#454 -PEEP, Tidal Volume, and Physiology, How Far Has Resuscitation Science Traveled? (ft Dr. Charles Roehr)

Hello friends 👋

How far has delivery room ventilation really come? In this special episode, recorded in collaboration with the Neonatal Resuscitation Symposium, Ben sits down with Dr. Charles Roehr, professor of neonatology and perinatal medicine at the University of Bristol, clinical trialist at the University of Oxford, and member of ILCOR. Together they trace the evolution of respiratory support at birth, from the era of fixed inflation breaths to today's focus on physiologic stability and gentle cardiopulmonary transition. Dr. Roehr reflects on a quarter century of resuscitation science, the enduring challenge of human factors in the delivery room, and where the field may be heading, from better intrapartum monitoring to increasingly specialized resuscitation teams.

Dr. Roehr will be delivering a keynote, "Optimizing Effective Ventilation Strategies in the Delivery Room," at the Neonatal Resuscitation Symposium, taking place September 10 to 11 at Indiana University in Indianapolis. Learn more and register here: https://medicine.iu.edu/pediatrics/specialties/neonatal-perinatal/education/resuscitation-symposium

Link to episode on youtube: https://youtu.be/gFwNo8HIMWs

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Short Bio: Dr. Charles Christoph Roehr, MD, PhD, is a neonatal intensivist and clinical scientist. He is Associate Professor of Paediatrics at the University of Oxford and Clinical Director of the Clinical Trials Unit within the National Perinatal Epidemiology Unit. Since 2021, he has also served as Honorary Professor of Neonatology and Perinatal Research at the University of Bristol, based at Southmead Hospital. His clinical and research focus is neonatal stabilization, resuscitation, and non-invasive respiratory support, and he has published over 175 peer reviewed articles in the field. Charles is President of the European Society for Paediatric Research and immediate past NLS Scientific Co-Chair of the European Resuscitation Council. He trained in Berlin and completed postdoctoral research in Melbourne with Professors Stuart Hooper and Peter Davis before joining Oxford.

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

Ben Courchia (00:00.962)Hello, everybody. Welcome back to the Incubator podcast. We are back today for a special episode that we are organizing in collaboration with the Neonatal Resuscitation Symposium. We have the pleasure of having with us in the studio today, Dr. Charles Roehr. Charles, welcome. Welcome back to the podcast.

Charles C. Roehr (00:22.254)Hey, hi, man. Good to see you.

Ben Courchia (00:23.778)Good to see you again. We spoke recently at PAS. And I'm very happy that we get to come back to the show for a longer conversation under the umbrella of the Neonatal Resuscitation Symposium. I'm just going to give a quick plug to the conference now, and we'll talk about it a bit later. But the Neonatal Resuscitation Symposium is going to be taking place September 10 to 11. And it's taking place at Indiana University in Indianapolis.

You can Google Neonatal Resuscitation Symposium, which will land you on the Indiana University website, and you can register there and see the brochure. Charles, for people who don't know you, you have a long background. We were joking off air that your bio reads very long because of all your accomplishments.

You are a clinical scientist with a strong interest in neonatal research. You're a member of ILCOR (International Liaison Committee on Resuscitation). You're a member of the European Consortium on the Management of RDS (Respiratory Distress Syndrome), but most notably you're a professor of neonatology and perinatal medicine at the University of Bristol. You're a clinical trialist at the University of Oxford. And you are going to participate in this conference by talking about optimizing effective ventilation strategies in the delivery room. If it's okay with you, I wanted to maybe start off this conversation by saying, how far have we come in terms of ventilation strategy in the delivery room? Because I think that it's been incrementally evolving. And with increments, usually we forget how far we've traveled.

Charles C. Roehr (02:12.074)Thanks, Ben. It's a great pleasure to be here in this room with you. So thanks very much for having me today. It's equally a great pleasure to be asked to give the keynote at Professor Edgardo Szyld's Neonatal Resuscitation Workshop in Indianapolis. It's a great meeting. I've had the pleasure to attend last year as a discussant, and the format of neonatal resuscitation enthusiasts from all around the world gathering for two days to discuss the hottest topics and have a very interactive platform is just fabulous. So I really enjoyed it. And Edgardo gets all the credit for pulling this off. It's mirrored on one of the meetings Professor Mario Rüdiger has done for 16, 17 years now in Germany. And it's just great to see so many enthusiastic people trying to help discuss and research how we can make transition easier for babies and go away from resuscitation and really do a stabilization.

