T-Piece Resuscitator | OSCE clinical Procedure skills

It's time to change over from neonatal Ambu bags

It's hard to change old habits, but now that the data clearly shows that it's time to get rid of neonatal Ambu bags.  While, as a matter of fact, we still need Ambu bags, we also need to switch over to more newborn-friendly interfaces.

My first experience with T-Piece Resuscitator

In my NICU rotation during residency, I first got to work with T-Piece Resuscitator (Neo-puff) in our unit. I was skeptical to start using it since I was more comfortable with a bag and mask for resuscitation, especially for labor room and OT calls.

"Why can't we just bag?" That was my first impression before I learned how easy and more physiological T-Piece Resuscitation is !

What is T-Piece Resuscitator?

Neo-puff, Neo-Tee, are the brand name, and most literature refers to them as t-piece resuscitators. 

It's a manually operated, gas-powered resuscitator to provide controlled breaths unlike, the AMBU bag where each breath delivered will have varying peak pressures and practically Zero PEEP.

T-Piece Resuscitator delivers set peak inspiratory pressure and PEEP during each artificial breath delivery thus mimicking a mechanical ventilator.

Anatomy of T-Piece Resuscitator

At the bottom, you can see the inlet for gas (left bottom of the image) where the oxygen source is attached.

Parts of T piece resuscitator

On the right bottom is a gas exit where a corrugated tube is attached. This tube is attached to a T Piece at the end.

One of the arms of this T piece can be attached to either mask or an Endotracheal tube (just like an AMBU bag), while the other arm has the PEEP valve (white).

The white circular knob at the end of the T piece can be moved in a clockwise or anticlockwise direction to set PEEP. The knob can be adjusted for required PEEP using a pressure monitor given at the top. The PEEP valve has an opening in the center. Closing this opening with a finger/thumb will deliver the breath.

T piece resuscitator PEEP valve

The two knobs as seen in the image, the one on the right side is for setting peak inspiratory pressure (PIP) while the left one is for setting the pressure for the pop-up valve (for pressure safety). 

On the top is a pressure manometer for monitoring these pressures. 

How does it work?

All you have to do to ventilate the baby is to use your thumb to block the PEEP valve. There is no exhaustion at all.

Even if a ventilator is not available for a brief time, we can continue with NEOPUFF.

Being very light and portable, it can be carried to the labor room for resuscitation. 

But the greatest advantage is not for the caregiver but for the patient. With an AMBU bag, the pressures can not be controlled plus you cannot provide PEEP.

T-Piece Resuscitator on other hand gives constant gentle pressure which is much more friendly on a neonate's fragile lung, especially in case of preterms.

Evidence now shows that inconsistent pressures from the Ambu bag can cause bruising in the neonate airway. The resulting barotrauma from unregulated pressure can lead to further complications.

We in our unit started following the evidence..have you?

The following video depicts the correct use of an infant t-piece resuscitator for neonatal resuscitation. Demonstrating the use of a T-Piece Resuscitator can be asked separately or as a part of the NRP station.

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Author

Ajay Agade | DNB(Pediatrics), FNB(Pediatric Intensive Care), Fellowship in Pediatric pulmonology and LTV

Ajay is a Paediatric Intensivist, currently working in Pediatric Pulmonology & LTV at Great Ormond Street Hospital NHS, London