#478 - How Much CPAP Is the Baby Actually Getting?
Hello friends 👋
Dr. Charles Roehr joins Daphna for the third episode of The Incubator’s special series on non-invasive ventilation, recorded ahead of Hot Topics in Neonatology. The conversation starts with a question most of us stopped asking long ago: is the pressure on the screen the pressure in the lung? From there they work through leak, interface cycling and skin injury, how to tell whether a baby needs more pressure, why a unit’s familiarity with its equipment may predict success better than the mode itself, and when the right wean is no wean at all. Charles closes with his wish list for the ideal neonatal interface.
This series is produced in partnership with Hot Topics in Neonatology and Fisher & Paykel Healthcare.
Join us at Hot Topics in Neonatology
National Harbor, MD, December 6 to 9, 2026. Register here: https://hottopicsinneonatology.nemours.org/registration.html
Don’t miss the live session continuing this conversation: Pressure, Flow, and the Grey Areas In Between. Monday, December 7 at 11:45 AM
Link to episode on youtube: https://youtu.be/vUCcnWoWCDk
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The articles covered on today’s episode of the podcast can be found here 👇
Dr. Roehr’s previous Incubator episode. #454 PEEP, Tidal Volume, and Physiology: How Far Has Resuscitation Science Traveled? https://www.buzzsprout.com/1739595/episodes/19517439
Rib counting paper. Dahm SI, et al. (Tingay DG, senior author). Diaphragm Position on Chest Radiograph to Estimate Lung Volume in Neonates. JAMA Pediatr. 2025. https://pubmed.ncbi.nlm.nih.gov/40690243/
Accompanying editorial. Raffay TM, et al. (Roehr CC, co-author). Bedside Technologies to Challenge Traditional Rib Counting in Neonatal Respiratory Care. JAMA Pediatr. 2025. https://pubmed.ncbi.nlm.nih.gov/40690226/
FONDUE trial. Blank DA, et al. (Roberts CT, senior author). Face mask versus nasal mask device use for initial resuscitation in extremely and very preterm infants (FONDUE): an open-label, single-centre, randomised, controlled trial. Lancet Child Adolesc Health. 2025. https://pubmed.ncbi.nlm.nih.gov/40908053/
European Consensus Guidelines. Sweet DG, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023. https://pubmed.ncbi.nlm.nih.gov/36863329/
Charité leak studies. Fischer HS, Roehr CC, Schmalisch G, et al. Is volume and leak monitoring feasible during nasopharyngeal continuous positive airway pressure in neonates? Intensive Care Med. 2009. https://pubmed.ncbi.nlm.nih.gov/19771409/
Fischer HS, et al. Assessment of volume and leak measurements during CPAP using a neonatal lung model. Physiol Meas. 2008. https://pubmed.ncbi.nlm.nih.gov/18175862/
Cochrane reviews. Lemyre B, et al. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev. 2023. https://pubmed.ncbi.nlm.nih.gov/37497794/
Lemyre B, et al. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev. 2023. https://pubmed.ncbi.nlm.nih.gov/37466143/
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The transcript of today's episode can be found below 👇
Daphna Yasova Barbeau, MD (00:06.354)
Welcome back, everybody. We are continuing on our mini-series on non-invasive support and interfaces and supporting babies at the bedside. I am so thrilled to have with me in the studio today Professor Charles Roehr. Right. Welcome back to the podcast.
Charles Christoph Roehr (00:44.344)
Thank you, thank you, Daphna, for having me. It’s great to be back. Thanks.
Daphna Yasova Barbeau, MD (00:47.994)
Yeah. For people who don’t know, well, we’ve covered a number of your papers, obviously, on the podcast. And you were a guest on episode 454, entitled “PEEP, Tidal Volume, and Physiology: How Far Has Resuscitation Science Traveled?” So people can take a listen there. And that was highlighting your keynote address at the recent Neonatal Resuscitation Symposium, and your talk there was called “Optimizing Effective Ventilation Strategies in the Delivery Room.”
