Neonatologist Adel Bougatef, MD, PhD, has partnered with San Antonio pediatric respiratory durable medical equipment provider Wave Healthcare to create an approach to mechanical ventilation that accounts for each individual patient’s unique lung compliance with the goal of reducing ventilation-related complications.
“I love caring for infants because it’s often more complex than treating adults. Newborns can’t express what they feel.” — Dr. Bougatef
Mechanical Ventilation’s Double-edged Sword
Nearly 10 percent of babies born in the United States are premature, according to the CDC. Several of the most common health threats children face are related to immature lungs and an inability to breathe independently. For these infants, mechanical ventilation can be lifesaving, but it can also cause sequelae that may have long-term consequences for their quality of life.
“Everything clinicians do for this patient population affects the rest of these children’s lives,” says Dr. Bougatef, who spent 18 years as Clinical Director of the Neonatal Intensive Care Unit at the Universitair Ziekenhuis Brussel (UZ Brussel — University Hospital Brussels) in Brussels, Belgium. “Mechanical ventilation is not a treatment — it is support to keep newborns alive until their lungs can function autonomously. The objective is not only to foster survival, but to minimize side effects, as well. Excessive oxygen delivery can be toxic for premature newborns and can cause conditions such as bronchopulmonary dysplasia and retinopathy of prematurity. Preventing oxygen toxicity is a primary challenge when caring for these infants.”
Bronchopulmonary dysplasia, also known as chronic lung disease, typically affects infants born at least 10 weeks prematurely and weighing less than two pounds, according to the National Heart, Lung, and Blood Institute (NHLBI). These infants often have poorly developed lungs or insufficient surfactant, a fluid found inside the lungs that helps facilitate respiration. Immature lungs or lack of surfactant can cause respiratory distress syndrome. This condition may require mechanical ventilation, which, over time, can damage the lungs, causing bronchopulmonary dysplasia — structural and cellular changes in the lung architecture that inhibit normal function. The condition affects 5,000 to 10,000 children in the United States each year, according to the NHLBI.
“Dr. Bougatef was an invaluable partner in assisting in the management of a complex infant with bronchopulmonary dysplasia who required respiratory support in the NICU via high flow nasal cannula but was otherwise ready to go home,” says Martha Morse, MD, Associate Professor of Pediatrics in the Division of Pulmonary Medicine at Baylor College of Medicine. “Through his recommendations, we were able to duplicate the support on a home ventilator and cut months from this child’s hospitalization. This infant went home with his parents and received all the benefits of nurturing and development that come at home versus continued care in an NICU and was weaned off respiratory support over months at home.”
Oxygen toxicity resulting from mechanical ventilation harms more than the lungs — it can also damage the eyes. Excessive oxygen is a risk factor for retinopathy of prematurity, which affects 14,000 to 16,000 premature babies in the U.S. each year, according to the National Eye Institute. Characterized by the development of abnormal blood vessels in the retina, retinopathy of prematurity can lead to blindness if it is severe or left untreated.
Helping premature newborns avoid the pitfalls associated with mechanical ventilation has been the focus of Dr. Bougatef’s more than three decades in medicine, particularly the time he spent overseeing the NICU at UZ Brussel.
“I concentrate on everything related to the lungs to ensure that these infants ventilate and oxygenate effectively, which is critically important to the entire body, all while avoiding adverse complications,” Dr. Bougatef says. “The rate of chronic lung disease in premature infants varies between 9 and 20 percent. During my tenure as Clinical Director of the NICU in Brussels, we experienced a rate of 5 percent and discharged only six premature babies close to their original due date with supplemental oxygen.”
When Dr. Bougatef immigrated to the U.S. in 2012, his success of minimizing the number of patients in his care who discharged with supplemental oxygen caught the attention of Wave Healthcare President and CEO Rodney Gray, who spent years working at a NICU in a San Antonio hospital. Dr. Bougatef became a consultant for Wave Healthcare in 2014. Currently, he is developing an alternative approach to conventional mechanical ventilation that should prove to transform the way premature babies in San Antonio and beyond are provided with respiratory support.
“Dr. Adel Bougatef brings a wealth of clinical expertise and scientific knowledge to San Antonio as he works to advance technology used to care for both critically ill infants and adults.”
— Evan Renz, MD, general surgeon, Professor of Surgery, who has cared for burn and trauma patients of all ages across the globe
Rodney Gray and Dr. Adel Bougatef in 2013
Dr. and Mrs. Evan Renz welcome Dr. Bougatef and his family to San Antonio.
Allowing for Respiratory Individuality using Mechanical Ventilation
Dr. Bougatef believes a fundamental conundrum faces mechanical ventilation and pulmonary practitioners: Why, with the sophisticated technology currently available, do outcomes for patients with severe respiratory illness remain poor?
“Mechanical ventilation technology has progressed quite fast, but the literature indicates that patient outcomes haven’t improved during the past 15 years,” Dr. Bougatef says. “Mortality remains high. The approach to ventilating patients with severe respiratory illness has stalled. I have developed another method that allows a protective ventilation strategy approach to solve conventional mechanical ventilation’s primary problem: the imposition of rigid pressure and volume on respiration — a process that is inherently flexible.”
During respiration, the individual controls two things: the timing of breathing and the flow of air into the airway. The volume of air that enters the airway and the pressure at which it does so is uncontrollable during independent respiration. Mechanical ventilation controls the pressure and volume according to strict, consistent parameters, which is at odds with the way the lungs normally function.
“An adult patient on ventilation who is scheduled to receive a tidal volume based on estimated body weight will receive precisely that amount — each breath will be exactly the same,” Dr. Bougatef says. “This is contrary to how people breathe because each breath is different. In a sick lung, all respiration is not the same and air distribution varies from space to space in the lungs. Conventional mechanical ventilation doesn’t allow for individualization in the breath cycle. The technology I’m working on will instantaneously adjust volume and pressure delivered with each breath, and in accordance with the patient’s needs and existing physiologic parameters.”
“Adel Bougatef has a deep understanding of pulmonary
physiology,” says Tarak Patel, MD, with Texas Pediatric Specialties and Family Sleep Center. “With his clinical experience as a neonatologist and as a scientist, he has taught me new ways to approach children with acute and chronic breathing difficulties. He is a great teacher and is passionate about improving the lives of children.”
Dr. Bougatef presenting to a group of pediatric pulmonologists his approach to preventing lung injury
Dr. Bougatef expects the protective ventilation strategy device to reach the market in the next 18 months, pending regulatory approval.
“We have to do everything we can to help premature babies breathe independently as soon as possible; and we must improve outcomes of all patients with acute and chronic respiratory illness,” Dr. Bougatef says. “Survival is important, but quality of life is equally important. Our mission is not merely to provide maintenance, but by being proactive and innovative, we can avoid ventilator-related complications.”
“Dr. Adel Bougatef is one of the finest gentlemen I have had the privilege to know. In addition to being an outstanding human being, Dr. Bougatef is a brilliant physician, engineer and scientist. Although a great loss to the clinical community, Dr. Bougatef resigned as NICU director to further develop and improve his technology, not only for premature infants but also for adults with acute and chronic lung injury. The exciting news is that the first of the prototypes of Dr. Bougatef’s devices will be available for testing in the near future. My research team and I will have the great privilege and honor to be the laboratory that will test this new generation of devices.”
—Gary Nieman, Department of Surgery, SUNY Upstate Medical University
For information about Wave Healthcare, visit wavehealthcare.com.