SCCM Pod-448 Noninvasive Respiratory Support: Opinion- or Evidence-Based Medicine?

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When should clinicians intubate preterm infants? The answer is not always straightforward, according to podcast guest Deepak Jain, MD, FAAP. He and host Pamela M. Peeke, MD, MPH, FACP, FACSM, discuss strategies that optimize noninvasive ventilation and when such strategies are appropriate, referring to a 2015 JAMA article (Stoll BJ et al. JAMA. 2015;314:1039-1051). Dr. Jain is interim chief in the Division of Neonatology at Rutgers Robert Wood Johnson Medical School. This podcast is supported by an unrestricted education grant from Medtronic.

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This podcast is supported by an unrestricted educational grant provided by Medtronic. Any statements, opinions, findings, conclusions, or recommendations contained in the podcast are strictly those of the host and interviewee and do not necessarily reflect the views or opinions of Medtronic or any of its affiliates, including Covidien. This podcast is for educational purposes only and does not constitute medical or professional clinical advice. 

Pamela M. Peeke, MD, MPH FSCP, FACSM: Hello and welcome to the Society of Critical Care Medicine’s iCritical Care podcast. I’m your host, Dr. Pam Peeke. Today, we’ll be talking about noninvasive respiratory support: opinion or evidence-based medicine? I’m joined by Dr. Deepak Jain, who is the interim chief, Division of Neonatology, at Rutgers Robert Wood Johnson Medical School. Welcome, Dr. Jain. Before we begin, do you have any disclosures to report?

Deepak Jain, MD, FAAP: Thank you, Pam, for inviting me. Yes, I would like to disclose that I have received funding for speaking engagements from Medtronic.

Dr. Peeke: Thank you. For our audience, the learning objective today is to discuss aspects of noninvasive ventilation in the pediatric population. Why is this podcast needed? We need to discuss the impact of strategies that optimize noninvasive ventilation. The knowledge gaps that this podcast will address include strategies to optimize noninvasive ventilation, including synchronized modes of noninvasive ventilation, noninvasive positive pressure ventilation, CPAP, and more. First I’d like to ask you, Dr. Jain, why is this such an important topic right now?

Dr. Jain: We have to start looking at whether avoiding ventilation really helps. We have a large number of babies who are born extremely preterm. At some point, we have to decide whether these babies need to be intubated or not. The answer to whether noninvasive ventilation is required or not is not really that straightforward. There is some good evidence from randomized controlled trials that avoiding intubation in extremely preterm infants is better than invasive ventilation. A recent meta-analysis showed reduction in bronchopulmonary dysplasia or death and had numbers needed to treat of about 35. But one of the concerns that many of us neonatologists have is whether giving these babies noninvasive ventilation increases the risk of-short term morbidities like intraventricular hemorrhage. When we start many of these patients on noninvasive ventilation, they fail, they have higher carbon dioxide levels, increasing the risk of IVH. But the good part of that meta-analysis was that it did not show any significant difference in rate of IVH between the two groups.

Dr. Peeke: Is there an age issue? You shared with us an excellent analysis of trends and care practices, morbidity, and mortality of extremely preterm neonates. This study took place between 1993 and 2012. In this study, they were looking at morbidity and mortality specifically in babies who were very preterm. Could you explain a little bit about what this study revealed?

Dr. Jain: This study looked at data from 1990s to recently. The study revealed how morbidity and mortality have changed over this period of time. It clearly showed that most of the morbidities actually have decreased in extremely preterm infants, but the only morbidity that has not changed much or actually has gone up a little bit is bronchopulmonary dysplasia. And the question is: Why is that? Why are we not able to decrease bronchopulmonary dysplasia in this group of patients?

Dr. Peeke: What is the answer to that? It is an interesting trend. Were you surprised to see that?

Dr. Jain: I think most of us were not really that surprised. I think there are multiple reasons for this. One, I think, is that more extremely preterm infants are surviving. In the 1990s, the babies had normal mean gestational ages of 28 weeks. Now we have babies surviving at 23 and 24 weeks. So it’s likely that these babies will have more bronchopulmonary dysplasia.

Dr. Peeke: So basically you’re suffering from your own success and that is that babies are now very preterm and of course then you will see something like this. Does that make sense?

Dr. Jain: Yes, exactly. And in addition to that, how we define bronchopulmonary dysplasia also could be one of the factors. We have to start thinking of what we should look at as our outcome. Maybe we should look at more longer-term respiratory health for these babies.

