Neonatal PATHSHALA - NNF Gujarat State Chapter

[00:00:05]hospital between two OPDs, hospital too.

[00:00:29]Relax. Relax.

[00:00:39]Divided days.

[00:00:48]So you're live now. So no personal discussion.

[00:00:51]>> Okay. Okay.

[00:00:56]>> So good afternoon everyone and welcome to all of you for today's session of neonal part. Today we are going to discuss about issues beyond the guidelines related to neonatal ventilation and respiratory support about the newborn.

[00:01:14]So uh today I request my president sir whose birthday is there today. First of all I would like to wish Dr. Yogeshwari sir wish you happy very happy birthday and I request him to start over to you.

[00:01:29]>> Yeah thank you dear Dr. Bira and uh we warm welcome for our respected chief guest Dr. Rabitup guest of honor Dr. Sunil Gawani G uh today's C our academic program moderator Dr. Sinas Morti G our esteemed panelist Dr. Nitu Mundra Dr. Dod Makarji Dr. Sjib Banga and Dr. Anish Shiha and dear Dr. Punal and Dr. Ronak and whole team of the NNF Gujarat we are welcoming all of you for this digital platform of the NNF Gujarat and all the delegates who have joining this platform. So it is very immense pleasure to welcome you all for this very much needed session of the neonatal partella.

[00:02:13]We all know the neonatal part is the flagship CME series of the NNF Gujarat and it is running since more than 5 years and we all know this initiative is born out of our collective vision to create the structured academic platform where the new practice is discussed not just within the boundaries of the guideline but uh in the light of the real world dilemas and the innovation and the shared experience and the vision. So today's uh very much needed panel discussion uh under the moderation of the Dr. Sinas Murki the beyond guidelines respiratory support dilemma in the neonatal practice. So it reflects the very spirit of the our series of the neonal partial and we all know the neon respiratory care is a very much important both for the science and the art. So uh with the all this evidence-based guideline provide us with the framework uh the true uh challenge lies in the navigating the gray zones.

[00:03:14]So what are the gray zones? We are discussing what are the situation where the textbooks end and where the clinical judgments begins. So it is in these moments let us dialogue and the debate and the shared uh wisdom become the invaluable. So as a president of Gujarat, I welcome you for this new part. It is not only the CME series but is the movement and the mission uh as our commitment to continuous learning and collaboration and advancing new care across our state and the beyond the Gujarat state and uh we know that most of the participants are watching the on the YouTube more than 200 300 sometime more than 500 uh across the state across the India and even the from the UAE and the foreign country also. So with the every session we aim to empower young pediatrician neonatlogist to strengthen our academic uh discourse and uh ultimately improve the outcome of for our tiny newborns. So I extend my heartfelt gratitude to Dr. uh our today's chief guest Dr. Amitupady G and guest of honor Dr. Sunil G for gracing the valuable time for the new part of Gujarat. So I extend my thanks to our NN Gujarat team Dr. Bir Shakar our dynamic secretary Dr. Kunal our project coordinator for this uh month and for Dr. Ron he our backbone of the our NN Gujarat new partala and whole team of the NNA Gujarat executive board members and office bearsers. So take together let us make the new part the backbone of the knowledge unity and the progress in the neonal medicine and whatever the we are learning today from the palist and the moderator Dr. senas will uh it will be imple implemented in our day-to-day practice and the impact will be the seen in the uh near future. So thank you very much. I look forward for the engaging the discussion under the esteem panelist. Thank you over to you bir and thank you for the birthday wishes. Thank you.

[00:05:23]>> Thank you sir. And uh now it is my uh pleasure to introduce Dr. Amit sir. Uh Dr. Dr. Amitadia is the chief guest for today's and sir has done his neonatlogy from as Delhi. After that he has done his fellowship in neonology even from Australia and currently he's working as a consultant neonlogologist at his private hospital Natuma hospital at meut and uh he is also secretary of NNF India that is central NF. So welcome Dr. Amit and I request you to say a few words about parala in today's topic.

[00:06:03]>> Thank you for the invite Dr. Baj and uh Gujarat NNF. It has been a pleasure coming to this highly academic forum and Dr. Yogesh Parik sir has uh told us in detail about shala already. So I wouldn't say take too much time in talking about that. I just uh encourage you all to keep on carrying the academic um you know the agenda in front and uh as Gujat always does and let's uh go on to the wonderful panel discussion led by Dr. Shinas Morti a dear friend over to you Dr. Virat.

[00:06:46]>> Thank you Ahmed and uh it is my pleasure to introduce Dr. Sunil Davani. Uh Dr. Sunil is our guest of honorum and he is a professor and head of department of neonatlogology at Sambalpur in Orurangabad. He is also a consultant at his own hospital that is neon children hospital in Orurangabad and he is an executive board member of and central. He has multiple research and publication and he has presentations at many ch uh conferences. So uh uh welcome to you Dr. Sunil and I request you to say few words about Shala in today's session.

[00:07:31]>> Thank you ma'am. Uh good afternoon everyone. Uh Sonil here first of all at out just want to wish you sir happy birthday. uh and thanking NF Gujarat and team Bchala for inviting me as a guest of honor. It's really honor like to be part of this uh I think network is the issue that you placed. Is he audible to anyone?

[00:08:03]>> No, no, >> right. Yeah, >> me it's a Hello.

[00:08:11]>> Yes, your network is probably you may you may switch off your uh video share.

[00:08:17]>> It's okay now. It's okay. It's fine.

[00:08:19]>> Yeah, this is better now. Yes. Yes.

[00:08:21]Right. So the thing is like being a student of Krishna sir it's always great like pride and privilege for me every time when I listen to him and for the other the participants also and everybody this will be a great opportunity for learn and the topic which we are today discussing it's again like sir sir is like master in this field like CPAP and ventilation so it's a great opportunity for all of us to learn from him our knowledge and get our doubts clarified as Amits said uh Let it be more interactive question like please ask questions. So this is a great opportunity for everyone to clear the doubts and thanking again you for inviting me and let it be more interactive we are there and thank you sir thank you v madam and kunal and all team man for inviting me so all the best so please continue.

[00:09:12]>> Uh thank you Dr. Sanil and u I have my uh coordinator Dr. Dr. Kunal who supported me for this thing and Dr. Ronak is also probably there but Dr. Kunal is little busy so I'll be introducing uh and taking this program further in between he probably is jointly am I right Kunal are you are you going to be there >> I will in between I will have to leave I have emergency patient that's why >> fine so I just yeah so we have our speaker orator Dr. Murki sir and it is my it is my pleasure to introduce Dr. Muki sir uh sir is a DM neonlogologist from has done his DM neiologist from Chamigar and sir is having a more than 30 plus years of experience in neonatlogology he doesn't need any introduction but currently he's working as a senior consultant at Ankura hospital for women and children Hyderabad am I right sir >> yes yes >> yeah so previously he was at Fernandez and he has now he's now working as at Ankura hospital and sir has multiple research and as Dr. Sunilin said that it is always our pleasure to listen to Murki sir. So sir thank you for accepting the invitation and thanks for uh being here for this panel. Um and we have a panelist with us Dr. Dr. DVD Mukharaji he's one of the panelist and he has he has done his fellowship from UK MRCPH followed by fellowship in neonatlogy from Manchester UK and he has also done his fellowship in pediatric critical care from UK he has multiple publications and his special area of interest is extremely low gastational newborns neal reset stationation and simulation and antibiotics and he is also a state academic coordinator for advanced NRP uh in from 24 to 26 6 tenur and uh we have another panelist Dr. Dr. um Sep Ba he is a DM neurologist from New Delhi and he's currently working at in Cloud9 Hospital Ludana he was ex consultant at Dalander and ex assistant professor at Adesh Institute of Medical requesting everyone to mute yourself he's having international experience from New York and Washington DC's from different different hospitals and he has multiple research and publications too.

