#306 - BPD Care: The Nationwide Children’s Hospital Model

Hello friends 👋

In this inspiring and deeply informative episode of The Incubator Podcast, Dr. Audrey Miller, neonatologist at Nationwide Children’s Hospital and newly appointed Medical Director of their BPD Service, joins the hosts to unpack the intricacies of chronic lung disease care and her rapid career ascent. Miller outlines the five key principles guiding her team’s nationally recognized approach to BPD: ventilator strategies tailored to BPD physiology, aggressive infection prevention, proactive pulmonary hypertension screening, prioritization of linear growth, and uncompromising developmental care.

She shares the rationale behind “slow lung” ventilation, the importance of recharacterizing infants as they evolve from micro-preemies to complex chronic patients, and how individualized, patient-driven care often begins by doing less, not more. Beyond technical insights, Miller reflects on the professional mentorship and collaborative culture that propelled her into leadership just two years post-fellowship.

She offers candid advice on tackling imposter syndrome, embracing delegation, and building confidence in administration—while remaining anchored in purpose. Whether you’re a fellow exploring BPD, a clinician curious about slow lung strategies, or an early-career neonatologist navigating your next move, Miller’s perspective is both practical and empowering. This is a must-listen for anyone thinking seriously about the future of chronic care in neonatology.

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Short Bio: Dr. Audrey Miller is an attending neonatologist and assistant professor at Nationwide Children’s hospital and the Ohio State University School of Medicine. Her clinical and research interests focus on improving the life-long outcomes for patients with bronchopulmonary dysplasia. She serves as medical director for the 24-bed BPD NICU at Nationwide Children’s Hospital. She also serves as chairman for the advocacy committee in the BPD collaborative.

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

Ben Courchia:

Hello everybody, welcome back to the Incubator Podcast. We are back with a special interview today. We are joined by Dr. Audrey Miller. Audrey, thank you so much for being on the podcast with us today.

Audrey Miller:

Thank you so much for having me. I'm honored to be here.

Ben Courchia:

The pleasure is all ours. Audrey, you are a neonatologist at Nationwide Children's Hospital. You're an assistant professor of pediatrics at The Ohio State University College of Medicine. you are the newly minted director of the BPD service at Nationwide. Congratulations on that. It's a pleasure to have you on and to talk a little bit about BPD and a little bit about career choices. We're very excited to have you on.

Audrey Miller:

Thank you, I'm thrilled to be here.

Ben Courchia:

Daphna, is there anything that you were thinking of touching on this coming 30 minutes?

Daphna Yasova Barbeau:

I was just going to say every time we plan for an interview, we get so excited, and this interview got a little delayed. So we've been really looking forward to having you on and talking about all the amazing things that you have been doing. We have a lot of trainees in early career neonatologists. We have lots of different listeners, but you've done a whole lot in a very short amount of time in your career. So we're really excited to tell people about that.

Audrey Miller:

That's very kind, thank you.

Ben Courchia:

Yeah. I wanted to get right into it, talking a little bit about BPD, because we know that Nationwide Children's is world renowned for its management of babies with chronic lung disease or bronchopulmonary dysplasia. I wanted to ask you if you could, in a nutshell, tell us what are the guiding principles that make the care of BPD babies at Nationwide so special? What are tenants?

Daphna Yasova Barbeau:

Yeah, pull back the curtain for us.

Audrey Miller:

Happy to. One of the best parts of my job is sharing what we do so that hopefully it can be replicated at other centers. So we have five big principles that we like to follow within our service and our unit.

The first is we focus on ventilator settings tailored to BPD physiology. We call that a chronic lung ventilator approach. So we're really adjusting the ventilator settings we're using to reduce work of breathing, to have our babies be comfortable consistently over time. We also, in that light, are also doing very slow weans, if any, so that our babies are not chronically under-supported, so that they feel supported from a respiratory standpoint so that they're able to grow and interact and develop.

Our second principle focuses on preventing mortality. So we try really hard to avoid infection. And for us, that looks like using very little central lines if possible and removing them as soon as we can. We tend to prioritize feeding through pretty much everything, even if we're in a very rare case where we need to do paralysis, we're still feeding through that. We also have really great guidelines that our nursing leadership staff have created for wound care and central line monitoring, things like that to hopefully avoid infection.

