Elsevier

Resuscitation

Volume 67, Issue 1, October 2005, Pages 113-118
Resuscitation

A comparison of three neonatal resuscitation devices

https://doi.org/10.1016/j.resuscitation.2005.02.016Get rights and content

Abstract

Background:

Ventilation during neonatal resuscitation involves the use of self-inflating bags, flow-inflating bags, and T-piece resuscitators. The ability of operators to deliver desired peak inspiratory pressures (PIP), positive end expiratory pressures (PEEP), prolonged inflations and the length of time to transition between different pressures has not been compared for all three of these devices.

Objective:

To compare the ability of neonatal resuscitation personnel to deliver predetermined ventilation interventions using these devices in advance of a clinical trial of neonatal resuscitation.

Design/methods:

We studied 31 operators (neomatologists, neonatal respiratory therapists, neonatal fellows, a pediatrician, pediatric residents, neonatal nurse practitioners, and neonatal nurses) using a T-piece resuscitator (Neopuff®, Fisher & Paykel Healthcare, Auckland, New Zealand), a self-inflating bag (Baby Blue II, Vital Signs, Totowa, NJ), and a flow-inflating bag (Model E191 Anesthesia Associates, San Marcos, CA). The self-inflating bag was tested with and without the manufacturer's PEEP valve. Using a continuous pressure recording system and a neonatal manikin, we evaluated the ability to deliver a consistent PIP of 20 or 40 cmH2O and a PEEP of 5 cmH2O during 30 s of ventilation, the ability to maintain a 5 s inflation at a PIP of 20 cmH2O and the time to transition from a PIP of 20 to 40 cmH2O. Each device was evaluated with and without a qualitative CO2 detector (Pedicap® Nellcor Pleasanton, CA).

Results:

The T-piece resuscitator delivered the desired PIP more precisely and consistently compared with the self-inflating bag at a target of 20 cmH2O (maximum PIP 20.7 cmH2O, S.D. = 0.8 versus 24.7 cmH2O, S.D. = 2.8; p < 0.001). At a target of 40 cmH2O, the maximum pressure delivered with the T-piece resuscitator was significantly less than both the flow-inflating bag and the self-inflating bag (39.7 cmH2O, S.D. = 2.1 versus 44 cmH2O, S.D. = 3.3 versus 45.3 cmH2O, S.D. = 4.7; p < 0.001). It took significantly longer to increase the PIP from 20 to 40 cmH2O using the T-piece resuscitator compared to the self-inflating bag or the flow-inflating bag (5.7 s versus 2.2 s versus 1.8 s; p < 0.001), and three operators could not make the transition in the allotted 15 s time limit. During the 5 s prolonged inflation, the T-piece resuscitator and the flow-inflating bag maintained a pressure greater than 18 cmH2O for a longer time than the self-inflating bag (4 s versus 3.7 s versus 2.2 s; p < 0.001). The self-inflating bag with the PEEP valve in place provided significantly less PEEP than both the T-piece resuscitator and the flow-inflating bag (3.6 cmH2O versus 4.4 cmH2O versus 4.4 cmH2O; p < 0.005). The Pedicap® did not significantly affect any of the observed results, and there were no consistent operator differences between different disciplines or years of experience.

Conclusions:

The T-piece resuscitator delivered the desired pressures more accurately, but required greater time to increase the PIP from 20 to 40 cmH2O. It was difficult to maintain a prolonged inflation and deliver the desired PEEP with the self-inflating bag even with the PEEP valve in place. There is a need for improvement in the design and function of current manual resuscitation devices and for prospective trials to evaluate the optimal method of bag and mask ventilation during resuscitation of the newborn infant.