[00:11:53]He was the he's the first author in neural and pediatric research and his paper is accepted at 2025 and as 2025.

[00:12:03]>> Uh we have another panelist Dr. Anish Sa Dr. Anish has done his DM neurology from my own area that is Karamad under Dr. Sumi Khas and he has been faculty to various conferences.

[00:12:20]He's currently working as a consultant and neontologist at Reuben and MGM hospital uh in Kpur.

[00:12:29]Uh we have another panelist Dr. Nitu Mundra. Dr. Nitu is having more than eight years of experience in neonatlogy and pediatric care. He's currently working as the NICU in charge and consultant neonatlogist at Vocard Hospital, Mumbai. and uh he was previously with the KM hospital as an assistant professor and senior DM resident uh he has done his DM neurondrology uh and um yeah and he is having a multiple research and publications so thank you all the panelists for accepting the invitation and being here with us to discuss today's topic and now over to uh you Dr. Dr. Murki sir to take this further.

[00:13:12]>> Thank you Dr. Bira and thank you team NNF U once again happy birthday Yogesh sir and thank you for bringing Amit and Sunil also to the forum my dear friend and my dear student uh uh Sunil. So with those words I think we'll take away with the panel discussion and I welcome the panelist again. I I think Dr. Nitu is a girl and so bira I think you were addressing her as he so Dr. Nu is working uh he's at Mumbai. The other three panelists are obviously males. Uh but uh just wanted to be sure on that.

[00:13:56]Uh so we'll move to the panel discussion. So the panel is on a topic which is uh which says respiratory support dilemas in unital practice beyond guidelines. So we try to frame this uh panel under these 10 questions.

[00:14:15]So what is the role of current TPAS TPS when and how to use what are the gaps in it usage? Then role of humidification during TP's use and during transport and then moving on to the niku is Lisa best method of administration or surfactant.

[00:14:32]What about salsa and uh what about liido larangoscopy for endoscopy or for intubation and if you're planning to give sactin when should we how long we can give weight for the first dose and how many doses we are eligible to give then um from there we'll move to see what bubble or nib for primary respiratory support then is caffeine a routine for all pre and also we'll try to cover something like is assist control or PSV the ideal mode of respiratory support. Should we extubate all newborns to NIV or CPAP for after extation failures to reducing extation failure? What are the simple measures to prevent extation failures and when and how for steroids and uh late steroids in babies on prolonged ventilation? And these 12 to 13 questions we'll try to answer in the next 40 45 minutes. And I once again welcome all our esteem panelists who are um not only aerodite at the topic and also have lot of experience in dealing with these situations. So we'll move straight to the questions and uh I request both Anish and uh Nitu to switch on their videos so that I can see them. Yeah.

[00:15:49]Okay. Thank you. So we move to the first question. What is the role of current TPS? When and how to use and what are our gaps or uh uh what are the gaps in the usage of the current TPS? SEP over to you.

[00:16:06]>> Uh very good afternoon sir. Thank you for the question. Um so it's a TPS it's a it's a device to deliver positive pressure ventilation. So PPV is actually the main stay of neonatal resuscitation.

[00:16:18]So currently various kind of devices are available and most commonly we all are using uh self-inflating bags and TPS. So about TPS actually uh it is a gas powered device. It requires some constant supply of air or oxygen to work and the best part about this TPS is it can deliver some preset determined pressures in the form of PIP and P to the baby. So which makes it better than the self-inflating bag. Another advantage it carries is it provides PWP which a self-inflating back cannot provide. So now in the market so various kinds of TPS are available and uh we have recent addition in India called as MKS device and uh which has an added advantage in the form of it has got an inbuilt blender. So with this device we need not to add any external source of air. It works with just uh room air only. And if we want to addition of FiO2 only then we have to attach the oxygen.

[00:17:18]So as this uh uh TP delivers precise pressures in the form of PIP and P. So it is actually it carries importance when we want to resuscitate a baby where we want to avoid a barot trauma especially in case we are going to uh resuscitate a pre-term baby there we should use a TPS resuscitator because it also carries an added advantage of PE so that to maintain the FRC in those babies another use it carries it in the form of delivery room CPEP so any baby with respirator is breasted in the uh uh in the labor room we should it uh the TPS is used to provide CPAP in the delivery room only. Another use is in the form of uh while we are doing insure technique uh for the surfactant we can use a TPS in between. And last but not least is in the form of neonatal transport. So when whenever we are transporting a baby either it is an intubated baby or on a non-invasive mode of on on the non-invasive mode we can use this TPS resuscitator with the addition of RAM scan canula in front of the circuit. So these are the various indications. Uh and if we talk about uh the uh clinical evidences uh if comparing it with the self-inflating bag. So there is a recent meta analysis which has been published in American Academy of Pediatrics. It says that this uh uh TPS resuscitator actually helps in reducing the duration of PPV and in the long term also reduces the risk of BPD in the pre-term babies.

[00:18:47]So these are some benefits and proven benefits and based on these guidelines the Ilkore has recommended TPS's over self-inflating back for the resuscitation but still there are some uh gaps uh related to the TPS resuscitator. First the TPS still cannot we are not having the option of measuring tidal volume with the TPS resuscitator. So there is another risk of inadverent PE. Suppose so we are resuscitating a baby. Sometimes during resuscitation the compliance of the lungs change. So if we are ventilating a baby with an self-inflating bag depending upon if the resistance is reduced we can reduce the uh force of uh uh squeezing the bag. But in the case of Tpiece resuscitator CMP will be delivered throughout even if the compliance is improved. So it can increase the risk of inevit.

[00:19:37]Another one is still the uh none of these devices have got an inbuilt blender. We have to use an external blender for uh titrating the FiO2. And last these TP resuscitator while using it we still lack the humidification. So the dry years can have all its own disadvantages. So this is all about a TP resuscitator over.

[00:19:58]>> So thank you. Thank you Dr. Sep. I think he has highlighted all the uh benefits of a TPS and also the gaps evident. So stepace is going to become part and parcel of everybody's resistation. So all although we now currently say definitely for pre-terms but I think it is useful even for term babies to do resistation especially with when you want to do room a resistation especially those TPS with inbuilt blenders. So regarding the gaps as he rightly pointed out we already have an Indian-made device that is our own device where uh it's manufactured in Ahmedabad Gujarat.

[00:20:36]So so it is very near to Gujarat people.

[00:20:39]So this has an inbuilt battery and it can operate for 4 hours. It can titrate the FO2 and pressures and it also doesn't require it works on room air. So it suggest river flows and pressures and obviously if you want to improve the FO2 you can connect oxygen to this a cylinder oxygen or a concentrated oxygen and you can increase the FO2 it also measure the pressure delivered and FO2 delivered also. So that's how we have been able to overcome some of the gaps related to TPS. But if you're using a TPS with 100% oxygen definitely it is not correct. We need to move on to use TPS which have inbuilt blender and uh um and we'll be able to deliver.

[00:21:28]So obviously we know that brief period of hyperoxy is not good for small babies either in the delivery or during transport also.

[00:21:36]>> So with that we move to the second question. So definitely TPS is a great addition. We need to look for TPS either with a blender and humidifier and also we need to titrate pressure and FO2.

[00:21:49]Yes, currently we still not been able to measure the tidal volumes. So the second question um we just talked about humidification and uh obviously although we have TPSS with blenders which can titrate FO2 and pressures but we still do not have humidification in TPS and either for use during transport or during resistation. Um Dr. Anish can you highlight the need for humidification in during use of TPS?

