by just a number of saying, well, this is a 29 -weeker. Well, there are very different kinds of 29 -weekers. And I think sometimes we forget that our strategies need to be adapted to this changing landscape of babies with very different profiles or phenotypes arriving in RNA -Q.


Do you agree with that? Do you have a way of thinking of your patients in a more elaborate manner?


Bryan A King (11:52.11)

Yeah, so thinking about that, I generally classify 22 to 25 weekers or let's say sub 600 grammars in their own classification. So the nano -premies. Now I don't care what number you choose. I've gone to NICUs that choose 750 for that number of 500 grams. I don't care, but somewhere in that really small range is nano -preemies. But still, a 22 -weeker does not have the lung maturity that a 25 -weeker has. And so...


Ben Courchia MD (12:00.346)

Mm -hmm.


Ben Courchia MD (12:07.994)

Mm -hmm.


Ben Courchia MD (12:19.34)



Bryan A King (12:21.134)

To me, you've got to start with a goal. You just, you know, you've got a strategy. You're either a bubble CPAP house, you're, or at least hopefully you do. You're a bubble CPAP house. You're a volume targeted ventilation house. You're an early high -frequency house. And again, I don't necessarily care which that's your strategy. I'm sorry. That's your, yeah, that's your strategy. then what's your goal? And this, this is the thing when I would teach, I would say, what's your goal? Your goal.


Ben Courchia MD (12:41.946)

Yeah, that's a strategy. That's absolutely right.


Bryan A King (12:48.942)

When you go to a 22 week or nobody goes into a delivery and says on May the 10th for this specific baby, I hope I get a really good blood gas and a really good X -ray. That's incredibly specific. What you're really your, your goal should be long -term. I want to send this kid home as free of lung damage as possible. That's it. I would say then, so then don't treat every single blood gas.


Like it's the most important battle you've ever fought in your life, right? Just remember that your long -term strategy has to be to send this kid home as free of lung damage as possible. So don't overreact to these things. Remember your, your goal. And so the way I would generally help people or, or, or try to get people to focus was, all right. So, so what's going to help us send these children home free of that free of lung damage. And to me,


The thing that I've seen in my careers is hyper expansion, avoiding hyper expansion. It's the thing in this nano preemie population. That's the hardest thing to fix. Once you become hyper expanded, it's so difficult to dial that back and fix it. And so, and Jonathan Klein at the university of Iowa hits on this quite a bit. I don't know that he says it directly.


Ben Courchia MD (13:59.002)

Mm -hmm.


Bryan A King (14:15.726)

But a lot of his strategy is working at lower lung volumes. He's running these kids seven and a half, eight ribs expanded, avoiding hyper expansion at all costs. Hyper expansion is lung damage and it's really hard to undo.


Ben Courchia MD (14:32.378)

You said a few things that I think are worth highlighting. Number one, I appreciate the idea that you're bringing forward of saying our goal is to send these babies as free as possible of lung disease, because in a way, by saying it in this manner, you are abstracting all sorts of definitions, right? Free of BPD and free of what definition of BPD? I think that's such a more holistic way of looking at this. And I think I want to...


Bryan A King (14:53.678)



Ben Courchia MD (15:00.026)

maybe I want to follow up on this idea of avoiding long hyper -expansion because we tend to be taught in school that the lungs are elastic. There's some recoil that is associated with long expansion, but we tend to forget that for our nanopremies, as you've classified them, that ability may not always be there. And so I think, right, the reason you're saying this is because once hyper -expansion becomes overt, then it may not be...


just a matter of reducing pressure to then create that recoil and say, we're just going to slowly dial it back. You may be on a one -way street. Is that correct?


Bryan A King (15:35.534)

Yeah, it's the, all right, so the way I generally think about it. All right, so you look at all of the early volume targeted ventilation studies, their own babies that were decent size. So on average, probably 28 weekers. All right, so 28 weeker could be 800, 1000 grams. Well, I'm talking about a 325 gram. The reason I use that number, it's the smallest kid I ever intubated, but thinking about a 325 gram baby.


doesn't have anything in common with an 800 gram baby, right? It's got the 800 gram baby's got five more weeks of lung maturation. We don't know what volumes we can safely give a kid who's 22, 23 weeks. We don't know that that information is not there. And so thinking about that, what's we know or we say we know that four to six mls per kg,


is the biblical definition of volume targeted ventilation, right? Exactly. Exactly. But we don't know that that's true for a 22 -weeker. As a matter of fact, they're going to have a higher relative dead space than a larger baby. If you were alveoli, right? And so if you've got more dead space and some of these children may have up to four or five mls per kg of dead space, you give the, you give a kid with five mls per kg of dead space.