So you are certainly an expert, but I’d like to give people a little bit more about your background. Dr. Roehr is a neonatal intensivist and clinical scientist at the University of Oxford. You serve as the clinical director of the clinical trials unit within the National Perinatal Epidemiology Unit, as well as holding a professorship of research at the University of Bristol. Your career has really centered around neonatal stabilization, resuscitation, and the use of non-invasive respiratory support. You’re a long-standing member of ILCOR and the Neonatal Life Support Task Force, and co-author of the European Consensus Guidelines on the Management of Respiratory Distress Syndrome. And furthermore, you’re the immediate past president of the European Society for Paediatric Research and a senior editor for Pediatric Research, the journal. So welcome.
Charles Christoph Roehr (02:07.266)
Thank you very much. It’s great to be here.
Daphna Yasova Barbeau, MD (02:10.194)
It’s really our pleasure to have you and share some of your expertise with the community. Well, first, I guess let’s talk a little bit about the Neonatal Resuscitation Symposium that just occurred in early September of this year. I know you have been a longtime participant. Were there any major highlights or takeaways from the conference this year?
Charles Christoph Roehr (02:32.343)
Thanks. It’s been a phenomenal conference, and Professor Szyld and colleagues put together an expert panel who always present the latest view on the evidence and science that we generate over the year.
Charles Christoph Roehr (04:36.556)
The beauty of that conference is there’s always a panel of people who then discuss the latest evidence that we’ve seen over the year, or topical things like how to optimize non-invasive respiratory support, in that case. And it’s just really great to be able to bounce evidence, clinical practice, and the blue horizon ideas that people have off one another. It’s a very engaging conference. So I thoroughly enjoyed being there and bouncing ideas around, and I took home a lot of new things.
The main emphasis for me is always to try to be better at my job by interacting with colleagues, learning from their experience, and looking back into the past to see how bright the future can be for neonatology. And all of that is what this conference is about.
Daphna Yasova Barbeau, MD (05:35.657)
I love that. And if you’re taking home a bunch of things, then that means that all of us will learn a lot at the next Neonatal Resuscitation Symposium. So we’ll keep an eye out for that in the coming year. I guess we like to start with the basics. Let’s start with the fundamentals, okay, of CPAP. We often talk about CPAP pressure as though the number on the machine is the pressure the baby is receiving.
I think this is difficult for trainees, even early career neos, our new respiratory therapists, and especially parents. How different can the set pressure be from the pressure that the lungs are actually seeing?
Charles Christoph Roehr (06:15.81)
Yeah, it’s a great question, and it’s an observation that we all need to get our heads around. I think I’ve said it before: us neonatologists, respiratory therapists, people caring for small babies, we like to operate in a system of security, and numbers give us security. Dialing up a PEEP of five is what we assume is the PEEP that is presented to the baby. But as soon as the interface transmits whatever we dial up on the system to the baby’s airways, there are so many things that interplay that we can’t measure. And the most obvious thing is leak. As much as we talk about leak in manual respiratory support and resuscitation airway support, on a CPAP system, the baby just needs to open its mouth and there is an egress of flow, and therewith pressure. So ideally, all of these idealistic numbers work on a closed system, and we hardly ever have a closed system on a baby.
The absolute number to translate the observed leak into intra-alveolar pressure is really hard to gauge. So I think in clinical practice, the aim should be to reduce leak by putting a dummy into the baby’s mouth, giving the baby something to work with, or positioning the baby. Some people use chin straps, which is a definite way to help with mouth closure, but it’s also probably not the kindest thing to the babies. However,
Charles Christoph Roehr (08:10.52)
the point that those people make is that you’re definitely transferring the pressure point from the nose or the mouth or the nares to the alveolar spaces. So I take the physiological reasoning behind it, but babies are little fragile humans, and we want to be kind to them as well. So my take on this is...
maybe we need to dial up a little bit of a higher pressure if we take leak into consideration. We just shouldn’t fool ourselves into thinking that just because the machine says eight or 10, that’s the intra-alveolar pressure that we’re generating.