My talk on optimizing the respiratory transition goes back to something that's so close to my heart and actually is what brought me into research as a start. I hate to look back now a quarter of a century almost — hate to say it, but I love to look back and think, wow, where were we and how far have we come? I mean, the fact that nowadays everybody knows about tidal volume during resuscitation, what's the PEEP (Positive End-Expiratory Pressure) or CPAP (Continuous Positive Airway Pressure) level that we might be aiming for — people can have an educational discussion about this. That's something that fills me with a lot of joy and just tells me how far we've come.

Ben Courchia (04:07.632)And in terms of, I mean, the conference obviously is geared towards people with a high level of understanding and a high level of involvement in the process of neonatal resuscitation. I think that we're moving more and more towards an approach in neonatal resuscitation that is geared towards physiologic goals when it comes to ventilation, rather than just simply an effect on clinical vital signs. I think that when we do an NRP (Neonatal Resuscitation Program) or whatever resuscitation program in your respective countries, we are asked to reach those goals. But I think that with our understanding of the patients that are coming to us, specifically prenatal diagnoses, we understand them better. And I think that our objectives really become much more granular. Can you talk a little bit about that? And how does that change how we take care of patients at the bedside?

Charles C. Roehr (05:05.474)Yeah, I think that's a really good point to make — the understanding that we're trying to maintain physiological stability rather than to reach a certain threshold in terms of oxygen saturation or heart rate at a given, man-made time point. I think it's fair to say that the neonatal resuscitation setting is a perfect clinical scenario where you can learn from the physiological animal experiments from the many groups that are doing ongoing research, but also the past research of the time.

When I was a pediatric trainee, I wasn't even committed to being a neonatologist. I had my first training day on neonatology and my supervisor said, you know, this is a T-piece and here's a mask, and you pop it on the baby's face and you give three long inflation breaths and everything will be fine. And I was like, I just looked at her and I thought, wow, how does she know that? And as I said, it's 25 years ago, and to this day, I'm so grateful for this moment that I was able to enter this questioning, this spirit of questioning what we're doing in order to learn and improve. So from those times, the research that I read was Björklund et al, a great Swedish resuscitation scientist who established that giving high tidal volumes rather than lots of pressure basically impedes your surfactant function with the application of a few hard breaths. So very valuable animal experiments which directly translated into practice.

From Björklund's work there came those great experiments from Hooper et al in Melbourne, who showed us that lung inflation has a direct impact on pulmonary vascular blood flow, etc. The presence of PEEP is highly important in maintaining alveolar patency, et cetera. So all this work is so well discussed in the ILCOR resuscitation guidelines and in the European Resuscitation Council guidance that it's like reading a little physiological textbook.

With that comes the importance of good clinical observation through the practitioner's eyes, but also through objective measurements like, for 25-plus years, oxygen saturation. More, it may be more a recognition that rather than saturation, it's important that you get cardiac stability and good heart rate. And we've seen the omission of color — you know, Colm O'Donnell's great observations that people, particularly men, are really bad at judging a baby's color at birth — completely wiped color out of the algorithm. So to any of those listeners who might think that everything is cast in stone for decades on end — no, no. ILCOR has only been around since the 2000s, and the iterations, particularly in the neonatal resuscitation field, have developed so rapidly that it's really worth going back and just having a little read and a chuckle at what we did 20 years ago, all with the best intentions, to help babies improve at birth.

Charles C. Roehr (08:41.812)Yeah, so from just being very procedurally driven, I think there's a recognition that we are now much more focused on physiological stability. And that leads us far away from just what we do with the lungs and with airways. It includes the whole package of cardiopulmonary transition at birth and leads us into delaying cord clamping and all that. You know, it's a big field and there's lots happening, and it's super exciting to this day. It just gives me a thrill to think about how far we've come and how much we can still improve.

Ben Courchia (09:14.636)I didn't realize it was just 20 years. I mean, we talk about it like it's 20 years old, and so on and so forth. But when you put it in those terms, that ILCOR began in the early 2000s — that's mind-boggling. I had not realized that.

Charles C. Roehr (09:29.87)Yeah, I think 1999 was the first meeting, and you can see those minutes and those published guidances. If you're an evidence-based medicine aficionado, you would think that this is the greatest timeline of how things went from opinion-based medicine — with all good intentions, I'm not being critical here — to what's now become an iterative, evidence-based process.

