Abstract
The objective of this randomized controlled manikin trial was to examine tidal volume (VT) delivery and ventilation rate during mask positive pressure ventilation (PPV) with five different devices, including a volume-controlled prototype Next Step™ device for neonatal resuscitation. We hypothesized that VT and rate would be closest to target with the Next Step™. Twenty-five Neonatal Resuscitation Program providers provided mask PPV to a newborn manikin (simulated weight 1 kg) in a randomized order with a self-inflating bag (SIB), a disposable T-piece, a non-disposable T-piece, a stand-alone resuscitation system T-piece, and the Next Step™. All T-pieces used a peak inflation pressure of 20 cmH2O and a positive end-expiratory pressure of 5 cmH2O. The participants were instructed to deliver a 5 mL/kg VT (rate 40–60/min) for 1 min with each device and each of three test lungs with increasing compliance of 0.5, 1.0, and 2.0 mL/cmH2O. VT and ventilation rate were compared between devices and compliance levels (linear mixed model). All devices, except the Next Step™ delivered a too high VT, up to sixfold the target at the 2.0-mL/cmH2O compliance. The Next Step™ VT was 26% lower than the target in the low compliance. The ventilation rate was within target with the Next Step™ and SIB, and slightly lower with the T-pieces. In conclusion, routinely used newborn resuscitators over delivered VT, whereas the Next Step™ under delivered in the low compliant test lung. The SIB had higher VT and rate than the T-pieces. More research is needed on volume-controlled delivery room ventilation.
Highlights
Inappropriate tidal volume (VT) delivery during positive pressure ventilation (PPV) has been associated with an increased risk of both brain and lung injury in preterm infants [1, 2]
We have previously demonstrated that T-piece and self-inflating bag (SIB) VT were above the target in an intubated model with high airway compliance when a set peak inflation pressure (PIP) was used during PPV [11]
The main difference was between the Neo-Tee and the StepTM (p = 0.002), and the SIB and the StepTM (p < 0.001). In this randomized, controlled study comparing VT delivery during mask ventilation at different compliance levels, we found that VT delivery with widely used neonatal resuscitators was twofold to sixfold higher than our targeted VT at high airway compliance, whereas volume delivery was lower than targeted with a prototype volume-controlled resuscitator at the lowest compliance
Summary
Inappropriate tidal volume (VT) delivery during positive pressure ventilation (PPV) has been associated with an increased risk of both brain and lung injury in preterm infants [1, 2]. Modern mechanical ventilators use flow sensors to deliver volume-targeted ventilation. Mask Ventilation in Newborn Resuscitation ventilation, commonly used neonatal resuscitation devices [4, 5] [e.g., self-inflating bags (SIBs) or T-piece devices] are pressure limited. We have previously demonstrated that T-piece and SIB VT were above the target in an intubated model with high airway compliance when a set peak inflation pressure (PIP) was used during PPV [11]. Distension of the facemask and upper airways during PPV might contribute to a difference in VT needed to achieve adequate lung inflation during mask PPV compared to ETT ventilation [12]. Mask leak and airway obstruction are other significant complicating factors during mask PPV [13, 14]
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