Doctor reviews: LISA!! Step-by-step instructions on how to administer!

Lisa, or Less Invasive Surfactant Administration, isn't just a clever name. It is a way of giving surfactant to the baby that is not intubated less invasively. So basically, in a baby who's usually on CPAP or high flow nasal cannula, we decide that we want to give them surfactant. Instead of intubating with an endotracheal tube like this one, what we're actually doing is just putting a little skinny catheter down into the trachea and giving the surfactant that way. Hi, I'm Dr. Tala, and I've been a neonatologist for 18 years now. In a second, I'm going to go through all the different steps that you need to do for Lisa. But first, I'm going to talk about why Lisa is so good for the babies. Number one, while you're giving Lisa, you can keep the baby on the CPAP or the high flow nasal cannula. So you don't worry about removing the apparatus, putting the tube in, and then having to put it back on again. And more importantly, you're not as worried about losing that pressure in the lungs, losing the functional residual capacity or the PEEP that the CPAP is giving while you're actually intubating. Two, less barotrauma to the babies. When we're giving Lisa, we're squirting in the surfactant using a syringe. Whereas when we intubate babies, we're bagging the surfactant in. So by definition, we're giving positive pressure ventilation. As you all know, any amount of positive pressure ventilation can be damaging to a little baby's lungs. Three, you're less likely to cause trauma to the vocal cords or the trachea with this skinny little catheter versus a larger endotracheal tube. So altogether, you hope that the whole process is going to be significantly less traumatic. And four, you can't just keep in this catheter after you've given the surfactant and be like, oh, let's just keep the baby intubated and make sure the baby's okay. Because what often happens in the little babies when you're just like, they're on CPAP, they just need a bit of surfactant, you intubate them, maybe they were a little bit of a hard intubation or something. And then everybody's like, oh, I don't know if we can actually extubate this baby or not. And you might just end up keeping in the endotracheal tube just to be safe. Whereas really, when you put this in, it has to come out. There's no way, obviously, you can use this to put the baby on the breathing machine. And so it really, the whole thing does become a lot less traumatic and also a lot faster. You keep the baby on the CPAP, you intubate with this little catheter, and then you remove this and the baby's still on the CPAP. But there are other little problems with Lisa. One of the issues is that we need to be able to check that we are in the right place after we put the catheter down below the vocal cords. Obviously, when you intubate a baby, there's lots of signs to see whether the baby's intubated. There can be mist in the endotracheal tube. You can hear bilateral breath sounds. If you're intubating for respiratory depression, you see the heart rate go up. And we also use this CO2 colorimetric device. As you all know, these are usually purple when they're exposed to regular air with tiny amounts of carbon dioxide. But if you are actually in the correct place and there's carbon dioxide coming up through the lungs that the baby is expiring, then this will actually turn yellow. So when you put this on, it will go from purple to yellow and you know that you are correctly intubated and the endotracheal tube is going down into the trachea. In our units, when we started doing LISA, after we put in the angiocath, we would then give some surfactant and then suck out the stomach contents using an OG tube. And if the surfactant was in the stomach, which means that the angiocath was in the wrong place, then obviously we'd get surfactant out. You can see why this was not ideal for so many reasons. If it really was in the stomach, you've already wasted some surfactant. Also, there are a lot of secretions in the stomach that are sticky and mucusy and maybe milk looks a bit like surfactant. So pulling any of that back, even if it's not surfactant, makes everything a lot stickier. And if you've got tape here to mark how deep it should go, then sometimes that would become all wet and move around. So the whole thing was just a very sticky procedure. Honestly, it wasn't ideal. It took quite a bit of time and it became kind of quite a sticky procedure. And for a long time, I kind of felt like in and out was much easier, even though obviously not ideal for the babies. And this is where some brilliant friends of mine, Drs. Shuruvallu and Dr. Rees, as well as Callie Turner, Kim Miklas and Amy Reedy, they all discovered a solution to this problem. Matthew Hawke, our leader of respiratory therapy, was actually the genius that figured out the logistics. And obviously he's on the paper as well. Matthew figured out that if you take the 16-gauge angiocath, which is what we had been using to deliver surfactant, a 3.0 endotracheal tube adapter. So normally this little adapter is at the end of a 3.0 ET tube. It attaches perfectly to that 16-gauge angiocath. And then after you actually put this angiocath into the trachea where it should be, where you're about to give surfactant, before you give the surfactant, you can attach the colorimetric device or the PD cap. And after a few breaths, it will turn yellow. Initially, we were concerned that the catheter was so tiny that maybe there wouldn't be enough like CO2 going through it to actually be able to turn the PD cap yellow. But as they very effectively showed in this paper, basically 98% of the times it accurately determined that the catheter was in the right place. There was one false negative. And we're going to go through the individual steps now. But let me tell you, this has made the whole process so much easier and more efficient. It's way quicker now than doing in and out surfactant. And like I keep saying, you don't have to take the baby off CPAP. So we absolutely love using this method right now. Thank you, team. Thank you, Matthew. Now let's go through the individual steps of actually giving Lisa. And we'll start with the equipment that we need. So you still need a blade so that you can actually visualize the vocal cords and so that you can actually intubate, quote unquote, with the catheter. We've been using a 16 gauge angiocath catheter. And this comes with a needle in it. So make sure when you're actually using it, that you remove the needle. That could be pretty