Introduction

Approximately 5–16% of neonates require some type of resuscitation at the time of birth [1], [2]. Bag and mask ventilation is the most common intervention occurring in up to 10.6% of neonatal resuscitations [1], and is perhaps the most problematic area of neonatal resuscitation. Currently there are three different types of bag and mask devices used in neonatal resuscitation. These devices include self-inflating bags, flow-inflating bags (also called anesthesia bags), and the T-piece resuscitator (such as the Neopuff®). At this time there is little evidence as to which device is the most effective for neonatal resuscitation. The most recent Neonatal Resuscitation Program (NRP) Textbook [2] describes the flow-inflating bag and the self-inflating bag and reviews the advantages and disadvantages of each device, but does not recommend one device over the other. This lack of recommendation is likely to reflect the limited evidence on the efficacy of each device. There is no mention of T-piece resuscitators although they are used in clinical practice. In a survey by O’Donnell et al. [3], a questionnaire was sent to 46 NICUs in 23 countries. They reported that the Neopuff® was used in 30% of centers. The use of all three bag–mask ventilation systems including the T-piece resuscitator was discussed by Zideman et al. in their recommendations on resuscitation but no recommendations was given as to the superiority of any device [4].

Hussey et al. recently compared the Neopuff to the self-inflating and anesthesia bag with an intubated neonatal manikin [5]. They found that the self-inflating bag delivered a significantly higher peak inspiratory pressure (PIP) and lower positive end expiratory pressure (PEEP) then the other two devices. There was no manometer or PEEP valve used with the self-inflating bag and potentially useful interventions including 3–5 s prolonged inflations [4], [6] were not evaluated. An in vitro comparison with bag and mask of the self-inflating bag, the flow-inflating bag, and the T-piece resuscitator evaluating the operators ability to consistently deliver targeted PIP, PEEP, prolonged inflations, and an efficient transition from a lower to higher PIP with each device is essential before initiating a clinical comparative trial during actual neonatal resuscitations.

During our review of video taped resuscitations, we found that a colorimetric CO2 detector placed between the mask and the ventilation device changed color when an airway was established. Although this doesn’t confirm adequate ventilation, it is useful for the operator to know that there was a patent airway. There currently is no literature on the use of a colorimetric CO2 detector during bag–mask ventilation. We believe that the use of CO2 detector can provide important information for the operator, and we wanted to evaluate whether the use of such a device would compromise the ability of operators to use any of the currently available bag and mask devices.

Section snippets

Methods/subjects

We asked a variety of operators to participate in this study to reflect operators from different disciplines and years of experience who participate in neonatal resuscitation. The operators included neonatal respiratory therapists, neonatal nurses, neonatologists, neonatal fellows, neonatal nurse practitioners, and pediatric residents. The years of experience in neonatal resuscitation and job discipline were recorded for each participant prior to the start of the study for later comparison. The

Results

Thirty-one individuals participated in the study. There were 6 neonatologists, 5 neonatology fellows, 1 pediatrician, 2 pediatric residents, 1 neonatal nurse practitioner, 13 neonatal respiratory therapists, and 3 neonatal nurses. The years of experience varied from 1 year to greater than 20 years. All participants completed all aspects of the evaluation, which required approximately 40 min for each participant.

The detailed results are presented in Table 1. At a target PIP of 20 cmH2O, there was

Discussion

This study compares all available types of resuscitation devices and the operators’ ability to deliver PEEP and a prolonged inflation, two potentially beneficial resuscitation interventions. In our current prospective model, we chose to evaluate the ability of operators to create and maintain a seal with each of the devices and to deliver goal pressures. We chose pressures of 20 and 40 cmH2O to represent our PIP targets and 5 cmH2O for our PEEP target. As discussed by both NRP [2] and Milner [7],

Conclusions

Our results demonstrate that all current types of bag and mask devices for neonatal resuscitation can deliver target PIPs. Self-inflating bags cannot deliver a sustained prolonged inflation or provide adequate PEEP, even when equipped with a manufacturer's PEEP valve. Although the Neopuff® delivers more consistent pressures with less variability, it requires more time to increase peak inspiratory pressures during resuscitation interventions. There is a need for improvement in the design and

Conflict of interest

Dr. N Finer has received research support from Fisher & Paykel. Neither Fisher & Paykel nor any other manufacturer was involved in the design, conduct, analysis or writing of the manuscript for this study, which is the sole responsibility of the authors.

Acknowledgement

We gratefully acknowledge the provision of the pressure monitoring apparatus by Fisher & Paykel, Auckland, New Zealand.

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A Spanish translated version of the Abstract and Keywords of this article appears as an Appendix at 10.1016/j.resuscitation.2005.02.016.

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