Hello Friends 👋

In this insightful episode of our special podcast series on managing respiratory distress, we welcome Andy Niccol, General Manager for Respiratory Humidification at Fisher & Paykel Healthcare. Andy brings his 18 years of product design experience in the medical device industry to the table, discussing the challenges and breakthroughs in designing respiratory care devices for neonatal, pediatric, and adult patients. Andy delves into the complex process of product development, emphasizing the need for deep understanding of clinical problems and patient needs. He shares how his team embeds itself in clinical environments to develop empathy with caregivers and patients, thereby creating innovative and valuable solutions. Andy gives concrete examples from his work, such as the development of the Optiflow Junior nasal high flow cannula and FlexiTrunk interface, demonstrating the intricate balance between patient safety, comfort, and effective therapy delivery. The conversation also touches on the critical aspect of user feedback in product design, especially when dealing with delicate patients like neonates. Andy candidly shares a story of a design failure that led to significant improvements in their approach to prototyping and testing.

Lastly, the episode explores Fisher & Paykel's philosophy of 'care by design' – prioritizing patient outcomes in every design decision. Andy's passion for improving neonatal care shines through as he discusses future trends and the increasing shift towards non-invasive respiratory support.

Enjoy!

Our heartfelt thanks to Fisher & Paykel for sponsoring this series.

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Watch the video below to learn more about how interface design can affect your therapy outcomes, or for further insight into the evidence, download the NIV in NICU Clinical Evidence Summary Booklet.

Fisher & Paykel Healthcare offer a full neonatal care continuum which helps provide the best start possible to our precious babies worldwide.

To help demonstrate the importance of interface, Fisher & Paykel Healthcare have created a neonatal airway simulator (Baby LIV) which is based off a 28–30-week gestational age neonate. The simulator helps visualize pressure and flow therapies. For more information and to book an in-person demonstration, go to https://www.fphcare.com/us/hospital/infant-respiratory/cpap-interface-design/

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Short Bio: Andy is the General Manager for Respiratory Humidification, a role that spans several business units that look after invasive and noninvasive product portfolios for the neonatal, pediatric and adult patient populations. He is responsible for setting and delivering the strategic direction for each of these business units, which involves product development, clinical research, education, and marketing teams.

Andy’s background is in product development, having studied mechanical engineering and plastics at the University of Auckland. He has 18 years of product design experience, including 14 years in the medical device industry.

He has spent much of his time at Fisher & Paykel Healthcare designing and working across the full neonatal and pediatric care continuum, including the Neopuff™ Infant T-piece Resuscitator, Infant Evaqua™ 2 invasive circuits, Bubble CPAP system, Flexitrunk™ patient interface, and the award-winning Optiflow™ Junior and Optiflow Junior 2 nasal high flow patient interfaces.

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The transcript for today's episode can be found below 👇:

Ben: 1:06

Hello everybody, welcome back to the Incubator podcast. We are back in our series on the management of respiratory distress syndrome in newborn infants and we are doing a tech Thursday today with Andy Nicole. Andy, good morning and thank you for joining the podcast.

Andy Niccol: 1:26

Yeah, thanks so much for having me. It's great to be on.

Ben: 1:29

It's a pleasure to have you on and for people who are not familiar with who you are, you are the general manager for respiratory humidification, a role that spans several business units at Fisher and Paykel that look after invasive and noninvasive product portfolios for neonatal, pediatric and adult patient population. You're responsible for setting and delivering the strategic direction for each of these business units, which involve product development, clinical research, education and marketing team. You have a background in product development. You've studied mechanical engineering and plastics at the University of Auckland and you have 18 years of product design experience, including 14 years in the medical device industry. Most of your time has been spent at Fisher and Paykel healthcare designing and working across the full neonatal and pediatric care continuum. A lot of the things you've worked on we're all very familiar with Neopuff, the High Flow Nasal Cannula and the bubble, cpap, the flexi trunks, the Optiflow, and so a very impressive line of items that I personally use on a day-to-day basis. So, andy, thank you for making the time and congratulations on such a long list of accomplishments.

Andy Niccol: 2:33

Oh yeah Now, it's always a team effort when we design these things, but it's great to be here. I'm really excited to talk about all of them, for sure.