[00:22:18]>> Thank you sir for the question. So why there is need of humidification? So why the unconditioned gas hurts the units and especially the pre-term units? So the core issue is uh here is so whenever we deliver the gas the newborn isothermic boundary that is at the karina it should warm the gas at 37°C and the absolute humidity of 44 mAh per liter. So what happens is if you are not delivering the uh conditioned gas or if you are not humidifying it what it does is as we all know that babies have a increased area to mass ratio thin epithelium mucoseleric uh clearance is impaired plus if you are giving cold or dry gas it further impair it leading to occlusion or mask occlusion further it can lead to epithelial injury which can further lead to airway resistance and which can further lead to adelctis. So this is the thing with a cold gas that is happening and other thing is there is also evaporative heat and water loss. So evidence- wise I want to say is a Melbourne study was done which showed increasing the uh increasing uh giving humidification can lead to decreased rates of hypothermia plus providing a norm normoxic and normotheric temperature to the baby and it is especially important in very preterm babies and not for not more for the term babies. What happens is in very pre-term baby with the extensive use of resuscitation we are uh resuscitating baby for around 10 minutes or 15 minutes in a delivery room. So if we give dry gas these all thing will increase and if we provide humidification this can further down like this all things that we have discussed this can further further down. So proper is to use the uh humidification but due to the equipment complexity the cost the high power supply and the uh mechanics behind it many of the centers and still are lacking behind using humidification. So that's the thing why there is need of humidification.

[00:24:34]>> Y thank you. Thank you Dr. Anish. So the current recommendation is that if you are to give respiratory therapy for any babies, the gas should be delivered at at least 33 mg per deciliter of air should have at least 33 mg per deciliter of absolute humidity. Now when you're giving room air or when you're when you're when you're giving compressed gases likely from the cylinders or central sources the temperature is as low as 8 or 9°C and the absolute humidity is less than 10. So which is definitely damaging if you use it for prolonged time. So that is why if you want to use it for long time at least more than half an hour we should be able to add on humidification.

[00:25:19]So at least in the labor room and in the transport I think time has come for adding humidifier if you're already using Tpieces it has a great advantage on improving the outcomes. Now imagining giving the such low temperature gas into the nose of an extreme preterm even 15 minutes whatever else you do you're cooling from inside. So the admission temperature could be lower and that we all know increases the risk of morbidity and mortality. So it not only saves the lung but also saves the temperature by adding humidity early to our TPS.

[00:25:52]>> So this study has shown definitely that almost half the hypothermic episodes can be decreased in small babies if you use TPS.

[00:26:02]>> So I request everybody to put down their questions in the chat box so that we can answer in the end.

[00:26:08]>> So the next question was isification.

[00:26:12]>> Hello his his modification is necessary during transport. So I would say it is very more than necessary it is very essential as the neonatlogology has progressed. We all are taking babies or going for the transport of babies for even for a longer distance by rotary wing or by car by ambulance. So it is very essential for having humidification during transport. But the problem uh what what effects in transport the cabin temperature inside is very low. Plus if you use Hello. Am I audible?

[00:26:51]>> You are audible but somebody else is uh >> I'm muting her. Punam sa mute yourself.

[00:26:56]Yeah.

[00:26:58]Yeah. Yeah. Anish go ahead.

[00:27:00]>> Yes. So the thing is when we use uh cars, ambulance, rotary wing for transport, the cabin temperature is very low. Plus if you are using a TPS or if you are transporting by uh at tube or anything if you are not using humidification again if you are giving the dry gas again the same problem will be there and the problem the worst part is sometimes TT also gets blocked and the real problem arise here that you have to change the ET in between a hectic and a long transport. So adding humidification is very necessary and now we have two type of humid humidification. The one is active heated humidifier and the second is passive humidifier. So the gold standard and to use the thing we should use active heated humidifier. So again it prov it is the only real option for prolonged invasive ventil ventilation and only real option for transporting very pre-term babies or extreme preterm babies. Again gaps the gaps is power draw is very high equipment complexity space it takes the space it needs the reservoir and again rain out in the circuit is also there. So this is the thing with the activated humidifier but if we try to cover all this we can use the activated humidifier. The second part, the second part is that we have to we can use passive humidifiers also which is also causes HMES, heat mo heat exchanges. It is passive, it is light and it it use no power but the only problem is it increases the dead space and as all we know once the dead space increase again the secretions will occlude again the efficacy will go down again atisis can happen. So summary of all this is if we need to do short transfer use low space HME. If you want to do long transfer or in very pre-term babies or in extremely bum babies you should use active humidification. Thank you.

[00:29:04]>> I think these are the most important points. Currently you can see that most of our TPCs do not have humidifiers and as you rightly pointed out the biggest reason is because these humidifiers require very high power. So you need a draw power or dry power. So which is which you you cannot use in a battery.

[00:29:23]That is a problem with humidifiers. And obviously because they are heating the gases from 10° to 37 which is a huge range. And while they're heating they also need to warm the water. So these are the two important problems we have.

[00:29:36]And I'm sure with with all the people sitting out here, we will very soon come out with a humidifier from India which may be able to warm and humidify the gases at uh um at the recommended values and also from our own country. So we are looking at these humidifiers how do we manufacture and I'm sure the very soon we'll be coming out with the humidifier uh um either in the labor room or during transport. uh HME is an option for adults but in children you do not get adequate HME because the rate of breathing is also very fast so the expired air will be very little have scope to heat the inspiration hair so these are the problems currently but I'm sure very soon this is still remains a dilemma but we know that we are not doing very great thing by not adding humidification during resistation and transport so next Dr. Dip the um is Lisa. So we have come from niku transport to the niku. So resistation transport to the niku and we have a baby where we need to administer surfactant. Now you have so many different methods insure Lisa, misa, salsa and nebilize. So can you can you highlight on Lisa? Is this the best method of surfactant administration? Are there still issues with this?

[00:30:56]So uh yes I mean uh there are various methods of surfectant administration at the present moment and for spontaneously breathing pre-term entrance LISA happens to be uh the best method at the moment.

[00:31:09]So lots of trials looking into it. To begin with, there was the optimist a trial which was in 2021 looking at pre-terms between 25 and 28 weeks where uh Lisa was compared against a sham treatment in the control group. And then there has been the European consensus guidelines last year as well which found uh Lisa to be the preferred method for surfactant delivery. And uh yes the cockrine database has also looked into uh literature and uh that also recommends uh LISA as uh the better method of surfactant administration. So to begin with there was a lot of insure and that has actually gone down and over the years with all the research that has gone in. It has been found that Lisa carries benefits in terms of reducing the BPD rates uh reducing the mechanical ventilation days. It reduces the severe IVH and more importantly there is reduced need for uh sedation and better long-term pulmonary outcomes. However, most of uh the research for Lisa has been actually early or late LIISA versus uh uh sham treatment in the control groups or it has actually not looked much into LISA versus insure. So the LISA versus insure trials have been quite few. Uh so we shall go into that in the next slide. But uh also yes there are a bit of limitations with regards to LISA. So the catheter it's not available um still at uh various places. Uh there is a a lot of uh training that needs to go about it and so the entire team has to be on board before Lisa can be done safely. Uh it has to be uh it can be done safely in a spontaneously breathing pre-term. So where uh the baby is quite floppy uh it's uh insure is still a better method. Uh we have to look into sedation as well. So we have to appropriately sedate however it should not be quite significantly heavy sedation. So a bit of dextrose swaddling uh helps although there's lot of trials going on into looking at sedation. So coming to LISA versus insure. So the trials have been very few. So recently SSK came in Kolkata they looked at uh so they did the RCT on 58 pre-terms between 28 and 34 weeks and uh they did LIISA versus insure and ensured that these baby babies went on to NIBPV as the standard mode of non-invasive ventilation. So they uh found that uh there was a comparable efficacy. So there was no difference in terms of outcomes except for the LISA patients having fewer hours of hospital stay which in an Indian setting uh definitely matters because it also means less costs as well. So uh uh SSKM also has looked into using uh replacing the Lisa catheter with a five French uh nasogastric tube as well. So that can also be done where the catheter availability is a bit difficult. So uh overall if you look at so yes if it's a spontaneously breathing less than 34 weaker Lisa is quite safe uh when they are on CPAP or NIPV thin catheter versus NG tube so it can NG tube can be used once we freeze it uh then it becomes a bit hard and can be used to replace a Lisa catheter where it's difficult to obtain in terms of sedation a bit of sucrose and minimal sedation is is quite sufficient It can be done in Nikus and in terms of training yes structured program is needed. Simulation based training is often quite helpful to have the entire team on board in using Lisa as the standard method of subactin delivery.

