Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review

T-Piece resuscitator versus self-inflating bag for delivery room resuscitation in preterm neonates: a randomized controlled trial

The establishment of adequate ventilation is the cornerstone of neonatal resuscitation in the delivery room (DR). This parallel-group, accessor-blinded randomized controlled trial compared the changes in peripheral oxygen saturation (SpO2), heart rate (HR), and cerebral regional oxygen saturation (crSO2) with the use of a T-piece resuscitator (TPR) versus self-inflating bag (SIB) as a mode of providing positive pressure ventilation (PPV) during DR resuscitation in preterm neonates. Seventy-two preterm neonates were randomly allocated to receive PPV with TPR (n = 36) or SIB (n = 36). The primary outcome was SpO2 (%) at 5 min. The secondary outcomes included the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, fractional-inspired oxygen (FiO2) requirement, minute-specific SpO2, HR and FiO2 trends for the first 5 min of life, need for DR-intubation, crSO2, need and duration of respiratory support, and other in-hospital morbidities. Mean SpO2 at 5 min was 74.5 ± 17.8% and 69.4 ± 22.4%, in TPR and SIB groups, respectively [Mean difference, 95% Confidence Interval 5.08 (-4.41, 14.58); p = 0.289]. No difference was observed in the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, the requirement of FiO2, DR-intubation, and the need and duration of respiratory support. There was no significant difference in the minute-specific SpO2, HR, and FiO2 requirements for the first 5 min. CrSO2 (%) at one hour was lower by 5% in the TPR group compared to SIB; p = 0.03. Other complications were comparable.

CONCLUSIONS

TPR and SIB resulted in comparable SpO2 at 5 min along with similar minute-specific SpO2, HR, and FiO2 trends.

CLINICAL TRIAL REGISTRATION

Clinical trial registry of India, Registration no: CTRI/2021/10/037384, Registered prospectively on: 20/10/2021, https://ctri.icmr.org.in/ .

WHAT IS KNOWN

• Compared to self-inflating bags (SIB), T-piece resuscitators (TPR) provide more consistent inflation pressure and tidal volume as shown in animal and bench studies. • There is no strong recommendation for one device over the other in view of low certainty evidence.

WHAT IS NEW

• TPR and SIB resulted in comparable peripheral oxygen saturation (SpO2) at 5 min along with similar minute-specific SpO2, heart rate, and fractional-inspired oxygen requirement trends. • Short-term complications and mortality rates were comparable with both devices.

The Respiratory Management of the Extreme Preterm in the Delivery Room

The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.

Ventilation devices for neonatal resuscitation at birth: A systematic review and meta-analysis

Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are available: fixed pressure devices (FPD; T-pieces or ventilators) and hand driven pressure devices (HDPD; self- or flow-inflating bags). This systematic review and meta-analysis aims to compare clinical outcomes after neonatal resuscitation according to device type.

METHODS

Four databases were searched from inception to 2022, January. Search strategies included Mesh/Emtree terms as well as free language without any restriction. Randomized, quasi-randomized studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included.

RESULTS

Nine studies recruiting 3621 newborns were included: 5 RCTs, 2 RCTs with interventions bundles and 2 prospective cohorts. Meta-analysis of the 5 RCTs demonstrated significant reductions in bronchopulmonary dysplasia (RR0,68[0,48-0,96]-NNT 31) and other respiratory outcomes: intubation in the delivery room (RR0,72[0,58-0,88]-NNT 13,4), mechanical ventilation requirements (RR0,81[0,67-0,96]-NNT 17) and duration (MD-1,54 days[-3,03- -0,05]), need for surfactant (RR0,79[0,64-0,96]-NNT 7,3). The overall analysis found a lower mortality in the FPD group (OR0,57[0,47-0,69]-NNT 12,7) and confirmed decreases in intubation, surfactant requirement and mechanical ventilation rates (OR 0,56[0,40-0,79]- NNT7,5; OR 0,67[0,55-0,82]-NNT10,7 and OR0,58[0,42-0,80]- NNT 7,4 respectively). The risk of cystic periventricular leukomalacia (cPVL) decreased significantly with FPD (OR0.59[0.41-0.85]-NNT 27). Pneumothorax rates were similar (OR0.82[0.44-1.52]).

CONCLUSION AND RELEVANCE

Resuscitation at birth with FPD improves respiratory transition and decreases BPD with a very low to moderate certainty of evidence. There is suggestion of decreases in mortality and cPVL. Further studies are still needed to confirm those results.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Devices for Administering Ventilation at Birth: A Systematic Review

CONTEXT

Positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation.

OBJECTIVE

To compare T-piece resuscitators (TPRs), self-inflating bags (SIBs), and flow-inflating bags for newborns receiving PPV during delivery room resuscitation.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, and trial registries (inception to December 2020).

STUDY SELECTION

Randomized, quasi-randomized, interrupted time series, controlled before-and-after, and cohort studies were included without language restrictions.

