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Shah D, Tracy M, Hinder M, Badawi N. Positive end expiratory pressure and respiratory system resistance between self-inflating bag and T-piece resuscitator in a cadaveric piglet lung model. Front Pediatr 2022; 10:1014311. [PMID: 36467494 PMCID: PMC9714259 DOI: 10.3389/fped.2022.1014311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In neonatal resuscitation, T-piece resuscitator (TPR) are used widely, but the evidence is limited for their use in infants born at term gestation. The aim of this study was to compare the delivered positive end expiratory pressure (PEEP) and respiratory system resistance (Rrs) using TPR and self-inflating bag (SIB) in a cadaveric piglet model. METHODS Cadaveric newborn piglets were tracheotomised, intubated (cuffed tube) and leak tested. Static lung compliance was measured. Positive pressure ventilation was applied by TPR and SIB in a randomized sequence with varying, inflations per minute (40, 60 and 80 min) and peak inspiratory pressures (18 and 30 cmH2O). PEEP was constant at 5 cmH2O. The lungs were washed with saline and static lung compliance was re-measured; ventilation sequences were repeated. Lung inflation data for the respiratory mechanics were measured using a respiratory function monitor and digitally recorded for both pre and post-lung wash inflation sequences. A paired sample t-test was used to compare the mean and standard deviation. RESULTS The mean difference in PEEP (TPR vs. SIB) was statistically significant at higher inflation rates of 60 and 80 bpm. At normal lung compliance, mean difference was 1.231 (p = 0.000) and 2.099 (p = 0.000) with PIP of 18 and 30 cmH2O respectively. Significantly higher Rrs were observed when using a TPR with higher inflation rates of 60 and 80 bpm at varying lung compliance. CONCLUSION TPR is associated with significantly higher PEEP in a compliant lung model, which is probably related to the resistance of the TPR circuit. The effect of inadvertent PEEP on lung mechanics and hemodynamics need to be examined in humans. Further studies are needed to assess devices used to provide PEEP (TPR, SIB with PEEP valve, Anaesthetic bag with flow valve) during resuscitation of the newborn.
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Affiliation(s)
- Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Tracy
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Murray Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nadia Badawi
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, NSW, Australia.,Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, NSW, Australia
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Holte K, Ersdal H, Eilevstjønn J, Gomo Ø, Klingenberg C, Thallinger M, Linde J, Stigum H, Yeconia A, Kidanto H, Størdal K. Positive End-Expiratory Pressure in Newborn Resuscitation Around Term: A Randomized Controlled Trial. Pediatrics 2020; 146:peds.2020-0494. [PMID: 32917847 DOI: 10.1542/peds.2020-0494] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND International guidelines for resuscitation recommend using positive end-expiratory pressure (PEEP) during ventilation of preterm newborns. Reliable PEEP-valves for self-inflating bags have been lacking, and effects of PEEP during resuscitation of term newborns are insufficiently studied. The objective was to determine if adding a new PEEP valve to the bag-mask during resuscitation of term and near-term newborns could improve heart rate response. METHODS This randomized controlled trial was performed at Haydom Lutheran Hospital in Tanzania (September 2016 to June 2018). Helping Babies Breathe-trained midwives performed newborn resuscitation using self-inflating bags with or without a new, integrated PEEP valve. All live-born newborns who received bag-mask ventilation at birth were eligible. Heart rate response measured by ECG was the primary outcome, and clinical outcome and ventilation data were recorded. RESULTS Among 417 included newborns (median birth weight 3200 g), 206 were ventilated without and 211 with PEEP. We found no difference in heart rate response. Median (interquartile range) measured PEEP in the PEEP group was 4.7 (2.0-5.6) millibar. The PEEP group received lower tidal volumes (4.9 [1.9-8.2] vs 6.3 [3.9-10.5] mL/kg; P = .02) and had borderline lower expired CO2 (2.9 [1.5-4.3] vs 3.3 [1.9-5.0] %; P = .05). Twenty four-hour mortality was 9% in both groups. CONCLUSIONS We found no evidence for improved heart rate response during bag-mask ventilation with PEEP compared with no PEEP. The PEEP valve delivered a median PEEP within the intended range. The findings do not support routine use of PEEP during resuscitation of newborns around term.