[00:34:54]>> So just to ask you um practically they in all your patients you're doing LISA?

[00:35:00]>> Yes sir. Nitu.

[00:35:04]>> Yes sir. For all patients we are using Lisa with surficate actually >> and Anish >> no sir in some patients only we are doing and usually 30 to 32 week we are using and not less than 28 weeks. So we have apart from that Sep I'm using it for less than 32 to 34 in the bigger babies I'm still preferring insure.

[00:35:25]>> So I think although evidence is very clear but rightly pointed out evidence is comparing Lisa with delayed surfactant. So that is why you have so many benefits but uh there is a lot of learner curve in LIISA. So if your learner curve is static now if you have been comfortable and if you have improved your experience and skill I think Lisa is a preferred method simply because you're not doing any bag and mask or tubing during the time of lease administration and your PEEP always remains static. So your dispersion must be better off. But saying that just the LISA versus insure is likely to decrease mortality BPD is like a huge task or a huge uh huge benefit which is unlikely to happen just comparison wise. But if you delay surfactant because in optimus trial if you see it is CPAP with in with LIA versus CPAP and insure or surfactant when the baby is ventilated which means your one group got early the other group might have got delayed. So obviously if you delete circ surfactant from the early therapy your outcomes will be less optimal. So I'm sure uh most of the people know about this and SSCM should be congratulated for doing this study where they've shown that and they feel that even with a feeding tube you can easily give Lisa and maybe we need to learn from their experience how to do Lisa better with a feeding tube.

[00:36:55]So now comes uh the other technique which is becoming popular or slowly gaining momentum is salsa. Um Nitu I think uh you are the youngest in this group I think.

[00:37:06]>> So so this is the looks like this is the therapy which may be futuristic. So and can is this a doable method or can we allow nurses to do this method?

[00:37:19]>> Yes sir.

[00:37:20]>> So what is your thoughts on this?

[00:37:21]>> Basically as DPS has already said key yes we can do LIA but it needs a good learning curve. So we are always looking for some alternative as we are coming from very invasive to non-invasive we were incubating we were giving uh inshore then we went to lasa now whether not to give anything don't use langoscope at all so is it possible so with that this very fancy name salsa has come out where we are giving surfectant with supraotic airway or lingial mask airway we are using this LMA for our resuscitations for the those babies as an alternative airway when intubation skills are not available especially in a setup where you don't have a peditation ontologist available. So it has been used. Now can we can we use it for uh surfectant also? Yeah, there are some studies which they have used before that I'll just brief on how it is done. So you insert your LMA until the resistance is there then you see your color change in CO2 or you see the bilateral air entry pass a surfectant you five French or six French um RT will do and deliver your surfectant in alicots. Now there was advantage. What are the advantage?

[00:38:27]The advantage are this that it is passed easier insertion than an ET tube. Even it will be easier than using a surfic or the catheter for Lisa because where an expertise is needed you need to see the vocal cord marks and you you have to use the langoscope. So no langoscope required here. decreased need of mechanical ventilation versus CPAP alone was shown in one of the study where RR is very uh impressive which is um almost 0.43 43. So it is safe. There's no significant air leak or BP on IVH which was seen in this study was done in 2018 by robot at all. So simple to play is suited where skilled providers are not available. Yes, can be performed by nurses. Yes, but after an appropriate training but it's not as easy or as simple as it seems. So next slide sir.

[00:39:18]So what are the problems we can face with the uh LM? So number one problem what we say in uh our setup is the availability of the appropriate element.

[00:39:28]If I say practically we use surfectant after this use of non-invasive ventilation and CPAP the use of surfectant has gone down down and it is mostly used for more of the pre-term babies. Now the LMA which is available to us is for more than uh 2 kg babies.

[00:39:46]Even in the western world it is not available for less than 1.2 kg babies.

[00:39:50]So in those babies the difficulty will be there because you don't have the appropriate device. Second uh there could be some wastage of surfectant it is not appropriately placed some some unit has also faced the problem in placing the LMA uh the fold of the LMA at the vocal cord junction. So these are the problems which are still there. So it need larger trials a lot of uh uh studies and training so that it can be used for the settings where you are not uh where the expertise are not available. Though the evidences are uh very very u impressive as you can say that average device placement time was around 88 second and 65% of the time it was placed within 50 seconds. So given this where we have 1 million death of pre-term babies most death in the LMIC's so can in the LMIC in this resource limited setting salsa salsa could be a very good alternative in fact some countries like Ajaran they are using salsa is one of the very common method of delivering this affectant so sir it is doable for this larger babies after learning and training.

[00:41:02]>> Thank you. Thank you. I think like in the resistation this also will take time because uh I'm sure it is slowly creeping into resistation especially for bigger babies using langel mask I think to move from the leisation room to the NICU you need better devices smaller devices or smaller langel masks and in bigger babies when you're passing these cu LMA it gets folded sometimes it get folded so it becomes difficult to go deep and then give into into the airway and again there may be there will be salsa devices or LMS which have a side port which may help us in giving a peep and pip while we are giving a um surfactant. So maybe there is a there is a need for better devices or smaller devices to improve our usage of salsa but looks very promising. So I'm sure many of the >> those who are using salsa they are using those devices all the videos which are available they're using those PPS devices to deliver the feed simultaneously they do not uh drecruit the lung while giving salsa.

[00:42:10]>> Absolutely. Absolutely. So they're using LMAs with a side port so that they don't have the problem of passing a tube again. So I think uh wonderful I think uh we are midway. So yeah the next device which is coming into our uh respiratory care is the video larangoscopy and uh sep can you highlight to us what is the role of video langoscopy in unital incubation is it preferred over routine langoscopy and are we all comfortable with this or should we change or we should continue with routine langoscopy.

[00:42:49]Um so sir about uh very direct lingoscopy we need some straight line of vision to see the vocal cords and to intubate whereas this uh video lingoscopy is a kind of an advanced uh advancement in the airway management. So it is a technique that integrates the cameras in the front of the blade of the lingoscope along with the light source so that we can directly see what the our airway on an external screen. So there is a projection of some high resolution images of the airway on the external monitor. So as there is superior visualization and there is a wider magnified view. So the it has been seen in the various studies. So this is about uh from a cockrain published in 2021 which has seen uh it's about uh it has enrolled about four studies uh with around 580 intubations and it has seen that uh the first attempt intubation success is better with the vidual langoscopy as compared to the direct one and secondly it has also shown that it reduces airway trauma and some airway related adverse events such as desaturations bradicardia during the time of intubation.

[00:43:54]However, they have seen that the time for intubation has been same with both either if we have used direct or video langoscopy. The time is same and uh as the images are uh being projected on external screen so it enhances the teaching and supervision. So external view actually allows the real-time guidance for the new trainee. And last but not the least it is useful for difficult airways and inexperienced operators. So suppose there are the residents on floor and some junior person has floor in the hospital. So it is a device which which then take the preference over the direct lingoscopy.