DATA EXTRACTION

Two researchers independently extracted data, assessed the risk of bias, and evaluated the certainty of evidence. The primary outcome was in-hospital mortality. When appropriate, data were pooled by using fixed-effect models.

RESULTS

Meta-analysis of 4 randomized controlled trials (1247 patients) revealed no significant difference between TPR and SIB for in-hospital mortality (risk ratio 0.74; 95% confidence interval [CI] 0.40 to 1.34). Resuscitation with a TPR resulted in a shorter duration of PPV (mean difference -19.8 seconds; 95% CI -27.7 to -12.0 seconds) and lower risk of bronchopulmonary dysplasia (risk ratio 0.64; 95% CI 0.43 to 0.95; number needed to treat 32). No differences in clinically relevant outcomes were found in 2 randomized controlled trials used to compare SIBs with and without positive end-expiratory pressure valves. No studies used to evaluate flow-inflating bags were found.

LIMITATIONS

Certainty of evidence was very low or low for most outcomes.

CONCLUSIONS

Resuscitation with a TPR compared with an SIB reduces the duration of PPV and risk of bronchopulmonary dysplasia. A strong recommendation cannot be made because of the low certainty of evidence. There is insufficient evidence to determine the effectiveness of positive end-expiratory pressure valves when used with SIBs.

Newborn resuscitation devices: The known unknowns and the unknown unknowns

Infant resuscitation devices used at birth must be capable of delivering adequate and consistent ventilation in a controlled and predictable manner to a wide patient weight range, and combinations of transitional lung states. Manual inflation resuscitation devices delivering positive pressure lung inflation at birth can be classified broadly into two types: 1) flow generating, ie silicone self-inflating bags (SIB) also known as bag valve mask (BVM) and 2) flow dependent, ie anaesthetic flow inflating bag (FIB) and t-piece resuscitator (TPR) systems (eg: Neopuff, GE Panda and Draeger Resuscitaires). Globalization, lower production costs, and an expanding market need for devices, has led to a proliferation of brands (both reusable and single use) within a class type. T-piece resuscitators have become the dominant device particularly in high income countries. There remains a paucity of information on the performance characteristics of these devices and their ability to provide the required respiratory parameters for effective and safe ventilation across the full-expected weight range and lung states to which they will be applied. This review aims to inform current clinical practise on the biomechanical efficiency, reliability and efficacy of the most common devices used to apply PPV to newborns and infants ≤10 kgs.

T-piece resuscitator or self-inflating bag during neonatal resuscitation: a scoping review

BACKGROUND

To identify the evidence for administering positive pressure ventilation (PPV) to infants at birth by either T-piece resuscitator (TPR) or self-inflating bag (SIB), and to determine whether a full systematic review (SR) is warranted.

METHODS

Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews, eligible studies included peer-reviewed human studies, prospectively or retrospectively comparing a TPR vs. SIB for administering PPV at birth. Databases searched were OVID Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials. Review Manager software was used for the data analysis.

RESULTS

Following electronic literature search and review, data from four eligible studies (3 RCT and 1 observational study), enrolling a total of 2889 patients, were included. Studies differed regarding the investigated populations, reported outcomes and came from different geographical areas. In particular for preterm infants, use of TPR for providing PPV may improve survival, result in fewer intubations at birth and decrease the incidence of bronchopulmonary dysplasia.

CONCLUSIONS

This scoping review identified two new studies with substantive new evidence, pointing towards improved survival, decreased bronchopulmonary dysplasia and fewer intubations at birth, in particular among preterm infants treated with TPR. Full SR of the literature is advised.

IMPACT

This scoping review identified studies comparing TPR vs. SIB for respiratory support of newborn infants previously not included in the International Liaison Committee on Resuscitation (ILCOR) recommendations. Our review found substantive new evidence highlighting that device choice may impact the outcomes of compromised newborn infants'. This scoping review stipulates the need for full SR and updated meta-analysis of studies investigating supportive equipment for stabilizing infants at birth in order to inform ILCOR treatment recommendations.

T-piece resuscitators: can they provide safe ventilation in a low compliant newborn lung?

BACKGROUND

T-piece resuscitators (TPRs) are used for primary newborn resuscitation in birthing and emergency rooms worldwide. A recent study has shown spikes in peak inflation pressure (PIP) over set values with two brands of TPRs inbuilt into infant warmer/resuscitation platforms. We aimed to compare delivered ventilation between two TPR drivers with inflation pressure spikes to a standard handheld TPR in a low test lung compliance (Crs), leak-free bench test model.

METHODS

A single operator provided positive pressure ventilation to a low compliance test lung model (Crs 0.2-1 mL/cmH₂O) at set PIP of 15, 25, 35 and 40 cmH₂O. Two TPR devices with known spikes (Draeger Resuscitaire, GE Panda) were compared with handheld Neopuff (NP). Recommended settings for positive end-expiratory pressure (5 cmH₂O), inflation rate of 60/min and gas flow rate 10 L/min were used.