Ben Courchia MD (16:35.13)

That's what the Bible says.


Bryan A King (16:59.278)

a five ml per kg tidal volume, you've run into a math problem. You simply can't ventilate. So then what I would see people do in those situations is they would turn volume targeted ventilation off and go to straight pressure control. And then they would give what I would term supraphysiologic volumes. So they're giving volumes that are too large for this kid. That's where lung damage occurs. So again, if you have a child that you can start on volume targeted ventilation, your volume


Ben Courchia MD (17:17.178)

Mm -hmm.


Bryan A King (17:28.974)

targeted house and you start a 325 gram or five mls per kg and he does great and his x -ray doesn't get hyper expanded. Congratulations. Why would you change? Right? If he looks bad, why would you keep dancing with a partner that's stepping on your toes? Change. Right? You can't continue to do the same thing and hope for a different outcome.


on a kid that something's demonstrably not working. That's why I'm a big fan, even though I've worked for two specific companies, I'm a big fan of having lots and lots of treatment modalities because you've got to be able to cater the tool to the patient in the bed.


Ben Courchia MD (18:12.954)

Yeah, absolutely. This is what we've done in our unit as well. Trying to, yeah, I've purposefully asked that our division stocks basically every possible modality so that you want to do high frequency, you want to do high frequency jet ventilation, you want to do volume, you want to do pressure. All these are available. You tailor the care to your patient. I wanted to talk to you a little bit about volume targeted ventilation because you have so much knowledge about this. And I think that many people tend to think about this in a vacuum.


and then leave the specifics to the respiratory therapist. And so we understand that it's potentially the ideal modality for some of our smallest patients. But can you tell us a little bit about technically the limit, not the limitation, sorry. Technically, what are some of the challenges of delivering accurate volume targeted ventilation? You mentioned four to six ml per kilo.


on a baby that's like 500 grams. And so I think people sometimes, I think people often forget that when you're trying to provide five ml per kilo to a 500 gram baby, you're asking a machine to deliver 2 .5 milliliter of tidal volume on a consistent basis without making a single error. Because if you accidentally give double the volume, which would be just five ml, then you would give a serious change in pressure, tidal volume. And can you tell us a little bit about...


about the technicalities of delivering volume targeted ventilation.


Bryan A King (19:46.158)

Yeah. And so to me and the company I consulted for was Drager. And the reason I use the word consulting, I was still working full time as a staff respiratory therapist. But I would travel for them every say three weeks or so. And usually I would either do and we were early adopters of volume targeted ventilation at Forsyth. So they would send me to spots where they were trying to get


Ben Courchia MD (20:06.522)

Mm -hmm.


Bryan A King (20:16.174)

NICUs to adopt volume targeted ventilation or to facilities that had adopted it but were having trouble, you know, really implementing it and seeing positive change. And I think the thing that you've got to look at with volume targeted ventilation is what's the mode that you're tying it to. All right, so on Draeger you had three choices. You could go with assist control, you could go with SINV, or you could go with pressure support.


Ben Courchia MD (20:25.37)

All right.


Bryan A King (20:46.382)

Now pressure support to you and I sounds like a spontaneous mode, but that's not the definition of pressure support. The definition of pressure support is really down to the method for cycling pressure support flow cycles. So they had a pressure support mode that was ostensibly flow cycled assist control. And so you could set a baseline rate, let's say 30 to 40.


And the ventilator would make sure that it didn't, that the child didn't breathe less than that. They could breathe over it as much as they wanted. And then it becomes pure spontaneous. If they stopped breathing, it would kick in and deliver breaths for them, but it would still flow cycle. All right. So what does that do for us? Well, it takes inspiratory time out of the equation that can be both good and bad.