Ben Courchia (09:33.324)Wow.

Charles C. Roehr (09:58.292)It's super exciting. And you know, I'd love to highlight this for everybody out there. If you take resuscitation on the whole, it's, you know, it's always high-acuity, low-incidence kind of stuff, where you need big numbers to get confirmatory results in instructive trials. But the way that the neonatal resuscitation council, ILCOR, has addressed this under the leadership of people like — I'll start with Jeffrey Perlman, Myra Wyckoff — we've come so far, and we've been looked upon by the adult resuscitation specialists, and they've actually adopted what we're doing. For once, it's been the baby doctors who've made a massive impact on how resuscitation research is being conducted, disseminated, and also integrated into practice.

Ben Courchia (10:51.894)We always feel very proud of that fact. Whenever we get to teach something to the adults — I remember when the COVID days were upon us and we were talking about proning and surfactant, we all felt this sense of, our field is being represented to its just measure.

Charles C. Roehr (11:07.758)Absolutely, completely agree.

Ben Courchia (11:09.816)In terms of what we do in the delivery room, I think that one of the aspects is the human element that we don't talk very much about — the fact that resuscitation, just like any code situation, really the interventions have to be pre-thought. And really we want to swing into action quickly rather than pause to think. And it's quite a unique scenario, obviously, in which thinking is placed later, further down in the algorithm. First, you really intervene. But I think that there is a lot to think about as we are delivering ventilation. And I think that there's a lot of parameters to take into consideration. We talked about the physiology of the baby, but I think that the location of where these resuscitations take place varies so dramatically that obviously resources are not the same. And I'm wondering how the goal of ILCOR and of the NRP and all these organizations has been to really create a uniform approach that can be applied everywhere. And do we think that we're getting better at doing that, or are we going to reach instead maybe a breaking point where we say, well, you know, there's too many different babies, too many different types of units, that we can no longer approach it in the same manner? I'm just curious to get your thoughts on that.

Charles C. Roehr (12:42.414)Oh, it's a great question. Thanks for asking. It's got to be a multi-layered answer, because you're absolutely right. So first and foremost, I think within the same hospital, within the same birthing center, you'll find areas of high and areas of low resources. The mom could give birth at the entrance, in the entrance hall of your hospital, and all of a sudden you are in a limited-resource setting where you only have the equipment that you carry. Whereas if you give birth in a controlled setting, like in an OR, and you're there attending the birth, you're in a much more controlled setting. And with that comes the anticipation of resuscitation requirements, where if you meet a birthing mother in the entrance hall of your birthing center, you're basically facing a black-box scenario where you don't know what's coming.

Whereas if you have a highly monitored patient who's having a cesarean section, then your problem list shrinks. The challenge is what's going on in your head. So neonatal resuscitation is, as you alluded to, something which is best to be planned, and many scenarios need to be anticipated. We've learned a lot about risk profiles in the latter days of pregnancy, or impending premature birth, known antenatal risk factors for compromised transition at birth, and interplaying factors like anesthesia in the mother, etc., late-stage compromise of the baby, placental abruption — all of this can be trained for and accounted for.

Can all of this be reflected in a single, one-page resuscitation algorithm? No. The first and foremost shortcoming in the resuscitation algorithms to this day, and I take full responsibility for it as a member of ILCOR and the European Resuscitation Council, is that it doesn't apply to preterm birth as much as it applies to term birth, as much as it applies to postnatal collapsed babies. So all that we can do is provide guidance, which we refine, highlighting issues that ask you to engage your brain and not to follow it religiously step by step, but to know when to deviate and when to take appropriate actions based on the child, or the pathophysiology you see in front of you.

Ben Courchia (15:30.646)That's very interesting. And that leads me to my next question, which incorporates the human element. I think that we read algorithms and approaches to neonatal resuscitation, and obviously, the one thing that is impossible to account for, or at least difficult to account for, is the human variability element. I think that on the podcast, we've reviewed lots of studies looking at this — obviously, the variability, for example, in the delivery of ventilation based on the provider. I think that we all feel like we're delivering maybe the right volume or the right frequency, but we're all not really perfect. And I think that there's a lot of research being done on the use of ventilators in the delivery room to make sure that this is a bit more consistent. But it always seems that we can never really take the human factor out of the equation. So what is the next step? Are we going to reach the point where we connect babies to ventilators right away in the delivery room? Because I think that while humans are variable, they do provide some additional data. And I wonder if removing the human means that babies are going to be exposed to mechanical ventilation longer, for example. I don't know. But I'm just curious if you're thinking about it in those terms as well.