Ben: 2:42

It's actually so nice to be able to talk to you after the completion of a series of episodes on how do we manage respiratory distress in the neonate, and basically, something that has come about from our discussion with Richard Polin and with Lonnie Miner and some of the other guests that we have on, is that there's really an integral need to have an understanding of the technology that we are using in order to deliver what is the therapy that is intended to be delivered, and so I am wondering if, maybe, as we are discussing maybe the engineering side of things, can you give us maybe a rundown as to how do you, and maybe Fisher&Paykel as a whole, think about developing interfaces and what goes into that when you are going through this process?

Andy Niccol: 3:34

Yeah, absolutely yeah. So the first thing we try and do is really develop a deep understanding of the problem. So we did that in several ways. We want to get as close to those problems as we possibly can. So we like to embed the people who can solve the issues in really close proximity to the people who have the issues. So we like to get our engineers, clinicians and product managers in the environment and that way they can really develop that empathy with the caregiver, with the patient, so they can develop that deep understanding of what's actually going on. So we need to know what the physiology is, what condition we are trying to treat, what the mechanism of actions we are trying to deliver are, and the best way to do that is to actually get in the environment, ask lots of questions. We are always sort of trying to drill into what are the unmet needs of when you are in these environments, what are the things, those pain points that people really feel, and sort of get a deep understanding of what's going on behind that. And that's where we feel we can come up with the most innovative and valued solutions. So, rather than just something that solves a problem, something that really solves a meaningful problem and makes a big difference to the patient. That's sort of what our philosophy is really to understand that.

Ben: 4:54

How do you get a sense of what those pain points are? Is it just like a lot of communication with the people on the frontline?

Andy Niccol: 5:01

Yeah, so we do that in a number of ways. Yeah, it's definitely a lot of communication. We want to shadow clinicians. I mean, I'm talking from a neonatal point of view. If we're doing adult patients, we'll probably make out like we are the patient and use the interfaces and role play different things. But if we're in a clinical environment, we'll often shadow clinicians and shadow caregivers to really understand what their tasks are. And it's great being an engineer when you're in those environments, or a marketer or something like that, because you really there's no sort of stupid question so you can sort of ask well, hey, why are you doing that? What's the purpose behind it? Because what we're always sort of searching for is not what's on the surface level, it's the real underlying reason why people are doing things. That adds the value. Like if you or I were asked what we thought about a particular product, we'd probably be able to suggest a couple of things and a design company could go away and make those things, but all it would do is solve the problem that's in front of you. What we really want to do is understand what's driving those issues, what's driving those concerns, and solve the underlying root cause, and through that we think we'll develop much more innovative solutions. Does that make sense?

Ben: 6:18

100% 100%, and I think I really like the idea of the concept of not being afraid to ask stupid questions because you are trying to work out a problem, and I think that it's a path that's very similar to how we think about pathologies, even on the clinical side, so I really that really resonates with me. I'm just wondering, as we're talking technical aspect of this, what are some of the peculiar and frustrating aspects of designing things for newborns, specifically preemies? Can you tell us a little bit about that?

Andy Niccol: 6:49

Neonates would be probably fair to say would be the most challenging population to design for. I mean, I've worked across designing adult products, pediatrics and neonatal products, but with adult stuff you can design a mask or an interface or a breathing circuit and you can try it on. You can take it home see what it feels like. It's much easier to get your head in that space. With neonates it's really really hard. They're obviously incredibly delicate. Their skin is very soft and very susceptible to injury. They are very, very sick and we want to make sure we're doing everything we can to help them. So it is a real challenge actually. So we do a lot well, as much as we can in the lab before we go out and test on you know, clinically trial our products on neonates. We've developed over the years a lot of very intricate models to allow us to sort of learn as much as we can not on patient, so that we've got the maximum amount of confidence that you can before we'd go into a clinical trialing environment. Yeah, definitely, but they're very, very challenging.

Ben: 8:01

Yeah, and also, I think, because if you're like you said, if you're designing for adults, you actually can get human feedback from the user, from the user, in this case the patient In babies. It's a shame if the only feedback you're getting is when there is actually damage to the skin or injury. That's not acceptable. So I totally hear how challenging that can make the design process.

Andy Niccol: 8:23

Absolutely so. I mean with an adult, you can ask hey, is this comfortable? Are you feeling any pressure in certain areas of the face? Unfortunately, with a neonate, like you say, the only time or the first time you might find that out is if you cause a little bit of blanching to the skin or something like that. So yeah, it's definitely a very interesting area to design it.

Ben: 8:42

Do you have any stories of when you were in the process of designing something that you thought was going to be definitely a great idea and then you ended up trying it and you say, oh my God, I never foresaw that this would be the problem when I was designing it?

