Operating & troubleshooting a T-piece device
Contents
1. neoResus The Victorian Newborn Resuscitation Project Operating amp troubleshooting a T piece device Neopuff Infant Resuscitator Presentation developed by Rosemarie Boland Victorian Newborn Resuscitation Project ie Victorian Newborn Resuscitation Project Aims amp objectives This presentation has been designed to assist you tOo 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 Victorian Newborn Resuscitation Project i ie Victorian Newborn Resuscitation Project Manual ventilation devices The ARC Neonatal Guidelines state A self inflating bag a flow inflating bag or a T piece device are all acceptable devices which can be used to ventilate newborn infants either via a face mask or via an endotracheal tube ARC 2006 Guideline 13 4 Victorian Newborn Resuscitation Project ie Victorian Newborn Resuscitation Project T piece 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 The T piece device will not deliver PIP or PEEP CPAP above the set pressures if the flow remains constant The PIP amp PEEP a2. 00 O when using the Neopuff Victorian Newborn Resuscitation Project ie Victorian Newborn Resuscitation Project Recommended settings Gas flow rate Set at 8 L min Maximum pressure relief valve set at 50 cm H O Peak inspiratory pressure PIP set at 30 cm H O Positive end expiratory pressure PEEP set at 5 cm H 0 ARC 2006 Guideline 13 4 Victorian Newborn Resuscitation Project i ie Victorian Newborn Resuscitation Project setting up the Neopuff 6 steps e Connect the gas supply line to the gas inlet and the patient supply line to the gas outlet e Attach a test lung to the end of the patient supply line and turn the gas flow to 8 L min e Check the maximum pressure relief is set at 50 cm H O adjust as necessary Victorian Newborn Resuscitation Project LEE ie Victorian Newborn Resuscitation Project setting up the Neopuff 6 steps e Set the peak inspiratory pressure PIP to 30 cm H O e Set the positive end expiratory pressure PEEP to 5 cm H O e Create a good seal between the infant s face amp the face mask using the two point top hold Victorian Newborn Resuscitation Project 1 Connect the gas amp patient neoResus supply lines 2 Connect the patient supply i Connect the gas supply line NEOPUFF via the plastic peN line to the gas A 330 connector to outlet the gas inlet Victorian Newborn Resus
3. 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 good seal Checking the face mask seal srs Listen amp look technique Listen for a soft whistle of Look that a PEEP of 5 cm H O is gas through the PEEP cap displayed on the manometer 5 cm H O ie Victorian Newborn Resuscitation Project Face mask leak a Leaks averaging 40 to 70 so around face masks are common due to poor mask placement technique amp the manner in which the mask is held see box plots Be aware that a PIP of 30 cm H O may be reached on the manometer despite a leak of te ae up to 90 Wood et al 2008 Laerdal Round Mask Face Mask Leak n Delivering positive pressure rex inflations with the Neopuff 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 each manual inflation Victorian Newborn Resuscitation Project a neoResus The Victorian Newborn Resus citation Project Initial inflations Higher inflation pressures PIP gt 30 cm H O may be needed for the initial inflati
4. citation Project ie Victorian Newborn Resuscitation Project 2 Attach the test lung Attach the test lung to the end of the patient supply line patient T piece t 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 L min Victorian Newborn Resuscitation Project 3 Check the maximum pressure ieres has been pre set to 50 cm H O os I _ DF 50 80 o om H O ie Victorian Newborn Resuscitation Project Turn the inspiratory pressure control dial fully clockwise until it cannot turn any further A Occlude the PEEP cap on the patient T piece 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 will need to adjust it See following slide Victorian Newborn Resuscitation Project NEE ie Victorian Newborn Resuscitation Project Adjusting the maximum pressure Once the inspiratory pressure ZTN p yp Cue control dial is fully open i i Occlude the PEEP cap on the Nef he patient T piece 2 Open the cap covering the NGI A maximum pressure relief lt Turn the maximum pressure relief dial clockwise or anti clockwise to adjust the pressure to 50 cm H O 4 Close the max pressure relief cap Victorian Newborn Resuscitation Project SS 4 Set the peak inspiratory neoResu pressur
