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com
ADC-FNN Online First, published on September 19, 2016 as 10.1136/archdischild-2016-311164
1
Neonatal Intensive Care,
Westmead Hospital,
Westmead, New South Wales,
Australia
2
Faculty of Engineering and
Information Technologies,
BMET Institute, Sydney
University, Sydney, New South
Wales, Australia
3
Department of Paediatrics and
Child Health, Sydney
University, Westmead, New
South Wales, Australia
Correspondence to
Dr Mark Tracy, Department of
Paediatrics and Child Health,
Sydney University, PO Box 533,
Wentworthville, NSW 2145,
Australia; mark.tracy@sydney.
edu.au
Received 5 May 2016
Revised 18 August 2016
Accepted 23 August 2016
To cite: Hinder M, Jani P,
Priyadarshi A, et al. Arch Dis
Child Fetal Neonatal Ed
Published Online First:
[please include Day Month
Year] doi:10.1136/
archdischild-2016-311164
Hinder M, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2016-311164
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Original article
Neopuff T-piece resuscitator: does device design
affect delivered ventilation?
Murray Hinder,1,2 Pranav Jani,1,3 Archana Priyadarshi,1,3 Alistair McEwan,2
Mark Tracy1,3
ABSTRACT
Background The T-piece resuscitator (TPR) is in
common use worldwide to deliver positive pressure
ventilation during resuscitation of infants <10 kg. Ease
of use, ability to provide positive end-expiratory pressure
(PEEP), availability of devices inbuilt into resuscitaires
and cheaper disposable options have increased its
popularity as a first-line device for term infant
resuscitation. Research into its ventilation performance is
limited to preterm infant and animal studies. Efficacy of
providing PEEP and the use of TPR during term infant
resuscitation are not established.
Aim The aim of this study is to determine if delivered
ventilation with the Neopuff brand TPR varied with
differing ( preterm to term) test lung compliances (Crs)
and set peak inspiratory pressures (PIP).
Design A single operator experienced in newborn
resuscitation provided positive pressure ventilation in a
randomised sequence to three different Crs models (0.5,
1 and 3 mL/cmH2O) at three different set PIP (20, 30
and 40 cmH2O). Set PEEP (5 cmH2O), gas flow rate and
inflation rate were the same for each sequence.
Results A total of 1087 inflations were analysed. The
delivered mean PEEP was Crs dependent across set PIP
range, rising from 4.9 to 8.2 cmH2O. At set PIP
40 cmH2O and Crs 3 mL/cmH2O, the delivered mean PIP
was significantly lower at 35.3 cmH2O.
Conclusions As Crs increases, the Neopuff TPR can
produce clinically significant levels of auto-PEEP and thus
may not be optimal for the resuscitation of term infants
with healthy lungs.
BACKGROUND
The T-piece resuscitator (TPR) is a device widely
used to provide positive pressure ventilation during
resuscitation of infants ≤10 kg.1 The device
requires an interface to the patient via face mask,
laryngeal mask airway or endotracheal tube (ETT).
The Neopuff (Fisher & Paykel New Zealand) TPR
is a gas flow-dependent resuscitator consisting of
three operator-adjusted valves. These are set with
the aid of a built-in manometer to the desired level
for peak inspiratory pressure (PIP), positive
end-expiratory pressure (PEEP) and safety pressure
limit required to provide intermittent positive pres-
sure ventilation (IPPV). Driving gas of 5–15 L per
minute (LPM) is provided by blended gas, air or
oxygen flowmeter.
Two control dials located on the Neopuff
provide adjustable ranges for PIP of 2–75 cmH2O
and safety pressure limit of 40–80 cmH2O. PEEP is
adjusted by changing a variable orifice flow resistor
What is already known on this topic?
▸ Neopuff T-piece resuscitator performance has
been reported in preterm infants and low
compliance lung models.
▸ Use of Neopuff in resuscitation of term infants
with normal lung compliance has increased.
What this study adds?
▸ When using Neopuff T-piece resuscitator in a
lung model, as lung compliance increases, the
delivered positive end-expiratory pressure
(PEEP) may increase from the set PEEP value
and peak inspiratory pressures may be less
than intended.
▸ Clinicians using T-piece devices to resuscitate
term infants should be aware of an unintended
rise in PEEP that may be mitigated by reducing
inflation rate.
located at the distal end of the patient circuit. The
adjustable PEEP pressure range is 1–25 cmH2O.
Setting delivery pressures must be carried out in
the correct sequence stated in manufacturer docu-
mentation; otherwise, delivery of adequate ventila-
tion will not be successful.1 2 Any alteration to the
gas inflow rate after the initial setting and start of
IPPV requires recalibration by the user, which
requires disconnection from the patient.2 3 Hawkes
et al4 showed that adjustment of circuit gas inflow
from 5 to 15 LPM without recalibrating the deliv-
ery pressures resulted in an inadvertent increase in
PEEP (300%), PIP (40%) and safety over pressure
(33%) from the initial set value.
IPPV is started by occluding the gas outlet located
on the PEEP valve assembly. The operator deter-
mines inflation rate and inspiratory:expiratory ratio
(I:E ratio). If IPPV is not initiated and circuit seal is
maintained, a continuous positive airway pressure is
delivered to the patient at the same set PEEP value.
The use of the Neopuff for preterm resuscitation
is well published.5–7 Although it is widely used for
resuscitation in term infants,8 limited data support
its use in infants with weight 3.5–10 kg. We tested
the hypothesis that the delivered ventilation of the
Neopuff TPR is not different between low and
normal newborn lung compliance (Crs) (0.5–
3.0 mL/cmH2O).9
F1
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Original article

