#347 -CPAP with Purpose: Supporting Babies in the Delivery Room and the NICU (Part 2)

Hello Friends 👋

In this episode of The Incubator Podcast, Dr. Guilherme Sant’Anna, Professor of Pediatrics at McGill University, joins Ben and Daphna to discuss his team’s work on implementing an early bubble CPAP protocol in the delivery room. Although CPAP has long been considered standard practice for preterm infants, Dr. Sant’Anna explains why intubation rates remain high in the most immature babies and how his group sought to change this pattern.

The conversation reviews the background of the protocol, which began at McGill in 2014, and the cultural shift required to adopt bubble CPAP as the default approach. Dr. Sant’Anna describes the importance of multidisciplinary training, technical details such as proper prong sizing, fixation, humidification, and suctioning, as well as the challenges of sustaining practice change over a decade.

The results of this initiative are striking: lower rates of delivery room intubation, reduced severe BPD, and improvements in outcomes particularly for infants born before 28 weeks. Dr. Sant’Anna also reflects on lessons learned, the global implications of bubble CPAP in resource-limited settings, and the importance of sharing knowledge to improve care everywhere.

This episode highlights how attention to detail, persistence, and team culture can transform neonatal respiratory care.

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This episode is part of a special three-part series on the use of CPAP, supported by Fisher & Paykel Healthcare. Their sponsorship makes possible the logistical production of this podcast series but does not involve curation, moderation, or influence over the content of the discussions.

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

Watch the design matters video series and discover what drives the innovation behind their neonatal interfaces https://www.fphcare.com/hospital/infant-respiratory/support/design-matters/

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Short Bio: Dr Guilherme Sant’Anna is a Full Professor of Pediatrics, Faculty of Medicine, McGill University. He did his medical school and residency in Pediatrics/Neonatology in Rio de Janeiro, Brazil where he worked as a neonatologist from 1997 to 2001. Dr Sant’Anna went to McGill University in 2001 for his PhD studies in respiratory physiology under the supervision of Dr J. Mortola. From 2002 to 2004 he did a fellowship in Neonatal Perinatal Medicine at McGill University. After that, he worked for 4 years as Associate Prof of Pediatrics at the Neonatal Division at McMaster University before moving back to McGill University. Dr Sant’Anna is actively involved in education and has participated and organized several national and international meetings. 

His research interests are to better understand and optimize the respiratory assistance in preterm infants and the use of innovation and new technologies in neonatal intensive care. In collaboration with Biomedical Engineering and Computer Science at McGill University, and multiple international collaborations, he is working on the development of a SMART NICU/HOSPITAL by using wireless technology and advanced monitoring systems.

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The article covered on today’s episode of the podcast can be found here 👇

Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD.

de Carvalho Nunes G, Barbosa de Oliveira C, Zeid M, Leone M, Mardakis S, Remmer E, Boyer J, Hailu E, Altit G, Beltempo M, Shalish W, Sant'Anna G.Pediatrics. 2024 Jul 1;154(1):e2023065373. doi: 10.1542/peds.2023-065373.PMID: 38887808

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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 today for a special interview with Dr. Guilherme Sant’Anna. Guilherme, welcome back to the podcast.

Guilherme Sant'Anna: Thank you for the invitation. It's a pleasure to be here again.

Ben Courchia: Daphna is here with us in the studio as well. Daphna, good morning.

Daphna Yasova Barbeau: Thank you, thank you.

Ben Courchia: Guilherme, you are a professor of pediatrics at McGill University in Montreal, Canada. You have an impressive biography. You're originally from Brazil. You do a lot of work in research and clinical sciences related to respiratory distress. You do a lot of global neonatology work as well.

Your work was featured on our platform before – you were a Delphi speaker this past edition, and you've been interviewed by our friends at the Global Neonatal Podcast, Dr. Shelley Anne Williams-Dakari and Mbozu Sipalo, on episode 246, “From Brazil to Canada, How Community and Collaboration Can Lead to Change.” We will refer people to this interview for more information about your career.

Today, we're here to talk to you about early bubble CPAP. A few months ago, you and your team at McGill published a fascinating paper in Pediatrics titled “Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD.” You really take on in this study the association of an early bubble CPAP initiative in the delivery room and its potential long-term effects on the rates of death and severe BPD in very preterm infants.