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Affiliation(s)
- Kari Holte
- Department of Pediatrics and Adolescence Medicine, Østfold Hospital Trust, Grålum, Norway; .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Departments of Anesthesiology and Intensive Care
| | - Joar Eilevstjønn
- Strategic Research Department, Laerdal Medical, Stavanger, Norway
| | - Øystein Gomo
- Strategic Research Department, Laerdal Medical, Stavanger, Norway
| | - Claus Klingenberg
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway.,Pediatric Research Group, Faculty of Health Sciences, University of Tromsø-Arctic University of Norway, Tromsø, Norway
| | - Monica Thallinger
- Department of Anesthesiology and Intensive Care, Vestre Viken Hospital Trust, Bærum, Norway
| | - Jørgen Linde
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Pediatrics and Adolescence Medicine, and
| | - Hein Stigum
- Norwegian Institute of Public Health, Oslo, Norway
| | - Anita Yeconia
- Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania; and
| | - Hussein Kidanto
- Research, Stavanger University Hospital, Stavanger, Norway.,Medical College, Agakhan University, Dar es Salaam, Tanzania
| | - Ketil Størdal
- Department of Pediatrics and Adolescence Medicine, Østfold Hospital Trust, Grålum, Norway.,Norwegian Institute of Public Health, Oslo, Norway
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Abstract
Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of volume/cardiac medications. Although advanced resuscitation is infrequent, it is crucial that personnel adequately trained in these techniques are available to provide such resuscitative measures. In 2000, Louis Halmalek et al. called for a "New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment." This was one of the first articles to highlight simulation as a method of teaching newborn resuscitation. The last decades have seen an exponential growth in the area of simulation in newborn care, in particular in newborn resuscitation and stabilization. Simulation is best defined as an instructional strategy "used to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." Simulation training has now become an important point of how we structure training and deliver improved healthcare to patients. Some of the key aspects of simulation training include feedback, deliberate practice, outcome measurement, retention of skills and curriculum integration. The term "Train to win" is often used in sporting parlance to define how great teams succeed. The major difference between sports teams is that generally their game day comes once a week, whereas in newborn resuscitation every day is potentially "game day." In this review we aim to summarize the current evidence on the use of simulation based education and training in neonatal resuscitation, with particular emphasis on the evidence supporting its effectiveness. We will also highlight recent advances in the development of simulation based medical education in the context of newborn resuscitation to ensure we "train to win."
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Affiliation(s)
- Aisling A Garvey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT Research Centre, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT Research Centre, Cork, Ireland
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Hinder M, Jani P, Priyadarshi A, McEwan A, Tracy M. Neopuff T-piece resuscitator: does device design affect delivered ventilation? Arch Dis Child Fetal Neonatal Ed 2017; 102:F220-F224. [PMID: 27645491 DOI: 10.1136/archdischild-2016-311164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND The T-piece resuscitator (TPR) is in common use worldwide to deliver positive pressure ventilation during resuscitation of infants <10 kg. Ease of use, ability to provide positive end-expiratory pressure (PEEP), availability of devices inbuilt into resuscitaires and cheaper disposable options have increased its popularity as a first-line device for term infant resuscitation. Research into its ventilation performance is limited to preterm infant and animal studies. Efficacy of providing PEEP and the use of TPR during term infant resuscitation are not established. AIM The aim of this study is to determine if delivered ventilation with the Neopuff brand TPR varied with differing (preterm to term) test lung compliances (Crs) and set peak inspiratory pressures (PIP). DESIGN A single operator experienced in newborn resuscitation provided positive pressure ventilation in a randomised sequence to three different Crs models (0.5, 1 and 3 mL/cmH2O) at three different set PIP (20, 30 and 40 cmH2O). Set PEEP (5 cmH2O), gas flow rate and inflation rate were the same for each sequence. RESULTS A total of 1087 inflations were analysed. The delivered mean PEEP was Crs dependent across set PIP range, rising from 4.9 to 8.2 cmH2O. At set PIP 40 cmH2O and Crs 3 mL/cmH2O, the delivered mean PIP was significantly lower at 35.3 cmH2O. CONCLUSIONS As Crs increases, the Neopuff TPR can produce clinically significant levels of auto-PEEP and thus may not be optimal for the resuscitation of term infants with healthy lungs.
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Affiliation(s)
- Murray Hinder
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Faculty of Engineering and Information Technologies, BMET Institute, Sydney University, Sydney, New South Wales, Australia
| | - Pranav Jani
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Paediatrics and Child Health, Sydney University, Westmead, New South Wales, Australia
| | - Archana Priyadarshi
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Paediatrics and Child Health, Sydney University, Westmead, New South Wales, Australia
| | - Alistair McEwan
- Faculty of Engineering and Information Technologies, BMET Institute, Sydney University, Sydney, New South Wales, Australia
| | - Mark Tracy
- Neonatal Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Paediatrics and Child Health, Sydney University, Westmead, New South Wales, Australia
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Hawkes CP, Ryan CA, Dempsey EM. Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review. Resuscitation 2012; 83:797-802. [DOI: 10.1016/j.resuscitation.2011.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
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Abstract
AIM The current recommendation in setting up the Neopuff is to use a gas flow of 5-15 L/min. We investigated if the sensitivity of the positive end expiratory pressure (PEEP) valve varies at different flow rates within this range. METHODS Five Neopuffs were set up to provide a PEEP of 5 cm H(2) O. The number of clockwise revolutions to complete occlusion of the PEEP valve and the mean and range of pressures at each quarter clockwise revolution were recorded at gas flow rates between 5 and 15 L/min. RESULTS At 5, 10 and 15 L/min, 0.5, 1.7 and 3.4 full clockwise rotations were required to completely occlude the PEEP valve, and pressures rose from 5 to 11.4, 18.4 and 21.5 cm H(2) O, respectively. At a flow rate of 5 L/min, half a rotation of the PEEP dial resulted in a rise in PEEP from 5 to 11.4cm H(2) O. At 10 L/min, half a rotation resulted in a rise from 5 to 7.7cm H(2) O, and at 15 L/min PEEP rose from 5 to 6.8cm H(2) O. CONCLUSION Users of the Neopuff should be aware that the PEEP valve is more sensitive at lower flow rates and that half a rotation of the dial at 5 L/min gas flow can more than double the PEEP.
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