T-piece Resuscitator Research Articles

Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial

BackgroundPost-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA. Materials and methodsWe enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups. ResultsThe prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation. ConclusionThe use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates.

The Effect of a Higher Bias Gas Flow on Imposed T-Piece Resistance and Breathing in Preterm Infants at Birth.

ObjectiveThe resistance created by the PEEP-valve of a T-piece resuscitator is bias gas flow dependent and might affect breathing in preterm infants. In this study we investigated the effect of a higher bias gas flow on the imposed inspiratory and expiratory T-piece resistance and expiratory breaking manoeuvres (EBM) in preterm infants during spontaneous breathing on CPAP at birth.MethodsIn a retrospective pre-post implementation study of preterm infants <32 weeks gestation, who were stabilised with a T-piece resuscitator, a bias gas flow of 12 L/min was compared to 8 L/min. All spontaneous breaths on CPAP within the first 10 min of starting respiratory support were analysed on a breath-by-breath basis to determine the breathing pattern of each breath and to calculate the imposed inspiratory and expiratory T-piece resistance (Ri, Re), flow rates and tidal volume.ResultsIn total, 54 infants were included (bias gas flow 12 L/min: n = 27, 8 L/min: n = 27) with a median GA of 29+6 (28+4–30+3) and 28+5 (25+6–30+3), respectively (p = 0.182). Ri and Re were significantly lower in the 12 L/min compared to 8 L/min bias flow group [Ri: 29.6 (26.1–33.6) vs. 46.4 (43.0–54.1) cm H2O/L/s, p < 0.001; Re: 32.0 (30.0–35.1) vs. 48.0 (46.3–53.9) cm H2O/L/s, p < 0.001], while the incidence of EBM [77% (53–88) vs. 77% (58–90), p = 0.586] was similar.ConclusionDuring stabilisation of preterm infants at birth with a T-piece resuscitator, the use of a higher bias gas flow reduced both the imposed inspiratory and expiratory T-piece resistance for the infant, but this did not influence the incidence of EBMs.

Evaluation of T-piece resuscitator in the delivery room management of pre-term neonates with respiratory distress syndrome in resource-limited settings: A pre-post intervention study.

The aim of our study was to evaluate the impact of the T-piece resuscitator in the delivery room management of pre-term neonates in a resource-limited setting. We compared the incidence rates of delivery room intubation, surfactant replacement therapy, pulmonary air leak syndrome, and pre-term very low birth weight infant mortality, before and after T-piece use. Bi-monthly neonatal resuscitation training sessions were conducted for healthcare providers during the study period. We emphasized hands-on experience with the T-piece resuscitator and delivery room early respiratory care practices during the post-intervention epoch. Our pre- and post-intervention data recorded statistically significant decline in delivery room intubations, a 32% decrease in surfactant replacement therapy, and a 57% decrease in air leaks in pre-term neonates. However, the use of T-piece resuscitator did not have a statistically significant effect on pre-term very low birth weight infant mortality.

Efficacy of multi-powered continuous positive airway pressure device on neonates bearing respiratory distress syndrome: an observational analytical study

Background: CPAP (continuous positive airway pressure), an effective intervention for respiratory distress in neonates. Following the development of simple, safe and relatively inexpensive CPAP devices. Saans (CPAP device) is one such portable, easy to use device which is operable in low resource settings, can be used as T-piece resuscitator in the delivery room and during transport. The aim of this study was to evaluate the efficacy of a low cost, multi-powered and easy to use CPAP device Saans, developed by Coeo Labs Pvt. Ltd., Bangalore, on neonates with respiratory distress.Methods: An observational analytical study per the protocol, 35 neonates gestational age &gt;30 weeks were enrolled. Primary outcome variable was the need for mechanical ventilation. Secondary outcome variables were the rate of survival, duration of oxygen in hours, duration of ventilation in hours, duration of hospital stay in days, change Downe score, SAS score, heart rate, respiratory rate and FiO2 from enrolment 6 hours of intervention.Results: 89% (31 neonates) enrolled with respiratory distress. 11% (4 neonates) failed to improve on CPAP therapy. A significant decline in the need for FiO2, mean Downe score, mean R and heart rate observed from the baseline 6 hours CPAP (p&lt;0.001), t test analysis, factors significantly associated CPAP failure were high FiO2 at 1 hour and high positive end-expiratory pressure within 1 hour initiating CPAP (p&lt;0.001).Conclusions: Saans (CPAP device), successful therapeutic option for neonates with respiratory distress and can be effective even in a resource-constrained clinical setting.

Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns

AimT-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator. MethodObservational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1–20) and a late (inflation 21–100) phase. ResultsOf the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28–31) and 30 (27–31) mbar, and tidal volume was 4.5 (1.6–7.8) and 5.7 (2.2–9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes. ConclusionThere was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30–40 per minute are associated with the highest delivered tidal volumes.

Devices for Administering Ventilation at Birth: A Systematic Review.

Positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation. To compare T-piece resuscitators (TPRs), self-inflating bags (SIBs), and flow-inflating bags for newborns receiving PPV during delivery room resuscitation. Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, and trial registries (inception to December 2020). Randomized, quasi-randomized, interrupted time series, controlled before-and-after, and cohort studies were included without language restrictions. Two researchers independently extracted data, assessed the risk of bias, and evaluated the certainty of evidence. The primary outcome was in-hospital mortality. When appropriate, data were pooled by using fixed-effect models. Meta-analysis of 4 randomized controlled trials (1247 patients) revealed no significant difference between TPR and SIB for in-hospital mortality (risk ratio 0.74; 95% confidence interval [CI] 0.40 to 1.34). Resuscitation with a TPR resulted in a shorter duration of PPV (mean difference -19.8 seconds; 95% CI -27.7 to -12.0 seconds) and lower risk of bronchopulmonary dysplasia (risk ratio 0.64; 95% CI 0.43 to 0.95; number needed to treat 32). No differences in clinically relevant outcomes were found in 2 randomized controlled trials used to compare SIBs with and without positive end-expiratory pressure valves. No studies used to evaluate flow-inflating bags were found. Certainty of evidence was very low or low for most outcomes. Resuscitation with a TPR compared with an SIB reduces the duration of PPV and risk of bronchopulmonary dysplasia. A strong recommendation cannot be made because of the low certainty of evidence. There is insufficient evidence to determine the effectiveness of positive end-expiratory pressure valves when used with SIBs.

Neonatal Resuscitation With T-Piece Systems: Risk of Inadvertent PEEP Related to Mechanical Properties.

Background: Resuscitation of infants using T-piece resuscitators (TPR) allow positive pressure ventilation with positive end-expiratory pressure (PEEP). The adjustable PEEP valve adds resistance to expiration and could contribute to inadvertent PEEP. The study indirectly investigated risk of inadvertent peep by determining expiratory time constants. The aim was to measure system expiratory time constants for a TPR device in a passive mechanical model with infant lung properties.Methods: We used adiabatic bottles to generate four levels of compliance (0.5–3.4 mL/cm H2O). Expiratory time constants were recorded for combinations of fresh gas flow (8, 10, 15 L/min), PEEP (5, 8, 10 cm H2O), airway resistance (50, 200 cm H2O/L/sec and none), endotracheal tube (none, size 2.5, 3.0, 3.5) with a peak inflation pressure of 15 cm H2O above PEEP.Results: Low compliances resulted in time constants below 0.17 s contrasting to higher compliances where the expiratory time constants were 0.25–0.81 s. Time constants increased with increased resistance, lower fresh gas flows, higher set PEEP levels and with an added airway resistance or endotracheal tube.Conclusions: The risk of inadvertent PEEP increases with a shorter time for expiration in combination with a higher compliance or resistance. The TPR resistance can be reduced by increasing the fresh gas flow or reducing PEEP. The expiratory time constants indicate that this may be clinically important. The risk of inadvertent PEEP would be highest in intubated term infants with highly compliant lungs. These results are useful for interpreting clinical events and recordings.

Effect of two different chest compression techniques on ventilation during neonatal resuscitation.

To assess tidal volume (Vt) and minute ventilation (MV) during cardiopulmonary resuscitation (CPR) with two different chest compressions techniques: two-finger (TFT) or two-thumb technique (TTT) in a neonatal model. Vt and MV were continuously measured during consecutive periods of resuscitation in an intubated manikin. Thirty participants performed the two compression techniques in a random order for 2-min periods while performing positive pressure ventilation using a T-piece resuscitator (TPR) or a self-inflating bag (SIB). Vt during CPR with TFT was significantly higher than TTT with either TPR: 44.9 ± 4.3 vs 39.2 ± 5.4 ml (p < 0.001) or SIB: 39.2 ± 5.7 vs 35.6 ± 6.5 ml (p < 0.023). Similarly MV was significantly higher in TFT than TTT with either mode: 1346 ± 130 vs 1175 ± 162 ml/min, respectively, with TPR (p < 0.001) and 1177 ± 170 vs 1069 ± 196 ml/min with SIB (p < 0.03). Chest compressions during CPR using the TFT achieved higher Vt and MV than TTT in this model of neonatal resuscitation.