Daphna Yasova Barbeau, MD (08:52.722)
I love that. And certainly, I think we feel how leak is a meaningful problem for us at the bedside. How good do you think we are at detecting meaningful leak at the bedside? We see the number, what percent leak it tells us on the ventilator, but oftentimes it says a hundred percent leak, and we know babies are still getting some support. So how good are we at detecting it, and at what point should we be concerned that the leak is really impacting what we’re transferring to the baby?
Charles Christoph Roehr (09:26.83)
That’s a great question. What I struggle with in this day and time, and I mean this in the most positive way, is we’ve...
moved on from having very simple CPAP devices to bubble CPAP, which I love. It’s a very simple, very effective, cost-effective way of providing CPAP, which is still in use in many units, and rightfully so. But many units, particularly in the high-income countries, have moved on to providing non-invasive support
Daphna Yasova Barbeau, MD (09:43.07)
Hm.
Charles Christoph Roehr (10:06.828)
with ventilators, ventilator machines or standalone non-invasive support machines, and they are all flow-driven machines, many of which would correct a loss of pressure on the pressure transducer, whether it’s near the nose or whether it’s by the ventilator, by increasing the flow.
Just as in a ventilated baby, flow correction is commonplace, and therefore we find it hard to gauge, and I would like to say we don’t really know what’s happening on the side of the pressure device, the pressure provider, when leak occurs and the flow is upregulated. Ventilators are extremely clever nowadays, so we can trust that even if there’s an observable leak, the ventilator would correct for it to some extent. Fifteen years ago, Hendrik Fischer and myself at the Charité, under the guidance of Gerd Schmalisch, did a few studies looking at exactly the leak proportion in single nasal prong CPAP, something that few people do nowadays, because the evidence is very clearly towards binasal short prongs rather than a single nasal long prong. And we could see that on a modern ventilator, the pressure correction took place via the flow sensor if there was leak of more than about 33 to 34 percent. So pretty much as in ventilated babies.
Daphna Yasova Barbeau, MD (11:28.423)
Hmm.
Charles Christoph Roehr (11:53.816)
Does that help us at the bedside nowadays? I think a continuous distending pressure is important. The absolute number is probably less important than having the right pressure for the baby’s lung disease at the time, if you want to call it disease, the condition of the lung. Whether it’s in a low compliance state or in a higher compliance state, you need different distending pressures. And what you want to achieve ultimately is to keep the lung open, to keep the alveolar space open, to facilitate gas exchange, and allow the baby to breathe. What I observe sometimes... I hope I’m not babbling on too much, Daphna.
Daphna Yasova Barbeau, MD (12:35.026)
I love that.
Daphna Yasova Barbeau, MD (12:38.727)
No.
Charles Christoph Roehr (12:40.238)
What I observe sometimes is that in the face of too high a leak, let’s say in high flow nasal cannula, where we predominantly operate by flow and indirectly generate some pressure, if there’s insufficient pressure, we have a continuum of alveolar collapse.
And whilst it might look good on day one and two, when the baby’s in 25 percent oxygen and on a flow of seven and a PEEP of six, three days down the line, we may be in 40 percent oxygen. And what we’ve done is we’ve allowed the lung to consecutively collapse by giving insufficient distending pressure. And I think that’s where we need to be mindful to always provide the adequate amount of pressure, which obviously is a function of the baby’s lung disease, which we need to monitor with X-rays and an understanding of the physiology.
Daphna Yasova Barbeau, MD (13:50.932)
Well, to your point, yeah, it’s changing over time, isn’t it? And sometimes we have to change our strategy. I’m going to get to how much is enough in just a second. But just maybe to close our discussion about leak, how should we think about the trade-off between, again, getting a good seal and then, like you said, being gentle to these vulnerable little people? And is there a point where eliminating the leak actually causes more harm than benefit, one, from just pain, discomfort, interfering with the way the interface works, which I think some people don’t think too much about, and then, of course, skin breakdown. And I know lots of units are using this concept of cycling interfaces. So I’m curious about your thoughts on that.
Charles Christoph Roehr (14:40.622)
Again, that’s an excellent point. I remember a time where you could ask your medical technician on the ward to make you a silicone mask or interface that would fit the baby. And that’s, of course, long gone.