RESULTS

2293 inflations were analysed. Draeger and GE TPR drivers delivered higher mean PIP (Panda 18.9-49.5 cmH2O; Draeger 21.2-49.2 cmH2O and NP 14.8-39.9 cmH2O) compared with set PIP and tidal volumes (TVs) compared with the NP (Panda 2.9-7.8 mL; Draeger 3.8-8.1 mL; compared with NP 2.2-6.0 mL), outside the prespecified acceptable range (±10% of set PIP and ±10% TV compared with NP).

CONCLUSION

The observed spike in PIP over set values with Draeger and GE Panda systems resulted in significantly higher delivered volumes compared with the NP with identical settings. Manufacturers need to address these differences. The effect on patient outcomes is unknown.

Neonatal Resuscitation With T-Piece Systems: Risk of Inadvertent PEEP Related to Mechanical Properties

Background: Resuscitation of infants using T-piece resuscitators (TPR) allow positive pressure ventilation with positive end-expiratory pressure (PEEP). The adjustable PEEP valve adds resistance to expiration and could contribute to inadvertent PEEP. The study indirectly investigated risk of inadvertent peep by determining expiratory time constants. The aim was to measure system expiratory time constants for a TPR device in a passive mechanical model with infant lung properties. Methods: We used adiabatic bottles to generate four levels of compliance (0.5-3.4 mL/cm H₂O). Expiratory time constants were recorded for combinations of fresh gas flow (8, 10, 15 L/min), PEEP (5, 8, 10 cm H₂O), airway resistance (50, 200 cm H₂O/L/sec and none), endotracheal tube (none, size 2.5, 3.0, 3.5) with a peak inflation pressure of 15 cm H₂O above PEEP. Results: Low compliances resulted in time constants below 0.17 s contrasting to higher compliances where the expiratory time constants were 0.25-0.81 s. Time constants increased with increased resistance, lower fresh gas flows, higher set PEEP levels and with an added airway resistance or endotracheal tube. Conclusions: The risk of inadvertent PEEP increases with a shorter time for expiration in combination with a higher compliance or resistance. The TPR resistance can be reduced by increasing the fresh gas flow or reducing PEEP. The expiratory time constants indicate that this may be clinically important. The risk of inadvertent PEEP would be highest in intubated term infants with highly compliant lungs. These results are useful for interpreting clinical events and recordings.

Effect of T-Piece Resuscitator versus Self Inflating Bag on Arterial CO2 Levels in Preterm Neonates

OBJECTIVE

To compare the effect of self-inflating bag (SIB) vs. T-piece resuscitator (TPR) on PaCO₂ levels, when used for brief manual ventilation during administration of first dose of surfactant.

METHODS

Preterm neonates were randomized to receive positive pressure ventilation with either self-inflating bag or T-piece resuscitator during administration of first dose of surfactant. Arterial blood gases were obtained at baseline and 1 h after the intervention. Primary outcome was the mean change in PaCO₂ levels 1 h after the intervention.

RESULTS

Eighty neonates were enrolled (40 in each group). The drop in PaCO₂ at 1 h was significantly greater in the self inflating bag group as compared to the T-piece resuscitator group [8.96 ± 9.06 mmHg vs. 1.37 ± 9.06 mmHg, Mean difference = 7.58 mmHg, (95% CI: 3.78 to 11.4); P < 0.01]. The PaCO₂ change was also statistically significant in the subgroup of infants that required only non-invasive ventilation. The need for second dose of surfactant was higher in the self-inflating bag group [77% vs. 55%, RR - 1.41 (95% CI: 1.02 to 1.94); P = 0.03].

CONCLUSIONS

T-piece resuscitator results in smaller reduction in PaCO₂ levels compared to the self inflating bag, when used for brief manual ventilation during surfactant administration.

Sustained Inflation vs Standard Resuscitation for Preterm Infants: A Systematic Review and Meta-analysis

IMPORTANCE

Most preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy.

OBJECTIVE

To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants.

DATA SOURCES

MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019.

STUDY SELECTION

Randomized clinical trials of preterm infants born at less than 37 weeks' gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation).

MAIN OUTCOMES AND MEASURES

Death before hospital discharge.

RESULTS

Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, -0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision.

CONCLUSIONS AND RELEVANCE

There was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.

Comparing positive pressure ventilation efficacy of a novel foot operated resuscitator with self-inflating bag and mask in a manikin model

Aim

To compare positive pressure ventilation efficacy of a novel foot operated resuscitator (FOR) during positive pressure ventilation with that of self-inflating bag and mask (SIBM) using a manikin model.

Method

A comparative trial was conducted with 117 participants at a level III neonatal intensive care unit using Baby Anne (Laerdal Medical, Norway). Flow and pressure sensors were used to measure tidal volume propelled (Vp) and delivered (Vt). Each participant delivered 60 breaths, using each device targeting adequate chest-rise defined as that corresponding to a Vt of 15–21 mL. Vt, Peak Inspiratory Pressure (PIP), Leak Percentage (%), Inspiratory Time (Ti, millisecond) and other parameters were recorded using a PC (Dell, Windows V.10) on a custom application (LabView 2014 platform NI, USA). The proportion of breaths achieving target range Vt, other key ventilation parameters and their variability were compared between a generic CE approved bag and mask and a novel FOR (NeoBreathe, Phoenix Medical Systems, India).