Newborn resuscitation devices: The known unknowns and the unknown unknowns

Infant resuscitation devices used at birth must be capable of delivering adequate and consistent ventilation in a controlled and predictable manner to a wide patient weight range, and combinations of transitional lung states. Manual inflation resuscitation devices delivering positive pressure lung inflation at birth can be classified broadly into two types: 1) flow generating, ie silicone self-inflating bags (SIB) also known as bag valve mask (BVM) and 2) flow dependent, ie anaesthetic flow inflating bag (FIB) and t-piece resuscitator (TPR) systems (eg: Neopuff, GE Panda and Draeger Resuscitaires). Globalization, lower production costs, and an expanding market need for devices, has led to a proliferation of brands (both reusable and single use) within a class type. T-piece resuscitators have become the dominant device particularly in high income countries. There remains a paucity of information on the performance characteristics of these devices and their ability to provide the required respiratory parameters for effective and safe ventilation across the full-expected weight range and lung states to which they will be applied. This review aims to inform current clinical practise on the biomechanical efficiency, reliability and efficacy of the most common devices used to apply PPV to newborns and infants ≤10 kgs.

Sustained Lung Inflation in Pre-term Infants at Birth: A Randomized Controlled Trial.

Invasive mechanical ventilation (IMV) of pre-term infants may be associated with high rate of mortality and iatrogenic complications in low- and middle-income countries. Sustained lung inflation (SLI) may help to reduce their need for IMV. This randomized controlled trial included 160 infants with gestational age (GA) ≥27 and ≤32 weeks who were randomly assigned to receive either SLI; using a pressure of 20 cmH2O for 15 s followed by nasal continuous positive airway pressure (CPAP) of 5 cmH2O or nasal CPAP alone, through an appropriate mask and a T-piece resuscitator. Primary outcome was the need for IMV in the first 72 h of life. There was no difference in the primary outcome between SLI group; 55% (44 out of 80) and the control group; 65% (52 out of 80) [odds ratio (OR): 0.623, 95% confidence interval (CI): 0.33-1.18; p = 0.145]. However, SLI significantly reduced the primary outcome in the sicker infants; who had clinical eligibility criteria (CEC; OR: 0.224, 95% CI: 0.076-0.663; p = 0.005) and in the smaller babies; whose GA was <30 weeks (OR: 0.183, 95% CI: 0.053-0.635; p = 0.005). SLI was not harmful. Although, it did not lead to reduction in the need for IMV in the first 72 h of life in pre-term infants with GA ≥27 and ≤32 weeks, SLI reduced this outcome in the subgroup of infants with CEC and those with GA <30 weeks. Future trials are needed to investigate the effect of SLI on these two subgroups. Clinical trials.gov, NCT03518762. https://www.clinicaltrials.gov/ct2/show/NCT03518762?term=NCT03518762&rank=1.

Characteristics of referral neonates in Sanglah Hospital: reviewed from the S.T.A.B.L.E program

The purpose of this study was to investigate the number of referral neonates that came with an unstable condition (according to a S.T.A.B.L.E program) and characteristic of unstable conditions of the referred neonates. An observational prospective study was conducted for two years from 1st January 2018 to 31st December 2019 in the Emergency Department of Sanglah Hospital, Bali, Indonesia. Referred neonates were assessed in terms of gender, gestational age, referral characteristic, and condition on arrival at the hospital according to S.T.A.B.L.E criteria. According to S.T.A.B.L.E criteria, 283 neonates (54.8%) came on unstable condition. Prematurity (42.6%) was the main reason for referral, 37.9% of them were very low birth weight. Most of them were referred from Denpasar (33.9%), the equipment of transportation was incubator transport (41.8%). T-piece resuscitator was used in 30.4% of referred neonates. Characteristics of unstable conditions were mostly hypoglycemia (33%) and 36% of unstable neonates had more than one condition of instability. This study revealed 283 neonates were unstable and the main reason of transfer neonates is prematurity. Most of them come with unstable conditions that could lead to higher mortality. This study could be a reference for improvement in the neonatal transportation system in Bali.

Effect of T-Piece Resuscitator versus Self Inflating Bag on Arterial CO2 Levels in Preterm Neonates.