Thankfully, we now have devices and CPAP interfaces from manufacturers who have paid a lot of attention to the anatomy of the baby’s premature or mature nose and give you a selection of prongs and masks to choose from. So far...
in clinical practice, we see the best results with, as you say, cycling at a six, eight, or 12 hour interval on one form of interface and then the choice of another. So sometimes prongs, sometimes nasal masks. I sense that masks are getting much better and are tolerated by babies.
The material is much softer, and a lot of thought goes into how the seal can be optimized around the nose and the baby’s face. And that’s very exciting to see, whilst the predominant seal in CPAP should be a snug fit in the nose or around the nose.
And the mouth leak is something that is on the side of the art of the nurse, to position the baby, to use a pacifier or other things to keep the mouth closed. So it’s exciting times, and there are new developments coming out frequently, which we’re excited to look out for and then use on the units.
Daphna Yasova Barbeau, MD (16:33.949)
And back to your point, you’ve written a number of articles on evaluating the effectiveness of non-invasive support. So how do we know that the baby is getting enough, that we won’t have that progressive atelectasis? Is it ultrasound? Is it X-ray? Is it the clinical presentation of the baby?
Charles Christoph Roehr (16:57.378)
Thank you. I think you’ve given us the three best indicators. First and foremost, it’s the baby that you can see in front of you. Is the baby comfortable? Is the baby struggling? Are the clinical signs of RDS increasing? Do we need to react, not just by dialing up the oxygen, but by asking ourselves, is this baby breathing comfortably? Yes or no?
Non-invasive ventilation on the whole, but particularly continuous distending pressure, as with CPAP, is quite easy to change whilst you’re by the bedside. So you can do your ward round, you see a baby on seven centimeters of CPAP, and the baby just doesn’t look right. You can increase the CPAP by a centimeter or two and come back later. I think we’ve moved away, because our understanding has moved on, to learning that it’s not the CPAP per se that causes the pneumothoraces that people were accusing the earlier CPAP studies of, just in relation to an increase in pressure. So I think by clinically observing the patient and gently increasing the pressure by a centimeter, or a max of two, that will tell you a lot about whether the baby needs more pressure. You look at recessions, the respiratory rate, and of course the oxygen saturation, but you need to give it some time. Likewise, obviously, chest X-ray, with radiation, is the least preferred option, and lung ultrasound is moving more towards giving us some non-radiating information on lung
Charles Christoph Roehr (18:55.854)
and also regional lung expansion, but I leave it to the experts in lung ultrasound to talk more about that. I wish I would use it more in clinical practice, but for me, the bedside observation of the baby, with an understanding of the baby in front of me, is currently the best way of managing my babies. Conversely, if the baby has too low a pressure and we feel that the lungs are collapsing and the oxygen requirement goes up, it’s a big challenge to re-recruit a preterm baby’s lungs with just simple non-invasive continuous distending pressure. And then we might want to think about ways to increase our mean airway pressure, one of which would be to use non-invasive positive pressure ventilation or high-frequency oscillatory ventilation through a non-invasive interface. All of this is a bit of clinical practice without much evidence behind it, but the trials, by and large, show that it’s encouraging to see that the endotracheal tube isn’t the next step after CPAP failure. There are escalation steps that we can take before we intubate and ventilate.
Daphna Yasova Barbeau, MD (20:20.031)
I was especially interested in your article challenging traditional rib counting in neonatal respiratory care, and how we’ve recognized that just the rib expansion on a one-shot X-ray may not give us the whole picture.
Charles Christoph Roehr (20:39.682)
Yeah, you’re definitely giving me too much credit. This is a paper by David Tingay from Melbourne and his group. It’s a fascinating paper where he compared chest CT scans and conventional X-rays. It’s published in the Blue Journal, I think, at the end of last year. It’s a phenomenal paper, and thought-provoking, to lead us away from a two-dimensional understanding of the lung. And that’s literally what we do when we do rib counting, isn’t it? We look at a two-dimensional image, and we’ve tried to make an assessment of a three-dimensional body like the thorax and lungs. But thank you for highlighting this paper, to which I think I wrote the editorial. So it’s fascinating how little the things that we were taught by our forefathers, and that we took to the bedside and practice day to day, medicine actually...
