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Resuscitation 83 (2012) 369–373

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Simulation and education

Heating of gases during neonatal resuscitation: A bench study夽
Andrew D. Shearman a,b,∗ , David Hou a,b , Kimble R. Dunster c,d , Luke Jardine a,b
a

Department of Newborn Services, Mater Mothers’ Hospital, South Brisbane, Australia
Mothers’ and Babies Health, Mater Medical Research Institute, South Brisbane, Australia
c
Medical Engineering, School of Engineering Systems, Queensland University of Technology, Brisbane, Australia
d
Paediatric Critical Care Research Group, Mater Children’s Hospital, South Brisbane, Australia
b

a r t i c l e

i n f o

Article history:
Received 4 February 2011
Received in revised form 11 July 2011
Accepted 22 August 2011

Keywords:
Neonatal resuscitation
Infant
T-piece resuscitator
Humidification
Temperature
Bench test

a b s t r a c t
Aim: Standard practice within the neonatal unit is to use heated humidified gas as it decreases respiratory
complications in neonates requiring respiratory support. Using cold unhumidified gases during resuscitation could potentially cool the baby as well as exacerbate potential lung injury. We aimed to study the
temperature and humidity aspects of using heated, humidified gas for neonatal resuscitation.
Methods: A heated patient circuit was connected to a T-piece resuscitator via a humidifier. An oxygen
flowmeter was set at 10 L/min. Temperature recordings at the humidifier chamber (T1), distal temperature probe (T2) and T-piece (T3) were taken over 20 min at 30 s intervals. A humidity sensor was placed
at T3.
Results: Target temperatures were not reached. Time to 36 ◦ C (mean (sd)): T1 11.1 min (1.71); T3 11.6 min
(1.77). T2 took 13.6 min (1.07) to reach 39 ◦ C. T1 and T3 were within ±1 ◦ C at 5.1 min (0.6). A biphasic
relationship demonstrated the time lag between the temperatures of the heated patient circuit and the
humidifier chamber. T3 strongly correlated to T1 when T1 is ≥28 ◦ C (r2 = 0.85). Humidity was difficult to
measure and results were inferred from temperature recordings.
Conclusion: This in vitro test showed that heated, humidified gas is possible during neonatal resuscitation. Adequate time must be allowed for the humidifier chamber to warm to near optimal temperature.
The patient circuit is initially heated faster than the humidifier chamber. The displayed T1 temperature
correlates to the temperature at T3 at ≥28 ◦ C.
© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The provision of heated humidified gases for non-invasive and
invasive ventilation is standard practice in neonatology. However, heated humidified gases are not standard practice during
resuscitation. Resuscitation guidelines recommend efforts to keep
the preterm baby warm though none mention the use of heated
gases.1,2 The use of heated humidified gases during resuscitation
has been shown to reduce the postnatal decrease in temperature.3
There was no statistically different number of babies with mild
hyperthermia between groups resuscitated with heated humidified
gas or “cold and dry gas”.
Humidification has been shown to prevent drying of the respiratory mucosa and aids mucociliary clearance of secretions.4,5 There

夽 A Spanish translated version of the summary of this article appears as Appendix
in the final online version at doi:10.1016/j.resuscitation.2011.08.027.
∗ Corresponding author at: Neonatal Critical Care Unit, Mater Mothers’ Hospital,
Raymond Terrace, South Brisbane, 4101 Queensland, Australia.
Tel.: +61 7 3163 5378; fax: +61 7 3163 5676.
E-mail address: andrew.shearman@mater.org.au (A.D. Shearman).
0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.08.027

are significant safety concerns with overhumidification and underhumidification. Significant underhumidification can cause severe
tracheal injury in ventilated animals.6 Underhumidification causes
increased viscosity of mucous and decreased ciliary function, with
mucous retention and airway obstruction as a result.7 Severe tracheal injury with inflammation, erosions, necrosis and blistering
occurring 5 mm below the tip of the endotracheal tube (ETT) was
caused in animals ventilated in 30% relative humidity (RH) compared with 90% RH.6 Overhumidification, where absolute humidity
(AH) is higher during inspiration than expiration, can cause copious
mucous secretions which can overwhelm ciliary transport.7 It has
been recommended that medical gases should routinely be heated
and humidified to 37 ◦ C and 100% RH for delivery to the patient.8
Heating and humidifying gas used in ventilation decreased insensible water losses to below that of extubated infants.9
The initial breaths during resuscitation may trigger the inflammatory cascade behind the pathogenesis of bronchopulmonary
dysplasia.10 Studies in lambs have shown a trend to increased
inflammatory markers in the lungs of those resuscitated in cold
unhumidified air compared with those in heated humidified air.11
Surveys of resuscitation practices, including the use of T-piece
resuscitators, have been published.12–14 Survey respondents using