5. d and apply the face mask again Still unable to achieve the set PIP Consider intubation if mask ventilation is unsuccessful Victorian Newborn Resuscitation Project Most importantly look at the ects baby not at the manometer Effective ventilation is confirmed by An increase in the heart rate above 100 bpm A rise of the chest amp upper abdomen with each inflation Achieving the set PIP on the manometer is not a sign of effective ventilation A PIP of 30 cm H O on the manometer can be achieved with leaks of up to 90 Wood et al 2008 Victorian Newborn Resuscitation Project NN ie Victorian Newborn Resuscitation Project Remember lf the heart rate remains lt 100 bpm and or the chest is not moving despite ventilating with good technique TURN UP THE PEAK PRESSURE PIP 30 gt 40 gt 50 60 cm H O Continue to provide positive pressure ventilation until the heart rate is above 100 bpm and the infant has established effective spontaneous respirations Endotracheal intubation should be considered if ventilation via a face mask is unsuccessful Victorian Newborn Resuscitation Project ie Victorian Newborn Resuscitation Project References Australian Resuscitation Council 2006 Guideline 13 4 Airway management and mask ventilation of the newborn infant Accessed December 10 2009 from http www resus org au Fisher amp Paykel Healthcare 2004 Neopuff Infant Resuscitator Optimal resusci
6. e PIP Occlude the PEEP cap on the end of the patient T piece Turn the inspiratory pressure control anti clockwise several times to decrease the pressure from 50 cmH O down to 30 cm cmH O The set PIP is displayed on the y ce manometer when the PEEP cap on the patient T piece is occluded Victorian Newborn Resuscitation Project I 5 Set the positive end expiratory sses pressure PEEP Set the PEEP by turning the cap on the patient T piece clockwise or anti a clockwise until a PEEP of 5 cm H O is a NY displayed on the manometer Sse Caution If the PEEP has been set ona F flow rate of 8 L min any increase in the flow rate will result in a dangerously high increase in PEEP Morley Schmolzer amp Davis 2009 f you change the flow rate then re set and re check the PEEP Victorian Newborn Resuscitation Project 6 Create a good seal between rests __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 a finger onto the chin tip the guide finger Line up the outer 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 Victorian Newborn Resuscitation Project T Holding the mask in place using reres two point top hold Apply evenly balanced downward pressure onto the mask using the thumb
7. ons Subsequent inflations usually require less pressure although some babies may need higher inflation pressures higher PIP Improvement in heart rate is the primary measure of adequate ventilation If heart rate is not improving assess chest wall movement Higher PIP may be required Victorian Newborn Resuscitation Project fj Adjusting the PIP whilst USING xs the Neopuff Higher pressure inflations Ca can be given by increasing 3 a the inspiratory pressure a control to deliver higher PIP zT This can be changed while C resuscitating but requires a second person to achieve this efficiently Victorian Newborn Resuscitation Project ie 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 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 Victorian Newborn Resuscitation Project NN ie 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 hea
8. re displayed on the manometer The operator can control the length of the inspiratory time by varying the duration of occlusion of the PEEP cap Victorian Newborn Resuscitation Project 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 especially in very premature infants n Resuscitation Project ie 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 Agas supply line green oxygen tubing with the plastic connector supplied The patient supply line tubing amp T piece A test lung Victorian Newborn Resuscitation Project Patient supply line Gas supply a Gas supply line Test lung ie Victorian Newborn Resuscitation Project Which gas Air or oxygen The ARC recommend Use air 21 initially If there is no improvement in condition within the first minutes of life then introduce supplementary oxygen ARC 2006 Guideline 13 4 N B Unless an air amp an oxygen cylinder a blender is available you will have to use 1
9. tation 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 Victorian Newborn Resuscitation Project i ie 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 Victorian Newborn Resuscitation Project ie Victorian Newborn Resuscitation Project Disclaimer This teaching program has been developed by the Newborn Emergency Transport Service NETS part of The Royal Women s Hospital RWH 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 RWH shall not be held responsible for any act or omission which may result in inj
10. ury or death to any baby as a result of reliance on this material Victorian Newborn Resuscitation Project ha I TheVictorian Newborn Resuscitation Project Copyright This material is copyright NeoResus The Victorian Newborn Resuscitation Project 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 Victorian Newborn Resuscitation Project
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