Andy Niccol: 8:54

Oh, definitely so many. I mean, one that sticks in my mind was when we were designing OptiFlow Junior, which is a nasal high flow cannula. And you know, it's one of the things is you've got babies and their various sort of widths of septum and things. So we thought, well, why do we even need a septum, a joint in the middle of our prongs? Let's just make two independent prongs and have them not joined in the middle. We thought, oh, this is amazing. You know, you'll be able to treat every infant with one size cannula. You don't have to worry about a septum spacing or anything like that. And we, you know, we had a clinical trial down at a local hospital. Well, I say local is about two hours drive away. So we drove down there incredibly excited and you know it was really excited as we put the product on the baby and the nurse put the product on the baby and baby happened to be sucking on a pacifier or a dummy, we call them down here and the prongs immediately popped out of the nose and we're like, oh, and then the nurse sort of delicately pushed them back in and then the baby sucked on the pacifier again, they popped out again and it's like, oh okay, this is absolute failure. So we took the product off the baby and drove all the way back home and yeah, it was a very quiet car ride, but yeah, it was. It's, it's. It's interesting and it happens so often, things that you know you think work really well on a, on a doll here in the lab and it's just a great idea. Once you sort of get to real life they don't. They don't work at all, so that that that failure actually spurred us to make much better dolls. So we do. I'm not sure if you've seen or been past one of our, our shows and at a conference or something we've got a whole lot of sort of baby faces that we have on the stand.

Ben: 10:45

And so we're going to get to that. I wanted to save that maybe a bit for later, because I wanted to maybe talk a little bit about some of the things we mentioned in your bio when it comes to the Optiflow and the FlexiTrunk, and I want to maybe understand what are the different. So these are interfaces that are available for the administration of either positive pressure or flow, and I am wondering if you could walk us through what the options, what are the available options that you guys offer and what purpose do they serve in the management of RDS, and how do you and how do you see this on a on a spectrum of saying well, we have these options available and this is the reason why we have two options wide right. Some people may say why do you even have a FlexiTrunk and an Optiflow? Couldn't you just come up with one? And I think the thought process that you guys put in behind that is is very interesting.

Andy Niccol: 11:36

Yeah, definitely. So you've touched on two of our non-invasive interfaces there. So the FlexiTrunk, which is designed to deliver a CPAP so continuous positive airway pressure and the Optiflow Junior Canula, which is designed to deliver nasal high flow. So, yeah, very different therapies, although you know are often used to treat similar patients and it's really important that people understand the difference between the two, like like you touched on, and you know we think we think a lot about that when we're designing the interface. And things like that we think about when you're designing are probably the things that people should be thinking about when they're selecting an interface, because you want to, you want to sort of understand the underlying physics of what's going on, because that'll that'll help you select the right interface to really deliver what you're trying to achieve. So you know, if I was designing a CPAP interface like FlexiTrunk, I'd be thinking, well, okay, what are the mechanisms of action we're trying to deliver, what's the underlying physiology we're trying to treat? So I'd be thinking, okay, the stint, the stending pressure, we want to stint, open the airways, we want to drive the fluid off the lungs, we want to help recruit that lung roll. You really maintain that functional residual capacity. But all of that is driven by by the pressure that we want to deliver, right. So I'm thinking pressure. I'm thinking you need to be sealing on the face Anytime there's a leak in the in a CPAP system, whether it's at the nose or coming out of the mouth or whatever. What you're setting at the bubbler or at the ventilator or on an EME flow driver or or PSYPAP or something like that, that pressure will not be being delivered to the baby. So if you have a good seal, that means that the pressure you set will be the pressure you're delivering. So the next thing I'll be thinking about is okay, these neonates have incredibly delicate skin To seal on them. I need to touch that skin and apply a little bit of physical pressure on that skin, and anytime you're doing that there's potential to lead to an injury. So there needs to be a mechanism to essentially allow you to alleviate that pressure, or a strategy, with the interface you're selecting, to be able to rest the areas of the skin, such as swapping between prongs and mask or something like that. So I'll be thinking about that and I'll also be thinking, because we're sealing on the baby's face, the baby has to breathe in through the interface and out into that interface, so they're getting all that air from the interface and then when they exhale it's going back into that interface. So it's really important that the resistance to flow of that interface is as low as it could possibly be. So imagine if you've got an interface that has very small tubes in diameter, then that has a very high resistance to flow. Be like us trying to breathe through like a garden hose or a very long straw, the imposed work of breathing would be very high. So you want to have large, low resistance to flow tubes and that would really help minimize any imposed work of breathing that might come from that interface. Then the next thing I'll be thinking about is well, none of that matters if you can't hold it in place. So if your fixation methodology is no good, if the bonnets loose or the tape you might be using to hold it on the face it keeps coming loose and the prongs come out of the nose, then none of that really matters. Yeah, and also we know with CPAP you want to be sort of inspecting the kid's nose and things every four to six hours to make sure and doing cares and suctioning and whatever the clinicians need to do at the bedside, so you need a way to be able to easily remove it and put it back on and get that alignment as simple as possible. So those are sorts of things I'll be thinking about with CPAP for sure, because it's pressure-based, you want to have a really good seal. You want to make sure that it's got low resistance to flow because they're breathing in and out through it. You want a really good solid fixation system and a methodology for leaving any pressure that you might put on the face. And the other thing, the CPAP interface is obviously quite important because if you start failing a pressure-based therapy, a true pressure-based therapy, the next step up that respiratory care continuum is obviously intubation, which we want to avoid. We want to keep these kids treated in the least invasive way as possible.