Our third pillar focuses on preventing cor pulmonale. So with that, we tend to have higher oxygen saturation targets than even recommended nationally. When you look at those national groups, we tend to target 94 and above. We also do frequent echo screenings, like all other centers, for BPD-associated pulmonary hypertension.

Our fourth pillar focuses on good growth and nutrition, because we know that linear growth is correlating to lung growth, and the fastest way for babies to get better is if they're growing.

Our last principle focuses on providing really excellent developmental care during this time.

Ben Courchia:

Very cool. I know we'll talk a little bit about that. I'd love to go back to the first principle of slow long ventilation. It's something that I had the pleasure of getting familiar with, interacting with you and other members of the BPD collaborative. For the people who don't really know what slow long is, can you give us, I know it's a silly question, but can you give us ranges? Because for some people, going above a PEEP of six, for example, is terrifying. Going above tidal volumes of six ml/kg is terrifying. But you guys have really outlined a radically new approach to ventilation for these chronic patients. It's paying tremendous dividends for them and their outcomes. So I'd love for you to tell us a little bit about what that looks like for a typical baby that'd be “slow long ventilation.”

Audrey Miller:

Absolutely, it's not a silly question at all. It's a great question. I think ultimately it depends on the gestational age to a certain extent, but speaking to babies who are 36 weeks and above, we know these patients have really high resistance, so they have this obstructive phenotype. We know that our biggest goal is to allow them to fully empty their breath, to have a full exhale, before we're pushing in another ventilator breath. This allows for us to hopefully counteract that hyperinflation phenotype that we see with BPD babies. So our biggest principle is dropping the rate. While we do that, we're also increasing our I-time. So for example, just to throw some numbers out there, because I think that's helpful, for a baby that's 36-40 weeks, we would feel very comfortable using a rate of around 16-20, with a corresponding I-time of around 0.6 to 0.7. That is the biggest principle allowing us to have better V-Q matching that we see with our patients.

With that said, we know that in order to maintain minute ventilation, with our equation being rate times tidal volume, if we're dropping our rate, we also have to increase our tidal volume. Otherwise, we're gonna drop our minute ventilation and our patients aren't gonna do well. They're gonna become hypercarbic and have more respiratory failure. So that's the piece where we're increasing our tidal volume or PIP, depending on which mode of ventilation you're using.

I definitely get it, I think it can be very scary to go above certain volumes that have been so ingrained in our training to prevent volutrauma. It's a big aspect of our training, especially with those little babies. But for the bigger patients who already have lung disease, we can't prevent it anymore. It's established. They definitely need this type of approach in order to do well.

Ben Courchia:

What's very interesting to me is this cognitive dissonance where we feel that these babies that have reached 36, 37, 38, 39, 40 weeks are babies that we intimately know. Like, I know this baby . You like I've cared for this baby for the past three months and so on. But what I've seen from your team is that there's really an incredible amount of effort that is expanded in order to re-understand who these children have become . What is their phenotype? They are no longer the micro preemie that was born at 23 weeks. They are a completely different individual and you guys do a tremendous amount of work in order to understand who they've become, whether in terms of their BPD phenotype, whether it is through bronchoscopy, dynamic studies and so on and so forth. Can you tell us a little bit about how you try to re-understand these infants as they have established BPD in order to then deliver the best care for them specifically, whether they have an obstructive phenotype, restrictive phenotype, BPD-associated pulmonary hypertension, etc.?

Audrey Miller:

Yeah, absolutely. you're right, we're learning more and more that there's different phenotypes within the umbrella of severe BPD. We do know from prior studies that about 90% of these patients will have some degree of an obstructive phenotype. So most of our patients do very well with our slow rate, long I-time approach.

With that being said, we also find that some patients are really benefiting from bronchodilators or inhaled corticosteroids or diuretics. For us, that tends to be a unit policy where all of our patients will get a bronchodilator and an inhaled corticosteroid, because most of our patients respond to that. When it comes to things like diuretics, we tend to do a three day course to see if there's going to be a response, before we would start a chronic medication.

