Operating & troubleshooting a T-piece device
Contents
1. I neoResus The Victorian Newborn Resuscitation Project Operating amp troubleshooting a T piece device Neopuff Infant Resuscitator Victorian Newborn Resuscitation Project Updated February 2012 NE neoResus The Victorian Newborn Resuscitation Project Aims amp objectives This presentation has been designed to assist you to Assemble the Neopuff T piece device Set the recommended flow rate amp pressures Operate the Neopuff T piece device Troubleshoot the Neopuff T piece device We suggest that you print a copy of this presentation and have the Neopuff at hand to practice each action Updated February 2012 Victorian Newborn Resuscitation Project m neoResus The Victorian Newborn Resuscitation Project Manual ventilation devices The Australian Resuscitation Council ARC amp the New Zealand Resuscitation Council NZRC guidelines state A T piece device a self inflating bag and a flow inflating bag are all acceptable devices to ventilate newborn infants either via a face mask or endotracheal tube ARC amp NZRC 2010 Guideline 13 4 Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project T plece device e g Neopuff Infant Resuscitator Advantages of using a T piece device The operator sets the peak inspiratory pressure PIP amp positive end expiratory pressure PEEP The2. T piece device will not deliver PIP or PEEP CPAP above the set pressures if the flow remains constant The PIP amp 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 Updated February 2012 Victorian Newborn Resuscitation Project NN neoResus The Victorian Newborn Resuscitation Project Positive end expiratory pressure T piece device Self inflating bag Can provide CPAP Does not deliver or PEEP CPAP or PEEP Unless a PEEP valve has been fitted Why is PEEP so important It assists with lung expansion It helps to establish functional residual capacity It leads to improved oxygenation Updated February 2012 Victorian Newborn Resuscitation Project NEE neoResus The Victorian Newborn Resuscitation Project Setting up the Neopuff To check amp set the Neopuff you will need A Neopuff Infant Resuscitator A compressed gas source A gas supply line green oxygen tubing with the plastic connector supplied The patient supply line tubing amp T piece A test lung Victo suscitation Project SS I neoResus The Victorian Newborn Resuscitation Project The components of the Neopuff Gas supply Gas supply line AA Patient supply line with T piece amp mask Test lung SS neoResus The Victorian Newborn Resuscitation Pro
3. each manual inflation Updated February 2012 Victorian Newborn Resuscitation Project SS neoResus The Victorian Newborn Resuscitation Project Air or oxygen for resuscitation Term newborns Use air 21 initially Preterm newborns lt 32 weeks Use air or blended air and oxygen 21 to 30 oxygen to start Use air if a blender is not available Supplemental oxygen should be used judiciously ideally guided by pulse oximetry The first priority is to ensure adequate inflation of the lungs followed by increasing the concentration of inspired oxygen only if needed ARC amp NZRC 2010 Guideline 13 4 Updated February 2012 Victorian Newborn Resuscitation Project S during the first minutes after birth Time after birth in minutes Targeted pre ductal SpO after birth during resuscitation with supplemental oxygen 1 minute 60 70 2 minutes 65 85 3 minutes 70 90 4 minutes 75 90 5 minutes 80 90 10 minutes 85 90 ARC amp NZRC2 2010 Guideline 13 4 Updated January 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project Initial inflations Higher inflation pressures PIP gt 30 cm HO may be needed for the initial inflations Subsequent inflations usually require less pressure although some babies may need higher inflation pressures higher PIP Improvement in heart rate is the primary measur
4. if mask ventilation is unsuccessful Updated February 2012 Victorian Newborn Resuscitation Project m Most importantly look at the teess infant not at the manometer Effective ventilation is confirmed by three signs An increase in the heart rate above 100 minute A slight rise of the chest and upper abdomen with each inflation An improvement in oxygenation Achieving the set PIP on the manometer is not a sign of effective ventilation Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project Remember If the heart rate remains lt 100 min and or the chest is not moving despite ventilating with good technique TURN UP THE PEAK PRESSURE PIP 30 40 50 60 cm H O Continue to provide positive pressure ventilation until the heart rate is above 100 min and the infant has established effective soontaneous respirations Endotracheal intubation should be considered if ventilation via a face mask is unsuccessful Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project References Australian Resuscitation Council amp New Zealand Resuscitation Council 2010 Guideline 13 4 Airway management and mask ventilation of the newborn infant Accessed February 2 2012 from http www resus org au Fisher amp Paykel Healthcare 2004 Neopuff Infant Resusc
