Saving Little Lungs & Lowering Costs -- In-Depth Doctor's Interview

What is used in the United States to help premature babies breathe?

Dr. Mario Rojas: In the early 1960s, Dr. Mildred Stahlman, who was trained in Sweden to do research, observed that babies there that had tetanus were put on breathing machines that were used for adults to help them breathe. She saw that many of these babies survived, so when she came here and started to work at Vanderbilt, she was one of the first persons to put babies who had respiratory problems, breathing difficulty, on breathing machines. From that time on, it extended through the rest of the country as one of the main interventions to help babies who have difficulty breathing. That increased the survival of these babies and that technology has developed tremendously over the years.

Are there any downfalls to putting a premature baby on mechanical ventilation?

Dr. Rojas: Yes, there are downfalls. Like everything, it’s a double-edged sword. There are good things and there are some bad things to it. First of all, it requires the placement of a tube down the wind pipe of the lungs which can damage the airway if left for a very long time. This is followed by placement of the baby on mechanical ventilation. As the babies were followed, we found out that there were some that were exposed to mechanical ventilation and high concentrations of oxygen that developed something that we now call chronic lung disease. Damage to the lungs was due in part to the fact that the way we normally breathe is very different from what the breathing machine does. The breathing machine is basically like if you were taking a balloon and trying to inflate it, putting high pressures into the lungs, sometimes overinflating them. When we breathe spontaneously, our rib cage expands and we create like a negative pressure that sucks in the air, but we don’t put pressure into the lungs. Mechanical ventilation, although it’s very good to improve survival, has also been responsible for the development of chronic lung disease in these babies as demonstrated by many studies in animals and humans.

What percentage of these babies develops chronic lung disease?

Dr. Rojas: The younger and the more immature the baby is, the higher the incidence. In babies that are less than a thousand grams, it could be up to 40 to 50 percent. In babies that are more than a thousand grams, it starts dropping to 20 percent, and then to 10 percent as they get to 34 weeks. The more immature they are, the higher the incidence of this problem.

Was your CPAP machine study originally based on children in developing countries because here we automatically put babies on ventilation?

Dr. Rojas: Yes, that’s the general trend, but in the 1970s, an anesthesiologist, Dr. Gregory, observed that when babies had difficulty breathing, and because of the lack of a substance – surfactant that coats the inner surface of the air sacs – your air sacs collapse. When you breathe in, you open up your air sacs, but when you breathe out, they collapse and that makes it very difficult to breathe. Babies that are immature lack that, so when they are born, they grunt. He observed that when they grunted, those little babies were trying to keep air inside their air sacs generating a positive pressure at the end of expiration so they wouldn’t collapse, so he developed an apparatus that is placed in the nose and is what we call now nasal continuous positive airway pressure, which is that CPAP system. It didn’t catch on as well as the mechanical ventilation. A lot of people were very attracted to the technology of mechanical ventilation, but there was one hospital here in the United States that used it as the initial management for babies that had this problem, and that’s the Columbia Presbyterian Hospital in New York. In the 1980s, they did a study to look at units in the United States, and look at the incidence of this problem, which is called chronic lung disease. They found that out of all the hospitals in the United States, the hospital that had the lowest incidence of chronic lung disease was the Columbia Presbyterian Hospital. In that hospital, they use CPAP as the starting treatment for babies, not mechanical ventilation. Only babies that failed when they were on CPAP then went to mechanical ventilation.

That really caught everybody’s attention. It was studied multiple times after that and it’s always been confirmed that this hospital, Columbia Presbyterian, which uses nasal CPAP as a primary treatment for respiratory failure in the babies, is the hospital with the lowest incidence of chronic lung disease in the United States The doctors at Columbia Presbyterian placed the babies that had signs of respiratory distress on nasal CPAP in the delivery room. When we saw that, we saw this as an apparatus that is much less expensive, it’s much less invasive, and it could reduce chronic lung disease, because now you don’t have that negative effect of the high pressures going into the lungs, the baby can continue to breathe spontaneously while on nasal CPAP. It would support to keep the airway open and the air sacs open, but you’re not putting positive pressure intermittently like you do with the mechanical ventilator. We also felt that we could improve survival of premature infants in countries that had limited access to mechanical ventilation, which is very expensive.