Certainly when there's a BPD associated pulmonary hypertension phenotype, that changes how we think about our patients with using nitric and other agents if needed. What I found is that these patients let us know. If they don't appreciate what we're doing, they let us know. They usually let us know pretty quickly, which is very helpful for us and our team. So we can tailor our management approach based on what they're telling us in the moment.

Ben Courchia:

What's very interesting about it to me is that it is a complete subspecialty of neonatology. You cannot take what you've learned in fellowship, learning to resuscitate a micro-premie the first 48 hours of life and say, I'm going to try to apply these same principles to the BPD patients. You guys have outlined and shown very clearly that this is almost like a PICU-NICU hybrid, where you have to take some of the things you've learned and recall some of the things you were doing in the PICU to try to really manage these babies as best as possible. So I think it's very helpful. I think it should alleviate a lot of the shame and guilt that you're like, my God, like, how come I don't know what to do for this particular patient? Because it is completely different.

Audrey Miller:

It is, and it's not something that's part of our routine training and fellowship for most centers. There's such a degree of chronic care where we want our patients to have minimal changes and to not have a lot of interventions - that can be very counterintuitive. It took me a while to get used to that as well, coming from an ICU mindset. So there should definitely not be any shame whatsoever. It's a very complex group of patients that require a very different management that we don't often see in training.

Daphna Yasova Barbeau:

I love this concept of reimagining the patient, because I think that's what makes neonatology so complicated. The babies are not like an adult patient who has a new injury. They are growing and developing, they're this dynamic system across their entire admission. We really have to change what we do. I really appreciate your outlining of the settings. We're pretty comfortable with slow long in our unit. I find where people get hung up is that it is such a drastic change. So I see a lot of people who are trying to get there. They're doing these moderate settings - go down a little on the rate, up a little bit on the tidal volumes, but it's not enough to get that complete emptying that you're talking about. So how do you think we give people the comfort in learning and practicing and trying these things with babies in their unit?

Audrey Miller:

You make a great point that if we do it halfway or if we do it partially, it doesn't work. So I think then people could get frustrated and say, well, we tried, but it didn't work and kind of go back to more tiny baby settings. For example, when we get a new patient into our unit at this 36 week mark, we would change all the settings right away. We wouldn't do it in a stepwise fashion. We wouldn't feel like we needed to wean things in order to make these changes. We would go straight to our approach. And again, the patient will show you pretty quickly if they tolerate it or not. What we'll see at the bedside is within five minutes of getting that good chest rise on that slow rate, as our patients will relax, the work of breathing will calm down, the oxygen saturation will shoot up, and we're starting to wean oxygen. That's all seen within the first few hours.

I think knowing that the patient's gonna let you know if it's working or not could provide some comfort in giving it a try. A lot of the times when we're doing consults with outside centers, these patients are incredibly sick. The teams have done an amazing job trying everything you can think of. This is also just kind of one more step that we could try before feeling like we need to go down a different pathway.

Daphna Yasova Barbeau:

I love that you say the baby will let you know. It's not immediate, but it's pretty remarkable when the babies respond to the new type of settings. I want to highlight what you said and your five pillars really do for babies. It basically is saying, we're letting babies' lungs readjust to these new settings, hoping that they will function in a way that is a little better than they've had the opportunity to do. In the interim, we're going to optimize all of the other things about this baby. It's almost like we're going to ignore the respiratory system for a little bit while we grow this baby. We let the baby have developmentally appropriate stimulation. We keep infection away. Obviously everybody knows I like this focus on development, but I think it's a really important concept that goes underappreciated in what you guys do and in the NICU course altogether. It's basically like, how can we support this baby to be as comfortable, to grow as well as they can, all of which impact the lungs in the short and long term. So I'd love for you to speak a little bit about that.