It’s fascinating how we have a false sense of security by doing what we’re doing.
Daphna Yasova Barbeau, MD (21:55.392)
We’re learning over time, right? That’s the scientific method, I think. You already mentioned we have an array, in high-resource units, of course, of opportunities for non-invasive support: CPAP and bubble CPAP, non-invasive PPV, bilevel support, high flow, and other supportive modes of synchronized non-invasive ventilation.
I think you’ve touched on this a little bit. Are we sometimes putting too much emphasis on the mode and not enough on the interface, like we’ve discussed?
Charles Christoph Roehr (22:35.564)
Yeah, thanks. When we wrote the update of the European Consensus on the Management of Respiratory Distress Syndrome, we were a group of quite...
senior physicians and neonatologists and people with a very deep understanding of non-invasive respiratory support modes. And we came to the conclusion that over the last 30, 40 years, we’ve seen a lot of advancement, but the biggest predictor for success of a single form of support mode comes with what the unit itself, and therefore the nurses and doctors of that unit, are used to.
When you’re good at something, try to refine what you’re doing rather than embracing the ever-expanding new technologies, unless you’re really certain that you’ve maxed out your individual potential. The interfaces are really important.
We talked about this, how they’ve improved, and we are seeing the launch of new interfaces this winter, this December time. And it’ll be very exciting to see these new interfaces come into play.
Nasal CPAP, for instance, the traditional way: midline prongs and Hudson prongs, INCA prongs, all going sideways or around the nose, all have their benefits and their downsides. The most important thing is to have a snugly fitting interface that does not compromise microcirculation in the skin. The worst thing that can happen to a baby is to have nasal skin erosions
Charles Christoph Roehr (24:22.032)
or nasal columellar erosions, philtrum erosions, and then be scarred for life. Therefore, the best-suited individual interface, paired with very vigilant observation of the clinical state of the baby and its nose, is really important. And training, retraining, and a good governance system around this on your unit are really important, because CPAP injury, as devastating as it can be, is definitely preventable through good training. So choosing the interfaces carefully and training the staff is as important as knowing how to dial up pressures or change between different modes.
Daphna Yasova Barbeau, MD (25:12.573)
Yeah, that was totally my next question. Is it really the mode? Is it the interface? Or is it really who’s at the bedside monitoring the infant that predicts success on non-invasive support?
Charles Christoph Roehr (25:27.564)
Yeah, really good question. I think we always need to go back to what the baby is dealing with at this time. Is it an extremely preterm baby with a very immature respiratory system, biochemically as much as anatomically, or is it a more mature baby that’s dealing with congenital pneumonia or meconium aspiration, for example, and secondary surfactant inactivation, for instance? So we want to stabilize the respiratory system, and we want to give the most appropriate support, which has to be transmitted through the interface and the device.
That’s obviously looking at the literature. If you do systematic reviews, as my group has done in the past, you end up with an all-or-nothing verdict. You end up with a forest plot which tells one story: that A is better than B, or there’s no difference between B and C.
But it doesn’t tell you much about the granularity of the data behind it. And that’s the challenge of our times in neonatology, that we’ve got a very diverse population which we treat. Even if you include babies, let’s say, only less than 32 weeks of gestation, you’re including babies which can differ 10 weeks in their gestational age, and with that differs their lung disease.
The literature, at least the systematic reviews, doesn’t give you enough information on what to use for which baby. And we’re in an exciting time where people address this by doing larger trials, by doing trials where they don’t exclude the smallest babies, or where they focus on specific patient groups. And it’s this kind of evidence that we need in order to help us care better for our babies, by choosing the right equipment and the right mode
Charles Christoph Roehr (27:43.808)
at the same time.