Charles C. Roehr (16:59.096)Yeah, you touch on many very important topics. I would like to really thank you and the Incubator podcast for doing these great journal clubs and really highlighting important studies. I know we all really benefit from your hard work. It's great stuff. Human factors — it's so important, and it's omnipresent. You will not be resuscitated in the same way in the same hospital if you get a different attendant from the other.

And that may be a lottery that every mother-baby dyad enters. Guidelines give guidance on how to standardize things, but the perception of acuity differs from person to person. The capability to lead a multi-professional team differs from person to person. I really value the fact that simulation training can help standardize how we provide care. And I think neonatal resuscitation is a great example of how to use good simulation on a regular basis, both for operational as much as for procedural purposes.

I love the work, the early works from Liz Foglia, where she really sketched out what are the optimal positions for people attending resuscitation, giving specific tasks to specific people, allowing for people to have oversight. We've come a long way through safety training and aircraft pilot training, to call out and to give permission to call out from every team member when things aren't going well. We've learned so much more about how to have a level playing field when it comes to skills. So attaching a sats probe is not something that only a nurse can do — every doctor should be able to do that, et cetera, et cetera. But still to this day, human factors, I guess, remain the big unknown. As I mentioned, perception of acuity — some people might take a different route than you would have and get themselves into a rabbit hole, all depending on how secure you feel in the situation. And I think that's where experienced teams come in and support each other. And it's important to have a very open and collegial atmosphere in the delivery room so that we don't obstruct each other's thinking, but we help each other along.

Ben Courchia (19:44.79)Very interesting. The time is flying by, and I have a lot more things that I was hoping to discuss with you. Without giving away too much of what you're going to discuss, because we really invite people to participate and register for the Neonatal Resuscitation Symposium — if you project yourself, like, 10, 20 years down the road, how will the resuscitation landscape — not just the landscape, but what a resuscitation in the delivery room looks like — be different from what it is today? And you have complete editorial freedom here. You're not constrained by any data. I'm just curious if, allowing yourself to project with the data you have now, what would be the ideal of what we should really be striving for when it comes to neonatal resuscitation in the delivery room?

Charles C. Roehr (20:42.582)Yeah, super question. Thanks. And I will try to answer part of what your last question implied with this, because you were alluding to whether we should have more machines doing airway management, et cetera.

Ben Courchia (20:52.888)Trying to circuitously get back to that as well.

Charles C. Roehr (20:57.048)That's right, I will. Look, I think, you know, a couple of the things that we need to get right in transition are temperature, airway, and breathing. And to do all of this properly, I think we need much better monitoring equipment. It's all fine to have a physical sats probe and to look and listen and all that. But in an age where we have such refined technologies elsewhere, I think we need to move towards more non-touch monitoring, faster data acquisition systems that give you feedback. And that will also help us do invasive things more effectively and less injuriously, whilst at the same time we hopefully will make a better judgment on how much invasiveness is needed at what stage.

So the future for preterm neonatal resuscitation, for me, is to start by having good intrapartum monitoring, and not just to stop 15 minutes before a cesarean section and then get the baby out in a completely different state than it was in utero. I think it's really important that, in my future, the perspective is that the birth of a compromised child, whether it be a preterm or term baby, is a continuation of its intrauterine life without too much of a nadir. And that's a combined perinatal, obstetric, and neonatal effort to facilitate. And with better outcomes, better monitoring, better equipment, and probably more gentle means of supporting babies — because if we avoid a big dip in the physiology, heart rate, saturation, cardiac output, temperature — then we can be more effective in stabilizing.

I can go on and go on, but I think that the future will be more technology-based, probably more centralized for certain conditions, and it will require all of us to be quite professional in what we are handling — and not just, well, to phrase it this way, I think neonatal resuscitation will be more and more delivered by specialized teams than by just whoever happens to be on the rotation through neonatology.