[00:44:32]But still it come with some gaps and limitations. First of all, it is uh much costlier as compared to the direct lingoscope which we are using and it's not very universally available throughout and secondly uh there are some lack of ideal hardware in the form of it is not still much available for extreme preeies and there are various kind of devices available and this the uh the our evidence from the study cannot be applied to each and every device and uh still it requires some structured protocolized training. for its effective use and another one is it may hamper our development of direct lingoscopy skills. So using uh video lingoscopy your trainee will not be able to intubate with the normal lingoscope.

[00:45:17]So these are some gaps. So uh in nutshell if uh if we want to go from uh direct langoscopy to the video langoscopy I would suggest that if your unit can afford a video langoscope it's always uh better to have a video langoscope in unit but in the meantime always have the uh have some ongoing trainings and all to keep our skills with the direct langoscopy.

[00:45:41]>> So thank you sep and again I want to ask each of the panelist Anish you are using video langoscope routinely. No sir. No sir.

[00:45:48]>> And uh Dave Deep. No sir. Nitu.

[00:45:52]>> No sir.

[00:45:53]>> No. Sep.

[00:45:54]>> No sir.

[00:45:55]>> Yeah. So I think this is the worry. See the studies are showing that it is easy to do it. It will improve the efficacy and your way shorter. But I think many of us who have been trained in doing dangolascopy we are worried that our laryangoscope skills are will be out. So I think uh that is a problem even with my residents when I spoke to them they said that we are comfortable with indirect langoscopy and we have good intubation rope so we don't want to go for video but yes if a traininee comes and if you're getting new fellows maybe you should allow them to use a videocope and make this process much more simpler much more easier to do because I think that's a that's a undervision uh intubation so definitely the success rates will be going to be better and maybe we don't know actually if we are given a chance and tested maybe we we might also do better with eligiboscopy but we are we are tough nuts to crack and then uh it'll take some time before we change also so I think there are as sep pointed out you can see here that uh the saturations are almost similar and heart rate changes are also similar uh but uh successful intubation first attempt is significantly higher in the medular angos. This is one large study which is published and this shows that medular langoscopy efficacy is definitely better.

[00:47:24]So obviously we are able to intervate whatever be the method or we are going to get up with Lisa or or with salsa but uh Anish can you let us know if you are successful wanting to give surfactant up to how many doses we can give and many of us get outborn babies because some of them may come at 48 hours some of them may come even after 3 4 days have typical RDS so should we give surfactant for them also so is there in a time limit We can wait before we give the first dose and if you're giving first dose how many doses we can continue to give.

[00:48:01]>> Okay. So let's talk about surfectant redosing as s pointed out the question that is how many and how soon. So first of first of all we will see the CPG guidelines. What CPG guidelines say. So whether the baby is on invasive or non-invasive ventilation. Fio2 requirement more than 40 and or a map or PEEP more than 7 cm of H2O you have to give second dose but before giving the second dose check the mechanics. Check the mechanics whether it is in position whether it is patent whether some air leak has developed or whether you have given delivered the surfectant correctly. After checking it give a pause reconsider your diagnosis whether like is there any chance of developing sepsis is there any signs of sepsis take a probe take a unit eco probe do eco see if there is pda or not then think of other diagnosis like if there's a developing PPHN or pneumonia or some congenital conditions like very rare but it can happen if there is surfectant protein B or C deficient So check it out because if you give the dose and if you give the second dose it will add to the cost plus it will also cause the wastage of the surfectant. So give a pause think first and then decide about the red. So as per the slide I will just cut it down in the summary then you can repeat all the surfactants that we have infrasal everything has to be given after 6 hours. So before 6 hours you don't have to give the second dose wait for 6 hours see for the improvement then give the second dose of surfectant. Now what like how what is the maximum dose? So maximum dose is three. Never try to give the fourth dose. So gap at three do and stop it. So this is the thing about how many and how soon.

[00:50:08]So the next thing so as sir has mentioned many of us receive outbound patients. So what about them? So when when it to give so as soon as the patient curve if there is symptomatic RDS like respiratory distress is going on don't wait for the radiography just you can give the surfactant dose and the second thing you again before giving you have to rule out pneumonia PDA misplaced tube before giving it and CPG guidelines what it say it says that do not use the surfectant beyond on 72 hours but I think many of the units nital unit have a variation that is called as practice variation they use beyond 72 hours also even in our unit we also sometimes baby come to us uh it around fourth day 5 day so till 7 days we still are given one dose of surfectant if the baby has not get uh in the uh previous NIC thank you sir >> thank you thank you uh for highlighting the two important things. I think all of us are comfortable up to two doses and but however going for third dose we have to get a eco done. We have to rule out PPH and we have to rule out air leaks PDA and one very important diagnosis many of us miss is a TAPVR. So I think TBAPVR is something which should be always be ruled out before we give the even the second or third dose. The another important thing is if you are not able to improve maybe it is a conventional surfactant protein B deficiency. So we should be careful because instead of giving multiple doses and then raising your hands later it is better to tell the parents that okay we are giving for second dose but if it doesn't then we have to see whether we have a congenital surfactant deficiency rather than a premature related RDS. So, so we move to the seventh question. Um, so we we have finished intubation, we have finished surfactant, now we want to start CPAP or NAV for uh babies with respiratory distress. So, Dr. Di, which is preferred CPAP, bubble CPAP or NIV as a primary mode of respiratory support?

[00:52:28]So um bubble cap I mean remains u the standard of care because of its uh simplicity, easy to use, low cost and easily easy easy availability uh in most centers. However, I mean the NIV outscores the bubble cap in quite a few ways. So can can we mute please?

[00:53:01]Can you mute mute the people who are not able?

[00:53:10]>> Yeah. Babe, go ahead. So I mean the NIV outscores bubble cap. So in terms of post extubation support, so it's been seen across many trials that the NIV reduces the reintubation rates when we extubate babies to NIVs from mechanical ventilation. So it also works where there are recurrent apneas of prematurity compared to bubble CPAP. So the bubble CPAP appears to be quite insufficient over here and it's moderate to severe RDS. The NIV is much better in terms of delivering better outcomes. So if it's a stable pre-term, bubble CPAP remains the preferred mode of choice but in the high-risk ones the NIV is much better uh than bubble CPAP. Um so can we move to the next slide?

[00:53:57]So uh there there are areas when we prefer choosing the NIPV over the bubble CPAP. So where the NIPPV is available, it definitely is the better mode of non-invasive ventilation. Uh quite significant reduction in intub reintubation risks and better improvements in CO2 clearance as well.

[00:54:15]And yes, in less than 28 weeks um the benefits are quite significant. The synchronization of NIPP is also uh helps and where available the synchronized mode should be preferred over unsynchronized NIPP or bubble CPAM. So um and the bubble CPAP uh preferably in more than 30 vehicles with mild to moderate RDS where the NIPPV is not available uh the bubble cap can be a better mode of uh ventilation.

[00:54:45]So thank you. I think uh for ease of use I think bubble cap still remains the primary mode of respiratory support for most of the babies. Yes. uh when when you have a very high risk of failure like in extreme preterm less than 27 28 weeks when you are likely to have a very high rate of failure people prefer to use NAPB as a primary mode but I think all babies more than or equal to 28 weeks I think it's preferable to start with bubble cap and yeah because it also has other functions of bubble cpap is less costly um and more cost effective and uh the other important thing is I often we forget humidification also is slightly better off in bubble CPAP than in in NIV.

[00:55:31]So uh Dr. Nu we have put baby on CPAP or NIV. The other common medications which we use in the Niku is caffeine. I think caffeine is the molecule of this century where I think neonatlogists are living with caffeine both uh in with the babies and outside the babies also. I think many of us get the first kick with the daily morning caffeine and we want our same kick to go to our babies. So caffeine is become part and parcel of respiratory care or we still have some restrictions when and how long to use caffeine.