The aim of this study was to determine whether the delivered
ventilation with the Neopuff TPR varied with differing test Crs
(0.5, 1 and 3 mL/cmH2O) and different set PIPs (20, 30 and
40 cmH2O).
METHODS AND DESIGN
A single Neopuff TPR (Part Number: RD900AEU) and delivery
circuit (Part Number RD 1300-10) with a measured compliance
of 0.4 mL/cmH2O and tubing flow resistance of 6 cmH2O/L/s at
30 LPM were used in this bench study.
Two different leak-free test lungs were used (1) a 50 mL
Draeger test lung (Draeger, Lubeck, Germany) with measured
compliance of 0.5 mL/cmH2O; resistance 50 cmH2O/L/s and (2)
a 200 mL IMT newborn test lung (Smart Lung Infant, IMT
medical, Buchs, Switzerland) with adjustable measured com-
pliances of 1.0 and 3.0 mL/cmH2O; resistance 50 cmH2O/L/s. A
Florian respiratory function monitor (RFM) (Accutronics,
Medical Systems AG, Zug, Switzerland) was connected via the
hot wire pneumotach and pressure sensor line sited between the
Neopuff TPR and the test lung. The Florian monitor was cali-
brated with an external syringe of known volume and pressure/
flow via a traceable reference ventilator analyser (PF300, IMT
Medical, Buchs, Switzerland). The analogue signals output from
the RFM were collected and digitised at 200 Hz with analysis
software (Grove Medical, London, UK). The test lungs and
monitoring system were pressurised to static pressure of
50 cmH2O and over 120 s, there was no fall in pressure indicat-
ing the system was leak free.
A single operator experienced in neonatal resuscitation was
asked to deliver 2 min of IPPV in a randomised sequence to
each of the Crs models (0.5, 1, and 3 mL/H2O) at the prede-
fined PIP levels (20, 30 and 40 cmH2O).
The RFM pneumotach was rezeroed and the TPR settings for
circuit gas inflow 10 LPM air, PEEP 5 cmH2O and over pressure
50 cmH2O were reset and checked with ventilation analyser at
the start of each randomised sequence. An inflation rate of 60
inflations per minute (IPM) guided by metronome was used
across all Crs and inflation pressure combinations. Operator was
blinded to RFM waveform display, only Neopuff manometer
was visible to operator. We have previously shown no difference
in delivered mask ventilation with operators guided by either
the Neopuff pressure dial or the manikin chest rise.10 Finger
dwell of <2 mm above PEEP valve orifice was observed to
impede gas output flow and increase PEEP during passive defla-
tion of the test lung. Thus, the operator was instructed to
ensure finger distance from valve orifice during deflation was
>2 mm. PEEP valve set position was marked and checked after
each sequence to ensure no operator induced change occurred
in adjusted valve position during IPPV.11 12
DATA ANALYSIS
Analysis was conducted using Stata (V.13 MP, StataCorp,
College Station, Texas, USA). The measured parameters
included the mean, minimum and maximum PIP, PEEP and tidal
volume (Vt). Analysis of variance (ANOVA) for repeated mea-
sures was used to determine differences between test Crs at dif-
ferent set PIP levels. Differences between means determined by
ANOVA were reported with p values adjusted F test using Box’s
conservative epsilon, p values of <0.05 were considered signifi-
cant. Table 1 provides measured mean PIP, PEEP and Vt with
IQR and SD for each Crs and set PIP with p values calculated
with ANOVA for repeated measures.
RESULTS
A total of 1087 inflations were analysed. Inspiratory times were
statistically different across all sequences (mean=0.53,
SD=0.04 s p≤0.001) but not considered clinically significant.
The measured PIP as a percentage of set PIP ranged from
100% to 101% with Crs of 0.5 and 1 mL/cmH2O, which were
not significantly different and was lowest at 88% with set PIP of
40 cmH2O and Crs 3 mL/cmH2O ( p<0.001) (table 1, figure 1).
The measured PEEP as a percentage of set PEEP ranged from
98% to 106% for Crs of 0.5 mL/cmH2O, 106% to 110% for
Cl of 1 mL/cmH2O and 122% to 164% for Crs of 3 mL/
cmH2O across set PIP range (p<0.001), this was highest at set
PIP of 40 cmH2O and Crs of 3 mL/cmH2O (table 1, figure 2).
The mean delivered Vt increased significantly with increasing
Crs for each set PIP level, ranging from 8.5 mL (Cl 0.5 mL/
cmH2O at set PIP 20 cmH2O) to 66 mL (Crs 3 mL/cmH2O at
set PIP 40 cmH2O) ( p<0.001) (table 1, figure 3).
DISCUSSION
The results of this bench study show when using Neopuff TPR
to provide IPPV, there is a significant difference between set and