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Fig. 1. Experimental set up schematic. Heated humidified T-piece resuscitation circuit. A – Flowmeter, B – Neopuff, C – humidifier chamber, D – humidifier with temperature
display, E – humidifier chamber temperature probe (T1), F – heated resuscitation circuit, G – distal temperature probe (T2), H – T-piece, I – T-piece temperature probe (T3), J
– DuoTemp temperature monitor, K – humidifier data output cable.

T-piece resuscitators; 48% of Australian and New Zealand units
in 2004,12 14% of USA units 13 in 2006 and 41%, 80% and 20% of
units in Germany, Austria and Switzerland respectively in 2010.14 A
heated circuit (900RD110, Fisher and Paykel Healthcare, Auckland,
New Zealand) utilising a spiral wound internal heating wire is now
available for a particular T-piece resuscitator (Neopuff, Fisher and
Paykel Healthcare, New Zealand). There is no literature examining the thermal safety aspects of using humidified gas in neonatal
resuscitation. Given this paucity of information, we investigated
the temperatures and humidity within a heated humidified patient
circuit used with a T-piece resuscitator.
This study bench-tested a method of delivering heated humidified gases as could be used in neonatal resuscitation. The aim was
to find the time taken for gas to reach recommended humidity and
temperature when a humidifier and heated humidification circuit
attached to a T-piece resuscitator was turned on. As the humidifier used displays the humidifier chamber temperature, we also
wanted to find how useful this measurement was in approximating
temperature at the T-piece.
2. Methods
2.1. Resuscitation equipment
A flowmeter set at 10 L/min delivered dry oxygen to the RD900
Neopuff T-piece resuscitator (Fisher & Paykel Healthcare). The
gas then flowed to a MR290 (Fisher & Paykel Healthcare) autofill
humidification chamber on a MR850 respiratory humidifier (Fisher
& Paykel Healthcare) set at the invasive (i.e. intubated) setting. The
gas then flowed through the 900RD110 patient circuit to the Tpiece (Fig. 1). The gas was free flowing throughout the tests with
no test lung or other obstruction at the end T-piece connection.
Water was added to a humidification chamber via the autofill.
When the chamber stopped filling, the amount of water in the
chamber was measured to be 108 g (BD-815U scales, Tanita Corporation, Japan). This weight was standardised across all trials to
reduce variation due to the effect of heating different water volumes. Weight was used as the volume of water measured would be
affected by changes in water temperature. The autofill was clamped
off during the trials

maximum length of 18 cm. A hole was drilled into the T-piece (T3)
and a temperature probe (900MR569, Fisher & Paykel Healthcare)
inserted and sealed (U-Tac, UHU GmbH & Co. KG, Germany) (Fig. 2).
A DuoTemp Temperature Monitor (Fisher & Paykel Healthcare)
recorded the temperature once per second at T3. The temperature
probes are based on the Yellow Springs Instruments 400 series thermistors with a response time of 20 s and have an accuracy of ±0.3%
across the temperature range encountered (Figs. 1 and 2).
2.3. Humidity monitoring
A HIH-4000-002 humidity sensor (Honeywell International Inc,
Minnesota, USA) placed inside the T-piece was connected to a custom built power supply and digital voltage display. After three tests,
it was observed that water would condense on the sensor and the
recorded values became unreliable. These tests are reported separately to the temperature analysis. As an indirect confirmation of
humidification, the loss of water from the humidification chamber was measured. Water loss was calculated by reweighing the
water left in the humidification chamber immediately after the
trial. Assuming the gas leaving the humidifier chamber to be at
100% RH, a similar temperature (±1 ◦ C) at the T-piece would also
be at or near 100% RH.
2.4. Data acquisition and analysis
A convenience sample of eight trials was chosen. The resuscitation equipment was allowed to completely cool and the tubing
dried with dry gas flow between trials.

2.2. Temperature monitoring
The humidifier monitors the temperature of the gas leaving the
humidification chamber (T1) and 112 cm further along the heated
patient circuit (T2). The temperature at T1 and T2 were monitored
with 900MR868 temperature probes (Fisher & Paykel Healthcare).
The collapsible tubing from T2 to the T-piece was extended to its

Fig. 2. Detail of temperature probe at T-Piece (T3).