It seems to me that CPAP in the delivery room is, or at least was, a done deal. It seemed like we knew what we were doing and there was no need to revisit anything. So what prompted you to say, “Let's go back to the delivery room and how we administer this first step of NRP”? Every international organization is adamant that the first important thing of resuscitation is ventilation, usually in the form of CPAP. So what made you think there was room for improvement there?

Guilherme Sant'Anna: That's a great question, Ben. And that's pretty much what we have done here in Montreal for a long time now. We initiated the protocol in 2014. It’s been more than 10 years that we're doing that.

Yes, I agree with you. CPAP in the delivery room is a done deal. We know that we should not preemptively intubate babies in the delivery room compared to keeping them on CPAP. However, if you look at the rates of intubation, the more immature the babies are, the higher those intubation rates still are. So although we know we should try to put them on CPAP, translating that into practice is not so easy. One of the motivations to establish this protocol of early CPAP in the delivery room was to motivate people to avoid intubation so quickly, the decision to intubate in the first or second minute of life.

The second point is that I am a true believer that not all CPAP is equal. We decided to adopt the bubble CPAP system in the delivery room. Most people provide CPAP using the Neopuff. The Neopuff is a mask. The advantage is that it can do some PPV and then you just switch to CPAP. However, you put pressure on the face of the baby. And we know that when you put pressure on the face, you can trigger a trigeminocardiac reflex that induces pauses or apnea in the baby.

The second thing is that you have no bubbling. And we can talk more about that, the effect of the bubbling when the flow goes into the water. But in practice, it’s quite impressive. We had many ELBWs on the Neopuff with saturations in the 80s, and then you put them on bubble CPAP and the saturation shoots up within 30 seconds.

Ben Courchia: You mention in the paper that bubble CPAP provides pressure amplitude at high frequencies due to the oscillations generated by the water bubbling. So just the bubbling itself creates that vibration almost.

Guilherme Sant'Anna: It does. And animal models have shown improved lung recruitment and stabilization of unstable alveoli. The pressure is not constant. If you put bubble CPAP at five, with the water going up and down, you get pressure amplitude at a very high frequency. The frequency is proportional to the compliance of the lung: the lower the compliance, the higher the frequency (because it’s a closed system). As soon as you open up the lung and compliance gets better, the frequency goes down. It bubbles, but at a different frequency. Jane Pillow demonstrated this in animal models with Alan Job many years ago in the American Journal of Respiratory and Critical Care. I think this is the reason why you avoid the trigeminocardiac reflex with prongs, you get positive effects of bubbling at high frequency, and you improve lung movement.

We’ve been doing that since 2014. We have the bubble CPAP system ready to go in the delivery room. Many kids are on bubble CPAP within 30 seconds. We suction, put in the prongs, and the baby starts to go. If the baby doesn’t breathe, then you provide PPV to trigger breathing. As soon as the baby is breathing, we put on bubble CPAP.

Daphna Yasova Barbeau: That was my question. I wanted to make sure we all understood when you were switching from a Neopuff. So if the baby comes out vigorous, they get no Neopuff. They go straight onto the interface. Very interesting. I think that helps set the stage.

Ben Courchia: Yeah. And so the methods of this study and this initiative are very interesting. First of all, I'm impressed that your initial approach was to put together a multidisciplinary group involving neonatologists, respiratory therapists, and nurses. You were dealing not just with a quality initiative, but also with a potential culture shift in your unit. Can you tell us why it was important to put this diverse group together and what cultural obstacles you needed to overcome as you implemented this project?

Guilherme Sant'Anna: Yeah, that's another excellent point. I'm not going to pretend it was easy. It was a long road. If anybody's listening here and wants to do that, it takes a lot of work, but it's worth it. It took us a year and a half, almost two years of several workshops, training, and getting all the key players together on board. So when you go to the delivery room, you have a nurse, a respiratory therapist, everybody helping you with this extremely preterm baby. They all had to be on board and understand why they were doing that.

And it's a continuum. This is the delivery room, but then you move the baby to the NICU and keep going with the same therapy. We invited experts for many years, like Jay Wong from Columbia, who came to Montreal four or five times. And Hany Aly from George Washington, now in Cleveland, came here twice. We invited nurses from Columbia to come here and do calls with our nurses, showing how they placed the prongs and fixed the whole system.

