doi:10.1111/j.1440-1754.2011.02036.

ORIGINAL ARTICLE

Providing PEEP during neonatal resuscitation: Which device

is best? jpc_2036 698..703

Jennifer A Dawson,1,2,3 Angela Gerber,1 C Omar F Kamlin,1,2,3 Peter G Davis1,2,3 and Colin J Morley1,2,3
1
Neonatal Services, The Royal Women’s Hospital, 2Departments of Obstetrics and Gynaecology, University of Melbourne, and 3Murdoch Childrens Research
Institute, Melbourne, Australia

Aim: The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self-inflating bag with a positive end
expiratory pressure (PEEP) valve, a T-piece resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and PEEP.
Methods: Participants were asked to use each device to give positive pressure ventilation to a modified neonatal mannequin via a face mask
to achieve 40–60 inflations per minute, aiming for a PIP/PEEP of 30/5 cm H2O. A manometer was visible to participants with each device. PIP,
PEEP, percentage leak at the face mask and expired tidal volume were measured using a hot-wire anemometer. We analysed 20 inflations from
each participant for each device.
Results: Fifty participants provided PIP and PEEP with each device. The T-piece was the most accurate and consistent. The flow-inflating bag
had the most variation. The leak was lowest with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide variation.
Conclusion: Each device was able to provide PIP and PEEP when used appropriately. When compared with other resuscitation devices, the
T-piece provided the most accurate and consistent PIP and PEEP.

Key words: delivery room; infant; newborn; positive end expiratory pressure; resuscitation device.

What is already known on this topic What this study adds

1 A T-piece resuscitator, a self-inflating bag or a flow-inflating bag
can be used to provide ventilation in the delivery room.
2 Positive end expiratory pressure (PEEP) can be provided by a
T-piece and flow-inflating bag. The addition of a PEEP valve to the
self-inflating bag will provide some PEEP.
3 Resuscitation devices vary in their ability to provide peak infla-
tion pressure (PIP), PEEP and expiratory tidal volume (VTe) during
positive pressure ventilation.
1 A T-piece provides the most accurate and consistent PIP, PEEP
and VTe during positive pressure ventilation.
2 The flow-inflating bag provides the least accurate and consistent
PIP, PEEP and VTe during positive pressure ventilation.
3 It is important for resuscitators to be thoroughly trained in the
use of whichever device is available to them.

If newly born infants require positive pressure ventilation (PPV)
to assist with breathing in the delivery room (DR), this can be
provided with a T-piece resuscitator, a self-inflating bag or a
flow-inflating ‘anaesthetic’ bag.1,2 The addition of positive end
expiratory pressure (PEEP) with PPV has been shown to
improve oxygenation in a preterm animal model.3 The T-piece
and flow-inflating bag provide PEEP. The addition of a PEEP-
valve to the self-inflating bag allows delivery of some PEEP.4,5
Correspondence: Dr Jennifer Dawson, Neonatal Services, Newborn
Research – 7th floor, The Royal Women’s Hospital, 20 Flemington Road,
Parkville, Vic. , Australia. Fax: 0011 61 38345 3789; email: jennifer.dawson@
thewomens.org.au
Conflict of interest: None to declare
Fisher & Paykel (NZ) provided the T-piece circuits for the study. No study
sponsor or company that manufactures markets or sells any equipment
used in the study had involvement in the study design, data collection or
interpretation, or the decision to present or publish the results.
Accepted for publication 8 December 2010.
There are advocates for each device, with local practice guide-
lines dictating which device is used.6 The most widely used are
self-inflating bags and T-pieces.7–9 Researchers have tested dif-
ferent combinations of T-pieces, flow-inflating bags, self-
inflating bags and self-inflating bags with PEEP-valve to provide
peak inflation pressure (PIP), PEEP or tidal volume (VT) to
mannequins during PPV.4,5,10 Bennett et al.4 and Finer et al.5
measured PIP and PEEP, but not VT. Kanter10 measured VT and
minute ventilation but not PEEP. Oddie et al.11compared a self-
inflating bag and a T-piece to ventilate a leak-free test lung; they
did not measure tidal volume. Other researchers have compared
resuscitation devices to provide PIP or PEEP to an intubated
mannequin.12,13 However, we found no reports comparing the
ability of participants to use a T-piece, flow-inflating bag and a
self-inflating bag with a PEEP valve to provide to provide PIP,
PEEP, expiratory tidal volumes (VTe) and leak when ventilating
a mannequin.
The primary aim of this study was to compare commonly used
neonatal resuscitation devices; T-piece, self-inflating bag with a