Ben Courchia MD (21:24.41)

Yeah. Yeah.


Bryan A King (21:44.014)

There's a good Marty Kessler used to say, and that's one of the folks I used to travel around and speak with. Marty used to say that you need at least say 0 .18 to 0 .24 eye times to adequately exchange gas. And the smallest children can guppy breathe. They can be lazy. And so they might really truncate their inspiratory times. You're going to really run into problems. If you do that, you'll need a different mode.


Ben Courchia MD (22:11.194)

Yeah. And sometimes you see that on their monitors where their eye time, like their breaths are like a spike almost. There's zzzz. Yeah.


Bryan A King (22:13.518)



Bryan A King (22:17.678)

Yeah, yeah, it's in this point one, right? And that's and that's just too fast. They're just not going to be able to exchange gas adequately. So you'll have to breathe faster. And so exchanging truncated items for a rate of one hundred is not a good exchange. So you've got to you've got to juggle these. So then you have to look at what are the advantages of each of the three modes if you're looking at SMB assist control or pressure support pressure support. I told you it's the flow cycle.


Ben Courchia MD (22:41.69)

It's just control.


Bryan A King (22:47.758)

It takes, it takes all of us out of the equation for eye time. And we are horrible at choosing eye times. Horrible. we're not because we're making a dynamic process static, right? That's my eye time. That's not the babies. All right. That's the one I chose. I imposed that. All right. So now there are children who can't handle that, right? It's like they can't handle that responsibility.


Ben Courchia MD (22:51.29)



Ben Courchia MD (22:56.314)

Why is that? I thought I was pretty good at it.


Ben Courchia MD (23:02.938)

That's true. Fair enough. Fair enough.


Bryan A King (23:16.174)

But so if let's say you choose assist control then what are the what's the value of this is controlled with volume targeted ventilation You have a set eye time You'll have a more stable mean airway pressure and that's one of the things you would see in PSV or pressure support ventilation with volume targeted you would see this erosion of mean airway pressure and so you've got to replace that with something generally. It should be peep But people are not necessarily peepophillic


Sometimes people are afraid of beep and I definitely understand. Nothing on a ventilator is consequence free. I don't have one of those knobs. Everything you turn has a consequence. I don't care if it's FIO2, everything has a consequence. All right, so for assist control, it's got more stable eye time, more stable mean airway pressure. You have a baseline frequency below which the child cannot breathe, but they can breathe over. And so that's a good thing. SINV.


I'm not as big a fan. I, it's where I started. So I started with SIMV. I think it's intuitive for people as the child starts to do more work, you get to wean the frequency and they're taking over the work of breathing, but your spontaneous breaths are not, are going to be pressure supported. That pressure support static. It's not adaptive.


meaning I'm going to either choose 5 or 10 and whatever volume they get on those breaths is what they get. They're not volume targeted.


Ben Courchia MD (24:52.474)

And as you win them, they're relying more and more on this inefficient pressure support that you're setting in between these mandatory breaths that you're setting on the SIMB. Yeah.


Bryan A King (25:04.27)

Correct. I would rather you stick to, if we're, if we're thinking about how best to treat sub 500 grammars or sub 600 grammars, which is the number I defined, then I would say that our better options would either be a cyst control or some sort of flow cycling ventilation. All right. So I think those would be better options because the SMB breaths, as you wean your set rate, you'd lose the ability to volume targets.


And if we're a volume targeted house, why would we take that away?


Ben Courchia MD (25:36.858)

Right. I think the... So following up exactly on this point is that the pressure support... By the way, I'll leave your email for all the SIMV fanatics that want to go at it. But what's interesting is that the pressure support idea was very popular, has always been a very popular one in neonatology because we have to deal with a baby that has an ever -changing...


Bryan A King (25:49.806)



Ben Courchia MD (26:06.022)

like you said, changing in front of us day by day. And ideally, babies that we would like to get off the ventilator sooner rather than later. And so unlike the gentleman or lady who goes to surgery at the age of 45 and who goes on assist control and suddenly wakes up with the same degree of long maturity and long function that they had pre -op, our babies are ever changing. And I think...