Table 1 Measured respiratory parameters with differing set peak inspiratory pressures (PIP) and test lung compliance
Test lung compliance

0.5 mL/H2O 1 mL/H2O 3 mL/H2O

Set pressure, cmH2O Mean IQR (SD) Mean IQR (SD) Mean IQR (SD) p Value

Measured PIP, cmH2O

20 20.1 0.06 (0.10) 20.3 0.09 (0.07) 20.0 0.06 (0.05) NS
30 30.0 0.06 (0.38) 30.2 0.09 (0.06) 29.3 0.21 (0.19) NS
40 40.4 0.06 (0.05) 40.3 0.09 (0.08) 35.3 0.99 (0.86) <0.001
Measured PEEP, cmH2O
20 4.9 0.03 (0.05) 5.3 0.06 (0.04) 6.1 0.18 (0.17) <0.001
30 5.1 0.06 (0.07) 5.4 0.09 (0.07) 6.9 0.37 (0.22) <0.001
40 5.3 0.12 (0.10) 5.5 0.12 (0.09) 8.2 0.77 (0.65) <0.001
Measured Vt, mL
20 8.5 0.21 (0.51) 10.1 0.22 (0.17) 25.6 0.45 (0.35) <0.001
30 12.7 0.14 (0.35) 15.8 0.18 (0.14) 46.4 0.83 (0.59) <0.001
40 16.3 0.14 (0.19) 21.8 0.21 (0.17) 66.6 3.70 (3.27) <0.001
PEEP, positive end-expiratory pressure; Vt, tidal volume.