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Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
JA Dawson et al.
PEEP valve and a flow inflating bag to accurately deliver PEEP.
The secondary aim was to measure PIP, VTe and face mask leak
with each device.
Participants
Ten participants from each professional group – neonatal con-
sultants, neonatal fellows, paediatric registrars, neonatal nurses
and anaesthetic registrars – completed the study.
Devices
We tested a T-piece (Neopuff, Fisher & Paykel, Auckland, New
Zealand), a self-inflating bag (Laerdal 240 mL silicone infant
resuscitator, Laerdal Medical, Stavanger, Norway) fitted with a
pop off valve, a PEEP valve (Laerdal Medical) and a flow-
inflating bag.
Methods
Fifty participants were asked to use each device in random
order to give PPV to a modified neonatal mannequin. A
Laerdal Resusci baby mannequin (Laerdal) was modified by
removing the lung and stomach bags, and positioning a 50-mL
test lung (Dräger, Lubeck, Germany) into the chest so chest
excursion mimicked that of an unaltered mannequin. The test
lung was connected by non-distensible tubing to the mouth
with an airtight seal. A pressure monitoring line was con-
nected to the airway. The system compliance when pressurised
to 30 cm H2O was 0.5 mL/cm H2O, with a maximal lung
volume of 65 mL.14 Inflations were given via a face mask to
achieve 40–60 inflations per minute, aiming for a PIP 30 cm
H2O and PEEP 5 cm H2O with good chest rise. Participants set
the target pressures on the T-piece and on the PEEP valve
attached to the self-inflating bag to 5 cm H2O before each
study. For the flow-inflating bag, participants controlled the
volume and pressure given by squeezing the bag and adjusting
the amount of gas escaping from the distal end of the bag
using their thumb and forefinger. A Laerdal mask size 0/1
(Laerdal Medical) was used with each device.
Participants were given time to practise with each device. We
started data collection when participants indicated they were
ready to start. We excluded the first five inflations, analysing the
next 20 inflations from each device. A manometer was visible to
participants with each device.
Airway pressure (PIP and PEEP) gas flow and VTe were mea-
sured by a Florian respiratory monitor (Acutronic Medical
Systems, Zug, Switzerland) connected between the mannequin
and the resuscitation device. Analogue signals from the Florian
monitor were digitised and analysed using Spectra data acqui-
sition and analysis software (Grove Medical, London, UK). Leak
between the mask and mannequin was calculated by expressing
the volume of gas that did not return through the flow sensor
during expiration as a percentage of the volume that passed
through the flow sensor during inflation (Leak (%) = ((inspira-
tory tidal volume - expiratory tidal volume) ⫼ inspiratory tidal
volume) ¥ 100).
Journal of Paediatrics and Child Health 47 (2011) 698–703
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Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Positive end expiratory pressure in neonates
Data analysis
We asked participants about their years of experience in neo-
natal resuscitation and experience using each device to provide
PPV to neonates. Inflation data are presented as median (range).
Analysis of variance was used to determine the effect of the
device on PEEP, PIP, VTe and leak with Bonferroni’s post hoc test.
A P value <0.05 was considered significant. Data were analysed
using Stata (Intercooled 10.0, Statcorp, College Station, TX,
USA).
Results
There were 50 participants, 10 from each professional group:
neonatal consultants, neonatal fellows, paediatric registrars;
neonatal nurses (nurses) and anaesthetic registrars. Partici-
pants had differing levels of experience with each device (see
Table 1). A number of participants were not familiar with each
device. Nine anaesthetic registrars had no experience using a
T-piece; one neonatal fellow, five paediatric registrars and two
anaesthetic registrars had no experience using a self-inflating
bag with PEEP; three neonatal consultants, two neonatal
fellows, all 10 paediatric registrars, nine neonatal nurses and
one anaesthetic registrar had no experience using a flow-
inflating bag for neonatal resuscitation. Ninety percent of par-
ticipants (n = 45) preferred to use the T-piece for neonatal
resuscitation; 4% of participants (n = 2) preferred to use the
self-inflating bag; and 6% of participants (n = 3) preferred to
use the flow-inflating bag.
Three thousand inflations were measured, comprising 20 per
device for each of 50 participants. Ninety-four (3%) inflations
were excluded from analysis (T-piece, n = 4; self-inflating bag
with PEEP, n = 34; flow-inflating bag, n = 56). These were
excluded as they had less than 10% leak; this is a difficulty with
the software and tended to happen when two inflations were
close together and Spectra did not record the inflations correctly.
In total, 2906 inflations were analysed.
PEEP
Participants were able to deliver PEEP (Table 1) with each
device. The T-piece was the most accurate (Fig. 1a). The median
PEEP was significantly different between devices (P < 0.001) and
participant group (P = 0.02) and experience in neonatal resus-
citation (P < 0.001), but not experience with the device (P =
0.27). The T-piece delivered a PEEP nearest the set level and the
flow-inflating bag delivered the PEEP lowest to the set level
(T-piece vs. self-inflating bag with PEEP (P < 0.001); T-piece vs.
flow-inflating bag (P < 0.001); self-inflating bag with PEEP vs.
flow-inflating bag (P < 0.001)).
Peak inflation pressure
Participants were able to provide PIP with each device. The
T-piece was the most accurate at providing PIP (Fig. 1b). The
median PIP was associated with device (P = 0.004), and partici-
pant group (P < 0.001), experience in neonatal resuscitation
(P < 0.001) and experience with the device (P < 0.001). The
median PIP was similar with each device. However, variability
699
Positive end expiratory pressure in neonates JA Dawson et al.