Bryan A King (26:07.342)



Ben Courchia MD (26:32.954)

I think people are really feeling challenged by these infants in terms of understanding when to wean and what is the slope that we should follow when it comes to weaning. And for many of them, for many of us, it's pressure support. But I'm just curious as to how do you view these infants, especially as they're in the recovery phase in terms of weaning them off mechanical ventilation? What is the strategy that you would employ? Because as you mentioned, when you're using assist control,


you are providing a significant amount of support. And so how do you, like I had a respiratory therapist that told me basically the vent is like a set of interconnected strings. As soon as you pull on one, you're pulling on something else. And so how do you deal with this as a baby is doing better and needs to be weaned off slowly but surely.


Bryan A King (27:22.126)

Right. So that's such a good question. All right. So then the way I would teach that when I was teaching at the bedside, don't set your, if you're on assist control, we'll just take that because I think most people start there. All right. So if you're on assist control, don't start on a rate that's too high.


For the most part, you're going to have these, you're going to have a baby that breathes. It may breathe immaturely. It may breathe inefficiently. It may, that may be a problem, but you're, you're intubated. You're on a device. You've, you've chosen your settings. I would choose a rate that's not so high that it discourages breathing over. So if you, I like 30 as a starting point, I could take 25.


I would see a lot of places start at 40 and then the kid's not breathing over. If the CO2 is 43, why would he? Right? So they need to breathe over and the reason they need to breathe over, it's more efficient. Right? So here's one of the things I would see frequently. So if the ventilator set at a rate of 40 and the child's not breathing over, well, that means the diaphragm's not dropping.


So they're not triggering breath. Well, the ventilator has to overcome that resistance. It has to physically push down the diaphragm. It has to use a higher pressure to achieve that same volume. Now that's a control breath. If you're encouraging more assisted breaths, it's simply more efficient. The diaphragm drops. All the ventilator now has to do is fill that space. It gets to use a lower pressure. So just thinking about weaning,


you can work at a lower pressure on a child who's breathing spontaneously than you can work on a child who's getting all control breaths. So you might think a child sicker just because you chose a rate of 40. It takes a higher pressure to achieve it. Does that make sense? And so it's the kind of thing that I didn't see a ton of thought process, related towards when I was, when I was teaching.


Ben Courchia MD (29:17.082)

Yeah, it's such a good point.


Ben Courchia MD (29:21.818)

Right. Right. That's a very good point. Absolutely.


Ben Courchia MD (29:36.314)

Mm -hmm. Yeah.


Bryan A King (29:37.134)

If you can have a kid with a PIP of 13 as opposed to a PIP of 18, the kid with a PIP of 13, you're thinking, I'm going to extubate this kid. The kid with a PIP of 18, you're not as fired up to do that.


Ben Courchia MD (29:48.95)

Yeah, I think that goes back to this phenomenon of unloading where a baby will let you do the work if you're willing to do the work for them. But we just have to encourage them to be proactive in that process. So no, that definitely... And I think that's a common misconception, which is that, on assist control, as long as the baby triggers the breath, then it's the same. And it's like, no, it's not. Because as you mentioned, right, it's...


Bryan A King (29:57.23)



Bryan A King (30:12.558)

It's not.


Ben Courchia MD (30:14.746)

A baby triggered breath on Assist Control is not perfectly identical to a vent mandated breath on Assist Control. Yeah, absolutely. I think that's a very good point.


Bryan A King (30:25.422)

And you need to pay attention to, all right, so let's say, and this is a, I think a problem with, with teaching ventilation. I think when I started in the field, if I saw a kid on a rate of 40 on assist control and they're, they're spontaneous or their total rate was 41, then I assumed they were getting 40 control breaths and one assisted breath. But that's not necessarily true.


Ben Courchia MD (30:49.43)



Bryan A King (30:52.398)

they could trigger any number between one and 41 in that scenario. So you have to pay attention to their spontaneous breathing or their effort to see which of those are assisted versus controlled. Because the assisted breaths tell you what a true measurement of the patient's compliance is.