Daphna Yasova Barbeau, MD (27:46.876)
Yeah, I think that’s such a good reminder, and I try to tell parents and my team this: what’s working for a baby one day may not work for the baby even the next day, certainly not the next week. So I appreciate you highlighting that. And then let’s talk a little bit about the baby who’s doing really well on the support that we’ve given them. What are some parameters, for those of us spending a lot of time at the bedside, for example, indicators that babies are really ready for weans on non-invasive support, not just a gut feeling, potentially, that we have as we’re walking around and rounding? And then how often should we be looking to wean non-invasive support?
Charles Christoph Roehr (28:28.438)
Yeah, again, a very, very practical, really relevant question. What we always need to consider is, by and large, how much do we expect this baby to require, and for how long does it require respiratory support? And usually it’s longer than we think. Particularly when something is non-invasive or less intrusive, we...
We sometimes use it as a means to show there’s progress. If we can’t increase the feeds, if we can’t get the baby out of the incubator, we can tell the parent or the caregiver, well, we made a bit of progress here on the PEEP, for instance.
I’m using this example to say that there’s often a tendency to change things, even though the baby may be comfortable or has just hit a comfortable spot. And I’m encouraging myself as much as my team to sometimes just sit on our hands and say, let the baby ride it out. Just because we’ve got oxygen stability between 25 and 30 percent, and the baby’s breathing looks quite comfortable on any given setting, doesn’t mean that we need to immediately lower these settings. We should try not to rush these things.
As I mentioned before, the worst thing is to try to re-recruit lost lung volume. Because most babies will be on respiratory support at least until they’re in their 30s of weeks of gestation, to me that means we don’t need to really rush into changing from one method to the other, or lowering the pressure at any cost. If, in your head, you extend
Charles Christoph Roehr (30:32.216)
this baby’s respiratory support period for a while and are comfortable with what you’re doing... I would urge people to rely on the baby and just observe the baby, not do too many blood gases, particularly whilst they’re in the stability phase, and only if the baby is really snug and comfortable in a low oxygen setting, 21 to 25 percent, then maybe consider going down on the CPAP level or the high flow level.
Daphna Yasova Barbeau, MD (31:09.787)
Yeah, I’m a tinkerer by nature. And every day when I walk into the unit, my mantra is, sometimes doing nothing is the best thing that I can do for this baby today. So I appreciate the reminder. We don’t have much time left together, so I wanted to look a little bit into the future. You mentioned you yourself are on the brink of an exciting new study.
But you have so much expertise in designing studies around non-invasive support. For our colleagues who are studying these nuances, what are the imperative features to include in the study design of respiratory support?
Charles Christoph Roehr (31:48.322)
Wow, that’s a great question. That’s a podcast in itself. Yeah, no. The importance of the clinical question drives everybody’s motivation behind it. My group, my collaborators, we always focus on practice-changing trials where we think that we can do the population of babies better.
Daphna Yasova Barbeau, MD (31:49.277)
That’s a big question.
You don’t have to give away all your secrets either, you know.
Charles Christoph Roehr (32:17.964)
To answer, well, to use an example of one of the trials that Professor Shalini Ojha and myself are conducting in the UK: we are conducting a study that compares nasal CPAP with nasal non-invasive positive pressure ventilation at comparable mean airway pressures.
This goes back to the aforementioned Cochrane reviews, which clearly point towards NIPPV, or modern nasal positive pressure ventilation, being superior to CPAP when it comes to avoiding intubation and, for sure, as post-extubation support. But what those Cochrane reviews don’t actually tell you is how those individual trials did the CPAP or NIPPV, how they...
modified it when the baby showed some success. And we just want to work on the hypothesis that if there’s a steady continuous distending pressure which is comparable between the two groups, is it then just mean airway pressure that is good for the babies, or is it the bridging of the apnea, et cetera, that people attribute as the positive effects of NIPPV? Now, to answer this question, you need to define the target population. Those are usually the babies of less than 32 weeks who are on non-invasive respiratory support. You also want to know how low you could go in your...