Table 1 PIP, PEEP, leak and VTe for each device and participant group

Consultants Fellows Paediatric registrars Neonatal nurses Anaesthetic registrars All

n = 10 n = 10 n = 10 n = 10 n = 10 n = 50

T-piece†
PIP (cm H2O) 29 (28–31) 29 (23–32) 29 (19–31) 29 (21–31) 29 (20–30) 29 (19–32)
PEEP (cm H20) 4.3 (3.3–5.3) 4.3 (2.4–5.3) 4.3 (3.3–6.2) 4.3 (1.9–6.2) 4.3 (2.4–6.2) 4.3 (1.9–6.2)
Leak (%) 14 (0–83) 22 (0–96) 10 (0–69) 16 (0–99) 39 (0–97) 16 (0–99)
VTe (mL) 10.2 (6.4–13.4) 10.2 (3.1–13.3) 10.9 (6.1–13.3) 10.4 (0.5–13.0) 9.2 (2.6–13.8) 10.0 (0.5–13.8)
Self-inflating bag‡
PIP (cm H2O) 29 (23–39) 29 (3–36) 30 (24–35) 30 (23–38) 28 (25–39) 29 (3–39)
PEEP cmH20) 3.3 (1.9–4.3) 3.3 (0.4–5.8) 3.8 (1.9–6.2) 3.8 (1.9–6.2) 3.3 (0.4–5.3) 3.3 (0.4–6.2)
Leak (%) 8 (0–92) 21 (0–97) 12 (0–85) 18 (0–99) 24 (0–97) 16 (0–99)
VTe (mL) 11.3 (3.4–15.0) 10.3 (0.3–17.6) 10.5 (7.2–18.8) 10.4 (0.2–15.5) 9.6 (0.4–16.6) 10.5 (0.2–18.8)
Flow-inflating bag§
PIP (cm H2O) 29 (15–35) 29 (8–38) 29 (6–36) 29 (20–43) 28 (22–37) 29 (6–43)
PEEP cmH20) 2.8 (0.9–7.7) 2.3 (0.4–5.3) 2.4 (0.4–5.3) 2.4 (0.9–7.7) 2.8 (0.4–27.6) 2.3 (0.4–27.6)
Leak (%) 17 (0–100) 47 (0–100) 55 (0–100) 82 (0–100) 21 (0–100) 45 (0–100)
VTe (mL) 11.2 (0.2–16.2) 11.5 (0.7–20.7) 10.1 (0.4–15.2) 9.3 (0.2–16.3) 10.6 (0.5–15.4) 10.6 (0.2–20.7)