Ben: 16:00

I think what you're describing is something where we need to understand that continuum, and I think you guys are displaying that. I think people may wrongfully sometimes assume that, oh, I'm going to have a baby on some form of flow support with an optic flow prong, and then if the baby fails, then I may go too invasive, when in truth, there are the steps to provide additional level of supports through better pressure at the level of the face and better pressure delivery at the level of the lungs. And so I think, going back to that concept, I think your team showed us the baby live, which is something you alluded to earlier, and so I wanted to maybe ask you a little bit, first and foremost, what was the imperative behind even the design of such a mannequin For people? I think we took a video of this and it's basically a baby's face on a plastic board with an artificial lung and a wave form, a screen with a wave form where you can actually see the impact of pressure and flow, depending on the settings you're using. So, before you walk us through what it does and so on and so forth, can you tell us a little bit as to why did you even have to come up with such a design or such a tool.

Andy Niccol: 17:22

Yeah, absolutely so. Yeah, it's been a really interesting tool actually. It's great to have in the toolbox and pull out when you're meeting with people. It's a so what we were sort of seeing as we traveled around the United States is a lot of confusion, or globally actually, but a lot of confusion around when to use what therapy and what to do when that therapy failed. You might have a child who is on a flow-based therapy and a lot of children, a lot of babies, can do very well on a flow-based therapy, but for those ones that fail, they're probably failing because they need the benefits delivered from pressure. So they need that distending pressure that help maintaining the functional residual capacity all that really good stuff. And what we were seeing is there was a little bit of a lack of understanding of what we were trying to achieve with flow. And when the baby was failing on a flow-based therapy, that kid was being intubated, so they were never given a chance to really show that they could do OK on a true sealed pressure-based therapy, non-invasively, prior to taking that intubation step. So we wanted to come up with something that could demonstrate and help change clinical practice around them. What are we trying to do with these interfaces and even just what's happening in your own unit. You know we'd go into a hospital and they'd be using a particular interface on a ventilator. It'd be great. Let's see with this thing. This baby lift device can show you what you're delivering to that baby and you can sort of get an idea of what's actually going on and then help make decisions around what happens when that particular therapy fails. Do you need to insulate? Do you? Can you try a true CPAP? Where are we at on that actual care continuum? So that's sort of what sparked that design actually.

Ben: 19:12

Yeah, I think what's interesting about it is that a lot of people sometimes put settings at the level of the machine, at the level of the ventilator, at the level of I guess the ventilator is good enough. But I'm saying we're putting settings on whether there are CPAP or non-invasive ventilation and then we our intent doesn't follow through to the interface. So, for example, a person may put a baby on CPAP and then put an Optiflow prong and then not realize that this may actually alter the intended therapy and how it is being delivered. And so I think that's hugely important. Do you have what is your advice when you're going into units and seeing, for example, babies on CPAP with maybe an Optiflow prong? What is your advice to these teams as to how they could maybe optimize their delivery of care?