We had two cycles of workshops. In the first one with Wong, we did about 20 workshops training everybody. And in the second one, about 10 workshops. You elect champions in your team – people who are more excited about it, a nurse or a respiratory therapist. You overtrain them, and then they train the others on a daily basis during calls.

So it is a culture change. The NICU at the Ohio Victoria Hospital used to intubate everybody below 28 weeks. When I came here in 2009, that was the standard of treatment: if you were 28 weeks, you got intubated. Then the trials came out, and things started to shift. We were lucky because all these trials came out between 2000–2012, and we established our bubble in 2014. Everyone was talking about CPAP in the delivery room, and we said, well, if we're going to use CPAP, let's use CPAP in this way.

You might ask why I had the idea to do it this way. It came from a lot of frustration with other methods that didn’t work out. We tried NIPPV, intubation, many things—and the rates of BPD were the same. Nothing changed. Until one day I said, these guys keep publishing very low BPD rates, like the groups in New York and George Washington. So I went to talk to them.

What I realized was that it wasn’t just the bubble—it was the whole holistic approach to delivering bubble CPAP. Once I understood that, I thought, we should try it and see if it works. If it works for them for 50 years, why can’t it work for us?

So I followed exactly what they did, with all the training I described. Believe me, it’s much easier to come up with a simple method like, “just give this in this way,” but that isn’t sustainable. We wanted something that would last. To make a big change, you have to change the culture and the way people approach babies. That makes it sustainable.

At the beginning it was tough. Many times I almost gave up. I’d say, this isn’t working. We train people, we talk to people, but yet the next baby that comes, they intubate. Someone told me, “Don’t worry. Start doing it yourself. Do it yourself, and they’ll see.”

So the next baby that came, a 24- or 25-weeker, I put on bubble CPAP in the delivery room. Everybody was ready to intubate, but I said, “oh we’ll intubate when we get to the NICU.” We didn’t intubate that baby for 24 hours. Everyone thinks, “oh my gosh. Well, this is just luck.” Then the next one came, a 25-weeker, who never got intubated. I think I did the first five or six myself. Then one day I saw other people doing it. I remember being in the NICU when the team came up from the delivery room with a baby intubated. They looked at me and said, “I’m sorry, I tried.” That’s when I thought, now it’s working. People got the message.

I was also fortunate to work with Dr. Elizabeth Hailu, a Columbia trainee who knew the New York bubble CPAP system. She took over the delivery room protocol, and she was very committed to bubble CPAP. So it is a lot of work, but it works.

Daphna Yasova Barbeau, MD: I love that. I want to thank you. I think it's so helpful for people to hear how hard it was, right? Because, like you said, there were probably many times you thought, this just isn’t going to work. And we all get there when trying to make culture change in our units. It’s helpful to hear about those struggles and what was successful – like you doing it yourself and showing that you believed in it, and getting those champions involved.

I wonder if throughout the process you’ve learned something about optimizing CPAP, like the way you put on the interface, maintain pressure, and avoid pressure loss, that could help people succeed on their first few tries.

Guilherme Sant'Anna: For sure. Wong always said that the more you do something, the more comfortable you become, and the better you do it. That’s true. If you do something once in a while, you never get good at it. Since we started, I’ve learned a lot over the past 10 years. If I may say, aside from ventilator or bubble, bubble CPAP is significantly better for RDS. But aside from that, the devil is in the details. Neonatologists sometimes think, “I prescribe CPAP” and then walk away. In this protocol, we didn’t walk away – we stayed, with a checklist. It covered everything: the right size prongs, fixation, suction, positioning, and humidification.