ObjectiveTo compare the effect of self-inflating bag (SIB) vs. T-piece resuscitator (TPR) on PaCO2 levels, when used for brief manual ventilation during administration of first dose of surfactant.MethodsPreterm neonates were randomized to receive positive pressure ventilation with either self-inflating bag or T-piece resuscitator during administration of first dose of surfactant. Arterial blood gases were obtained at baseline and 1 h after the intervention. Primary outcome was the mean change in PaCO2 levels 1 h after the intervention.ResultsEighty neonates were enrolled (40 in each group). The drop in PaCO2 at 1 h was significantly greater in the self inflating bag group as compared to the T-piece resuscitator group [8.96 ± 9.06 mmHg vs. 1.37 ± 9.06 mmHg, Mean difference = 7.58 mmHg, (95% CI: 3.78 to 11.4); P < 0.01]. The PaCO2 change was also statistically significant in the subgroup of infants that required only non-invasive ventilation. The need for second dose of surfactant was higher in the self-inflating bag group [77% vs. 55%, RR - 1.41 (95% CI: 1.02 to 1.94); P = 0.03].ConclusionsT-piece resuscitator results in smaller reduction in PaCO2 levels compared to the self inflating bag, when used for brief manual ventilation during surfactant administration.

T-piece resuscitators: can they provide safe ventilation in a low compliant newborn lung?

BackgroundT-piece resuscitators (TPRs) are used for primary newborn resuscitation in birthing and emergency rooms worldwide. A recent study has shown spikes in peak inflation pressure (PIP) over set values with...

T-piece resuscitator or self-inflating bag during neonatal resuscitation: a scoping review.

To identify the evidence for administering positive pressure ventilation (PPV) to infants at birth by either T-piece resuscitator (TPR) or self-inflating bag (SIB), and to determine whether a full systematic review (SR) is warranted. Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews, eligible studies included peer-reviewed human studies, prospectively or retrospectively comparing a TPR vs. SIB for administering PPV at birth. Databases searched were OVID Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials. Review Manager software was used for the data analysis. Following electronic literature search and review, data from four eligible studies (3 RCT and 1 observational study), enrolling a total of 2889 patients, were included. Studies differed regarding the investigated populations, reported outcomes and came from different geographical areas. In particular for preterm infants, use of TPR for providing PPV may improve survival, result in fewer intubations at birth and decrease the incidence of bronchopulmonary dysplasia. This scoping review identified two new studies with substantive new evidence, pointing towards improved survival, decreased bronchopulmonary dysplasia and fewer intubations at birth, in particular among preterm infants treated with TPR. Full SR of the literature is advised. This scoping review identified studies comparing TPR vs. SIB for respiratory support of newborn infants previously not included in the International Liaison Committee on Resuscitation (ILCOR) recommendations. Our review found substantive new evidence highlighting that device choice may impact the outcomes of compromised newborn infants'. This scoping review stipulates the need for full SR and updated meta-analysis of studies investigating supportive equipment for stabilizing infants at birth in order to inform ILCOR treatment recommendations.

Heated Humidifier versus Heat-and-Moisture Exchanger During Positive Pressure Ventilation With a T-Piece Resuscitator in Rabbits.

There are many proven benefits of the use of conditioned gases in mechanically ventilated patients. In spite of this, its use in the delivery room is limited, perhaps because of known difficulties with heated humidifiers (HH); moreover, there is no evidence regarding the use of heat-and-moisture exchangers (HME) in a delivery room setting. We sought to asess the airway's absolute humidity level using three diferents strategies: HH, HME and unconditioned gases. We conducted an experimental study in 12 intubated rabbits ventilated with a T-piece resuscitator. Absolute humidity levels in inspired gases were measured at baseline and at 5, 10, 15, and 20 min while using HH, HME, or no conditioning method (ie, unconditioned). The animals were initially randomized to one of the 3 interventions, and each animal underwent the other methods with at least 24 h between each test. There were no differences in vital signs at baseline or at the end of the procedures. Mean absolute humidity at the end of the tests was 38.2 ± 1.7 g/m3 for HH, 28.9 ± 4.7 g/m3 for HME, and 13.9 ± 5.1 g/m3 for unconditioned gas (P = .003). During ventilation with a T-piece resuscitator, the absolute humidity was the highest with HH. The absolute humidity with HME was lower, but it was still significantly more than that with unconditioned gas. Therefore, the use of a T-piece resuscitator with HME could be a good alternative to HH given that positive-pressure ventilation is used ideally for short periods of time in the delivery room.