Ben Courchia MD (30:57.594)



Ben Courchia MD (31:05.914)



Ben Courchia MD (31:15.386)

And that's something that I try to hone in with my team at the bedside too, which is that we tend to think of the vent as an input device where I input settings, but people don't really understand that it does give you back a lot of information about the patient, about the physiology. And I think this is where it can be so helpful to try to understand a little bit your patient better through the vent and not just by looking grossly at what's the respiratory rate and the stats on the monitor. Yeah, that's just not sufficient.


Bryan A King (31:22.894)



Bryan A King (31:43.406)

Yeah. So I'm giving you a long form answer for how you wean. And I think my answer is don't in reality, if you choose assist control, you're watching for four to six ML per kg volumes, and you're watching for a drop in this kid's peak inspiratory pressure or the PIP required to deliver that volume. If you wean or switch to SMV to wean, you could impose work of breathing.


Ben Courchia MD (32:04.186)



Bryan A King (32:13.646)

as opposed to just extubating when he gets to a number that's tenable for you. If 15 is that number that makes you feel good, extubate. Don't think in terms of weaning necessarily, or in reality, think of it this way. Kid got in antenatal steroids, hopefully has gotten doses of surfactant. When I put this child on, we were taking X amount of PIP over time that PIP required has dropped. He has weaned.


Compliance has gotten better, we have weaned. Switch Pro.


Ben Courchia MD (32:44.858)

I think people don't know that you could get those trends from their events, which is you could trend on your event the change in PIP over time, whether it is 3, 6, 12, 24, 72 hours. And you can see how your PIP has changed. And I think you're talking about the best case scenario. But there are some cases where the PIP will go up and you're like, shoot, why are we suddenly now required? Yeah.


Bryan A King (32:51.31)



Bryan A King (33:04.746)

Well, exactly. And that's the point at which, all right, so at that point, and the, and here's the way I would teach, when I taught volume target ventilation, it's a great way to extubate. It's a terrible way to ventilate. And what I meant by that is, volume targeted ventilation is not a sit or static mode. You're not going to be on this hopefully for days and days at a time. If you're not off the ventilator by about three days on volume targeted ventilation, then


maybe we need to think about our strategy. So at that point, if he weans, if the child weans, it worked exactly as we planned. antenatal steroids and surfactant had the positive effect we wanted. We chose great settings with our device. It's time to extubate. Now I don't get to control where the extubation works or not. And there are different strategies for that. But like you said, a lot of times things go in the opposite direction.


All right, so if you get hyper expanded or your peak inspiratory pressures go up, which is at least going to be a harbinger for later hyper expansion. If that occurs, what's your strategy? Well, I would switch. I would go to a high frequency device. If I get above pips of 20 for an extended period of time, sorry to interrupt.


Ben Courchia MD (34:18.458)

Yeah, and I think when you're...


No, no, I wasn't interrupting you. I'm so sorry. But I was thinking exactly what you're saying. After three days, other components of the baby's physiology can come into play, whether it is a more prominent display of the PDA that then increase a little bit of pulmonary overcirculation, maybe a bit more inflammation. And so these do change the picture and the landscape of what these babies needs. And I think your point there, I think...


Right, your point is not that if after three days your 23 weeker is not extubated, then you failed something. But maybe after three days, what's your strategy then, basically, right? Because I think, yeah.


Bryan A King (34:57.23)

Yeah, you've got to think about it. I think that's absolutely correct. I'm not necessarily saying that it has failed. It's just that you need to maybe consider what are other ways or other methods, you know, to get us off this ventilator.


Ben Courchia MD (35:14.65)

Yeah. Interestingly, I mean, we're starting to run short on time, so I want to make sure that I get all my questions in. I have a few questions about, you've mentioned this, you're using the term, like, what kind of house are you? I kind of like that about like different institutions. And it's true. It's like you saying, are you a pressure house, a volume house, whatever. But I mean, for some institutions, it's almost religious, right? I mean, there's...


Like some things are banned. And I think for many practitioners, it's a challenge because they will work at an institution or train at an institution. I mean, I trained at an institution that didn't use the jet for whatever reason. But then as individuals, we move on and we go to other institutions. And now suddenly we are in front of a high frequency jet ventilator. And they were like, okay. And I think we forget that all these vents work very differently and that a jet is not an oscillator.


Bryan A King (36:10.926)

Yeah. Right.