The prongs should be bigger, not smaller. Bigger prongs move less, cause fewer injuries, and reduce resistance. Remember, resistance is inversely proportional to the fourth power of the radius. So if they're breathing through the nose and you put a very narrow tube in the nose, that increases resistance quite a lot. When you apply a CPAP system that interfaces with the baby, the flow is passing by. The baby both inspires and expires into the nasal prongs. So if the prongs are too small or too narrow, it's too high resistance and increases the work of breathing in these patients. So we've learned that you need to use the bigger prongs. We’ve also learned that you need to have a proper fixation. We use a U-shaped Velcro (not V-shaped) far from the septum. Otherwise, you’ll have septal injury. The prongs need to be far out and not touching the septum. We also have a protocol for inspection and suction. Babies are obligate nose breathers, so suction is essential. Sometimes deep suction, because secretions accumulate in the back of the throat. In addition, positioning matters. Due to a prominent occiput, premature babies flex their head and obstruct their airway, so you need a roll under the shoulders. Always use OG, not NG, to avoid blocking airflow. Humidity and temperature must be perfect at 36.9 to 37 °C at the heater, so the baby receives air at 36.5. Cold, dry air causes nasal bleeding. Like the day I walked into the NICU and found four kids with nasal bleeding, because someone lowered the heater to 32.5 °C due to condensation.

These details make a huge difference. We learned these things through trial, error, and correction.

Ben Courchia: Yeah, absolutely. Like you said, the devil is always in the details, and it’s up to us. It’s not always easy and we’re pulled in many directions, but we have to stay involved and do quality control, especially with culture change.

Another interesting part of your protocol is the specified criteria for bubble CPAP discontinuation. The paper says a minimum corrected GA of 32 weeks to ensure prolonged exposure. You mention alveolar recruitment and lung growth in the introduction. We’ll have Dr. Cindy McEvoy on later to talk about extended CPAP treatment.

But what does your practice look like? In our unit, we go until 32 weeks, but the paper mentions a minimum of 32 weeks. How long do your babies usually stay on CPAP?

Guilherme Sant'Anna: If I’m not wrong, the paper shows a median of 33–34 weeks. So we went beyond 32. Currently, it’s often 35 or even 36 weeks. We learned this from Wong in New York. Animal studies show longer CPAP use promotes alveolar growth and protein growth. Cindy McEvoy’s studies also showed FRC doubling with two extra weeks of CPAP, and sustained lung function improvements at 6 and 12 months. The effect is that by applying this stochastic resonance that comes with the bubbling CPAP, there’s a big stimulus for lung growth. When I do my teaching in Brazil, I don't understand why people want to rush babies off CPAP to room air. What is the problem? They’re not intubated. It's strange – people sometimes are afraid to extubate. They’ll leave the baby intubated longer, but they have anxiety about stopping the CPAP.

So for us, the minimum is 32 weeks, >1.3 kg, FiO2 21%, no tachypnea, no bradys, tolerates system disconnection, then they’re ready to come off. That was the protocol but now sometimes we wait even longer, until 33-34 weeks.

But if they come off and then need oxygen, we put them right back on CPAP. Some people use low-flow nasal cannula, but I don’t see the point. It’s just masking desats, not helping growth. You're basically telling the baby, do it by yourself because I'm not helping you. CPAP actually promotes lung development.

if the baby fails weaning of CPAP quickly, within the first 24 hours, it’s because they still have lung disease. So we put it back on and leave for 3-5 days before we try again. If the baby initially does fine after removing the CPAP, but by day five they start having more bradys and desats, it’s because they’re almost there but with time they have derecruited. So we put them on bubble CPAP and then we try again in 24-48 hours.

Ben Courchia: Guilherme, I wanted to ask about surfactant. I’m sure listeners are wondering, what about surfactant for babies not intubated? Did you use LISA or INSURE? Or just intubation if needed?

Guilherme Sant'Anna: We don’t use INSURE or LISA. We use bubble CPAP. If it doesn’t work, we intubate and give surfactant. We focus on stable intubation with premedication, stable conditions, and minimal bagging. We keep them on minimal settings until they wake up, then extubate. Usually it’s not true surfactant deficiency, since after 24–48 hours babies produce their own. Most intubations happen due to central apnea or desats, not RDS.

Delaying surfactant doesn’t harm. The SUPPORT trial, if I'm not wrong, 83 % of the babies assigned to CPAP end up getting intubated later in the NICU. So delayed surfactant administration did not show any negative effects. In fact, survival improved for 24–25 weekers

not intubated in the delivery room. So we prefer later, controlled intubation if necessary.