Visual attention patterns of team leaders during delivery room resuscitation

AimTo assess visual attention of neonatal team leaders during delivery room resuscitation of preterm infants using eye tracking glasses. MethodsProspective observational eye tracking study. Gaze fixations and sequences were captured, categorized, and mapped during the first 5 min of the resuscitations. Gaze fixation metrics of total gaze duration, visit count, and visit duration were summarized and compared based on interventions performed and provider training level. Fixation sequences were compared between attending neonatologists and fellows. ResultsDuring 18 eye tracking recordings, practitioners focused most of their cumulative visual attention on the infant (median total gaze duration 57%, interquartile range [IQR] 38–61%), followed by monitors (24%, IQR 13–46%), clinical staff (5%, IQR 1–8%), other physical objects (4%, IQR 3–6%), T-piece resuscitator (2%, IQR 0–4%) and the Apgar timer (1%, IQR 0–2%). Visual attention parameters varied according to intervention, with higher visit counts on the infant during corrective ventilation steps than during Continuous Positive Airway Pressure (CPAP) or Positive Pressure Ventilation (PPV), and longer visit durations on monitors during PPV. Time and frequency-based measures of visual attention did not significantly differ by provider training level, but patterned fixation sequences were identified among attending neonatologists that were not observed in fellows. ConclusionTeam leaders predominantly gazed upon the infant and monitors during resuscitation, and visual attention parameters varied depending on the respiratory interventions performed. Attending neonatologists exhibited patterned fixation sequences that were not observed in fellows. Study results may have implications for optimizing delivery room design and training novice providers.

Oxygen supplementation in the delivery room: T-piece resuscitator cap open or occluded?

Updated neonatal resuscitation guidelines for free-flow oxygen administration with a T-piece resuscitator recommend higher gas flow and an open T-piece cap. We aimed to determine the effect of gas inflow rate and cap occlusion on oxygen delivery through a T-piece resuscitator. Using a NeoPuff™ T-piece, oxygen inflow was randomly adjusted from 4 to 10 liters per minute (LPM). Gas outflow and oxygen concentration were measured with the T-piece cap open and occluded. Data were analyzed with repeated measures 2-way ANOVA. Gas outflow was significantly decreased with the T-piece cap open compared with occluded at each inflow rate (p < 0.001). There was no difference in oxygen concentration of the outflow gas. Gas flow from the T-piece is affected by the inflow rate and cap occlusion but oxygen concentration is not. To deliver 5 LPM of free-flow oxygen with the cap open, a minimum of 8 LPM gas inflow is required.

Validation of the disposable T-piece resuscitator (Neo-Tee): a bench study

ObjectiveThe Neo-Tee Infant T-piece resuscitator is a disposable T-piece resuscitator. The aim of this bench study was to assess the accuracy of the Neo-Tee using a measurement set-up and settings...

Time to achieve desired fraction of inspired oxygen using a T-piece ventilator during resuscitation of preterm infants at birth

AimTo determine the time between adjustment of FiO2 at the oxygen blender and the desired FiO2 reaching the preterm infant during respiratory support at birth. MethodsThis observational study was performed using a Neopuff™ T-piece Resuscitator attached to either a test lung (during initial bench tests) or a face mask during the stabilization of infants at birth. FiO2 was titrated following resuscitation guidelines. The duration for the desired FiO2 to reach either the test lung or face mask was recorded, both with and without leakage. A respiratory function monitor was used to record FiO2 and amount of leak. ResultsIn bench tests, the median (IQR) time taken to achieve a desired FiO2 was 34.2 (21.8–69.1) s. This duration was positively associated with the desired FiO2 difference, the direction of titration (upwards) and the occurrence of no leak (R2 0.863, F 65.016, p < 0.001). During stabilization of infants (median (IQR) gestational age 29+0 (28+2–30+0) weeks, birthweight 1290 (1240–1488) g), the duration (19.0 (0.0–57.0) s) required to reach a desired FiO2 was less, but still evident. In 27/55 (49%) titrations, the desired FiO2 was not achieved before the FiO2 levels were again changed. ConclusionThere is a clear delay before a desired FiO2 is achieved at the distal end of the T-piece resuscitator. This delay is clinically relevant as this delay could easily lead to over- and under titration of oxygen, which might result in an increased risk for both hypoxia and hyperoxia.

T-piece resuscitators: how do they compare?

BackgroundThe T-piece resuscitator (TPR) has seen increased use as a primary resuscitation device with newborns. Traditional TPR design uses a high resistance expiratory valve to produce positive end expiratory pressure...