Clinical paperVariation in inspiratory time and tidal volume with T-piece neonatal resuscitator: Association with operator experience and distraction☆,☆☆
Introduction
The self-inflating (Laerdal®) bag, the flow-inflating (anaesthetic) bag and the T-piece device (Neopuff®) are all used to ventilate premature newborn infants in clinical practice, whether via face mask or endotracheal tube.1 The T-piece device (Neopuff®) has rapidly become a common feature for resuscitation both in the delivery room and neonatal intensive care unit, although there is a paucity of published data on its use.2, 3, 4, 5, 6, 7, 17 It has the twin theoretical advantages of delivering consistent limited inflating pressures (which may be manipulated in the clinical setting to optimise oxygenation) and of delivering positive end expiratory pressure (PEEP). These protect against atelectasis and lung injury, while also optimising lung compliance and gas exchange in animal models.2 Inspiratory time (Ti) (affecting tidal volume) and ventilation rate (affecting minute volume) remain under operator control and are susceptible to variation, particularly as the system does not need a built-in lag time to reset or refill (as in the case of hand bag ventilation). In the stressful setting of emergency resuscitation,8 there is a theoretical risk of using prolonged inspiratory times, which are known to be associated with increased rates of air leaks (including pneumothorax, pulmonary interstitial emphysema, pneumomediastinum and pneumoperitoneum).9
We sought to analyze the ventilation delivered using the T-piece device (Neopuff®), looking at Ti, respiratory rate (RR), tidal volume (VT) and minute volume (MV), and to evaluate the effects of operator experience. In addition we studied the effect of distraction techniques, mimicking an emergency situation, on these ventilation parameters.
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Materials and methods
This study recruited medical and nursing staff from the neonatal intensive care unit of a university-affiliated tertiary maternity hospital. All staff who agreed to participate in the study were deemed eligible. The staff member was positioned beside an open resuscitation table and provided with a T-piece resuscitator (Neopuff®, Fisher & Paykel Healthcare), set at a target PIP of 20 cm H2O and PEEP of 5 cm H2O. The T-piece device was connected directly to a calibrated VT Plus HF Gas Flow Analyzer
Results
19 staff members of a tertiary referral university-affiliated neonatal unit (3 consultant neonatologists, 2 neonatal research fellows, 5 registrars, 3 senior house officers and 5 neonatal nurses, including 3 sisters, and 1 midwife) participated in the study. 17 out of 19 subjects (89%) succeeded in setting up the Neopuff® device unaided. 2 out of 19 (11%) required assistance from an instruction manual. The PIP and PEEP remained stable throughout this study (results not shown).
Discussion
One of the benefits of the T-piece resuscitator is that it is considered equally effective regardless of level of operator experience. We have shown that decreased clinical experience is associated with prolonged Ti. However, the senior operators with the optimal Ti during normal ventilation were most affected by distraction techniques mimicking the stress of an emergency situation. In these cases distraction caused a reduction in respiratory parameters to levels that would provide adequate
Conflict of interest
None.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.06.024.
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Presented in part at the Society for Pediatric Research/Pediatric Academic Societies May 2007, Toronto, Canada.