Elsevier

Resuscitation

Volume 82, Issue 6, June 2011, Pages 717-719
Resuscitation

Clinical paper
Unintentional variation in positive end expiratory pressure during resuscitation with a T-piece resuscitator

https://doi.org/10.1016/j.resuscitation.2011.02.017Get rights and content

Abstract

Introduction

The ability of T-piece resuscitators to deliver consistent peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP) during real and simulated neonatal resuscitation has been well described. The Neopuff (Fisher & Paykel Healthcare, Auckland, New Zealand) has been the device used for nearly all of these comparisons.

Methods

All high risk resuscitations were carried out in our dedicated resuscitation room, and were recorded on video tape for quality assurance purposes.1 In addition to the audio and video recording, physiologic signals and resuscitation parameters, including oxygen saturation, pulse rate, airway pressure, FiO2, and others signals as appropriate were also captured. These recordings were reviewed on a biweekly basis as part of a continuing quality review process. Resuscitations were graded for standard of care and the resuscitation checklist was reviewed to determine if the team had any unresolved issues that needed to be addressed.

Results

In the year between April of 2009 and March 2010, a period when we fully reviewed approximately 120 videos, we recognized visually obvious PEEP changes on 8 different occasions in ELBW infants. Our target PEEP was 5 cm H20. We observed rapid changes in the PEEP to as high as 15 cm H20 during resuscitation.

Conclusion

Based on our single-center experience, a T-piece resuscitation device which has the adjustment for the PEEP level and the orifice which is occluded to deliver a breath in the same location has the potential to cause an inadvertent and potentially toxic increase of PEEP which might not be noticed by the operator.

Introduction

The ability of T-piece resuscitators to deliver consistent peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP) during real and simulated neonatal resuscitation has been well described. The Neopuff (Fisher & Paykel Healthcare, Auckland, New Zealand) has been the device used for nearly all of these comparisons.

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, a device first described in 1987 by Hoskyns, Milner and Hopkin as a tool that allowed them to consistently provide prolonged inflations.2 The most recent Neonatal Resuscitation Program (NRP) Textbook3 is the first to include the T-piece resuscitator as a manual ventilation option. In a survey by O’Donnell et al., a questionnaire was sent to 46 NICUs in 23 countries which showed that the Neopuff was used in 30% of centers.4 Similar reviews in Spain, Ireland, New Zealand and Australia indicated levels of usage between 45% and 50% in delivery room.5, 6, 7 In 2001 we published the first study comparing the Neopuff to two styles of anesthesia bags on a mannequin, as this device was being increasingly used for resuscitation of newborn infants.8 The comparison showed that only the Neopuff was able to consistently provide a target peak inspiratory pressure (PIP) or positive end expiratory pressure (PEEP) in the hands of operators of all education and experience levels. It also demonstrated that the prolonged inflation was easily and consistently achievable using this device. In a later study Bennett repeated this comparison using a self inflating bag and still found the T-piece to be superior in terms of consistency in the hands of a variety of resuscitators.9 The most significant limitation found in Bennett's trial was that changing pressure rapidly was nearly impossible using the Neopuff. Several turns of a small knob were required to change the pressure by 20 cm H20. Our recent review of recordings of airway pressure during resuscitations has revealed a new intermittent problem, i.e. a significant inadvertent increase in PEEP.

Section snippets

Methods

All high risk resuscitations were carried out in our dedicated resuscitation room, and were recorded on video tape for quality assurance purposes.1 In addition to the audio and video recording, physiologic signals and resuscitation parameters, including oxygen saturation, pulse rate, airway pressure, FiO2, and others signals as appropriate were also captured. These recordings were reviewed on a biweekly basis as part of a continuing quality review process. Attendees included the house staff,

Results

Based on our 10-year use of the Neopuff we have reviewed many hundreds of recordings using this device. In the presence of a good mask seal, PEEP and PIP levels using the T-piece have remained stable. However, in the year between April of 2009 and March 2010, a period when we fully reviewed approximately 120 videos, we recognized visually obvious PEEP changes on 8 different occasions. Table 1 describes the specific data from these recordings. Our target PEEP was 5 cm H20. We have seen rapid

Discussion

Hawkes et al. have shown that the device was flow dependent, and that very significant increases in flow rate could yield pressures well above those previously set.10 This group also suggests that infrequent users who have only had initial training by a manufacturer's representative are less able to use the Neopuff correctly when compared to a self inflating bag with no PEEP, a device they describe as ‘simple and ready to use’.11 McHale et al. found that 17 of 19 (89%) physicians and nurses

Conflict of interest statement

None to declare.

References (13)

There are more references available in the full text version of this article.

Cited by (17)

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    TPR users were not as good at detecting changes in compliance as users of the SIB and FIB.230 PEEP valves could be inadvertently screwed down leading to excess PEEP.231 TPR users needed more time to change the inflating pressures during resuscitation compared to users of the SIB or FIB.

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    Finer et al. video reviewed 120 preterm resuscitations and showed a rapid unexplained rise in PEEP from set values of 5 cmH20 to as high as 15.5 cmH20 (7.1–15.5cmH20) in 8 of the subjects. He concluded the Neopuff device can potentially cause a “toxic increase in PEEP that may be unnoticed by the operator” [41]. Recent reports of increased risks of pneumothorax in term newborns treated with delivery room CPAP using TPR devices may be of concern [31,32].

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    For this reason, it was recommended that a flow-inflating bag capable of rapid increases in pressure be available at all deliveries as a backup to the T-piece. We have noted that PEEP levels can inadvertently increase over time when using a T-piece device,16 and care should be taken to constantly observe the level of PEEP to ensure that it is not drifting (Fig. 1). Care should also be taken when intially setting up these devices, as we have observed PEEP levels in excess of 25 cm H2O on some devices.

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

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    One article used the Tom Thumb T-piece,39 and all others specifically included the Neopuff. Of the 30 remaining studies, 2 compared devices in infants,40,41 14 compared devices in a manikin or lung model,19–24,39,42–48 one observational study49 outlined the reduced morbidity associated with changes in delivery room practices, and 13 included the TPR without comparisons.18,50–61 Dawson et al.41 randomised infants less than 29 weeks’ gestation to receive positive pressure ventilation with the Neopuff or the SIB, and did not find a significant difference in mortality, need for endotracheal intubation or the need for respiratory support at 28 days.

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“A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.017”.

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