Ben Courchia MD (36:12.282)

And so I am wondering if you have, I think that's something that a lot of trainees, young career neonatologists are bringing back to us saying this is a big challenge for us because these institutions did not teach us about how to use a jet because that's not the policy of the house, as you say. What is your advice for people who are getting into a new job and they're seeing event that they're using for the first time? What is the best way to get familiar with the functioning of these new events?


All the while, you still have to care for patients, which is a big responsibility.


Bryan A King (36:44.782)

All right. So I would say a couple of things. You, if you're a level four NICU, you need to have all the tools. I mean, I just feel that way because you're, you're a teaching institution. You're taking care of the sickest of the sick. You have a responsibility to the folks who are coming through for residency and fellowship to teach everything. And so, I do not work for Bunnell. I have, I have no stake in this, but I think if you don't have every tool, it's a problem.


because it's incumbent upon us to have everything to be able to teach. All right. So, so that's one thing I would say. the second thing, right. Absolutely. I, all right. So here's one of the problems I have. I had a, I was at a conference and I heard someone once say, the tool doesn't matter. All that matters is your ability to use the tool. And I, well, that's, I grew up in the farming community in North Carolina.


Ben Courchia MD (37:21.146)

That's the PSA.


Bryan A King (37:44.43)

And that's the kind of thing that you say when you've never farmed. If I need to go get or put in a Phillips head screw, I don't go get a shovel and it doesn't matter how skillful I am with that shovel. It's not the right tool for screwing in a Phillips head screw. I need the right tool as well as the ability to use it. All right. So I think that that matters. and then thinking about how do we train.


Ben Courchia MD (37:49.05)



Bryan A King (38:14.542)

all of these folks moving forward. And this is a tough situation. I think that if you're at a facility that uses the JED or the oscillator or volume targeted ventilation or NAVA, there's a lot of experience with that device in -house. But what do you do if you're at that facility and they don't use some of the other tools and you're interested in them? Usually it's going to be people in the industry.


And I'm someone who has been in industry at that point. You're somewhat dependent on them not to come in and be biased. And they probably are. And then for them to be skilled at actually delivering information, not just understanding the device, but imparting that information to you in a group setting. I always felt like that was, you know, I have a ton of skills, but I always felt like that was one of mine.


I'm not from the, the incandescent intellectual wing that, that I have seen in my travels. I've got buddies, a buddy at Boston Children's, a buddy at Seattle Children's and then physicians that I've met who are just incandescent intellects. I'm not that I'm the next step down. What I am is I'm smart enough to understand what those folks can teach me. And I'm fairly skilled at delivering that information to other folks.


Ben Courchia MD (39:37.434)

Mm -hmm.


Bryan A King (39:42.36)

It's made a nice little career for me. But education is the key, but I also think it's really important to have all the tools at your disposal if you're a level four NICU.


Ben Courchia MD (39:53.964)

Yeah. Yeah, I think you're bringing a few good points here because number one, I think it's true. If you're a teaching institution, you should give all the tools to your trainees. I also feel like when you are in a new place that you're using a mode or a tool that you're not familiar with, then it's a good thing to ask because like you said, they all have very good experience with that tool and they can teach you. And we all have to have the humility of saying, hey, this is my first time working with this tool, teach it to me. And...


I'm going to go on a limb here, but I'm going to say that there's an argument to be made about using the tool you're comfortable with. I think there's an argument to be made there because it's true. If you're very comfortable with the tool, you're going to use it quite well. But I think sometimes this excuse is used as a substitute for not doing the legwork of learning a tool that you're not familiar with. And so I think this cannot be the cop -out of saying, well,


Bryan A King (40:30.222)



Bryan A King (40:47.886)



Ben Courchia MD (40:51.066)

just do what you're familiar with and don't bother with the jet since you're not familiar with that. It's like maybe, maybe try to do both, try to continue doing what you do best all the while becoming an expert with this. And eventually maybe you'll be able to master all these modes. And I think that's, that should be the ultimate goal for, for every clinician. And as we've seen on the podcast and you're the demonstration of that, doctors, respiratory therapists, nurses are all willing to teach someone else what they know. So you just, just got to, just got to ask.