Data are median (range). †T-piece: PIP was set at 30 cm H2O and PEEP at 5 cm H2O; ‡Self-inflating bag: PEEP valve was set at 5 cm H2O; §Flow-inflating bag
target was PIP 30 cm H2O and PEEP 5 cm H2O. PEEP, positive end expiratory pressure; PIP, peak inflation pressure; VTe expiratory tidal volume.

was greatest with the self-inflating bag with PEEP and flow-
inflating bag (T-piece vs. self-inflating bag (P < 0.001); T-piece
vs. flow-inflating bag (P < 0.001); self-inflating bag vs. flow-
inflating bag (P < 0.001)).
Face mask leak
The amount of leak generated with each device was very vari-
able. The T-piece and self-inflating bag with PEEP had the least
leak and the flow-inflating bag had the highest leak (T-piece vs.
self-inflating bag (P = 0.002); T-piece vs. flow-inflating bag (P <
0.001); self-inflating bag vs. flow-inflating bag (P < 0.001)).
VTe
The median (range) VTe generated with the self-inflating bag and
T-piece was similar. The flow-inflating bag had the greatest
variability, median (range) T-piece 10.0 (0.5–13.8) mL; self-
inflating bag with PEEP 10.5 (0.2–18.8); flow-inflating bag 10.6
(0.2–20.7).
Discussion
PEEP
Providing PEEP is important, especially in very preterm infants,
for the development of functional residual capacity. We have
previously shown that a Laerdal 240 mL self-inflating bag with
a PEEP valve can deliver PEEP, but the pressure falls rapidly
between inflations.15 In our current study, we asked participants
to provide 5-cm H2O of PEEP. On average, the T-piece provided
the target PEEP more often than the self-inflating bag with PEEP
or flow-inflating bag. The flow-inflating bag was the least accu-
rate device, with some participants able to generate a very high
PEEP (range 0.4–27.6 cm H2O). Bennett et al.4 tested the ability
of experienced clinicians to deliver a PIP of 20 or 40 cm H2O and
a PEEP of 5 cm H2O at a rate of 40–60 inflations/min to a
mannequin via a facemask using a T-piece device, a flow-
inflating bag and a self-inflating bag with a PEEP valve. In
contrast, they found that the self-inflating bag provided signifi-
cantly less PEEP than both the T-piece and the flow-inflating bag
(3.6 cm H2O, 4.4 cm H2O, 4.4 cm H2O; P < 0.005), respectively.
Bennett et al.4 did not measure the leak between the face mask
and resuscitation device. Leak may have contributed to the
variation in PIP or PEEP in the Bennett et al.4 study. We found
little difference in the leak between the self-inflating bag and
T-piece. This may have occurred because in our hospital, we
teach and use the technique of mask ventilation described by
Wood et al.16, which is shown to reduce leak. Leak may also be
related to the pressure inside the mask. The higher the PEEP, the
more leak there will be during expiration.
We asked participants to ventilate the mannequin with a face
mask to simulate ventilation in the delivery room. Hussey
et al.,12 Kelm et al.13 and Roehr et al.17 controlled for the effect of
mask leak with participants, using a variety of resuscitators, to
ventilate a leak-free intubated mannequin model. Hussey et al.12
asked participants to ventilate a mannequin with a T-piece,
flow-inflating bag and self-inflating bag without a PEEP valve at
40 inflations/min with a PIP/PEEP of 20/4 cm H2O. The mean
(SEM) PEEP for the self-inflating bag, flow-inflating bag and
T-piece were 0.15 (0.03), 2.8 (0.23), 4.4 (0.08) cm H2O, respec-
tively (P < 0.001). Without a PEEP valve, the self-inflating bag
did not generate any useful PEEP.12 Kelm et al.13 tested the
self-inflating bag fitted with 11 PEEP valves against five T-piece
resuscitators to ventilate an intubated mannequin (equivalent
to a 1-kg infant). Participants were asked to provide PEEP of
5 cm H2O, with an inflation rate of 40 per minute. All T-pieces
provided a PEEP >5 cm H2O (mean 5.59 cm H2O). In contrast,

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JA Dawson et al. Positive end expiratory pressure in neonates