[00:56:08]>> So yes, caffeine is one of the most commonly used drug in the pre-term babies in ICU. I mean day one, day two we generally start caffeine for all premum babies. So we know how caffeine works by stimulating the respiratory s center or increasing the CO2 sensitivity improving the diaphragmatic contractility or respiratory muscle endurance and it also facilitate extubation reduces apnea shortens the ventilation and reduces reduces the risk of BPD. When we talk about caffeine, we we cannot uh not talk about the cap trial which was done and which is one of the very biggest trial done on the caffeine which has shown it's definitively beneficial for the pre-term babies not only in the short term uh by reducing the risk of BPD or facilitating the earlier extation decreasing pediat need or ventilator days even for the better neurodedevelopmental outcome at 18 to 21 months even the further follow-up studies on the capra saying that the outcomes where uh as per the respiration is considered where for the long-term even after even 2 years of the age. So definitely caffeine is an onto drug for the pre-term babies. So now uh there are some still variation in the use of when to start whom to start how long to give. So I'll u doses loading dose are even before the cap trial the doses used were at around 50 migram of the caffeine or the 25 migram of the caffeine base but after cap trial the 20 migram which they have used is been become uh the standard and the maintenance dose 5 to 10 mig is which people are using. If the baby is having persistent apnea, some of them are using even the high dose as a maintenance up to 20 but uh it has been advised that it should be used under a research setting only that the 20 mig per kg per day is going as a maintenance dose but up to 10 mig yes is it it is recommended. So this is about the dosing. Now when to use most of the studies or most of the um guidelines says that you should use within first 24 to 20 uh 48 hours as early as possible because it is not just for apnea. So don't wait for apnea to happen. You should use it as a prophylactic also for the babies who are less than 28 weaker or the for the babies who are on some kind of respiratory support. So there are two lines. If it is less than 32 week, less than 1250 g as per the NF guideline, you use caffeine. If the babies are more than 1250 g or more than u 32 weeks, use caffeine if these babies either on ventilation or any kind of non-invasive support. The AAP guideline they says that use for all babies less than 28 week between 30 to 32 week use the for the babies who are on ventilatory support. As far as the European uh guidelines they says that use for less than 32 to 34 weaker babies within 24 hours with a loading of 20 and the maintenance of 5 to 10. Now the question comes uh or or the other indication is if you are extinguating the baby give a caffeine load for a easier extation and third if the baby is having recurrent apnea then yes cap is indicated. So these are the indications and the age group as per the different guidelines are considered. Now up to when to give sir. Yes sir.

[00:59:32]>> Yeah carry on carry on.

[00:59:33]>> So till when to give. So uh if we consider the CAP trial they their average uh age at the caffeine was stop was 34.4 week. So most of the guideline they says that you can stop at 34 to 35 week of postmenstrual age uh postmenstrual age. Now there's another thing that if the baby's apnee for last 5 to 7 days then yes a trial of caffeine off can be given. if the baby's otherwise stable. So at around 34 week baby's cap uh caffeine uh sorry apnea free for 5 to 7 days the trial of caffeine can be given. One word that if you are trying off caffeine weaning please observe the baby for another 5 days of caffeine that baby is not having the apneas. So these are the uh uh various guidelines on the caffeine when and how until what when to give.

[01:00:27]>> So just to summarize what Dr. Nitu said I think it is less than 30 weeks and less than 1250 g most people are preferral to give as a prophylactic dose or a routine dose. More than 30 and more than 1250 gabies who require respiratory support one can think of giving caffeine either during extation or right from the word go. It is like rescue.

[01:00:51]uh bigger babies at least more than 32 or 33 weeks. There are some people are still using caffeine but I think there the duration can be lasting just for 5 to 7 days because there you really don't have to continue long duration of caffeine but once you start for smaller babies you wait for 34 35 weeks and 1 week of apnea free interval most important like what Dr. Nitu said because caffeine has a very half long half life you need to allow the half T half to come down and before you can discharge otherwise you you may land a baby in going for apnea and coming back to you. Um so that is why you have to ensure that you start you stop caffeine at least 3 to 4 days before you discharge the baby from the niku.

[01:01:38]Um yeah we'll move from CPAP NIV to uh with caffeine to ventilation and Dr. Sep because currently I know there are very few of modes of ventilation which all of our using and can you let us know the differences between assist control and PSV and which is the ideal mode for mechan ventilation in um newborns and in preterms.

[01:02:03]>> Okay sir. So assist control and PSV actually are similar in in many ways.

[01:02:08]First of all, both of them are synchronized modes of ventilation. Both of them are patient triggered means they are initiated by the patient breath and both of them has got some uh backup in the form of the assist control has a backup rate where in the PSP mode when we are using there is an backup apnea mode is available. So both of them have some backup safety. The uh real difference lies between the TI the cycling mode means how the inspiration get terminated into the exhalation where in the assist control it is done by the clinician in the form of setting a TI whereas in the PSV mode the cycling is done by the flow which means that when the peak flow when the flow comes 15 to 25% of the peak flow then the inspiration gets converted into the expiration. So this is how the cycling is done in a PSV mode. So um assist control provides a fixed tidle volume whereas the PSV mode of ventilation provides a variable tidal volume to the patient. So this is the difference between the two modes of ventilation and uh so uh whereas the assist control mode is used for the initial stabilization.

[01:03:17]So if a baby is sick having acute respiratory condition, we would like to pref put the baby on assist control mode of ventilation in case we are uh we are weaning the patient uh from the ventilation then the PSV PSV mode of ventilation is used. So another thing to be kept in mind while using a PSV mode is about the uh TI uh in the pre-term baby especially. So the pre-term babies have got a very uh short TI. So but with the use of PSV mode of ventilation this uh they with the due to the low TI they can get lesser maps. So when we are shifting a baby to PSV mode always have a look on the what map are is being delivered to the baby. So in case the map is not adequate we have to increase the PE in that mode in the PSV mode. So this is all about assist control and PSV mode.

[01:04:09]>> Yeah. So thank you Sep. I think both these modes are almost similar except for the TI and if you switch from assist control to PSV your map will dramatically come down. So you need to work on increasing the PEEP to ensure that PSV works as good as assist control mode. Um but yes in spite of this I think assist control remains the standard gold standard respiratory support mode for all the babies during the acute phase and during the weaning phase most people are preferring PSV. I think more than these modes we are looking at hybrid modes where we add VG or volume targeting to these modes to improve the outcomes of uh lung mechanics as well as for lung injury decreasing lung injury. So Bira we have another 5 to 10 minutes.

[01:04:56]>> Yes sir. Yes sir.

[01:04:58]>> Okay.

[01:04:59]So after finishing ventilation should we extate all newborns to NIV or CPAP for reducing extation failure? Dr. Anish is it a good practice to extate all babies to NIV or CPAP for reducing extation failures?

[01:05:15]>> Yes sir. So first of all let me be clear all of the pre-term infants around 25 to 30% fail extation if you are not giving the extation or some distending pressure. So never extubate to bare oxygen. Still in some units we extubation to oxygen is also there. So the question is not which mode it uh the question is which mode and not whether so which and whom. So as per the coine trials that was done it included 19 trials which was done in 2023. It showed NIPV has a good effect than CPAP for extating the very pre-term babies uh after the intubation. So it is a good role in extation and preventing reintubation rates.

[01:06:04]Second thing, if you are giving a bubble cap more than 8 cm of X2, most of the units are using six 5 to 7 PE when extating. But if you give a CPAP more than 8 cm around then CPAP is also as good as NIPV. If you are extating term babies more than 30 weeks, more than 30 weeks. The third important thing is and the newest thing in this is NHFOV that is nasal HFO. Once the trial has come that is network meta analysis 2024 it showed NHFOV is the most effective and it has inverted all the rankings and now it like and inverted the rankings with the NHFOV decreasing the low extation rates but the trial that was done has not good quality evidence. So still you support with NIPV or CAP. So everyone has to be the nutshell is that everyone has to be extated to some distending pressure.