Bryan A King (41:18.926)

Yeah, here's the way I would say it. When I would go, let's say I'm lecturing at a facility that does not use the jet. And that was my job that the last two and a half, three years I was at Bunnell. So I go in and do this lecture and I would say, okay, if your BPD rate is zero and no one died this year, you don't need to change it. You never need to change. Congratulations, you guys are the best, but that's probably not true. And so the enemy of grade is good.


Ben Courchia MD (41:37.37)

You don't need me.


Bryan A King (41:46.99)

And so what, one of the things that I would see is that people would be, BPD rates, 17%. Well, I mean, that's almost one in five children to those five kids not get a say in this or that, you know, 17 % of they not get a say in this. if your strategy works, great.


Ben Courchia MD (42:04.89)

Yeah, but we're so afraid of rocking the boat. It's like, well, I don't want to, right? It's like maybe 17 is the best we're going to get. And so I think that sometimes paralyzes the whole team to experiment. Absolutely.


Bryan A King (42:14.222)

Sure. All right. So thinking about that, as I said, the enemy of, of, of great is good. The other thing that happens a lot is people will think something along the lines. They'll conflate first do no harm with first do nothing. And those are not the same thing. And so if, if you've got a child who's on your normal modality and you guys are experts at this, you teach it to other folks, people come to your center.


Ben Courchia MD (42:32.218)

Okay, that's right, that's right.


Bryan A King (42:44.174)

And there are centers like this to learn from you, but the child, this specific kid is not responding to this. Do something else. I don't think it should be that complicated. I know you're more comfortable with the other one, but there's expertise out there. Utilize it.


Ben Courchia MD (42:53.082)



Ben Courchia MD (43:02.138)

Yeah, it's kind of the ownership bias where we tend to give more value to stuff we own, we know, and we're like, no, no, this is good. This is really good. Yeah.


Bryan A King (43:06.83)



And it is, and it is, there are people doing great work with, like I said, bubble CPAP. There are people doing great work with volume targeted, with Nava, with the oscillator, with the jet. There are people that are great at those things, but what if it's not working for the child in front of you?


Ben Courchia MD (43:24.41)

That's right. That's right. We have a few minutes left. And so as I mentioned earlier in this episode, I wanted to ask you a little bit about this, this new journey you're taking on right now. You mentioned to us that you're in the process of writing a book. I wanted to know based on however much you can share with us, obviously, but what is, what is this book you're writing about? What is it focusing on? Can you tell us a little bit more about it?


Bryan A King (43:51.63)

Yeah. You know what? A lot of it is basically my journey into backing into becoming an educator and, what it's like to teach high level ventilation courses to physicians as a non physician. And it was incredibly, it has been an incredibly rewarding career. And I have so many just dear friends.


Ben Courchia MD (43:58.81)

Mm -hmm.


Ben Courchia MD (44:09.37)



Bryan A King (44:19.758)

that I've made through this journey. It's been great, but there are also times that I've run into obstacles and some of which have surprised me over time. And so there, there is some good, as a matter of fact, I would say on the balance, it's been amazing, but there are some things that I saw that I was troubled with because it can be a fraught situation to be a non -physician teaching physician sometimes.


Ben Courchia MD (44:49.442)

Right. I've read some stuff about writing and most people say you're always writing for someone. Who are you writing for? Who is this? I mean, that's more of a marketing question, but I'm saying in the back of your head when you're writing this, are you writing this for other respiratory therapists? Are you writing this for physicians? Are you writing this for both? Who?


Bryan A King (45:03.79)

What's my audience?


Bryan A King (45:08.27)



Ben Courchia MD (45:16.922)

Who is the person that this writing is really intended to go to the heart of?


Bryan A King (45:23.694)

That's really good. I would say that it's mostly the best audience would be those folks who are non -physicians teaching physicians. And I would also say it's physicians as far as receiving information. So that's a really good point.


Ben Courchia MD (45:34.746)

I see.


Ben Courchia MD (45:40.474)

What, right. In terms of, I mean, you're making a good point. I think as, as physicians, there's, there's a reluctance to, to learning at some point in our career, sometimes because we've been put through so much schooling. And at some point we say, it's got to, it's got to stop right at some point. But interestingly enough on the podcast, that's something that we talk to other people about everyone that we've had on that has been successful will always convey the same message, which is you must accept to become an eternal learner.