5. to the gas connector to outlet the gas inlet Updated February 2012 Victorian Newborn Resuscitation Project I neoResus The Victorian Newborn Resuscitation Project 2 Attach the test lung Attach the test lung to the end of A the patient supply line patient T Wii It is much easier to use the test lung as opposed to a face mask or the ball of your hand to set and test the Neopuff Turn the gas flow to 8 10 L min Updated February 2012 Victorian Newborn Resuscitation Project I The Victorian Newborn Resuscitation Project has been pre set to 50 cm H O 1 Turn the inspiratory pressure control dial ya fully clockwise until it cannot turn any eS further A 2 Occlude the PEEP cap on the patient T piece 3 Look at the manometer amp check that the pressure gauge points to 50 cm H O B If it does then the maximum pressure is set correctly If it is not 50 cm H O you a will need to adjust it See following slide Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project Adjusting the maximum pressure Once the inspiratory pressure M S control dial is fully open P a 1 Occlude the PEEP cap on the patient T A in piece 2 Open the cap covering the maximum pressure relief dial jit A 3 Turn the maximum pressure relief dial a T clockwise or anti clockwis
6. e of adequate ventilation If the heart rate is not improving with good technique then higher PIP may be required Updated February 2012 Victorian Newborn Resuscitation Project the Neopuff oon Higher pressure inflations can be at ark given by increasing the Fi 4 inspiratory pressure control to af i deliver higher PIP This can be changed while resuscitating but requires a second person to achieve this efficiently Updated February 2012 Victorian Newborn Resuscitation Project NN neoResus The Victorian Newborn Resuscitation Project Common problems amp solutions Unable to achieve the desired PIP amp PEEP when checking the Neopuff with the test lung Check that the gas flow rate is set to 8 10 L min and that there is gas flow through the Neopuff circuit Still unable to achieve the desired PIP amp PEEP when checking the Neopuff with the test lung Check the maximum pressure relief is set correctly at 50 cm H O and adjust if necessary Updated February 2012 Victorian Newborn Resuscitation Project NN neoResus The Victorian Newborn Resuscitation Project Common problems amp solutions Unable to achieve the set PIP when ventilating the infant Check the face mask seal using the look and listen technique Still unable to achieve the set PIP Reposition the infant s head and apply the face mask again Still unable to achieve the set PIP Consider intubation
7. e to adjust the maximum pressure to 50 cm H O 4 Close the maximum pressure relief cap Updated February 2012 Victorian Newborn Resuscitation Project ee 4 Set the peak inspiratory neoResus pressure PIP pa 1 Occlude the PEEP cap on the end of LN the patient T piece Turn the inspiratory pressure control anti clockwise several times to decrease the pressure from 50 cmH O down to the recommended PIP 20 25 cm H O for a premature infant or 30 cm H O for a term infant 3 The set PIP is displayed on the manometer when the PEEP cap on the ae a patient T piece is occluded Updated February 2012 Victorian Newborn Resuscitation Project NN pressure PEEP Set the PEEP by turning the cap on the patient T piece clockwise or anti clockwise until a PEEP of 5cm H O is displayed on the manometer l Caution Ifthe PEEP has been set on a flow lI ree O rate of 8 L min any increase in the flow rate will ie eel result in a dangerously high increase in PEEP Morley Schmoelzer amp Davis 2009 If you increased the flow rate to 10 L min then re set and re check the PEEP Updated February 2012 Victorian Newborn Resuscitation Project NN the infant s face amp the mask Remove the test lung amp attach a face mask to the patient T piece Position the infant s head in a neutral position Place the third finger onto the chin tip the guide finger Line up the ou