[01:07:10]More immature the lungs more immature set more highest settings use nitp robust pre-term or near-term use well set cap and for rescue measure if there is hypercapneia use an hfob. So that is the thing that you should uh do for extation to NIPV or uh this CPAP and whenever you you are using NIPV use synchronization. Thank you.

[01:07:39]Thank you. Uh thank you Anish and yes I think most of us now are exubing at higher settings some of times if up to 14 x 5 or 16 x 5 and if I to up to 25 30% that's why we are our aim is to cut down on the duration of mechanical ventilation so since we are extating on a higher setting without reducing the rates much so that is why most of us switch from um ventilation to either NIV or CPAP or any other mode but definitely we are all working on um on some or the other respiratory support. If you have all the adequate facilities I think synchronized nap is currently the standard but otherwise CPAP with slightly higher PE or NAV are equivalent and but don't forget other things that is caffeine nutrition and sometimes airway piloting these should be more important than u just giving the pressures. So uh with that we move to the next question which is almost relevant here. What are the simple measures to prevent exhibition failure?

[01:08:46]Rahep can you tell us some QI based measures which can be used to decrease the extation failures?

[01:08:54]>> So yeah I mean all of this data is from a recent uh QI and few of the measures that we can take to reduce excubation failures is optimizing the nutrition that we are providing to these pre-terms. So um adequate calorie intake is extremely essential. Um then yes caffeine as we have discussed. So give it before extation to reduce the risks of apnea. Uh treat a PDA uh if it's hemodynamically significant. So that also optimizes how the babies are before extation. Volume targeted ventilation uh will optimize the lung recruitment pre-extubation. So again is much more safer and gentler for these babies. try and we down to around 30% if I do before extation um early NIV yes this has already been discussed and mentioned by Dr. In the previous uh question as well correct anemia and many try and maintain more than 10 look at a spontaneous effort the baby's having before extating if the baby's otherwise very much sedated quite lethargic the baby might fail extation so optimization before extation is extremely essential to reduce the chances of extation failure.

[01:10:13]>> Thank you D. I think uh these are some of the very essential interventions.

[01:10:18]Extubation should be a planned process.

[01:10:20]It should not come to a stage where baby's pulling out the tube and telling us that I don't want your ventilation anymore. So I think it should be a planned process. So we should ensure that the nutrition. So this is one very important aspect of ventilation or respiratory care. The better nutrition, the earlier will be the baby will be out of respiratory support, lesser infections. So whenever you're ventilating or using any respiratory support equal concentration should be on the nutrition. So whether it is mom or whether it is donor milk or whether it is ental nutrition we should promote this as much as possible and we all should be aware that um ententral nutrition is not a contra indication for babies on any respiratory support and that is where we all have to work because one of the important things to babies on ventilation or on any respiratory support to get them out of the support as early as possible and the best way to do that is by preventing infections and the best way to prevent infection is by promoting entr feeds mostly with mother zone milk. The other things are all aware that you obviously you have to use volume guarantee and um you can use we have already discussed post extubation NIV support. Anemia correction is also very important. We should keep our PCB at least above 30 before we extate any pre-term baby.

[01:11:41]So this is one of the last questions. Uh when and how for steroids? I think uh uh this is one raging question always whether uh steroids and neonatlogy go hand in hand. Uh we are so fond of giving anti steroids and they we get we really get disturbed if a baby is born before 34 weeks and not getting steroid but again at the same time we get very disturbed when you have to give steroid for a baby uh who is in the niku and on prolonged ventilation. So we need to find out uh how do we deal with this dilemma uh of giving steroid for babies on prolonged ventilation. Should we give for all babies or there are some restricted guidelines. So Dr. Nitu can you help us on this topic?

[01:12:26]>> So yes this is I think the perfect last question because it will again make us to think about the postnatal steroids.

[01:12:34]one of the most controversial questions because we want to treat whether for treating or preventing the BPDS but we know there are side effect of the steroids the long-term side effects especially the neurodedevelopmental outcome so we have to find a sweet I would say the sweet spot where we should use the steroids which is going to over like overwway the uh benefits rather than the harms. So yes, there was a very beautiful uh individual patient analysis done by the doily at all recently where they have uh I'm concluding with this slide because this is the latest one and they where they have given the threshold how can you use steroid optimally. So the systemic steroid justified when predicted risk of moderate to severe BPD or death exceeds a benefit harm crossover threshold. So they they made a lot of thresholds diagrams and they have seen the crossovers where these different steroids are uh beneficial rather than the harmful. So if uh and how you have to calculate the risk of the BPD. So simply first question is how to calculate the risk of the BPD. So we can use the NICSD BPD uh calculator uh which can uh used from day 1 till day 28 and the area under the curve for the same is around 79 to 80% for all the days. So yes it's a reliable uh uh outcome indicator where we can see yes this baby is having a risk of uh BPD.

[01:14:01]The only crux for Indian setting is they have given race as one of the parameter where there are limited numbers where the Indian uh race is not included. So we can have actually our own it will be better that we can have an Indian BPD outcome estimator done with a large number of babies to estimate the risk of BPD. So before that we can use our clinical judgment also like the babies who are extremely preterm who are intubated for more than 7 days are having uh more risk of BPD. Now if you think that your predicted risk is less than 40%. This the harms out outweigh the benefits. If the predicted risk is around 40 to 50%, you can still consider but hydrocortisone crossover was at around 40 to 56%. So can be considered a early hydrocortisone on those these babies within 7 days. If it is 50 to 60% the predicted risk then either of the hydrocord or dexa can be used and but if the risk is more than 60% or 70% then only giving the long daazone alone is justified. So this is this was the conclusion with this IPD analysis. So uh yes if your risk is more than 50 to 60% then you should feel a bit more justified in using the postnetal steroids. So there are various regime for the postnetal steroids. I would discuss one or two that you can use either one as per your unit's guideline you can use one of the trial either the NICD or the premill trial or the dart regime where the timing the protocols and the doses are decided and when to be given which which is the window when you are giving your uh postnetal steroid is also to be looked at. Next question comes whether my baby is already on prolonged ventilation. So it is an established BBD. Can I use steroids?

[01:15:54]Yes. Again if if your uh risk is more than the benefit then you can't use but benefits are more then you can use for that one uh regime is there the bandari where they have used oral predisolon and very lower uh doses for the evolving BPDs and it has been shown to be helpful. So one line answer would be yes. If the risk is more then we should avoid. If the risk is uh less so that way we can use the steroids sir.

[01:16:39]>> Yes sir.