traumatic to the baby, especially since the needle will be poking out a bit from the bottom. The catheter doesn't have any markings on it because there's no reason for it to. And so we also need a little bit of tape to actually mark exactly how deeply we want the angiocath to go through the vocal cords and up to the lips. Then if we do want to use a PD cap to confirm that the angiocath is in the right place, then we need the PD cap, obviously. And this should be purple because it hasn't been exposed to any CO2 yet. And then we need a adapter from a 3.0 ET tube. And as I said, Matthew figured out that that 3.0 ET tube will attach directly to that 16 gauge angiocath so that we could then attach the PD cap to it like that. Then once you've confirmed placement of the angiocath inside the trachea, then the next step is to actually administer the surfactant. So you've got your syringe with surfactant in it. Then you've got the T connector, which will then attach to the angiocath like this. And then you'll be able to actually squirt in the surfactant. So now we're going to go through the individual steps on the actual mannequin. Okay, so you've got your baby on CPAP or high flow nasal cannula, and you've determined that your baby needs surfactant. The FiO2 has gone up or whatever else is going on, you've made that decision. The first thing that you need to do is figure out exactly how deeply the angiocath needs to go. Like we already said, it's not marked out. So let's figure out how deep this needs to go. One of the ways that you can measure how deep the catheter has to go is by measuring the nasal tragus distance. The tragus is that kind of little piece of the ear that sticks out and then add one. So we'll go down here, and that's six and a half. So plus one, that's 7.5 centimeters that we have to insert the angiocath. Because the angiocath isn't marked, we then have to measure 7.5 centimeters out on the tape measure, and then put that little piece of plastic there so we know exactly how deep to put in the angiocath. So let me put that piece of plastic on now. Okay, as everybody knows, there's no harder thing in the world to do than to put tape on with gloves. But I just measured this out, and I took my gloves off and put them back on again. And now I have put exactly where how deeply this should go. And so here we are with the tape in at the right place, seven and a half centimeters in. Right, we're all ready to go now. So do a timeout, make sure that the baby is calm and contained. In a little baby, you might want to give a bit of sedation. In the older babies, we've been giving sucrose, so kind of like the sweeties. Also make sure that the baby does have an OG in and that the stomach is decompressed. You don't want lots of fluid or air inside the stomach, irritating the baby even more. So we have the OG in. Like we said, the high flow cannula or the CPAP is still in place. And now we're all ready to go. Okay, so now we're ready to actually insert the catheter. So using the laryngoscope, I will intubate with the catheter. OG tube is completely the way now. So we're putting that down to the plastic marking so that it's at the lips. So now we know that that angiocath, at least we saw it go through the vocal cords. But now we want to check 100% to make sure that it is actually in. So like we said, now we can attach the 3.0 ET tube adapter and the PD cap. And we can actually see it change color. Normally, it can take kind of four to five breaths before it changes color. If after about six breaths of good breathing, the color still hasn't changed, then it probably is worth reassessing. For some reason, all the ones that I've done, it's actually turned yellow very, very quickly after we've attached the PD cap. Okay, in this case, it really did go yellow. So we know that we're in the right place. So we can remove the adapter and the PD cap. And then we can attach on the T connector like that. So now the T connector with the syringe full of the surfactant is attached to the angiocath. The way that we've been doing it is giving the surfactant in four aliquots. So say there's a total of four mls that we have to give the baby, then we've been giving one ml at a time. And then normally waiting about 10 seconds between each aliquot. During that time, the baby should be spontaneously breathing on the CPAP or whatever the baby is actually on. So we give the aliquots of the surfactant, like we said, really over about a minute total if you're including the 10 seconds between each one. After you've given all the surfactant, generally we flush with about one ml of air. So, you know, obviously you would have to take the syringe out, get more air in and then push one ml of air. If the infant becomes apneic or the saturations are plummeting during the procedure or becomes bradycardic, then at least give tactile stimulation. Obviously, if it continues, then the baby may need a lot more intervention than that. Generally, though, just because generally you are giving surfactant to babies that just have a slightly higher FiO2. You're not just giving Lisa to babies that have completely crashed and become completely apneic and their lungs are collapsed. So generally, the babies are pretty healthy and breathing quite easily if you are making the decision to just give Lisa. So they generally tolerate it really well. Then after you've finished giving the Lisa and given the one ml of air flush, you can pull out the tube and voila, the baby is still on the support that they were on previously. By the way, this actually happens really often that like the prongs or something have come out of the nose and you have to just make sure that everything is readjusted. Obviously, during the procedure, you should be documenting the minimum heart rate, minimum sats and everything and just making sure that the baby is carefully monitored so that they are doing fine through it. Sometimes it takes a little bit longer for the FiO2 to come down after Lisa compared to in and out. So give it kind of like an hour or so before you expect the FiO2 to start coming down on the baby. And that's it. Again, so straightforward. Thank you so much again to Dr. Reese et al. Thank you so much for Matthew for figuring out the 3.0 ET tube adapter. It really has made this entire process so much quicker. Thank you all so much for being here. If you are interested in neonatal education, then please think about actually subscribing to our channel. We are so thankful that you are here and we really hope that this helps you in your units as well. Thank you.