Dr. Peeke: What do you mean by that?

Dr. Jain: I mean that, for parents, let’s say I have a baby. Most of the time, it would not matter much to me whether my baby is classified as having bronchopulmonary dysplasia or not, what would matter more to me is whether my baby is going to have more asthma or some issues with respiratory health when he’s a child. Would he be able to exercise? I think those might be more important outcomes for me as a parent.

Dr. Peeke: I see. What we’re seeing now is survival that is increased most markedly for infants born at 23 and 24 weeks and survival without major morbidity increased for infants 25 to 28 weeks. So what we’re really seeing here is trending toward more and more survivability during this time. Does this inform the issue of ventilation? Were these young infants more likely to be ventilated earlier, say in the 1990s and the early 2000s versus now? Are there are different ways of thinking this through?

Dr. Jain: Yes, definitely. I think it’s very difficult to compare a patient population that was born at 28 weeks to a patient population that was born at 24 and 25 weeks. There are a good amount of data suggesting that, for almost 90% of babies who are born at 24 and 25 weeks, even if we try to give them noninvasive ventilation, initially they fail and require invasive ventilation. So it is quite clear that the babies who fail noninvasive ventilation actually do worse compared to babies who succeed.

Dr. Peeke: Why is that?

Dr. Jain: One thing is that there is a high risk that babies who fail will have higher carbon dioxide levels, and that can increase their incidence of intraventricular hemorrhage. And also we may be delayed in finding out that these babies are failing.

Dr. Peeke: Very good. We’re looking at a variety of different nuances with regard to the morbidity and mortality of these preterm babies over the years. Although the survival of extremely preterm infants has actually increased over the past two decades, including survival without major morbidity, let’s consider the individual and societal burden of preterm birth, which remains substantial. By last estimate, approximately 450,000 neonates are born prematurely in the United States each year. What do you have to say about that?

Dr. Jain: Yes, I fully agree. I think that’s a very important aspect of it. We do have to look at all of these factors and see what the impact is of survival on the individual and on society. I fully agree with that, but I think what we have to also figure out is how we can actually improve our noninvasive ventilation strategies so that we can take care of these extremely preterm infants in a better way so that we can decrease their long-term morbidities.

Dr. Peeke: Can you describe that? We are looking at the issue of noninvasive ventilation. Walk us through the decision-making process.

Dr. Jain: Let’s say I have a 24-week infant who is delivered. These babies can essentially be divided into three types. One group of babies will require intubation right in the delivery room; they will be mechanically ventilated. Another group of babies will be what we can call good babies, who will stay on CPAP and do well. The problem comes with the babies who are started on CPAP but who start requiring more and more oxygen. Then we have to start thinking, At what point do I need to start intubating this kid and escalate his respiratory support?
I think this is where we have not really been good: When do we actually have to intubate? We know that babies who are born at lower gestational age are more likely to fail. And there are some data suggesting that oxygen requirement could be a marker of predicting failure. These are the things for which we haven’t set out a clear-cut idea of when these babies fail.

Dr. Peeke: This a very critical point. Let’s look, for instance, at noninvasive positive pressure ventilation versus CPAP. What can you say about the difference between the two as research has borne this out?

Dr. Jain: There is a reasonable quality of randomized controlled data suggesting that noninvasive ventilation, in terms of providing positive pressure with a rate, as initial respiratory support and also as post-extubation respiratory support, does have improved short-term outcomes in terms of risk of further intubation. But there are not really good data in terms of whether it improves long-term respiratory outcomes like bronchopulmonary dysplasia or later-term respiratory health. Those data are lacking, and there are several caveats to that. One is that we don’t have a good number of studies. Some of the reasoning behind this could be that many of these modes we are using are nonsynchronized rather than synchronized.

Dr. Peeke: Could you describe that—synchronized and nonsynchronized?

Dr. Jain: What usually happens is, when we have a kid intubated, the ventilator detects a breath taken by the baby and tries to provide the rate at the same time that the baby is inspiring. The problem with noninvasive ventilation is that the usual ways the ventilator detects the breath don’t work because there’s a huge amount of leak from the patient interface, which causes the ventilator to not be able to detect those breaths. This is why traditionally the noninvasive ventilation was given by nonsynchronized mode. So the babies are breathing out, but the ventilator will try to give a breath. So there will not be any effective delivery of positive pressure when it’s needed.