[01:16:43]>> Sorry uh my mic switch. So she had made a very difficult question very easy by predicting the risk. So after seventh day we need to if the baby is on ventilator we need to see what is the risk of BPD at 36 weeks. So based on that we try to see whether we need to give steroid or not. the risk is more than 60% there is some justification in using steroid dexa between 40 to 60% I think we need to be very cautious and it should be given only with the consent of parents and explaining to them the risk and the benefit uh 40 to 60 is still a gray zone but more than 60 people strive to use any one steroid and whenever you use steroid use the smallest dose and for the shortest duration that should be the mantra of giving steroids if you're giving for personal use and obviously never combine with endomethsine or NACD because the primilak study has shown that rupture of the intestine or stomach can happen with using hydrocortisone and we need to rule out an active infection whenever we are giving steroids. So this is another thing and one uh thing which which came out of a um like a boom that was surfactant and bodhicinide uh many people thought it is going to do wonders because the first trial had shown significant reduction in BPD but I think subsequent trials to fail to catch up with the first trial and currently butite with surfactant are not option for babies with suspected or early evolving BPD. So we have only one choice that is uh and again if you see at the dexamethasone dart trial there it is not meant to decrease BPD the whole purpose was extation so how do we get the baby out of ventilator is what we are looking for when you're giving steroid and that's how the dart trial has become more famous uh for using a babies on ventilation so I think you have almost finished the last answer I'll try to answer myself should we prefer mechanical ventilation for all extreme preterms especially less than 28 weeks as initial respiratory support. Um there were some countries like uh the the US and Canada where they were and also the Japanese where they were trying to um do ventilation for about 3 to 5 days as a routine. But now with the coin trial and with the support trial showing that babies who are spontaneously breathing it may be better off to start with CPAP or NIV and then if they fail you may have a convert to ventilation rather than as a primary respiratory support. Still I think even in the small babies coin and taking the taking the queue from coin and support we should start with CPAP or NAV and then if they fail switch over to uh mechanical ventilation and once they're on ventilation you make for you wait for hemodynamic stability to happen and again you may extlight higher settings rather than coming down on very low setting before you switch over to NAB again. So that's all I think just to summarize uh we are talking about TPS.

[01:19:47]Yes, there are improved Tpieces now. We can give better PE PEEP and FIO2 but however humidification still remains a challenge. We need to improve on humidification for TPS. As far as LIA and salsa are concerned, Lisa is now become almost like a standard of care for most of the nikus. But however salsa needs to take up and then maybe better gadgets and better availability will improve salsa surfactant. Yes, two doses okay more than 2 days think about the differential and at least up to 48 to 72 hours we can give the first dose if that get delayed but after that we try to avoid recurrent doses. Then coming to the primary mode of respiratory support, we have all said that CPAP or bubble CPAP remains a standard. Although in units which have adequate facilities, they can think of or whenever your failure rates are expecting failure rate is higher, you can directly put on NIV and caffeine seems to be a routine drug for all less than 1250 less than 30 weeks more than 1250 more than 30 early rescue or poper extation. You can try to think of caffeine. Stop early if it is a mature baby or mature pterum and continue till 34 weeks till uh for extreme pre-ts or for less than 30 weeks uh at least after stopping wait for few days before you discharge because caffeine has a half long half life. Now the other thing is extation. We can prevent the extation failures by having extubating to CPAP or NIV by using a slightly lower FO2 lower pressure settings and also improving the nutrition that is a crux of preventing extation failures and video langoscopy definitely has helped us in may help us in early intubations and successful intubations. And the last thing was on uh the mechanical ventilation for all babies definitely not we can still try for babies who are having spontaneous breathing we can still try bubble cap or NIV as primary and then only when required we can switch over to NIV uh mechanical ventilation. So that's all I think we have summarized well and uh now I will leave the podium to the uh organizers for taking forward. Thank you everybody. There are any questions we can take up but I think we are all thank you sir there are there are couple of questions we'll take quickly couple of them have already been answered with Ram's canula can we give bubble caps so >> yeah we can give bubble cap NIV HOV with bubble CPAP but um um but with Ramula but ensure that the pressures are slightly higher >> and I never do something like yes while selecting the RAM if it's for HFO then HF Then you just select the nest diameter lesser less than 50%age of the diameter and for C pipe we select the diameter higher is that so yeah >> yeah so for do not use rams for HFNC Rams is used only for uh delivering the pressure so but never occlude completely because Rams mechanics does not allow for uh complete occlusion so there should be some gaps whenever you're using RAM but I think Rams has actually the logistics have become very useful uh with Rams because the interface fixation has become very useful and nurse friendly and baby friendly. So for CPAP, NIV, HFO, all modes we are using Rams.

[01:23:08]Uh it's a bit problem in extreme small babies but otherwise rest of the babies it's a very useful device.

[01:23:15]>> Fine. So can we discharge baby on oral caffeine? I think no. Uh we already answered this question, right?

[01:23:22]>> Yes. Then uh another thing is uh can we can quickly take three. Okay. Can HFNC be used a primary mode uh for non-invasive ventilation? What is the experience and available evidences?

[01:23:37]>> Sep you want to take up that Dr. Sep are you there?

[01:23:44]>> Hi ma'am have got a sick baby right now in the neck so I could I missed the question. No, is HFNC a primary mode of respiratory support?

[01:23:54]>> Uh so yeah, S3NC should not be used as a primary respiratory support in uh especially in in the extreme pre-terms uh because it has got higher failure rates if we compare it with the CPAP. So in the bigger babies we can use it as a primary support but not in the uh pre-term babies who are less than 28 weeks. Even we not use up to 30 weeks sir.

[01:24:18]>> Yeah. Okay. So I think HFNC as a primary road we have studied extensively the failure rates are very high compared to bubble CPAP or NAB. So we would prefer to use bubble CPAP or NAV and early switch over to HFNC so that the duration of NAV can be decreased.

[01:24:34]>> Okay any other question Kunal would you like to add upon anything? Anyone else if you want to unmute yourself and can ask the question. So any role of prophylactic hydrocortisone Dr. Nitu.

[01:24:47]So uh as we have said this we have to just see the risk benefit ratios. So uh if your risk is high you can start on early prophylactic hydrocortisone within 7 days if the risk is going beyond 50 to 60%. you cannot start for all the babies on day one itself and uh this NICSD uh that risk calculator it is good after 7 8 days even so I think you can't start on day one and you have to predict the risk at the day of day five day seven and further on and the risk prediction has to be done continuously it's not that you have done on day one because your respiratory parameters are going to change so whenever you are thinking of starting you assess the risk and then you take a decision I think as a prophylaxis we should discourage um steroid use less than 7 days. Uh but after 7 days as Nitu said evaluate the risk and take a call.

[01:25:42]>> Okay fine. Any other any other question?

[01:25:47]>> I don't think there are any other questions in this anything in YouTube >> just a second Dr. Ronach is also there.

[01:26:00]Dr. Kamal Parik is saying it's excellent. There are a couple of other comments. Good. Thank you. Dr. Nu has Thank you. Fine.

[01:26:12]>> So yeah, >> no questions on YouTube also.

[01:26:22]>> Questions.

[01:26:26]Okay, >> fine. You can Yeah, finish with the thanks. What? Thanks.

[01:26:32]>> Yeah, thank you so much everyone. It was a really insightful session and as always it is a delight to hear Murki uh is the champion of CPAP I would say.

[01:26:42]Sorry sir, I'm too young to comment. But still sir, we we have since our residency days, we have heard you have attended your ventilation workshops and it was always a delight and your blackboard technique or your the whiteboard technique also in which you explain is also wonderful and easy to understand. So thank you so much sir. It was the questions were excellent and covered almost all the aspects. Thank you all the panelists Dr. Nitu, Dr. Dudep, Dr. Sep and Dr. Anish. the the the explanation was thorough and uh it it was easy to understand for all. Uh I would thank uh uh our old team also Parika, Dr. Bira and Dr. Ronak. Uh and special thanks to all the delegates which were present in large numbers and I think today we had cross crossed 50 delegates and even on YouTube there are many more delegates who have attended and uh it will be there on our YouTube channel also. Uh so thank you uh once again to all and uh I think Dr. Bir we can wrap up.

[01:27:47]>> Yeah thank you all. Thanks for accepting the invitation and sparing the time for such a nice discussion. Thank you all and thanks all the delegates. Fine. I think we can uh end the session over here and see you all next Wednesday. Uh we are going to have a little bit change in the schedule. Uh first Wednesday is the breastfeeding. So next in August first Wednesday we are going to have a breastfeeding session. So that's why we are going to have a poker series next Wednesday. That is the fifth Wednesday of the of this month. So see you all again at 3:30 p.m. for the poker series.

[01:28:21]And bye bish.

[01:28:24]>> Thank you all. Thank you.