Resuscitation

1. Resuscitation of neonates with Ambu bag, Flow inflating bag and T-piece Ebtihal Hassan Al- Oweywee ID: 2120000528

2. Outlines: Definition of resuscitation Ambu bag Flow inflating bag T-piece Study about the hazards of T-piece without limitation of flow rate. Study that compare the 3 types of resuscitation devices.

3. Definition of neonatal resuscitation Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat. Before a baby is born, the placenta provides oxygen and nutrition to the blood and removes carbon dioxide. After a baby is born, the lungs provide oxygen to the blood and remove carbon dioxide. Many babies go through this transition without needing intervention. Some babies need help with establishing their air flow, breathing, or circulation.

4. Resuscitation devices Self inflating bag Flow inflating bag T-piece

5. Self Inflating Bag ( Ambu bag)

6. Self inflating bag Fill spontaneously after they are squeezed, pulling oxygen or air into the bag Remain inflated at all times Can deliver positive-pressure ventilation without a compressed gas source. Require attachment of an oxygen reservoir to deliver 100% oxygen

7. Without Reservoir With Reservoir

8. Advantages: Does not need a gas source to inflate Pressure release valve Portable and light weight Available in single use, disposable bags

9. Will inflate even without adequate seal. Requires a reservoir to deliver 100% oxygen. Does not provide PEEP/CPAP (unless a PEEP valve has been fitted). Disadvantages:

10. Place the mask firmly against your hand. Squeeze the bag repeatedly. You should feel air pressure against your hand and see the lip valve open and close If pressure is not felt, this device is not safe to use! Testing the self-inflating bag

11. Test the pressure relief valve (pop off valve) Remove the mask and occlude the patient port connector with your thumb. Compress the bag several times. Look & listen for opening of the pressure relief valve.

12. Connect an oxygen source & check that the reservoir bag inflates

13. Create a good seal between the infant's face & the mask How to use it ??!

14. Incorrect ways to hold a mask A: Do not hold the stem B: Do not hold the outer edge × ×

15. Air or oxygen for resuscitation? Term newborns: Use air (21%) initially. Preterm newborns < 32 weeks: Use air or blended air and oxygen ( 21% to 30% oxygen to start). Use air if a blender is not available.

16. Is your technique effective? If your ventilation technique is effective, three signs are observed: An increase in the heart rate above 100/min. A slight rise and fall of the chest and upper abdomen with each inflation. An improvement in oxygenation. If the heart rate is not improving: The technique of ventilation needs to be improved. Consider increasing the PIP. Endotracheal intubation should also be considered.

17. Flow Inflating Bag

18. flow inflating bag Fill only when oxygen from a compressed source flows into them Depend on a compressed gas source Must have a tight face-mask seal to inflate

19. Flow inflating bag will not work if The mask is not properly sealed over the newborn’s nose and mouth There is a tear in the bag. The pressure gauge is missing

20. Delivers 100% oxygen at all times. Easy to determine the adequacy of seal. “Stiffness” of lungs can be felt. Provide PEEP. Advantages:

21. Requires a tight seal to remain inflated Requires a gas source to inflate No safety pop-off valve Requires more experience Disadvantages:

22. T-Piece

23. Setting up the Neopuff ™ Gas supply Gas supply line Test lung Patient supply line with T-piece & mask Neopuff

24. Gas flow rate 10 L/min (8L /min if using cylinders) Maximum pressure relief valve 50 cm H2O PIP 30 cm H2O (term newborn) 20 - 25 cm H2O (preterm < 32 weeks’) PEEP 5 - 8 cm H2O Initial recommended settings

25. 1. Connect the gas & patient supply lines

26. 2. Connect the test lung to T-piece and turn on the flow 3. Turn the inspiratory pressure control dial fully clockwise Occlude the PEEP cap check that the pressure gauge points to 50 cmH2O

27. 4. Set the PIP and PEEP 20 – 25 cm H2O for a premature infant or 30 cm H2O for a term infant. Set a PEEP of 5 cm H2O Caution: any increase in the flow rate will result in a dangerously high increase in PEEP.

28. The operator can set the (PIP) & (PEEP). The T-piece device will not deliver PIP or PEEP/CPAP above the set pressures if the flow remains constant. The PIP & 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 . Advantages:

29. Requires a gas source to operate. The set PIP can be reached on the manometer despite a face mask leak of up to 90 %. As the T- piece device delivers a set pressure, it is still possible to deliver large volumes of gas to the infant which may cause a pneumothorax or damage the lungs of infant. Disadvantages:

30. Potential hazard of the Neopuff T-piece resuscitator in the absence of flow limitation

31. To assess (PIP), (PEEP) and ( Pmax ) at different flow rates To assess maximum PIP and PEEP at a flow rate of 10 l/min with a simulated air leak of 50%. The Aim

32. Method 5 Neopuffs were set to PIP of 20 PEEP of 5 Pmax of 30 flow of 5 PIP , PEEP and Pmax were recorded at flow rates of 10, 15 l/min and maximum flow. Maximum achievable PIP and PEEP at a flow rate of 10 l/min with a simulated air leak of 50%.

33. At gas flow of (15 l/min) PEEP increased to 20 PIP increase to 28 Pmax increase to 40 cm H2O At maximum flow (85 l/min) PEEP increase to 71 PIP increase to 92 cm H2O At 10 l/min flow, with an air leak of 50 %, the maximum PEEP is 21 The maximum PIP is 69 Result

34. Pmax is overridden by increasing the rate of gas flow and potentially harmful PIP and PEEP can be generated. Even in the presence of a 50% gas leak, more than adequate pressures can be provided at 10 l/min gas flow. We recommend the limitation of gas flow to a rate of 10 l/min as an added safety mechanism for this device. Conclusion

35. A comparison of three neonatal resuscitation devices

36. Method We studied 31 operators using a T-piece resuscitator, a self-inflating bag and a flow-inflating bag. we evaluated the ability to deliver a consistent PIP of 20 or 40 cmH2O and a PEEP of 5 cmH2O . evaluate the ability to maintain a 5 s inflation at a PIP of 20 cmH2O Evaluate the time to transition from a PIP of 20 to 40 cmH2O.

37. T-Piece resuscitator Self inflating bag Flow inflating bag (PIP) at the target of 20 cmH2O 20 24 - ( Pmax ) at the target of 40 cmH2O 39 45 44 The duration to increase the PIP from 20 to 40 5.7 2.2 1.8 Maintaining pressure greater than 18 for 5 s 4 2.2 3.7 Result

38. The T-piece resuscitator delivered the desired pressures more accurately, but required greater time to increase the PIP from 20 to 40 cmH2O. It was difficult to maintain a prolonged inflation time with the self-inflating bag Conclusion

39. References: Australian Resuscitation Council & the New Zealand Resuscitation Council. (2010). Section 13: Neonatal Guidelines. Retrieved February 2, 2012 from : http :// www.resus.org.au Up to date Laerdal Medical (2006) Laerdal silicone resuscitators: Interactive presentation. Accessed April 27, 2009 from http :// www.laerdaltraining.com/lsr Fisher & Paykel Healthcare. (2004). Neopuff ™ Infant Resuscitator. Optimal resuscitation in neonatal care. Auckland, New Zealand . http:// fn.bmj.com/content/94/6/F461.short http:// www.ncbi.nlm.nih.gov/pubmed/16081202