Audrey Miller:

You described it beautifully. It's so funny you say that because one of my colleagues, Dr. Matt Kielt, says quite often when we're meeting as a BPD team group that we just don't talk about the lungs anymore. We never talk about the lungs on rounds. It's true. The goal is for us to find settings where patients are comfortable on, and then to leave them alone. You won't see us weaning PIP, weaning PEEP; once we have good settings, we're just weaning the oxygen. All of our big milestones in terms of weaning support in our unit focus on that oxygen component. For example, we'll extubate a patient when they're less than FiO2 40%, regardless of the PIP. It's very common for us to extubate from PIPs in the high 40s or low 50s. we use that oxygen in the setting of good growth and good development with all those things, of course. But the goal is for our patients not to be constantly challenged and weaning, rather to be comfortably supported in focusing on growth. Because truly growth is the way these patients get better. It does take time, but they do get there.

Ben Courchia:

I wanted to ask you one more question about that. Can you talk a little bit about what adequate growth looks like in patients with BPD? Because for a lot of us, again, from these early days, it's weight gain. But truly, there's a shift that needs to happen probably even earlier than 36 weeks where linear growth is paramount, not only having weight gain, but good weight gain in relationship to good linear growth in order to not a short and fat baby, but a lean and well-grown infant. Can you talk a little bit about that?

Audrey Miller:

Absolutely, you're so correct. I think weight gain can be a little bit misleading to a certain extent, because when our patients are in this unstable, acute, early phase of BPD, we do see excessive weight gain in some of them, which can be more reflective of edema, stress, or inflammation than true weight. And so in our unit, we very much focus on linear growth. We use length boards and measure our babies once a week. That's the trend we really follow. Additionally, once they're able to go on the WHO growth curves, we're following the weight-for-length trends. That's very helpful to see more proportional growth.

But I agree, focusing on linear growth is really gonna help with outcomes way more than weight gain. The weight gain is going to fluctuate, I think. What we found interestingly is some of our patients in those acute phases don't need as many calories as we thought they needed to before. That can be counterintuitive too to back off on calories a little bit for babies when you think you want to grow them, grow them, grow them. We focus on linear growth, protein intake, and we actually have a lot of good success using zinc as a supplement. I don't know if a lot of centers are using that currently; we’re looking at that in the collaborative to see what zinc practices are across the country in the collaborative, but we like that and we start that pretty early usually after about a month of age.

Daphna Yasova Barbeau:

I love that. Nutrition is so interesting. We always talk about nutrition in terms of growth, but I want to get back to development, and nutrition really factors into development . We need to make sure that we're getting brain growth, that the baby has enough literal energy to focus on their therapy and in bonding with their families and things like that. I think we forget about how critical nutrition is to the whole system of function, especially in a brain that we're still trying to grow. Even in these babies who are corrected to term, their brain is still growing under this chaotic and stressful environment. I think you guys do a really nice job about development, in a way that I think some units aren't even doing for the little babies. So I'd love for you to speak a little bit about that.

Audrey Miller:

I totally agree with you. What's interesting is we tend to see growth and development parallel each other. So when we start to see that change and our babies are growing longer, then the therapy team starts telling us, they're doing great. They're really engaged. They're meeting all these milestones. so I agree, they definitely go hand in hand. I also think lung function parallels with that too. Usually when all these things are starting to improve, the lungs are doing great. We're talking about weaning support too.

Our developmental team is absolutely outstanding. I am so fortunate to work here and to work with them. They do an amazing job. We have dedicated therapists for BPD within our unit. So each patient has a combination of a PT, OT, or speech therapist, depending on where they are in their journey with a primary therapist that is able to do therapy, you know, two to three times a week with them. We're also really focused on teaching our parents how to do interventions (or our PCAs, if parents aren't able to be with us) so that our patients are getting as much developmental exposure as they can. We really try and, as much as we can, mirror a home environment while the lungs are growing. So we're very developmentally focused.

Ben Courchia:

Walking through your unit, I think it's important for people to understand the central place that developmental care takes. It is not uncommon for people to pass by a room and see mats on the floor, babies on the floor with the therapist doing work while the tracheostomy is connected to a vent. Like it's really not like let's just try to move whatever limb can move in the bed while the baby is on the vent. It is really letting therapy and neurodevelopmental care take center stage. that I think is something that is very innovative and something that people should learn from.