Result

Using an SIBM, participants delivered a mean (SD) Vt of 17.52 (5.22) mL, achieving target range Vt in 46.99% of all breaths, with a mean (SD) face-mask leak per cent of 32.51% (22.25). Using the FOR, participants delivered a mean (SD) Vt of 18.31 (3.90), achieving target range Vt in 54.37% of all breaths and a mean (SD) face-mask leak per cent of 18.89% (14.45). Variability of Vt, PIP and leak per cent was significantly reduced with FOR.

Conclusion

FOR significantly reduced face-mask leak, significantly increased the proportion of breaths achieving Vt within optimal range and could offer a novel alternative to a SIBM.

Use of a Mechanical Ventilator with Respiratory Function Monitoring Provides More Consistent Ventilation during Simulated Neonatal Resuscitation

INTRODUCTION

Positive pressure ventilation (PPV) with T-Piece and self-inflating bag (SIB) during neonatal resuscitation after birth is associated with variability in ventilation. The use of a ventilator with respiratory function monitoring (RFM) for PPV, however, has not been evaluated.

OBJECTIVE

To determine if ventilator + RFM can reduce ventilation variability compared to T-Piece and SIB in a preterm manikin at different combinations of target tidal volume (VT) and lung compliance (CL).

METHODS

Twenty clinicians provided PPV via mask and endotracheal tube (ETT) using SIB, T-Piece, T-Piece + RFM and Ventilator + RFM to a manikin with adjustable lung CL. Three combinations of CL and target VT: Low CL-Low VT, Low CL-High VT and High CL-Low VT were used in a random order.

RESULTS

The use of ventilator + RFM for PPV via ETT during High CL-Low VT period reduced the proportion of breaths with expiratory VT above target when compared to the other 3 devices (56 ± 35%, 85 ± 20%, 90 ± 25%, 92 ± 12% for ventilator + RFM, T-Piece + RFM, T-Piece, SIB, respectively; p < 0.05). During PPV via both mask and ETT, ventilator + RFM maintained the set Ti and rate, whereas SIB and T-Piece use resulted in higher rates, and T-Piece in higher proportion of breaths with prolonged Ti. During PPV via mask, ventilator + RFM reduced gas leakage compared to other devices.

CONCLUSION

In this simulation study, use of a mechanical ventilator with RFM led to an overall improvement in volume targeting at different settings of CL and reduced the gas leak during mask ventilation. The efficacy and safety of using this strategy to neonatal resuscitation in the delivery room needs to be evaluated.

T-piece resuscitators: how do they compare?

BACKGROUND

The T-piece resuscitator (TPR) has seen increased use as a primary resuscitation device with newborns. Traditional TPR design uses a high resistance expiratory valve to produce positive end expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) at resuscitation. A new TPR device that uses a dual flow ratio valve (fluidic flip) to produce PEEP/CPAP is now available (rPAP). We aimed to compare the measured ventilation performance of different TPR devices in a controlled bench test study.

DESIGN/METHODS

Single operator provided positive pressure ventilation to an incremental testlung compliance (Crs) model (0.5-5 mL/cmH₂O) with five different brands of TPR device (Atom, Neopuff, rPAP, GE Panda warmer and Draeger Resuscitaire). At recommended peak inflation pressure (PIP) 20 cmH₂O, PEEP of 5 cmH₂O and rate of 60 inflations per minute.

RESULTS

1864 inflations were analysed. Four of the five devices tested demonstrated inadvertent elevations in mean PEEP (5.5-10.3 cmH₂O, p<0.001) from set value as Crs was increased, while one device (rPAP) remained at the set value. Measured PIP exceeded the set value in two infant warmer devices (GE and Draeger) with inbuilt TPR at Crs of 0.5 (24.5 and 23.5 cmH₂O, p<0.001). Significant differences were seen in tidal volumes across devices particularly at higher Crs (p<0.001).

CONCLUSIONS

Results show important variation in delivered ventilation from set values due to inherent TPR device design characteristics with a range of lung compliances expected at birth. Device-generated inadvertent PEEP and overdelivery of PIP may be clinically deleterious for term and preterm newborns or infants with larger Crs during resuscitation.

Tidal volume monitoring during emergency neonatal transport

OBJECTIVE

The study aim was to identify the frequency with which tidal volumes were achieved in a target range in infants requiring positive pressure ventilation on emergency transport.

STUDY DESIGN

We performed a prospective observational study of infants requiring continued positive pressure ventilation during emergency transport after resuscitation and stabilization. Blindly recorded data were analyzed for percentage of breaths that were below range, in range, and above desired range of 4-6 mL/kg.

