Resuscitation of

neonates with Ambu

bag, Flow inflating bag

and T-pieceEbtihal Hassan Al-Oweywee

Definition of resuscitation

Ambu bag

Flow inflating bag

T-piece

Study about the hazards of T-piece without limitation of flow

rate.

Study that compare the 3 types of resuscitation devices.

DEFINITION OF NEONATAL RESUSCITATION

Neonatal Resuscitation is intervention after a baby is born to

help it breathe and to help its heart beat.

Before a baby is born, the placenta provides oxygen and nutrition

to the blood and removes carbon dioxide.

After a baby is born, the lungs provide oxygen to the blood and

remove carbon dioxide.

Many babies go through this transition without needing

intervention.

Some babies need help with establishing their air flow, breathing,

or circulation.

RESUSCITATION DEVICES

Self inflating bag

Flow inflating bag

T-piece

SELF INFLATING BAG

Fill spontaneously after they are squeezed,

pulling oxygen or air into the bag

Remain inflated at all times

Can deliver positive-pressure ventilation without

a compressed gas source.

Require attachment of an oxygen reservoir to

deliver 100% oxygen

• Does not need a gas source to inflate

• Pressure release valve

• Portable and light weight

• Available in single use, disposable bags

• Will inflate even without adequate seal.

• Requires a reservoir to deliver 100%

oxygen.

• Does not provide PEEP/CPAP (unless a PEEP

valve has been fitted).

Place the mask firmly against your

hand.

Squeeze the bag repeatedly.

You should feel air pressure against

your hand and see the lip valve open

and close

If pressure is not felt, this device is

not safe to use!

Remove the mask and occlude the patient port connector with your thumb.

Compress the bag several times.

Look & listen for opening of the pressure relief valve.

Create a good seal between the infant's

face & the mask

How to use it ??!

Incorrect ways to hold a mask

A: Do not hold the stem

B: Do not hold the outeredge

× ×

AIR OR OXYGEN FOR RESUSCITATION?

o Term newborns: Use air (21%) initially.

o Preterm newborns < 32 weeks: Use air or

blended air and oxygen

(21% to 30% oxygen to start).

o Use air if a blender is not available.

Is your technique effective? • If your ventilation technique is effective, three signs

are observed:

1. An increase in the heart rate above 100/min.

2. A slight rise and fall of the chest and upper abdomen with each

inflation.

3. An improvement in oxygenation.

If the heart rate is not improving: • The technique of ventilation needs to be improved.

• Consider increasing the PIP.

• Endotracheal intubation should also be considered.

FLOW INFLATING BAG

Fill only when oxygen from a compressed

source flows into them

Depend on a compressed gas source

Must have a tight face-mask seal to

inflate

The mask is not properly sealed

over the newborn’s nose and mouth

There is a tear in the bag.

The pressure gauge is missing

Delivers 100% oxygen at all times.

Easy to determine the adequacy of seal.

“Stiffness” of lungs can be felt.

Provide PEEP.

Requires a tight seal to remain inflated

Requires a gas source to inflate

No safety pop-off valve

Requires more experience

Gas supply

Gas supply line

Test lung

Patient supply linewith T-piece & mask

Neopuff

• Gas flow rate10 L/min (8L /min if using cylinders)

• Maximum pressure relief valve50 cm H2O

• PIP30 cm H2O (term newborn)20 - 25 cm H2O (preterm < 32 weeks’)

• PEEP5 - 8 cm H2O

INITIAL RECOMMENDED SETTINGS

1. Connect the gas & patient supply lines

2. Connect the

test lung to T-

piece and turn

on the flow

3. Turn the inspiratory

pressure control dial

fully clockwise

Occlude the PEEP cap check

that the pressure gauge points

to 50 cmH2O

4. Set the PIP and PEEP

20 – 25 cm H2O for a premature infant

or 30 cm H2O for a term infant.

Set a PEEPof 5 cm H2O

Caution: any increase in the flow rate willresult in a dangerously high increase in PEEP.

The operator can set the (PIP) & (PEEP).

The T-piece device will not deliver PIP or

PEEP/CPAP above the set pressures if the flow

remains constant.

The PIP & PEEP are displayed on the manometer.

The operator can control the length of the

inspiratory time by varying the duration of

occlusion of the PEEP cap.

Requires a gas source to operate.

The set PIP can be reached on the manometer

despite a face mask leak of up to 90%.

As the T- piece device delivers a set pressure, it is

still possible to deliver large volumes of gas to the

infant which may cause a pneumothorax or damage

the lungs of infant.

(1)To assess (PIP), (PEEP) and (Pmax)

at different flow rates

(2)To assess maximum PIP and PEEP at

a flow rate of 10 l/min with a

simulated air leak of 50%.

THE AIM

METHOD

• 5 Neopuffs were set to

PIP of 20 PEEP of 5 Pmax of 30

flow of 5

• PIP, PEEP and Pmax were recorded at flow rates

of 10, 15 l/min and maximum flow.

• Maximum achievable PIP and PEEP at a flow rate

of 10 l/min with a simulated air leak of 50%.

At gas flow of (15 l/min)

PEEP increased to 20

PIP increase to 28

Pmax increase to 40 cm H2O

At maximum flow (85 l/min)

PEEP increase to 71

PIP increase to 92 cm H2O

At 10 l/min flow, with an air leak of 50%,

the maximum PEEP is 21

The maximum PIP is 69

RESULT

Pmax is overridden by increasing the rate of gas

flow and potentially harmful PIP and PEEP can be

generated.

Even in the presence of a 50% gas leak, more than

adequate pressures can be provided at 10 l/min gas

flow.

We recommend the limitation of gas flow to a rate

of 10 l/min as an added safety mechanism for this

device.

CONCLUSION

METHOD

We studied 31 operators using a T-piece resuscitator, a

self-inflating bag and a flow-inflating bag.

we evaluated the ability to deliver a consistent PIP of 20

or 40 cmH2O and a PEEP of 5 cmH2O .

evaluate the ability to maintain a 5 s inflation at a PIP of

20 cmH2O

Evaluate the time to transition from a PIP of 20 to 40

cmH2O.

T-Piece

resuscitator

Self inflating

bag

Flow inflating

bag

(PIP) at the target of 20

cmH2O

20 24 -

(Pmax) at the target of 40

cmH2O

39 45 44

The duration to increase

the PIP from 20 to 40

5.7 2.2 1.8

Maintaining pressure

greater than 18 for 5 s

4 2.2 3.7

RESULT

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

time with the self-inflating bag

CONCLUSION

• Australian Resuscitation Council & the New Zealand Resuscitation

Council. (2010). Section 13: Neonatal Guidelines. Retrieved February 2,

2012 from:

http://www.resus.org.au

• Up to date

• Laerdal Medical (2006) Laerdal silicone resuscitators: Interactive

presentation. Accessed April 27, 2009 from

http://www.laerdaltraining.com/lsr

• Fisher & Paykel Healthcare. (2004). Neopuff™ Infant Resuscitator.

Optimal resuscitation in neonatal care. Auckland, New Zealand.

• http://fn.bmj.com/content/94/6/F461.short

• http://www.ncbi.nlm.nih.gov/pubmed/16081202