Audrey Miller:

Absolutely, it's uncommon for us not to have mats. Our babies are out a lot, which we really appreciate. I think it's helpful to get our therapists' feedback, too, on how these sessions are going. If we have a baby that's doing really well in therapy and then all of a sudden isn't, does that correlate with a respiratory wean? Is this moving too fast? We put the whole picture together so that even as we're trying to make respiratory advancements, we're keeping in mind developmental capacity.

Daphna Yasova Barbeau:

Yeah, and I think the opposite is also true. The way you mobilize patients improves their pulmonary function. I think we forget about that . We just want them quiet and wrapped up. But at this gestational age, these babies need that movement and engagement, and it opens up parts of their lungs that have been really underutilized. So I think that's a really interesting point that I think I hope people will take away with.

Another component of the development and this focus on outcomes that are important long-term and important to families, you guys also have a little bit of a different approach in terms of teaching babies to eat while they're undergoing this process. So I think in a lot of units, these babies have had no oral stim and no feeding progression because they're on high pressures, because they've been chronically intubated. I think the culture is changing on that. I think you guys are leading the way. I think so many people think like, well, if the baby's gonna get a trach and a G -tube, then they don't have to practice feeding. Tell us a little bit about what that looks like in your unit.

Audrey Miller:

We pride ourselves on that. We do a lot of oral stim from the time of admission, but I think the biggest impactor we're seeing with our outcomes that's making a difference is feeding on CPAP. So we started practicing feeding on CPAP at a certain gestational age, if the baby's on less than 40% oxygen, just so they can get those skills. The way we do it at first, is the first feed is with one of our therapists, and then they do their assessment to determine if it's safe for us to do. And if so, which most of the time it is, then that's something we start incorporating once or twice daily for our patients. What we're seeing is those patients tend to have faster time to achieving full oral feeds and lower G-tube rates. So we do think that's really helpful to start being able to do that. But agreed, it's not something that everybody is comfortable with doing. It's a new practice.

Ben Courchia:

Audrey, I'd like to transition a little bit during this interview because people must be listening to you talk and they say, this neonatologist with 30 years of experience is shedding such great pearls. But people may miss the fact that you completed your fellowship in 2021, so just a few years ago. I want you to give us a little neonatology consult. What is your advice for people who are entering the workspace, would like to follow in your footsteps, and have the career that you've had?

Audrey Miller:

That's really kind. Do you mean in terms of the BPD trajectory?

Ben Courchia:

Well, you are now the medical director of one of the most prominent BPD units in the country. You're just a few years out of fellowship. I am just wondering, what is your advice for people who would love to know how to get themselves ready to be prepared to take on these kinds of roles when the opportunity presents itself?

Audrey Miller:

I appreciate that. To a certain extent I got pretty lucky in my mentorship and where I was. I was fortunate enough to train with Dr. Al Gest, who came to my training institution to set up a BPD program. So from the time of residency through fellowship, I was able to work very closely with him. I learned the ins and outs of BPD and truly fell in love with that patient population, seeing just how amazing their outcomes can be with the right interventions. I think a lot of that was being open to that experience.

I think we can all admit not a lot of neonatologists love BPD . It's not what people gravitate towards. So despite hearing people's thoughts on that, I was very open to learning about this patient population and having this experience and ended up falling in love with it. A certain degree of that was very much luck, just having that mentor be there at the right time and then me just taking advantage of that and learning everything I could from him.

Daphna Yasova Barbeau:

I hope people take away that, we have very capable, passionate, young early career people who are totally able to do the work. So I hope people take that away, but I wouldn't say it's just luck. You had really engaged in not only research that aligned with those career goals, but really engaged in the community. So we've got lots of collaboratives with lots of different focuses, but it sounds like it's very valuable for fellows, even maybe residents, who know what they are interested in to start engaging with the people in those fields. They have the opportunity to talk to the big names and learn from them, and maybe take on smaller projects in the collaborative. So you did a lot of those things in preparation to make the leap, I guess.

Audrey Miller:

Yes, and I do feel like the collaborative has been an incredible door opening opportunity for me. I do share this with our trainees here, that you can really engage with so many different people across the country and really anything you're interested in related to BPD, there's a niche for in the collaborative. It has been a great way for me to meet new people and to jump on projects. As of last year, I started my own project and really am building up my comfort with taking on those roles, and those projects have been really helpful.