RESULT

Fourteen patients were monitored during transport from the delivery room to the neonatal intensive care unit, and 15 patients were monitored during inter-facility transport. During delivery room transport, 21 and 7% of patients were in target range greater than 50 and 90% of the time, respectively. During inter-hospital transport, 60 and 7% of patients were in target range greater than 50 and 90% of the time, respectively.

CONCLUSION

Clinical assessment of appropriate ventilation is difficult and often inaccurate during emergency neonatal transport. Improved monitoring of respiratory function to guide clinical status during transport is necessary. More investigation and implementation are urgently needed.

T-piece versus self-inflating bag ventilation in preterm neonates at birth

OBJECTIVE

To verify whether the use of the T-piece resuscitator compared with the self-inflating bag in preterm infants ventilated at birth modifies survival to hospital discharge without major morbidities.

DESIGN

Pragmatic prospective cohort study.

SETTING

20 Brazilian university hospitals of Brazilian Network on Neonatal Research. Patients were 1962 inborn infants in 2014-2015 ventilated at birth with 23-33' weeks gestation and birth weight 400-1499 g without malformations. Patients transferred until the 27th day after birth were excluded.

INTERVENTIONS

Positive pressure ventilation at birth with T-piece resuscitator or self-inflating bag without positive end expiratory pressure valve. Intervention with ventilation followed the Brazilian Society of Pediatrics guidelines. The choice of the equipment was at the neonatologist's discretion in each delivery. The main outcome measures were survival to hospital discharge without bronchopulmonary dysplasia, severe peri-intraventricular haemorrhage and periventricular leucomalacia. Logistic regression adjusted for confounding variables was applied for main outcome.

RESULTS

1456 (74%) were only ventilated with T-piece resuscitator and 506 (26%) with the self-inflating bag. The characteristics of those ventilated with T-Piece resuscitator versus self-inflating bag were birth weight 969 ± 277 vs 941 ± 279 g, gestational age 28.2±2.5 vs 27.8±2.7 weeks and survival to hospital discharge without major morbidities 47% vs 35%. Logistic regression adjusted for maternal characteristics, obstetric and neonatal morbidities showed that the T-piece resuscitator increased the chance of survival to hospital discharge without major morbidities (OR=1.38; 95% CI 1.06 to 1.80; Hosmer-Lemeshow goodness of fit: 0.695).

CONCLUSION

This study is the first that highlights the effectiveness of T-piece resuscitator ventilation in improving relevant outcomes in preterm neonates.

Neopuff T-piece resuscitator mask ventilation: Does mask leak vary with different peak inspiratory pressures in a manikin model?

AIM

The aim of this study was to compare mask leak with three different peak inspiratory pressure (PIP) settings during T-piece resuscitator (TPR; Neopuff) mask ventilation on a neonatal manikin model.

METHODS

Participants were neonatal unit staff members. They were instructed to provide mask ventilation with a TPR with three PIP settings (20, 30, 40 cm H₂ O) chosen in a random order. Each episode was for 2 min with 2-min rest period. Flow rate and positive end-expiratory pressure (PEEP) were kept constant. Airway pressure, inspiratory and expiratory tidal volumes, mask leak, respiratory rate and inspiratory time were recorded. Repeated measures analysis of variance was used for statistical analysis.

RESULTS

A total of 12 749 inflations delivered by 40 participants were analysed. There were no statistically significant differences (P > 0.05) in the mask leak with the three PIP settings. No statistically significant differences were seen in respiratory rate and inspiratory time with the three PIP settings. There was a significant rise in PEEP as the PIP increased. Failure to achieve the desired PIP was observed especially at the higher settings.

CONCLUSIONS

In a neonatal manikin model, the mask leak does not vary as a function of the PIP when the flow rate is constant. With a fixed rate and inspiratory time, there seems to be a rise in PEEP with increasing PIP.

Can Ambu self-inflating bag and Neopuff infant resuscitator provide adequate and safe manual inflations for infants up to 10 kg weight?

BACKGROUND

Manual resuscitation devices for infants and newborns must be able to provide adequate ventilation in a safe and consistent manner across a wide range of patient sizes (0.5-10 kg) and differing clinical states. There are little comparative data assessing biomechanical performance of common infant manual resuscitation devices across the manufacturers' recommended operating weight ranges. We aimed to compare performance of the Ambu self-inflating bag (SIB) with the Neopuff T-piece resuscitator in three resuscitation models.

METHODS

Five experienced clinicians delivered targeted ventilation to three lung models differing in compliance, delivery pressures and inflation rates; Preterm (0.5 mL/cmH₂O, 25/5 cmH₂O, 60 per minute), Term (3 mL/cmH₂O, 30/5 cmH₂O, 40 per minute) and Infant (9 mL/cmH₂O, 35/5 cmH₂O, 30 per minute). The Neopuff was examined with three gas inflow rates (5 litres per minute (LPM), 10 LPM and 15 LPM) and the Ambu with no gas inflow.