On average, a ventilator could cost between $27,000 and $36,000 USD. A system like the CPAP system, even done in a simple way, could cost less than $500, some less than a $100. The most expensive ones – the bubble CPAP systems – at the maximum, would cost around $1200. We felt that if we could reduce the need for mechanical ventilation and improve the survival of babies using this system in developing countries and at the same time, reduce the incidence of chronic lung disease, that would be helpful for babies in both developed and developing countries, and that’s why we decided to do this study.

What were the findings of your study?

Dr. Rojas: Babies that were born during the first hour of life that showed any evidence of difficulty breathing were placed on the CPAP system. One group was given surfactant very early and the other one was just left on the CPAP. What we saw in this study specifically was that in those that got surfactant and the CPAP, 74 percent of those babies did not need mechanical ventilation, and that was very important for us. We also found that there was a trend for those babies to have less of what’s called pneumothorax – it’s when the lung pops and there’s air that collapses the lung. We saw that combining the CPAP with the early surfactant decreased that complication. We also found a 10% reduction in the frequency of chronic lung disease in the group exposed to nasal CPAP and early surfactant. This important effect was mostly significant in the group of babies that were born between 30 and 32 weeks gestation, the most important thing is that only 26 percent require mechanical ventilation; 74 percent did not require mechanical ventilation and they survived and did well. That was very, very important for us.

Is this a case of less is more?

Dr. Rojas: It’s very interesting because less is more and it’s not worse. It’s just as good. That’s what we’re trying to say and prove here. When you look at the cost of healthcare and you look at different diseases across all populations of adults, children, and newborns, the most expensive one of all at the top of the list is management of respiratory failure in a newborn infant. That’s the most expensive, even more than coronary heart disease, cancer and others – at the top is respiratory failure in the newborn infant. It’s extremely expensive, and many of these babies spend very long periods of time in the hospital. To be able to find something that can significantly reduce the cost of care for these babies is very important. Something that we’re trying to do all over the country right now is to look at ways to decrease the cost, but, of course, it’s very important not to decrease the quality of care.

In the past, they used to think, ‘Oh no, CPAP, that’s less quality of care.’ Now we have evidence to show that it could be better than mechanical ventilation, that you can improve the quality of care and you can still improve the survival. The knowledge that we learned from the study that we did at Colombia S.A. is very relevant to what’s happening here in the United States. We’re focusing on trying to decrease the cost without affecting quality, and this is a great intervention for this.

Is this similar to a CPAP machine that an adult would use?

Dr. Rojas: Yes, what Dr. Gregory developed in the early 1970s is now being used in adults. This is rare. Usually, things that they use in adults get transferred to our babies and we adapt the technologies to our babies. This is different. This was created for babies and is now becoming very useful for adults that have apnea when they snore and they have difficulty breathing when they’re asleep, so it’s a technology that’s serviced also the adult population.

How does this new technology improve survival?

Dr. Rojas: On average, four million babies are dying every year around the world and they die in the first four weeks of life. Of all those babies, 98 to 99 percent die in developing countries, and many of them are dying as a consequence of respiratory failure because they do not have access to expensive therapies like mechanical ventilation. The use of CPAP as an alternative to mechanical ventilation is very important as a low cost, high-impact intervention, not only in developed countries, but worldwide and has the potential to reduce infant mortality. I think that’s a very relevant message that we would like to send.

If this was developed in the 70s, why has it taken us so long to use it?

Dr. Rojas: I think there were several reasons. One is, we got caught up in the technology, but also at that time, nobody wanted to do a study comparing CPAP and mechanical ventilation to determine how babies did with both of these technologies because at that point, the people who were using mechanical ventilation felt that that was the best technology. At Columbia Presbyterian, when they saw that the babies were doing well, they felt that that was the best technology, and they didn’t come together to do these studies. Thirty years later, we’re doing the studies that should have been done in the 70s, and now showing that yes, there is better technology and that this better technology is CPAP and not really mechanical ventilation.

It’s not that mechanical ventilation goes away, because there are cases where you do need mechanical ventilation, but those cases are far and few – when babies do not respond to the use of early CPAP with surfactant then you have the ventilator, but not like we do now that every baby who has respiratory problems gets put on mechanical ventilation. I think that we are doing more damage than benefit at this point with that technology.

END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

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