A.D. Shearman et al. / Resuscitation 83 (2012) 369–373
Table 1
Mean (SD) temperature measurements. na = not applicable.

12

T2 (n = 8)

T3 (n = 8)

22.3 (1.00)

22.9 (0.45)

22.6 (0.51)

0.24

11.1 (1.77)

6.9 (0.64)

11.6 (1.76)

<0.001

na

13.6 (1.07)

P

na

Temperature data were recorded at 30 s intervals for 20 min.
Real-time data for T1 and T2 from the humidifier was recorded
onto a laptop using View850 v1.8 software (Fisher & Paykel Healthcare) and T3 temperature was recorded at 30 s intervals. Time zero
was the measurement taken with the humidifier chamber filled
with water, gas flow on and immediately before the humidifier was
turned on. From product information about the humidifier,15 target temperature at T1 was 37 ◦ C and T2 was 40 ◦ C. It is assumed
that the unheated portion leading to T3 allows the gas to cool to
approximately 37 ◦ C. Humidity data was recorded every 30 s and
the voltage was converted to RH using a conversion equation.16
Data were then analysed using SPSS for Windows (Release 15.0.1
2006. Chicago: SPSS Inc). The mean (SD) time to target temperature
at each site was calculated. Data were analysed using ANOVA. A
relationship between the temperatures at T1 and T3 was explored
using polynomial regression and linear regression using the Pearson correlation coefficient. All other data presented as mean (SD)
unless otherwise stated.
3. Results
Target temperatures as described in the manufacturer’s product
information were never reached and there appeared to be a state of
equilibrium at 36.0 ◦ C at T1 and 39.0 ◦ C at T2. After post hoc analysis of the data, we chose the median equilibrium temperatures
of 36.0 ◦ C at T1 and 39.0 ◦ C at T2 for the purpose of data analysis.
Temperature at T3 reached 37.0 ◦ C only once, so again, 36.0 ◦ C was
chosen for analysis. In one trial, T3 did not reach 36.0 ◦ C and T2 did
not reach 39.0 ◦ C. In another trial the temperature at T3 exceeded
37.0 ◦ C (maximum 38.2 ◦ C). In the remaining trials, the temperature at T3 was <37.0 ◦ C when T2 first reached 39.0 ◦ C. The ambient
room temperature was monitored and remained at 22.5 ± 0.5 ◦ C.
Eight trials were completed without the humidity sensor in
place. Temperature results are given in Table 1. T3 showed a more
rapid increase in temperature than T1 (Fig. 3). The time it took for
the temperatures at T1 and T3 to be within 1.0 ◦ C of each other
was 5.1 min (0.6). Cubic polynomial regression found a relationship between the temperature at the humidifier chamber and the
temperature at the T-piece (r2 = 0.86) (Fig. 4). The data were further explored using linear regression where the T3 and T1 paired
data were excluded in a stepwise manner at 0.5 ◦ C increments
until the correlation coefficient reached a maximum or remained
unchanged. There was excellent correlation between the temperature at the humidifier chamber and the temperature at the
T-piece when ≥28.0 ◦ C had been reached at the humidifier chamber
(r2 = 0.85) (Fig. 5).
In the three trials in which the humidity sensor was used at T3,
RH at time zero was 41.7% (6.34) and 75.8% (0.97) RH was measured
by 2.5 min. In two trials the humidity sensor then failed due to condensation. In one trial, 100% RH was reached at 3.5 min before the
sensor failed. From the original 108 g of water within the humidification chambers, the mean loss at 20 min was 8.8 g (1.49) (8.3%). No
rainout or water droplets were observed within the patient circuit
in any of the eight trials undertaken without the humidity sensor
in place.

Temperature Difference (C)

T1 (n = 8)

9

6

3

0

0

1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19 20

Time (min)
Fig. 3. Median temperature difference (T-Piece (T3) −humidifier chamber (T1)). Box
shows medians and interquartile ranges, whiskers represent outliers, 䊉 represents
extreme outliers. Dashed line represents mean time for T-piece and humidifier
chamber to be within 1 ◦ C.