RESULTS

3309 inflations were collected and analysed with analysis of variance for repeated measures. The Neopuff was unable to reach set peak inflation pressures and exhibited seriously elevated positive end expiratory pressure (PEEP) with all inflow gas rates (p<0.001) in this infant model. The Ambu SIB accurately delivered targeted pressures in all three models.

CONCLUSIONS

The Ambu SIB was able to accurately deliver targeted pressures across all three models from preterm to infant. The Neopuff infant resuscitator was unable to deliver the targeted pressures in the infant model developing clinically significant levels of inadvertent PEEP which may pose risk during infant resuscitation.

Neopuff T-piece resuscitator: does device design affect delivered ventilation?

BACKGROUND

The T-piece resuscitator (TPR) is in common use worldwide to deliver positive pressure ventilation during resuscitation of infants <10 kg. Ease of use, ability to provide positive end-expiratory pressure (PEEP), availability of devices inbuilt into resuscitaires and cheaper disposable options have increased its popularity as a first-line device for term infant resuscitation. Research into its ventilation performance is limited to preterm infant and animal studies. Efficacy of providing PEEP and the use of TPR during term infant resuscitation are not established.

AIM

The aim of this study is to determine if delivered ventilation with the Neopuff brand TPR varied with differing (preterm to term) test lung compliances (Crs) and set peak inspiratory pressures (PIP).

DESIGN

A single operator experienced in newborn resuscitation provided positive pressure ventilation in a randomised sequence to three different Crs models (0.5, 1 and 3 mL/cmH₂O) at three different set PIP (20, 30 and 40 cmH₂O). Set PEEP (5 cmH₂O), gas flow rate and inflation rate were the same for each sequence.

RESULTS

A total of 1087 inflations were analysed. The delivered mean PEEP was Crs dependent across set PIP range, rising from 4.9 to 8.2 cmH₂O. At set PIP 40 cmH₂O and Crs 3 mL/cmH₂O, the delivered mean PIP was significantly lower at 35.3 cmH₂O.

CONCLUSIONS

As Crs increases, the Neopuff TPR can produce clinically significant levels of auto-PEEP and thus may not be optimal for the resuscitation of term infants with healthy lungs.

Tidal Volume Delivery and Endotracheal Tube Leak during Cardiopulmonary Resuscitation in Intubated Newborn Piglets with Hypoxic Cardiac Arrest Exposed to Different Modes of Ventilatory Support

BACKGROUND

There are few data available on the interaction of inflations, chest compressions (CC), and delivery of tidal volumes in newborn infants undergoing resuscitation in the presence of endotracheal tube (ET) leaks.

OBJECTIVES

To determine the effects of different respiratory support strategies along with CC on changes in tidal volume and ET leaks in hypoxic newborn piglets with cardiac arrest.

METHODS

Asphyxiated newborn piglets, intubated with weight-adapted uncuffed ET, were randomized into three groups and resuscitated according to ILCOR 2010 guidelines: (1) T-piece resuscitator (TPR) group = peak inspiratory pressure (PIP)/positive end-expiratory pressure (PEEP) 25/5 cm H2O, rate 30/min, inflations interposed between CC (3:1 ratio); (2) self- inflating bag (SIB) group = PIP 25 cm H2O without PEEP, rate 30/min, inflations interposed between CC (3:1 ratio), and (3) ventilator group = PIP/PEEP of 25/5 cm H2O, rate 30/min. CC were applied with a rate of 120/min without synchrony to inflations.

RESULTS

We observed a significant increase of leak (average increase 11.4%) when CC was added to respiratory support (p = 0.0001). Expired tidal volume was larger in the SIB group than in the two other modes which both applied PEEP. However, tidal volumes caused by CC only were larger in the two groups with PEEP than in the SIB group (without PEEP).

CONCLUSIONS

There is interaction between lung inflations and CC affecting leak and delivery of tidal volume, which may be influenced by the mode/device used for respiratory support. Leak is larger in the presence of PEEP. However, CC cause additional tidal volume which is larger in the presence of PEEP.

Golden 60 minutes of newborn's life: Part 1: Preterm neonate

"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.

Quality improvement project: implementing guidelines supporting noninvasive respiratory management for premature infants

PURPOSE

Based on research evidence, the purpose was to implement noninvasive approaches in the initial respiratory stabilization of preterm infants.

DESIGN

Quality improvement project.

SAMPLE

One hundred fourteen infants admitted to the neonatal intensive care nursery (NICN) from January 1, 2012 to May 31, 2012 served as a historical control group. Ninety-four infants admitted from January 1, 2013 to May 31, 2013 served as the intervention group.

RESULTS

After implementation of the quality improvement initiative, there was a statistically significant increase in the rate of using continuous positive airway pressure (CPAP ) by 65.3 percent for initial respiratory stabilization of preterm infants.

Sustained lung inflation at birth: what do we know, and what do we need to know?