F2 Hinder M, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2016-311164

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Figure 1 Measured peak inspiratory pressure (PIP).
Figure 2 Measured positive end-expiratory pressure (PEEP).
delivered pressures as Crs increases. The unintended rise in
delivered PEEP (auto-PEEP) at compliance of 3.0 mL/cmH2O
was clinically important.
Auto-PEEP can impair the reduction in pulmonary vascular
resistance important to circulatory adaptation immediately after
birth13 and increase risk of air leaks in term infants with meco-
nium aspiration syndrome. We suspect the auto-PEEP observed
in our study is due to circuit-imposed expiratory resistance of
the Neopuff PEEP valve and delivery circuit compliance,
increasing the system time constant, thus increasing lung defla-
tion time. Similarly, the observed inability to attain set PIP of
40 cmH2O at Crs of 3 mL/cmH2O during inspiration may be
due to insufficient fill time at the circuit inflow rate of 10 LPM
and inflation rate of 60 IPM (figure 4). The compliance setting
that we chose for our term lung model of 3 mL/cmH2O may be
typical of a term infant of 3500 g birth weight,9 a recent human
study by McEvoy et al14 suggests higher term infant values of
4–5 mL/cmH2O.
The development of auto-PEEP is tied to the time constant of
the lung and airway. The lung time constant is proportional to
the product of airway resistance (RAW) and Crs.
Increasing RAW for a given Crs and volume results in a
longer time for gas to exit the lung. Similarly, for a given RAW
and airways pressure increasing Crs will also result in longer
Hinder M, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2016-311164
Original article
Figure 3 Measured inflation volume.
time for gas to exit the lung.15 Imposed resistance due to venti-
lator device design has been shown to increase patient work of
breathing16–18 and change the overall respiratory system time
constant.18 19 Wald et al17 showed that the expiratory resistance
of the Neopuff TPR varied with gas in flow rate from
40.1 cmH2O/L/s at 15 LPM to 104.8 cmH2O/L/s at 6 LPM.
Finer et al detailed eight occurrences in a 12-month period
(n=120) of inadvertent increase in PEEP using TPR device
from set 5 cmH2O (min 6.7; max 15.8 cmH2O), IPM <60
during resuscitation of infants <1000 g which he attributed to
possible movement of the PEEP control knob. It is notable that
both the recordings of actual resuscitations illustrated have a
starting PIP of 40 cmH2O. Circuit gas inflow rate was not
reported, Finer concluded ‘the Neopuff has the potential to
cause an inadvertent and potentially toxic increase of PEEP
which might not be noticed by the operator’.11 We have
excluded PEEP valve positional changes contributing to rise in
PEEP in our study by checking there was no change in a marker
point on the PEEP valve during the experiment. Bennett et al
examined increasing PIPs with the Neopuff TPR in a manikin
model to 40 cmH2O as escalation to these levels may be
required with diseased or immature lungs.20 21
Limitations of our study are shared with other manikin and
test lung studies of the ability to generalise to actual human
resuscitations at birth. Changes in inflation rate and circuit gas
flow rate were not examined in this study and may contribute to
the level of device imposed auto-PEEP. The performance of
other brands of TPR’s may be different.
Preliminary data by our group in a piglet study22 (n=10)
comparing self-inflating bag (SIB) and Neopuff TPR delivered
ventilation has confirmed our bench test results that the TPR
device can contribute to the production of clinically significant
auto PEEP during IPPV compared SIB with PEEP valve.
Adaptive changes in pulmonary and circulatory physiology
and establishment of a functional residual capacity of the lung
during birth are complex. Detecting and adjusting for Crs
changes during resuscitation with either SIB or TPR devices is
difficult.23–25 The presence of leak during mask resuscitation is
common and can also influence Neopuff performance.26 Mask
leak that may be variable might obscure TPR generated
auto-PEEP by providing a path of least resistance for expired
gas. Mask ventilation by more experienced clinicians,27 using
improved mask techniques28–30 or the presence of ETT may
F3
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Original article
Figure 4 Pressure waveforms for lung compliance 3 mL/cmH2O at set peak inspiratory pressures 20 cmH2O (A), 30 cmH2O (B), 40 cmH2O (C) and
positive end-expiratory pressure 5 cmH2O.
provide a patient/device interface that is closer to leak free,
increasing device imposed auto PEEP from TPR devices.
The efficacy of the T-piece device for term resuscitation is not
established, and terms describing the device as the ‘gold-
standard’31 should be viewed with caution. Our data suggest
that in contrast to previous studies using Neopuff TPR in
preterm lung models,32 delivered pressures are not consistent
and vary from those preset as Crs increases.
CONCLUSION
We have shown in a test lung with compliance similar to that of
a term infant that use of Neopuff TPR may result in increasing
auto PEEP and decreasing PIP values. This is likely to be greater
with higher Crs and higher inflation rates. Lower inflation rates
may mitigate this effect. Operator finger position over PEEP
valve orifice during lung deflation may also contribute to unin-
tended PEEP. Clinicians using Neopuff to resuscitate term
infants should be alert to these potential consequences.
Contributors MH is the primary researcher responsible for conceiving, designing,
data collection, statistical analysis and writing manuscript. PJ contributed to data
collection, interpretation, manuscript construction and review. AP and AM
contributed to interpretation, manuscript construction and review. MT contributed by
assisting design, statistical analysis, manuscript writing and review.
Competing interests None declared.
Ethics approval This study was approved by the Western Sydney Local Health
District Human Ethics and Scientific committee approval number SAC2014/5/6.9
(3999)QA.
Provenance and peer review Not commissioned; externally peer reviewed.
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Hinder M, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F5. doi:10.1136/archdischild-2016-311164 F5

 Downloaded from http://fn.bmj.com/ on December 30, 2016 - Published by group.bmj.com

Neopuff T-piece resuscitator: does device

design affect delivered ventilation?
Murray Hinder, Pranav Jani, Archana Priyadarshi, Alistair McEwan and
Mark Tracy

Arch Dis Child Fetal Neonatal Ed published online September 19, 2016

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