Andy Niccol: 20:02

The first thing I try and do is help them sort of understand exactly what they are delivering, cause you know, if you're using a ventilator and you're setting a, you know pressures maybe 20 over five or something like that but you're delivering it through an unsealed interface like an Optiflow or these other ones out on the market, then you don't actually know what pressure the baby's getting. Then you know they're not getting 20 over five, you know that. So if you're comfortable from a safety point of view, you know you're not giving an excess of that. But what you don't know is where they are. So it could be anywhere. You know it could be very low. If there's a really, really large leak, then you could be delivering essentially nothing and you could be. If you've got very little leak, you could be delivering 20 over five. So it's somewhere on that spectrum. The interesting thing for me is that as the baby moves, or as you reposition the baby throughout their cares and things like that, you change the position of those unsealed cannula in the nose. Maybe their mouth's now shut where it was previously open and that can change where they sit on that pressure. So they might have been previously getting, you know, six over three, all of a sudden they shut their mouth and they're lying a little bit more with their face into the pillow or something Prongs, get pushed in a little bit more and now they're all of a sudden at 15, over five or something like that, and it changes and you, maybe the baby, then opens their mouth and then mouth and then they lose all that functional residual capacity you were trying to achieve. So what I'm trying to do when I talk to hospitals and show them the baby livers, show them that they don't know where they are on that spectrum and every baby is different. You know we make, you know, five or six sizes of cannula. Nostrils come in a variety of diameters, so the resistance of that fit on every baby is different and therefore the pressure, even in an optimal situation, on every patient would be different. So it's sort of getting them to understand that and then understanding that actually what they're doing is probably high flow. So there's flow going into the nose, it's coming out as a leak. You're not really giving the pressures that you think, but you're giving a flow rate. And then it gets really interesting because often on these ventilators you've got an inspiratory limb, so a tube taking the air from the vent to the patient, then what we call an expiratory tube taking the air from the baby back to the ventilator, and then you've obviously got an interface which goes from, like a Y piece to the baby normally. But the problem you've got is you don't know how much flow is going down the expiratory limb versus down the interface and again, as that balance changes, the amount or the proportion of flow going down the interface to the baby and going down the expiratory limb changes. So therefore, although it's a form of high flow, you don't actually know what flow rate you're giving the baby either, and it's sort of taking people on that journey to understand that actually you don't know what pressure you're delivering to the baby and it changes. You don't know what flow rate you're delivering to the baby and it changes. So actually, if you want to use high flow for all the benefits of the usability, the ease of use and all of that, let's use it as it was intended and in line with the clinical literature, and then hopefully you'll get the same outcomes that the KOLs and the key opinion leaders and the people doing that research achieved as well. So sort of taking them on that journey, if that makes sense.

Ben: 23:23

Yeah, and I think that's so important because then, because you're changing what is potentially being delivered, you can no longer assume that the settings, that a baby that's not potentially doing well has suddenly failed, the mode of ventilation you were intending to give at the ventilator, when in truth it's no longer what actually has been delivered. So I think, from that standpoint, the escalation of care, the decision to escalate care, can be really jeopardized if that is not understood. And you're being very nice in how you're describing all this, because I know how engineers feel when stuff are not used as intended. So kudos for being so gracious about all this.

Andy Niccol: 24:01

No problem. Yeah, it's when you're in that hospital environment when we we see a key part of our role at Fisher and Paykel healthcare is driving that clinical practice change and really helping people understand what's happening at the bedside so that they can, like you say, so that they can make those decisions around how to escalate. And we don't want to see babies intubated who could have done well with just a bit of pressure support.

Ben: 24:27

Yeah, absolutely, and I think something that's nice too is that the Fisher Paykel Health team is always very, very readily available. So if you are having questions about your interfaces, how you're utilizing them, like I know that we have benefited from multiple sessions where we sat down and like walked over our interfaces, see how we were, because every unit has sort of a cocktail of interventions that they prefer and so how it's very, it's very unit dependent as to, hey, we like to give this, we like to do this, and how can we optimize what we're doing. So I think that's another tool that sometimes people forget they have access to, and just reaching out to a rep and saying, hey, can you just come and walk us through this, or we're not really sure how to use that, and so on and so forth. That's actually very helpful.

Andy Niccol: 25:10

Personally, I travel around the United States talking to people. We've got a great team in the US who are more than happy to come and meet with people and show them the BabyLiv tool and just have a chat about what's going on in the unit and doing anything we can to help. Really that's where we see our key job is to really help drive that clinical practice change.

Ben: 25:32

Agree. When we were doing our research for this episode, a lot of the things that came back from our research on Fisher and Paykel is really something that you guys have coined care by design, and I thought that was a very interesting concept. Can you tell us a little bit as to how this concept of care by design comes into play when you're in the context of respiratory support for neonates?

