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Lisa is not just a Simpsons character. It's an important neonatal procedure that is growing in importance all the time. Lisa stands for less invasive surfactant administration and it is the preferred way to administer surfactant to babies with respiratory distress syndrome that do not require mechanical ventilation. Despite its usefulness, many doctors struggle with this skill and are unclear whether they have successfully administered surfactant into the correct place after completion. I'm Doctor Matthew Sayers, a consultant, pediatrician with over 10 years experience in pediatrics and I have completed a number of LISA procedures both successfully and unsuccessfully. In this video. I will share my tips and experience on how to perform the Lisa procedure successfully. Thanks to you all documents and guidelines in this video are available in the video description and also on the OA medical app. In this video, we will consider a case of a baby born at 29 weeks gestation by normal vaginal delivery. After spontaneous onset of labor, the baby cried at delivery and no resuscitation was required. They were placed on CPAP in the neonatal unit and their F IO two is slowly climbing from 25% to 35% at one hour of life. A capillary blood gas shows ph 7.33 P CO2 6.2 bicarb 22 base excess positive one lactate 1.8 and their chest X ray is as follows. Their birth weight is 1.8 kg in a baby with respiratory difficulties. There are a number of different modes of respiratory support. You can use to assist them low flow oxygen via incubator oxygen or nasal cannula provides additional F IO two but doesn't provide any pressure support. High flow oxygen or CPAP, provide continuous expiratory pressure support to keep the alveoli from collapsing but do not assist with inspiration, noninvasive ventilation or intubation and ventilation provides pressure support to both inspiration and expiration which can assist or take over from the baby's breathing. Which of these to use depends on the clinical status of the baby. The cause of respiratory difficulties where the baby will be cared for and blood gas results. We've heard about different modes of respiratory support. But how does Lisa come into this respiratory distress syndrome is caused by a deficiency of the baby's natural surfactant. This is most common in extremely premature babies but can also occur in term babies, particularly in meconium aspiration syndrome. In LISA, a small catheter is passed beyond the vocal cords and manufactured surfactant is instilled into both lungs. Replacing the natural deficiency surfactant reduces the alveolar collapse and improves lung compliance which improves ventilation and oxygenation this may need to be repeated as the surfactant is depleted by the lungs. After 48 hours of life, most babies are producing adequate amounts of their own surfactant and ELISA is generally not indicated beyond this point. In this case, Lisa procedure is most appropriate. The baby has signs of rds on the chest X ray, but their blood gas doesn't show any respiratory acidemia and they have stable breathing. So ventilation is not required. Their F IO two is climbing, which is a sign that their R DS is worsening and therefore liet is the most appropriate way to address this. The initial dose of cures is 200 mgs per kilogram, but this is rounded up or down to the nearest total vial as cures surf is extremely expensive for this baby. The dose of cures surf given would be 360 mg. This is made up of one vial of 240 mg and one vial of 100 and 20 mg where the first dose of cures. Surf has been given successfully. Subsequent doses are 100 mgs per kilo, which for this baby would be 100 and 80 mg. In this case, we would round this up to 240 mg as one full vial. There is not a risk of overdose and doing this. Prepare your equipment. You will need a Lisa catheter laryngoscope and appropriate volume of surfactant in a lure lock syringe as well as a face mask, neop puff and suction catheter in case of deterioration. Whilst Lisa is less invasive than an intubation, it is still a painful procedure for a baby. And if the baby is very distressed, it will make the procedure more difficult. Passing a catheter through the vocal cords can also provoke a strong vehicle response. Causing bradycardia, fentaNYL can be used as an analgesia, but please remember to give and flush this very slowly atropine should be given. If you think the baby is prone to bradycardia, more detailed information on premedication can be found on my video on neonatal intubation linked at the top of the screen. The baby should remain on CPAP throughout the procedure. Carefully, insert the laryngoscope into the mouth, taking care not to damage the lips or palate. The laryngoscope should be adjusted in an upwards and outwards direction. Don't rock it up and down as this can damage the palate, place the tip of the laryngoscope blade anterior to the epiglottis into the vacua and lift it upwards and outwards. The cords should then come into view. Pass the lisa catheter through the cords under direct vision, advance at around two centimeters and then remove the little endoscope. The syringe would normally remain attached to the lisa catheter. I have removed it to give a clearer view, hold the Lisa catheter firmly in place, get a helper to slowly inject the syringe of surfactant in small quantities over 2 to 3 minutes, the lisa catheter can now be removed after a lisa procedure, observe the baby over the next few hours for improvement. If there is no response or worsening, suspect an unsuccessful procedure or alternative pathology surfactant can be repeated after 1 to 2 hours if severe respiratory distress is still suspected. But if this follows a successful dose, a repeat dose of 100 mg per kilogram rounded to the nearest full vial should be given. Instead, the main benefit of Lisa is in avoiding the need for mechanical ventilation. And there is strong evidence that it reduces the rates of bronchopulmonary dysplasia compared to mechanical ventilation. The main complication is a field procedure, administration of surfactant into the esophagus and a later need for repeat Lisa or intubation and mechanical ventilation. But this risk is reduced with improved familiarity and training in the procedure. If the Lisa catheter is passed too far through the cords into the right main bronchus, there will be a very asymmetrical improvement in the degree of R DS seen on the chest X ray. There can also be desaturations and bradycardia associated with the procedure. But this is more commonly due to vehicle activity rather than decompensation as an intubation and the risk of this can be reduced through the use of atropine. You've probably heard a number of different acronyms for Surfactant administration including Mist Lisa and Insure and it's hard to keep track of what they all mean. Insure stands for intubate surfactant extubate. And it is essentially the same as a Lisa procedure. Only an ET tube is used rather than a surfactant catheter mist stands for minimally invasive surfactant therapy and it covers a number of different methods of administration. This includes Lisa as in this video, interferring gel and nebulised surfactant and also administration via laryng mask or I gel. Some units are using this to administer surfactant. We are not teaching this method in the video but please watch our sister channel Neo Sims. Very useful video on this topic. The link is at the top of the video. Thanks so much for watching. Please like this video. Comment with any clinical questions or feedback you have and subscribe to the channel and our other social media accounts including Instagram, Twitter, Med all and Ola to stay up to date with future videos. I look forward to seeing you again soon.