And if you look at the incidences of intubation and ventilation from birth or in the first three days of life, and non-invasive ventilation, you come to a sweet spot where you think that the majority of these babies would be between 26 weeks and 28 weeks. To conduct a trial that is absolutely confirmative for this small window of population, you need
Charles Christoph Roehr (34:25.346)
thousands of babies to show a clinically meaningful difference. That, even in an international trial nowadays, is the challenge. So people open the window towards including the higher and also the lower gestational age babies, sometimes at the expense of the power of the study. And it’s always a trade-off that purists frown upon, because it muddies the waters.
But I always say it’s down to the reader of the evidence and the people who interpret the trials to be vigilant and look at exactly in what bracket of the population there was the biggest improvement, or there wasn’t an improvement.
Daphna Yasova Barbeau, MD (35:11.657)
Yeah, your point is well taken. I think we feel that at the bedside. When you have two babies, even of the same weight and same gestational age, the reasons for their needing respiratory support can be very different. And do they need different things? And we’re looking to all of you and your colleagues to parse those details out for us. I... Go ahead.
Charles Christoph Roehr (35:33.038)
Fabulous idea to ask the audience, because I know we all struggle with the same issues. We want to do our babies best. And let me just also give a shout-out to all of the colleagues out there who are always engaged in meetings and other things. And also to industry, who, in all my engagements with them, all try to provide us with the best materials so we can care for the babies in the best way.
Yeah, a big shout-out to the neonatal community on the whole.
Daphna Yasova Barbeau, MD (36:04.847)
I love that. And here, I’m going to give you the opportunity to feed back to the industry. If you could redesign the ideal neonatal respiratory interface from scratch, from the beginning, what would that look like? What would it have that we don’t have yet?
Charles Christoph Roehr (36:25.166)
That’s a great question. If I just went on a whiteboard to design something...
As you’ve kindly mentioned, my talk in Indianapolis, where my mantra is we need to know what we’re delivering in terms of pressure as much as we need to know what the baby is doing in terms of its own breathing. So to do all this, we need some refined respiratory function monitoring, which includes possibly not just the breathing, the interface, and tidal volume measurements, et cetera, but also the chest and the regional ventilation. We need to have devices that are non-intrusive but highly supportive.
Douglas Blank and Calum Roberts showed in the FONDUE trial recently that the face mask may not be as good as binasal prongs from the first breath. So I strongly believe that we should try to avoid face masks at the start, but have well-fitted nasal interfaces, whether it’s a mask or a prong. And then we need to have ways to...
fix these interfaces to the baby’s head and face that are the least intrusive, allow the most interaction of mother, father, and baby, and give the baby the full sensory input that every newborn baby should have.
Charles Christoph Roehr (37:58.082)
And then lastly, I think it’s super important to have effective humidification. Warmed, heated, and humidified gases from the start are pivotal to having a well-functioning airway epithelium, to avoid desiccated secretions, and to help with mucociliary transport and avoid ventilator or non-ventilator associated lung injury. And all of that, of course, in the context of supporting a baby not just for days but also weeks. So it’s a big wish list that I have.
Daphna Yasova Barbeau, MD (38:36.775)
A big wish list. All right. My last question for you. If you had the opportunity to audit a NICU team using non-invasive support, what is one thing about how the team uses the support, not technology per se, like we’ve already discussed, but what sorts of changes in clinical practice do you think matter most at the bedside?
Charles Christoph Roehr (39:01.986)
I think what matters the most, I’m very convinced, is the familiarity of the team with the devices that they use. The experience of the nurses must be matched by the doctors’ understanding in the same way, and in America, of course, the respiratory therapists’ understanding, in exactly the same way as the nurses, of how to apply the device, what to do in troubleshooting, how to understand the baby that’s on the device, and to choose the best possible option of interfaces and pressure selection. So to me, it’s a continuous care package that needs to be part of every unit’s educational package.
Daphna Yasova Barbeau, MD (39:55.625)
Right. Well, a lesson for all of us to take to the bedside. Dr. Roehr, thank you so much for your time, for your expertise, for your ongoing studies that are helping us manage this very, very vulnerable population. It’s been lovely chatting with you today.
Charles Christoph Roehr (40:11.278)
It’s been lovely chatting to you too. Thank you so much.
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