Daphna Yasova Barbeau:

I think especially the BPD Collaborative, it's still pretty young as far as projects go, but it's one of the most established collaboratives in our field. How can people get involved? How can they lower the bar to entry? So it's a little bit more comfortable, especially with all the big names and big centers.

Audrey Miller:

Yeah, I think we're very welcoming when you get to know us. The way I did it was just started by asking questions. So I would go on to the meetings and just try and build up my clinical skills a bit, my research skills a bit, and ask questions. Everybody was very engaged and open to sharing their perspective and their knowledge and then taking it a step further and allowing you to participate on projects.

Ben Courchia:

For the people who are in the position that you find yourself in, I believe that there is no way to really completely remove the imposter syndrome whenever that position presents itself. How do you put that aside and leverage all the things that are around you to say, all right, it's not just whether I am capable of taking this on right now, but I do have a lot of levers around me that I can use, whether it is the mentors that were supporting you and so on. But how do you deal with just taking that leap and saying, okay, yes, I can take this role despite how intimidating this position might be?

Audrey Miller:

Absolutely. To be very honest, I thought this would be a role that I would be doing in five years, not now. So having that imposter syndrome is still very much a part of my day to day. I worry about the great outcomes that we have and not wanting to mess up this great unit and these great outcomes quite frequently. For me, that's been a lot of relying on my mentorship. Certainly Dr. Leif Nelin and Dr. Edward Shepherd are incredible, both clinically and from a leadership standpoint, and I rely on them a lot. We talk constantly about things. I've also tried really hard to develop my leadership skills. I took a year-long course through The Ohio State University recently, focused on improving leadership skills in clinical practice in medicine, and I found that to be really helpful.

There's a lot of trial and error as well and I try not to be too incredibly hard on myself, but that's hard. I'm constantly learning from myself and also from my team. I think one thing that I've had to learn recently is that delegating is great. I have this incredible team that's so engaged like our practitioners, our nurses, our leadership, our RT leadership, our dietitian. Everybody is so engaged in this population, wants them to do well, and is engaged in leadership and making good changes. So allowing myself to step back and letting those people really flourish and do what they do has been helpful too. That's been something I've had to learn recently. That in turn helps me feel like a little bit of the scary load is off me a little bit, if we're all one big team.

Ben Courchia:

Let me ask you then, going back to something you said in passing, but you said, this is something that I saw myself doing five years later. Do you think that still having that ambition, even if the timeline is completely off from the standpoint of what you set yourself, but things may open up sooner or later, but do you think that just setting your sights to something that you believe you can do is important? Do you think that plays a role?

Audrey Miller:

Absolutely, I do. I also think this would be very hard if I didn't have the support structure and the mentorship established. So I don't know if I would have said yes if I didn't have that, and knowing that I could lean on my mentors and my support as I was navigating this.

I remember when Leif asked me, I remember thinking, you sure? Right now? I thought this was going to be in a few years, but I'm really glad I said yes. I think it's definitely a great thing for people to keep in mind that they're certainly capable of rising to the challenge if that's something that they want to do. Keeping in mind you're well supported and making sure that this is something that fits for you in your life.

Daphna Yasova Barbeau:

I think a lot of people will say, okay, I have this clinical interest. I feel like I have the background. I think I can do it. But I'm concerned about the logistics and the administrative work and having to talk to the hospital administrators. Any recommendations for gaining confidence in that area?

Audrey Miller:

Still working on that myself. Honestly, it's been a lot of just diving in and getting that experience. The more I do it, the more comfortable I feel. Trying to supplement my leadership skills with reading and courses has been helpful too. But a lot of it, unfortunately, is kind of hands on learning and learning from my mistakes too.

Ben Courchia:

Audrey, thank you so much for taking the time to share this conversation with us. It's been a pleasure and congratulations on this amazing work that you're doing. We wish you tons of success and hope to have you on a couple of years down the road for more great updates from the great unit at Nationwide Children. Thank you for your time.

Audrey Miller:

Thank you so much for having me.