Ben Courchia: Thank you. In your study you had a pre-protocol baseline, then three periods. Surfactant use dropped from 96% pre-protocol, to 85%, then 70% in the latest cohort. That’s impressive. Primary outcomes were the composite of death before 36 weeks and severe BPD. You showed increased rates of survival free of BPD from 55 to 60%, and lower severe BPD rates in the later periods. There was clearly a shift in your patient population, where in the first period you would look at 14-19 % of moderate BPD and 14% of severe BPD. That shifted to either no BPD or mild BPD in period three, about 84% of the babies having either no BPD or mild BPD (16% having moderate or severe BPD). So quite impressive results.

You also have a lot of different secondary outcomes. Delivery room intubation decreased, with a significant decrease in the odds ratio for delivery room intubation over time. The number of infants not requiring any intubation within the first seven days went from 19% to 40%. There were no differences in mechanical ventilation duration, the need for postnatal steroids, length of hospitalization, nor was there any change in the rates of death. Interestingly enough, also the PDA treatment and late onset sepsis decreased over time.

And that the impressive thing for me was that in infants born before 26 weeks, they had the most marked reduction in delivery room intubation going down from 96% in the pre-protocol period, to 40% in period three. You mentioned obviously in the paper that the infants born between 26 and 28 weeks were the main drivers for the respiratory outcome improvements.

Very impressive results. How did your team react when you presented these outcomes, considering the long culture shift?

Guilherme Sant'Anna: We presented results at 2, 4, and 6 years. We waited six years for publication to show sustainability and the learning curve. We knew that sometimes you do things for 1-2 years, but then things go back. We stopped during Covid in 2020 given the complicated nursing situation.

The team was very happy, but honestly, they already knew. You could feel it in the NICU. More babies on CPAP, fewer intubations, almost none going home on oxygen. Our home O2 program even called me, wondering why no babies were being referred!

We saw 25–27 weekers going home at 36 weeks on room air and feeding. That was unheard of. Prolonged CPAP didn’t impair feeding: within 24 hours of stopping CPAP, most babies fed well. Some studies show that you can feed babies on CPAP. I have no problem with babies on CPAP, 21%, no respiratory distress, 35-weeker, why can’t you feed? In New York, they breastfeed on CPAP. But we don't do that in our place, because it would be too much work with the nurses and a strong culture to change. For most babies, by the time they get to this gestational age, you can remove the CPAP and they can feed very quickly.

Of course, the tiniest babies (22–24 weeks) often still needed intubation. But always trying CPAP first didn’t make them worse, and survival improved. We’ve stopped seeing kids needing tracheostomy. The staff sensed it daily, and the data confirmed it.

Daphna Yasova Barbeau: Thank you for sharing your experience. This is hugely impactful, even in high-resource settings. But you’ve also practiced globally. How do you think this approach changes care in low-resource countries?

Guilherme Sant'Anna: It’s critical. I go to Brazil a lot, and I advocate strongly for bubble CPAP. In low-resource settings, avoiding intubation is even more important. However, conveying knowledge is the hardest part. Companies can easily sell a new drug or device, but implementing bubble CPAP takes effort and training. Still, many Brazilian units have adopted it. I get messages daily. I just got a message from someone in Sao Paolo telling me about the survival of 1.5–2 kg babies who used to die after intubation. Studies in Africa and South Asia also show promise. Many babies >1.5 kg shouldn’t die from intubation complications if CPAP is used well. And bubble CPAP is the simplest, most efficient method.

Ben Courchia: We’re nearing the end. For listeners, I recommend downloading the supplemental information with your paper. Like you said, the devil is in the details, and the supplement lays it out clearly. I’m even going to share it with our respiratory team. My last question: what’s next for you and this project?

Guilherme Sant'Anna: Locally, we keep going. We reanalyze and update the protocol every four years, retraining new staff. I think we’re back to where we were pre-COVID, with great outcomes again.

But my biggest commitment is knowledge translation. I don’t want to keep this to myself. I want others to do it, improve it, and share it with us. Together, we’re stronger.

We recently got funding for a documentary on bubble CPAP. It will tell the story from Columbia University in 1973 to now, and include all the details. A 15–20 minute resource for anyone interested. We have no financial conflicts. I spend my own money to travel and tell people about it. At the end of the day, just like all of us, I just want babies to do better.

Ben Courchia: That sounds great. We may have announcements soon about featuring your documentary at the Delphi Conference. Guilherme, thank you so much for joining us. Congratulations on this impressive work and good luck with the future of the project.