Dr. Peeke: Technologically, what do we have today that didn’t exist, say, five or 10 years ago that could help us in terms of tools, not only to assess what type of decision to make, but also in terms of ventilation?

Dr. Jain: There have been quite significant improvements in our ventilator technology in the last few years. One of them is what we call leak compensation. There are automated algorithms whereby the ventilators detect the leak and try to compensate for it. And by compensating for it, they can try to get an effective synchronization, even though the baby is on noninvasive ventilation. This is one of the ways to do it. There are some early promising data to suggest that, in preterm babies, some degree of synchronization can happen, but we really don’t have any good clinical data to suggest that it improves outcomes. We’re still waiting for those results.

Dr. Peeke: Why is there a knowledge gap about strategies to optimize noninvasive ventilation, synchronized modes, etc.? What is going on with practitioners like yourself, leaders in the field, in terms of the ability to grab that new knowledge base that you’re describing and utilize it? What is happening and what is not happening that is feeding this knowledge gap?

Dr. Jain: I think there are several reasons. One is that we as neonatologists have been very careful in terms of adopting new technology, which is good. We’re still waiting for some data to show that it actually improves meaningful clinical outcomes before it can be adopted. The second reason is that doing large randomized controlled trials in the field of neonatology is always very difficult because the field is so small and it’s expensive and we really don’t have good clinical outcomes to use. So these are the challenges that neonatologists face day in and day out.

Dr. Peeke: I completely understand, and I know that our listeners empathize with this too. You have a very unique demographic. We’ve already discussed aspects of noninvasive ventilation in the pediatric population and addressed some of the challenges of the knowledge gap about these strategies that optimize noninvasive ventilation. As we’re concluding this podcast, what pearls of wisdom do you have that you would like to impart to listeners out there, your peers, who are considering ways to improve and enhance their own ability to impact outcomes positively in this patient population?

Dr. Jain: A couple of points I think we have to be a bit careful about. We do know that noninvasive ventilation is a viable alternative to mechanical ventilation. I think that’s quite clear from the data. And I think we also know that the smaller the baby and the most at risk the baby, the higher the likelihood of failure. For these infants, we have to be very careful when we select respiratory support and closely monitor with early correction of worsening respiratory status. I think we all have this challenge to find the right respiratory support for the right patient at the right time.

Dr. Peeke: Excellent. What do you consider to be one of the biggest challenges in achieving the goal of enhanced patient care in this population?

Dr. Jain: I think the biggest challenge for us will always be to find a suitable balance in terms of finding the right respiratory support, not just looking at short-term outcomes but also at longer-term outcomes.

Dr. Peeke: Excellent. I don’t think there’s any question about that. I can’t thank you enough for being able to address noninvasive respiratory support in this very challenging demographic, as well as the trends over time in both technology and understanding of how our knowledge base, as it applies to ventilation and to optimal care in this demographic, has changed over time and has been beneficial to this demographic. Thank you very much, Dr. Jain, for being our expert on this podcast. Dr. Jain is interim chief, Division of Neonatology, at Rutgers Robert Wood Johnson Medical School. We’ve been talking about noninvasive respiratory support: opinion or evidence-based medicine? I know that our listeners have benefited greatly from this. This concludes another edition of the iCritical Care podcast. For the iCritical Care podcast, I’m Dr. Pam Peeke.

This podcast is supported by an unrestricted educational grant provided by Medtronic. Any statements, opinions, findings, conclusions, or recommendations contained in the podcast are strictly those of the host and interviewee and do not necessarily reflect the views or opinions of Medtronic or any of its affiliates, including Covidien. This podcast is for educational purposes only and does not constitute medical or professional clinical advice.

Pamela M. Peeke, MD, MPH, FSCP, FACSM is a nationally renowned physician, scientist, expert, and thought leader in the field of medicine. Dr. Peeke is a Pew Foundation Scholar in nutrition and metabolism, assistant professor of medicine at the University of Maryland, holds dual master’s degrees in public health and policy and is a fellow of both the American College of Physicians and the American College of Sports Medicine. Dr. Peeke has been named one of America’s top physicians by the Consumers Research Council of America. She is a regular in-studio medical commentator for the national networks and an acclaimed TEDx presenter and national keynote speaker. Dr. Peeke is a three-time New York Times best-selling author and is a science and health advisor for Apple.

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