4. Discussion
Absolute humidity is the amount of water vapour in a given
volume of gas (mg/L). The maximum water vapour capacity of a
gas depends on the temperature, increasing as the temperature
increases. Relative humidity is how much water vapour is in the
gas compared to how much it would contain at maximum capacity; expressed as a percentage. At 37 ◦ C and 100% RH, air has an
AH of 44 mg/L. If a gas is heated without adding water vapour, RH
decreases.
As the humidifier chamber warms up, it increases the water
vapour within the gas and therefore both AH and RH change.
Measuring humidity is an inexact and technically difficult science,
especially near saturation. Mathematical models17 and laboratory
tests18 have been developed, but are not practical.19 Humidity
sensors are expensive and become inaccurate if subject to condensation, as in our trial. Temperature can be used as a surrogate
measure for humidity, but can also be inaccurate.18 However, when

40.0

T-piece Temperature (C)

Temperature at time
zero (◦ C)
Time to reach 36.0 ◦ C
(min)
Time to reach 39.0 ◦ C
(min)

371

35.0

30.0

25.0

20.0
20.0

25.0

30.0

35.0

40.0

Chamber Temperature (C)
Fig. 4. . Plot of humidifier chamber temperature and T-piece temperature. Cubic
polynomial regression (r2 = 0.86).

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A.D. Shearman et al. / Resuscitation 83 (2012) 369–373

T-piece Temperature (C)

40.0

38.0

36.0

34.0
y = 1.086x - 3.332

32.0

30.0

28.0

30.0

32.0

34.0

36.0

38.0

Chamber Temperature (C)
Fig. 5. Correlation between displayed chamber temperature and T-piece temperature once humidifier displays ≥28 ◦ C. r2 = 0.85.

the temperature at the humidifying chamber and the T-piece were
the same, we assumed RH at these points to be equivalent.
The results at time zero showed that the gas at T3 was close
to room temperature and was partially humidified. Water vapour
content would have increased as the dry gas passed over the water
in the humidification chamber. Although the humidity sensor failed
early in testing, RH rose quickly and reached 100% in 3.5 min in a
single trial. This is faster than the time temperature at T1 and T3
became equivalent. It is possible this is due to the unreliability of the
humidity sensor as it filled with condensate or that the temperature
sensors had a longer response time.
It is not known whether AH or RH of the inspired gas is the
more important for normal physiological function.7 A gold standard
for humidity is also unknown, though international organisations
have a set a minimum AH; 33 mg/L for the United Kingdom and
International Organization for Standardization and 30 mg/L for the
United States.5 If adequate temperature and humidity are provided,
an area within the lung known as the isothermic saturation boundary (ISB) can maintain normal physiological function.8 The ISB is the
location where the upper respiratory tract has warmed and humidified inspired gas to 37 ◦ C and 100% RH.4,5,7 Below this location,
humidity and temperature are constant. The ISB is normally below
the carina, but it is a dynamic boundary and changes depending on
the temperature and humidity of the inspired gas.
Initially the heating wire within the patient circuit heats rapidly,
then the rate of the temperature rise is reduced, taking a longer time
to reach target temperature. As the water takes longer to warm
than the heating wire, heated gas not at full saturation would be
delivered to the patient. The temperature at the T-piece reached a
maximum of 38.2 ◦ C during one trial, whereas in all other trials, the
temperature remained below 37 ◦ C. While a temperature of 38.2 ◦ C
appears supraphysiological, the actual energy transferred to the
respiratory lining is minimal. The energy content within air is made
up of the sensible heat content (air temperature) and the latent heat
content (water vapour mass).4 It takes significantly more energy to
increase the water vapour’s heat content than it does to increase
the air temperature. As a quantitative example, air at 37 ◦ C at 100%
RH contains 143 J/g of energy and air at 39 ◦ C at 90% RH contains
145 J/g.4 Therefore, slight increases in the temperature of humidified gas, although supraphysiological, may not be as injurious as it
first appears.
One of the goals of neonatal resuscitation is to prevent
hypothermia in the newborn due to associated effects such as
hypoglycaemia, metabolic acidosis and coagulopathy.20 The most