Ben Courchia (23:33.112)I think that's very interesting. I think that by default, we do have a lot of guidance when it comes to resuscitation about how to prepare for deliveries, and we have certain questions that we should be asking, and so on and so forth. But really, what most of the guidelines don't mention is how far you can extend the preparatory phase. I think that we're seeing, for example — I'm going to talk about my center right now, and this is probably applicable to many other centers — we've become involved a lot more on the prenatal side; we get to know a lot more about our patients prenatally. I find that when I compare myself to the days of my early training, we didn't have so much involvement on the prenatal side. And I feel like the fact that we know so much, we can actually anticipate multiple things, gives us an opportunity for enhanced preparation. And so I think that this is, in my opinion, an avenue that people can explore when it comes to codifying this and incorporating it into the algorithm — how far can we push the preparatory phase — because then we get to be the Formula 1 pit crew, because that really leads to this high degree of efficiency.

Charles C. Roehr (24:50.35)And to just bring it back to Edgardo Szyld's symposium — Edgardo and his team from his days in Oklahoma, they wrote a great paper just looking at how you would prepare, how the risk profile of a preterm infant leads you to think how many people you'll need at this birth, this resuscitation, this stabilization. And it's just the simple recognition, as you say, Ben, that what we learned before from the mother and the pregnancy itself should inform us whether there are two bodies on the shop floor, or four, or six. It can be anticipated with a bit of preparatory work. So again, credit to the host of the symposium.

Ben Courchia (25:35.0)So that's a great segue into the discussion about this symposium specifically. I think that we have today a lot of opportunities to attend a variety of conferences. I think that, for example, we were together at PAS — there's the PAS of the world, where really you go and it's a massive, massive conference, and there's lots of topics being discussed, ranging across all areas of pediatrics. But then we really have these hyper-focused conferences where we're going to talk about resuscitation. And I think that it really is the opportunity to level up, in my opinion — if you are interested in resuscitation, this is probably the place where you should be finding yourself. Can you tell people, from your experience having attended the conference in the past, what are some of the appeals of coming to such a conference? What kind of attendees, and what kind of potential networking opportunities are there, because we're looking more and more for these working meetings where we're going to leave with a pack full of ideas and potential projects to collaborate on.

Charles C. Roehr (26:45.974)Yeah, thank you. No, it's a great conference. It's very conveniently located in Indianapolis. For me, as a European, I like it.

Ben Courchia (26:54.328)The guy from Bristol saying that it's conveniently located in Indianapolis is quite funny.

Charles C. Roehr (27:02.51)Well, yeah, once you're on a big plane, it doesn't really matter where you're from. But it's still at an airport which is very accessible and gets you to the conference center very quickly. That's just the logistics of getting there. But the spirit of the meeting is very collegial, very approachable. The resuscitation folks are just really lovely people and so easy to talk to. Anybody who...

Ben Courchia (27:15.01)Fair enough.

Charles C. Roehr (27:30.51)There's no barrier. People don't have a massive ego there. You can ask anybody anything and you get into contact so quickly. It's a lecture hall with maybe 250 seats. It's usually booked out, so book quickly. People are there from all over the US, North America, South America, and Europe.

It's great to make contact, to present your ideas. You can pick people's brains very easily. You can showcase your own work. And as I said before, resuscitation is such a broad topic — you can do so many things and go down so many avenues and find somebody who can give you advice, share knowledge, or do stuff together. I'm just speaking from my own experience — I've just really gone from great project to great project just by being at such meetings, where you meet all the people who've done stuff and who are eager to do more. So yeah, it's the interaction, the connections, the low-level hierarchy between groups. And there's plenty of discussion — you look at the program, it's just discussion, discussion, discussion, posters, oral presentations. It's really well thought out to be an interactive program. That's what makes it so special.

Ben Courchia (29:00.312)Very nice. Charles, thank you so much for taking the time to talk resuscitation with us. Your presentation will take place at 8:45 a.m. on September 10th, I believe. It's called "Optimizing Effective Ventilation Strategies in the Delivery Room." We will have a second part to this episode where we will welcome another distinguished speaker from the conference, Dr. Roger Soll from the University of Vermont, who will talk at the conference about early surfactant administration. We'll be able to review some of the data there. So look out for that episode as well. Charles, thank you. Thank you again so much for making the time and for sharing your thoughts with us today.

Charles C. Roehr (29:45.454)Thanks, Ben, for having me. It's been a great pleasure.

Ben Courchia (29:47.864)Same.