Andy Niccol: 25:55

So, yeah, so keep by design is really our design philosophy. Right, it's how do we design products so that we can achieve our key purpose, which is improving care and outcomes. So that's what drives our company is we want to improve care and outcomes for all our patients, make life easier for all our caregivers, and keep by design is how we make it sort of tangible for all our R&D teams. Yeah, so it's. It's about developing that really deep understanding of the environment, patient and the problems that exist, and then that's how we think we'll end up in those really innovative solutions. So we it's essentially it's how we make decisions as well. So we like to hold the patient really central in our thinking. So when you're a design engineer, there's always trade-offs between options and things like that, and making those decisions can be very, very difficult. But through this care by design philosophy it actually becomes a lot simpler. You just think about what's the best outcome for the patient, what design choice here would lead to the best outcome for that patient? And often, more than often, that is the right thing to do with the design. So it's a way to sort of guide our young designers and our R&D people and a way of making sure that we keep the patient always central in our in the design, and that's the way we think about things.

Ben: 27:19

Yeah, I mean, I think, as you're designing this, especially as a company, there are a lot of metrics, a lot of pressure points on your end that you could, you could be answering to, and I think centralizing the outcome and the patient is really what, what makes your, your company, so successful? And I wanted to ask you a personal question as we get close to the end of this interview. But I mean, as an engineer, you have the opportunity to work in multiple fields and I think you are at Fisher and Paykel working with neonates by choice, and I'm wondering what has been the most rewarding aspect throughout your career about working with this particular patient population.

Andy Niccol: 28:01

Neonates are incredibly rewarding. It is a very, very difficult patient population to design for, but it makes a huge impact. I mean all our patients. Whenever we design products for any of our patients, you know we're extending their lives, we're making their journeys easier and that's that's incredibly rewarding across the board. It's very, very obvious with neonates when you do that. One of the things we do when we get new people into our businesses is to get them into that environment as soon as we can. A lot of your listeners you know they work in there, obviously day to day, and are probably very used to it. For an engineer and an R&D person, one of our clinical research scientists or our product managers they've probably never been in that environment before. To place them in that environment, see our products making a difference, getting an understanding of the problems that need to be solved it's very engaging, very, very rewarding and makes better designers and better R&D people from being in that environment. We find that with all patient populations, but definitely with neonates, it's very, very obvious these incredibly small, incredibly vulnerable patients. Yeah, it's just fantastic the work that you and your listeners do to.

Ben: 29:28

Don't spend it on us. The reason I was asking you this is because I think sometimes we tend to see especially when we're talking about industry, we tend to see this as faceless corporations that are providing plastic-y products. We forget that behind all this there are people that care just as much about the patients. I think it's very nice to hear this from you. Who is an engineer, right? Who is not a nurse or physician? I think that that matters. I think it truly matters for us as clinicians.

Andy Niccol: 30:00

Yeah well, we're not here to make a Me Too product With neonatal products and pediatric products. A lot of them can be scaled down adult versions. That's not what we're about at all. We want to design meaningful solutions that really help these patients from first principles understand what's going on and make a product that actually works and is designed for them. That's what we're here to do.

Ben: 30:26

Yeah, Andy. My last question for you today is are there anything that you are seeing on the horizon for the care of newborns that gets you excited? It may not have to be anything concrete that's either in the pipeline, but just a direction in which the field is going that gets you excited, for you and your team at Fisher and Paykel.

Andy Niccol: 30:49

One of our key things as well is when we meet with people. We want to understand trends and where things are going. It takes us so long to design a medical device that if we design a solution for today, it would be worthless tomorrow. We want to make sure we're thinking 10 years in the future. Our company thinks very, very long term in general. I guess one of the trends we're seeing is a lot more use of non-invasive means of respiratory support, which is fantastic, and that movement of that respiratory support to be on children as soon as possible after birth, Whether that's in the delivery room or as soon as they can get into the NICU, that type of thing. A lot more use of non-invasive, which we think is a fantastic thing.

Ben: 31:33

I think so. I think the data supports that trend. Anyway, I think you're on the right track. Andy, thank you so much for making the time to be with us this morning. It was a very enlightening conversation. I really enjoyed getting to see behind the scenes as to the thinking process and how you guys look at the problems we face at the bedside on a day-to-day basis. It's very comforting to see a team of caring engineers and people at Fisher Paykel working on some of these solutions. Thank you for that.

Andy Niccol: 32:05

Oh, thanks, it was my pleasure to be here today and to chat to you. Thanks so much.