recent guidelines,1,2,20 make recommendations for keeping the
preterm baby warm. These include polyethylene wraps, warming
the delivery room temperature to 26 ◦ C, hats, thermal mattresses
and skin-to-skin care as adjuncts to standard practice.
Resuscitation guidelines have not previously mentioned heated
humidified gases as a method to prevent hypothermia. Neonates
ventilated in dry gas for one hour dropped their rectal temperature
by 1.4 ◦ C.21 The observational trial by te Pas3 looked at a cohort
of premature (<32 weeks gestation) infants who were ventilated
with cold unhumidified gases followed by a cohort ventilated with
heated humidified gases. The study showed the cohort ventilated
with heated humidified gases had a significantly higher mean rectal temperature (36.4 ◦ C v. 35.9 ◦ C), a significantly higher incidence
of normothermia and significantly less moderate hypothermia.
However, the non-randomised nature of the study lends itself to
bias. 19% of the babies in the heated humidified gas cohort were
excluded because the humidifier was not turned on or due to a
mistake by the physician attending.
Heating and humidifying gases during resuscitation may help
decrease injury and inflammation to the lungs. Pillow et al.11
showed a trend towards increased levels of IL-1␤ mRNA expression
within the lungs of newborn lambs ventilated with cold dry gases.
However, hyperoxia had a significantly greater effect on inflammatory changes and also worsened gas exchange. Tarnow-Mordi
et al.22 showed a decreased severity of chronic lung disease as
well as less pneumothoraces in those extremely low birth-weight
infants ventilated in gases heated above 36.5 ◦ C.
While acute lung inflammation and hypothermia may be a
consequence of using cold, unhumidified gases, adult animal
studies have shown hypothermia may protect from acute lung
injury.23,24 A recent study investigated if inflammatory changes
in the lungs of fetal lambs would be reduced with moderate systemic hypothermia.25 This study did not show any protective effect
as hypothesised as neither moderate hypothermia or moderate
hyperthermia reduced inflammatory changes within the lung.
Temperature at the distal probe and humidifier chamber did not
reach the target values described in the operator’s manual.15 It is
unclear whether this is an equipment error or problem with study
design. A temperature of 36 ◦ C and inferred 100% RH of the gas
as measured at the T-piece occurred after 11.5 min. This has clinical implications in the resuscitation situation, and would only be
practical in situations where there was enough time to turn on the
equipment. The te Pas study3 used only 20 mL of water within the
humidifying chamber and suggested it took less than three min to
“warm up”, though did not provide any information to whether this
was tested prior to the trial beginning. The volume of water chosen
in our study was the volume initially delivered by the autofill itself.
The loss of 8% of the chamber water volume indicates humidification of the gas flowing through. Decreasing the volume of water in
the chamber may make the system more usable in clinical practice
by allowing more rapid heating from a “cold start”.
This bench study found the displayed humidifier temperature
correlated well with the temperature of the delivered gas when
≥28.0 ◦ C. Staff involved in a resuscitation observing the temperature on the humidifier is >28.0 ◦ C could correlate this with the
temperature of the gas at the T-piece and assume high RH. Alternatively, regardless of the displayed temperature, 5.1 min after the
humidifier is switched on, the gas at the T-piece should be at or
near 100% RH.
With a lack of information about using heated humidified gases
during resuscitation, it may be unwise to extrapolate benefits from
its use in ventilation to its use in resuscitation. From this study there
are a number of future directions for research. Performing a similar simulation connecting to a test lung immersed in a 37 ◦ C water
bath with and without application of intermittent positive pressure breaths. Measuring the effect of variables such as movement,

A.D. Shearman et al. / Resuscitation 83 (2012) 369–373

air flow and overhead radiant heating, during simulated transfer to
the NICU. Investigating the effect of turning the humidifier off during patient transfer. te Pas3 used an uninterruptible power supply
during patient transfer. There may be financial benefits if the system can provide adequate and safe humidification without a UPS.
Other safety aspects to be investigated include; the risk of rainout leading to water inhalation and, the potential for delivering dry
heated gas due to total evaporation of a small fixed water volume
in the humidification chamber.
5. Conclusion
Despite some practical limitations, this study shows it is possible to heat and humidify gas for a T-piece infant resuscitator.
However, with this experimental set up the manufacturer’s target
temperature levels were not reached. The heating wire within the
patient circuit initially warmed the gas but near optimal heating
and humidification at the T-piece occurs after 11.6 min. At 28 ◦ C,
the temperature displayed on the humidifier chamber correlates
to the temperature of the gas at the T-piece, and the gas should
theoretically be at 100% RH. More research into the safety aspects
of heating and humidifying gas at resuscitation needs to be done
prior to further clinical trials.
Conflict of interest
None.
Acknowledgements
Fisher & Paykel Healthcare provided the resuscitation equipment, DuoTemp and View850 software. Kristen Gibbons provided
advice on statistical analysis and graphs.
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