I mean, and people don't always use that term, but some variation of that term. If through your experience, through what you're writing in the book, what is your message to physicians who sometimes could interact with non -physicians in an educational setting?


Bryan A King (46:27.438)

All right. So I was very fortunate in my career starting at Wake Forest and Forsyth to have an incredible mentor, Dr. Robert Dillard, just a brilliant, brilliant man and clinician and took an interest in my career when I had done nothing to deserve that. He just, he saw something in me, he fostered it and, and I will never be able to repay that kindness. Right.


and everybody needs someone like that in their career. Well, so I've, I've got so many of his, aphorisms, but one of them was be careful what you know, because the things that you know today may not be the things that you know tomorrow. So don't be intransigent when it comes to receiving new information, because this is a constantly evolving profession. And if you, if you wanted,


A profession that wasn't constantly evolving. You probably should have chosen something else. We're, we're lifetime learners and there are so many things in my career that I've been, the term I use is confident, but confidently wrong. I've been confidently wrong about, one of the ways I've learned to deal with that is to, if you're someone who does teach when you're wrong, it's really important for you to own that.


Ben Courchia MD (47:28.314)

That's true.


Bryan A King (47:52.494)

don't back away from it. And so I would have an opinion. We're wearing rounds and I had a really good friend who was one of our fellows who he and I just thought about things incredibly differently or just incredibly differently. And this, he would have a goal. I would have a goal and it would be very different. Now, again, we were good friends. We hung out, went to the fair together. I mean, we were really good buddies, but we just thought about things differently. And I thought one of the ways to approach that would be to say things that, you know, this was my thinking.


Ben Courchia MD (48:03.834)

Mm -hmm.


Ben Courchia MD (48:11.898)



Bryan A King (48:22.158)

I understand your thought process. What if we try yours? Give it our best shot. If it doesn't work, then we'll try mine. And I found that that worked really well. And then afterwards, if his thought process was correct, I would go up in front of people and say, Hey man, great call. You were right. I was wrong. This is great. So I get to add that information.


Ben Courchia MD (48:30.938)

Right. Yeah.


Ben Courchia MD (48:43.482)



Bryan A King (48:49.486)

To my compendium that now I get to use that moving forward, right? He made me a better clinician, but be humble. It's not, it's not that complicated for all of us.


Ben Courchia MD (48:53.786)

Yeah. Yeah. Yeah. Yeah. Yeah. It's, this works with so many other things, like so many times in sports, we'll hear athletes saying, well, I saw this guy do this. And I was like, this is kind of good. I'm going to try to add this to my repertoire. And I think, I think it makes everything such a healthier type of environment. And, and I think, ultimately.


people don't realize that it's that type of behavior that earns the respect of the team long -term where people will say, well, I have respect for this person because if they are incorrect, they will own to it. The person who is incorrect and doesn't own up to it is someone you become suspicious of. So in the end, I think it's the healthiest way of working together. Yeah.


Bryan A King (49:39.79)

So one of the things Dr. Dillard said to me one time was, he was, why would I be, why would I not be open to new ideas? It was it's information that I can gather that I get to add to my armamentarium for treating these children moving forward. So I love that.


Ben Courchia MD (49:56.154)

Yeah. Yeah. And that's been what we talked about earlier. Again, talking about having all types of modalities available. It's why wouldn't you want a toolbox full of tools instead of just having a hammer? It's the best way to practice. Brian, this was a phenomenal conversation. I had such a good time. And I learned a lot from you. We will leave your information on the incubator podcast show notes. And...


Let people ask you questions directly if they had any. Thank you very much for your work. And we're going to be looking forward to the publication of your book. Do you have a title yet or no?


Bryan A King (50:35.726)

not yet. I've been workshopping some things. Yeah.


Ben Courchia MD (50:39.93)

Yeah, it has to come to you. I was told, I was told like you write the book and then, and then you, it will be apparent what the title should be. So good luck with that. Thank you so much. And again, this was, this was great.


Bryan A King (50:50.862)

Thank you so much for your time. I really appreciate it and had a great time.


Ben Courchia MD (50:54.074)

Thank you.



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