A sustained inflation has been advocated as a potential method of augmenting lung aeration at birth. Clinical trials have suggested that a sustained inflation may lead to a reduced need for intubation and ventilation in the first few days of life, without cardiovascular compromise or increased lung injury. Despite this, a sustained inflation is not currently a standard of practice, mainly due to a lack of clarity regarding the optimal delivery method. Animal trials have sought to refine delivery techniques. This review will outline current recommendations regarding a sustained inflation, discuss potential strategies for its optimal delivery and suggest priorities for future research.

Manual Ventilation and Sustained Lung Inflation in an Experimental Model: Influence of Equipment Type and Operator's Training

Aim

To compare the influence of devices for manual ventilation and individual experience on the applied respiratory mechanics and sustained lung inflation.

Methods

A total of 114 instructors and non-instructors from the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics participated in this study. Participants ventilated an intubated manikin. To evaluate respiratory mechanics and sustained lung inflation parameters, a direct comparison was made between the self-inflating bag and the T-shaped resuscitator (T-piece), followed by an analysis of the effectiveness of the equipment according to the participants’ education and training.

Results

A difference between equipment types was observed for the tidal volume, with a median (interquartile range) of 28.5 mL (12.6) for the self-inflating bag and 20.1 mL (8.4) for the T-piece in the instructor group and 31.6 mL (14) for the self-inflating bag and 22.3 mL (8.8) for the T-piece in the non-instructor group. Higher inspiratory time values were observed with the T-piece in both groups of professionals, with no significant difference between them. The operator’s ability to maintain the target pressure over the 10 seconds of sustained lung inflation was evaluated using the area under the pressure-time curve and was 1.7-fold higher with the use of the T-piece. Inspiratory pressure and mean airway pressure applied during sustained lung inflation were greater with the self-inflating bag, as evaluated between the beginning and the end of the procedure.

Conclusion

The T-piece resulted in lower tidal volume and higher inspiratory time values, irrespective of the operator’s experience, and increased the ease of performing the sustained lung inflation maneuver, as demonstrated by the maintenance of target pressure for the desired period and a higher mean airway pressure than that obtained using the self-inflating bag.

Comparison of efficacy of three devices of manual positive pressure ventilation: a mannequin-based study

BACKGROUND

We compared the efficacy of and consistency in manual ventilation by trained healthcare professionals using three devices: self-inflating bag, flow-inflating bag, and T-piece resuscitator.

METHODS

Prospective analytical study at a level III Neonatal unit of a tertiary care hospital. Forty participants (consultants, postgraduates, interns, and neonatal nurses - 10 each) manually ventilated a mannequin with the above three devices for three minutes each. This procedure was video recorded. The pressure delivered during the three minutes and the breath rates for the first minute, second minute, and third minute were analyzed. Descriptive statistics were used to describe the study population and group statistics were used for various parameters of interest. Factorial analysis of variance was conducted to determine the main effects of device and specialty of users.

RESULTS

The mean (SD) peak inspiratory pressure of T-piece resuscitator was 16.5 (1.2), self-inflating bag (SIB) was 20.7 (4.4), and flow-inflating bag (AB) was 21.2 (5.0). The mean (SD) positive end expiratory pressure of T-piece resuscitator was 4.7 (0.9) cm of H2O and AB was 1.8 (1.7) cm of H2O. The maximum pressure delivered by T-piece resuscitator was 17.5, AB was 26.2, and SIB was 25.2 cm of H2O. Clinically appropriate breath rates were delivered using all of the devices. More effective breath rates were delivered using T-piece. There was no significant difference among the professional groups.

CONCLUSIONS

The T-piece resuscitator provides the most consistent pressures and is most effective. Level of training has no influence on pressures delivered during manual ventilation.

Neonatal resuscitation: evolving strategies

Birth asphyxia accounts for about 23% of the approximately 4 million neonatal deaths each year worldwide (Black et al., Lancet, 2010, 375(9730):1969-87). The majority of newborn infants require little assistance to undergo physiologic transition at birth and adapt to extrauterine life. Approximately 10% of infants require some assistance to establish regular respirations at birth. Less than 1% need extensive resuscitative measures such as chest compressions and approximately 0.06% require epinephrine (Wyllie et al. Resuscitation, 2010, 81 Suppl 1:e260–e287). Transition at birth is mediated by significant changes in circulatory and respiratory physiology. Ongoing research in the field of neonatal resuscitation has expanded our understanding of neonatal physiology enabling the implementation of improved recommendations and guidelines on how to best approach newborns in need for intervention at birth. Many of these recommendations are extrapolated from animal models and clinical trials in adults. There are many outstanding controversial issues in neonatal resuscitation that need to be addressed. This article provides a comprehensive and critical literature review on the most relevant and current research pertaining to evolving new strategies in neonatal resuscitation. The key elements to a successful neonatal resuscitation include ventilation of the lungs while minimizing injury, the judicious use of oxygen to improve pulmonary blood flow, circulatory support with chest compressions, and vasopressors and volume that would hasten return of spontaneous circulation. Several exciting new avenues in neonatal resuscitation such as delayed cord clamping, sustained inflation breaths, and alternate vasopressor agents are briefly discussed. Finally, efforts to improve resuscitative efforts in developing countries through education of basic steps of neonatal resuscitation are likely to decrease birth asphyxia and neonatal mortality.