8. hall not be held responsible for any act or omission which may result in injury or death to any baby as a result of reliance on this material Updated February 2012 Victorian Newborn Resuscitation Project a j neoResus Copyright This presentation was developed by Rosemarie Boland on behalf of the Victorian Newborn Resuscitation Project 2012 The material is copyright NeoResus This presentation may be downloaded for personal use but remains the intellectual property of NeoResus and as such may not be reproduced or used for another training program without the written permission of the Victorian Newborn Resuscitation Project Executive Please contact us at admin neoresus org au Updated February 2012 Victorian Newborn Resuscitation Project
9. itator Optimal resuscitation in neonatal care Auckland New Zealand Morley C J Schmolzer G M amp Davis P G 2009 Potential hazards of the Neopuff using appropriate gas flow Archives of Disease in Childhood Fetal and Neonatal Edition 94 F467 F468 Wood F E Morley C J Dawson J A Kamlin C O Owen L S Donath S amp Davis P G 2008 Improved techniques reduce face mask leak during simulated neonatal resuscitation Study 2 Archives of Disease in Childhood Fetal amp Neonatal Edition 93 F230 F234 Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project Acknowledgements The animated graphics used in this presentation have been reproduced with the kind permission of Dr Andy Gill Consultant Neonatologist King Edward Memorial Hospital Western Australia The Neopuff colour diagrams have been reproduced with the kind permission of Fisher amp Paykel Healthcare Australia and New Zealand Updated February 2012 Victorian Newborn Resuscitation Project NE neoResus The Victorian Newborn Resuscitation Project Disclaimer This teaching program has been developed by the Newborn Emergency Transport Service NETS Victoria as an educational program around neonatal care with the assistance of a grant from the Department of Health Victoria Whilst appreciable care has been taken in the preparation of this material NETS s
10. ject Initial recommended settings Gas flow rate Set at 10 L min 8L min if using cylinders Maximum pressure relief valve Set at 50 cm H O Peak inspiratory pressure PIP Set at 30 cm H O term newborn Set at 20 25 cm H O preterm lt 32 weeks Positive end expiratory pressure PEEP set at5 8 cm H O ARC amp NZRC 2010 Guideline 13 4 Updated February 2012 Victorian Newborn Resuscitation Project SS neoResus The Victorian Newborn Resuscitation Project Setting up the Neopuff 6 steps e Connect the gas supply line to the gas inlet amp the patient supply line to the gas outlet e Attach a test lung to the patient supply line and turn the gas flow to 8 10 L min e Check the maximum pressure relief valve is set to 50 cm H O adjust as necessary Updated February 2012 Victorian Newborn Resuscitation Project NNN neoResus The Victorian Newborn Resuscitation Project Setting up the Neopuff 6 steps e Set the peak inspiratory pressure PIP to 30 cm H O term or 20 25 cm H O preterm e Set the positive end expiratory pressure PEEP to5 8cmH O e Create a good seal between the infant s face amp the face mask using the two point top hold Updated February 2012 Victorian Newborn Resuscitation Project DI 1 Connect the gas amp patient neofesu supply lines 1 Connect the 2 Connect the gas supply line patient supply via the plastic line
11. ter edge of the mask into the groove between the guide finger and the chin tip Roll the mask onto the face from the chin upwards Updated February 2012 Victorian Newborn Resuscitation Project a Holding the mask in place using rex the two point top hold Apply evenly balanced downward pressure onto the mask using the thumb and index finger positioned toward the outer edge of the flat area of the mask two point top hold Apply jaw lift with the remaining fingers so that the upward pressure works against the downward pressure from the two point top hold to create a Updated rena ae non Newborn esuscitation roject good seal Listen amp look technique Leaks averaging 40 70 are common due to poor mask placement technique Therefore Listen for a soft whistle of gas through the PEEP Cap Look that a PEEP of 5 cm H O is displayed on the manometer Be aware that a PIP of 30 cm H O may be reached on the manometer despite a face mask leak of up to 90 Wood et al 2008 Updated February 2012 Victorian Newborn Resuscitation Project SS Delivering positive pressure tex inflations with the Neopuf ud Occlude the PEEP cap using your thumb or finger for 0 5 seconds then release for 0 5 seconds This will provide a ventilation rate of 60 inflations per minute Continue to check your mask seal by checking that the PEEP CPAP returns to 5 cm H O on the manometer after
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