Comparison of training in neonatal resuscitation using self inflating bag and T-piece resuscitator

BACKGROUND

Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins.

METHODS

100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests.

RESULTS

Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3-6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices.

CONCLUSION

It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.

Positive-pressure ventilation during transport: a randomized crossover study of self-inflating and flow-inflating resuscitators in a simulation model

BACKGROUND

Positive-pressure ventilation during transport of intubated patients is generally delivered via a hand-pressurized device. Of these devices, self-inflating resuscitators (SIR) and flow-inflating resuscitators (FIR) constitute the two major types used. Selection of a particular device for transport, however, remains largely an institutional practice.

OBJECTIVE

To evaluate the hypothesis that transport ventilation goals of intubated pediatric patients are better achieved using an FIR compared to an SIR.

METHODS

This randomized crossover simulation study compared the performance of SIR and FIR among anesthesia providers in a pediatric transport scenario. Subjects hand-ventilated a test lung while simultaneously maneuvering a stretcher bed to simulate patient transport. Hand ventilation was carried out using a Jackson-Rees circuit (FIR) and a Laerdal pediatric silicone resuscitator (SIR). The primary outcome was the proportion of total breaths delivered within the predefined target PIP/PEEP range (30+/- 3, 10+/- 3 cm H2O). Secondary outcomes included proportion of total breaths delivered with operationally defined unacceptable breath variables (PIP > 35 cm H2O or PEEP < 5 cm H2O).

RESULTS

Overall, participants were four times more likely to deliver target breaths and one-third less likely to deliver unacceptable breaths using the FIR compared to the SIR. When comparing device performance, a 44% increase in the proportions of target breaths and a 40.4% decrease in unacceptable breaths using the FIR were observed (P < 0.0001 for both).

CONCLUSIONS

Hand ventilation during patient transport is superior using the FIR compared to the SIR to achieve target ventilatory goals and avoid unacceptable ventilatory cycles.

Accuracy of a disposable compared to a non-disposable infant T-piece resuscitator

Both disposable and non-disposable T-piece resuscitator (TPR) devices are used. Accuracy of the disposable and non-disposable infant TPR was compared. Peak inspiratory pressures (PIP) and positive end-expiratory pressures (PEEP) were measured during ventilation of a test lung. Measured PIP ±1 cmH2O and PEEP ±0.5 cmH2O of the desired pressures were considered acceptable. We tested the following: (A) Accuracy of setting pressures using built-in manometers of three disposable TPRs, (B) Minimal and maximal PIP and PEEP levels for the non-disposable and disposable TPR were measured using different gas flow rates, and (C) Accuracy of 25 caregivers setting pressures (PIP 25 cmH2O and PEEP 5 cmH2O). The results of the tests performed were as follows: (A) With pressures set: PIP 20, 25, 30, and 40 cmH2O and PEEP 5-8 cmH2O with 1 cmH2O stepwise increment, measured PIPs and PEEPs were in acceptable range. (B) At gas flow rates 5, 8, 10, and 15 L/min (disposable vs. non-disposable), min-max PIP were 4.0-43.2 vs. 2.9-77.1 cmH2O and min-max PEEP were 0.3-22.3 and 0.6-59.7 cmH2O. (C) Set PIP (cmH2O) by participants using disposable vs. non-disposable TPR was 25.8 (0.8) vs. 25.9 (1.3) (ns). PEEP was 5.4(0.5) vs. 4.7(0.5); p < 0.001.

CONCLUSION

The accuracy of the disposable TPR is comparable to that of the non-disposable TPR.

Short- and intermediate-term outcomes of preterm infants receiving positive pressure ventilation in the delivery room

Although recent advances in neonatal care have improved survival rates, rates of bronchopulmonary dysplasia remain unchanged. Although neonatologists are increasingly applying gentle ventilation strategies in the neonatal intensive care unit, the same emphasis has not been applied immediately after birth. A lung-protective strategy should start with the first breath to help in the establishment of functional residual capacity, facilitate gas exchange, and reduce volutrauma and atelectotrauma. This paper will discuss techniques and equipment during breathing assistance in the delivery room.

Resuscitation of preterm infants: delivery room interventions and their effect on outcomes

Despite advances in neonatal care, the rate of oxygen dependence at 36 weeks' postmenstrual age or bronchopulmonary dysplasia has not fallen. Neonatologists are increasingly careful to apply ventilation strategies that are gentle to the lung in the neonatal intensive care unit. However, there has not been the same emphasis applying gentle ventilation strategies immediately after birth. A lung-protective strategy should start immediately after birth to establish a functional residual capacity, reduce volutrauma and atelectotrauma, facilitate gas exchange, and improve oxygenation during neonatal transition. This article discusses techniques and equipment recommended by international resuscitation guidelines during breathing assistance in the delivery room.