Fig. 1 (a) Box plots show the positive end expiratory pressure (PEEP) generated by each device. The horizontal line is the median, the box represents the 25th
and 75th centiles, and the ends of the whiskers are the 5th and 95th centiles. The horizontal line at 5 cm H2O indicates the target PEEP. (b) Box plots show the
peak inflation pressure (PIP) generated by each device. The box represents the 25th and 75th centiles and the ends of the whiskers are the 5th and 95th centiles.
(c) Box plots show the expiratory tidal volume generated by each device. The box represents the 25th and 75th centiles and the ends of the whiskers are the
5th and 95th centiles.

only one of the 11 PEEP valves provided the target PEEP. In our
study, participants ventilated a mannequin with a face mask
rather than via an endotracheal tube. In the DR, clinicians
ventilating an infant via a face mask may have different results.
PIP
On average, the T-piece provided the target PIP more often than
the self-inflating bag with PEEP or flow-inflating bag. The flow-
inflating bag was the least accurate device (range 6–43 cm H2O).
Volumes
There is growing awareness about the effect of excessive volume
during neonatal resuscitation. In an animal model, Hillman
et al.18 showed that volutrauma could occur even when low
levels of PIP are given during positive pressure ventilation in the
DR. Kanter10 measured minute volume administered when 50
participants ventilated a mannequin with a self-inflating bag
and a flow-inflating bag. He reported that minute volume was
lower with the flow-inflating bag (P < 0.001). He did not report
the ventilation rate for each device.
Roehr et al.17 compared the tidal volume administered with a
self-inflating bag and T-piece with an intubated mannequin
(equivalent to 1-kg neonate). The median (interquartile range)
tidal volume was lower with the self-inflating bag 5.1 (3.2) mL
and higher with the T-piece 3.6 (0.8) mL (P < 0.0005).
Schmölzer et al.19 recommends targeting delivery of a tidal
volume of 4–8 mL/kg when providing PPV to reduce the risk of
volutrauma. However, this is difficult to achieve without a res-
piratory monitor.20,21
Inexperienced clinicians may be called to perform neonatal
resuscitation. Many participants in our study had little or no
experience with using a flow-inflating bag for neonatal resusci-
tation. This may have contributed to the greater variability in
PEEP given with the flow-inflating bag. Kanter10 and Mondolfi
et al.22 previously demonstrated that it was more difficult for
inexperienced operators to reach ventilation targets with the

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Positive end expiratory pressure in neonates
flow-inflating bag. Finer et al.5 showed that respiratory thera-
pists were able to consistently deliver PEEP with a flow-inflating
bag (P < 0.05) when compared with other neonatal health
professionals. In the United States, respiratory therapists are
likely to be the health professional with the most experience in
providing PPV during neonatal resuscitation. In contrast,
Bennett et al.4 did not find any operator differences between the
self-inflating bag with and without a PEEP valve, flow-inflating
bag and T-piece for ventilating a mannequin.
Ninety percent (n = 45) of participants in our study declared
a preference for the T-piece for DR resuscitation. Only 6% (n
= 3) preferred the flow-inflating bag in neonatal resuscitation.
The participants preferring the flow-inflating bag claimed that
with the flow-inflating bag, they could ‘feel’ the compliance of
an infant’s lungs and could adjust the amount of pressure
delivered in response to changes in compliance. Spears et al.23
tested the assumption that clinicians could ‘feel’ these changes
and showed that only 4 of 24 anaesthetists were able to detect
changes in compliance during hand ventilation of either a
preterm or term lung model. In contrast, using a computerised
lung model, Kattwinkel et al.20 found that resuscitators were
able to change PIP during DR resuscitation in response to
changes in compliance. He masked resuscitators to changes in
lung compliance while they ventilated a computerised lung
model with a flow-inflating bag, a self-inflating bag and a
T-piece resuscitator. Participants were directed to maintain a
constant inflation volume, first while masked to delivered
volume and then with the volume displayed with all three
devices. When participants used the self-inflating bag, with
only pressure visible, there was a significant change in mean
(95% confidence interval (CI)) and inflating pressure cm H2O
(3.56 (2.24–4.87, P < 0.001)) when lung compliance was
changed from high to low. The participants’ ability to change
their inflating pressure by such a small amount might not be
clinically important. There was no difference in mean (95%
CI) cm H2O when the flow-inflating bag (0.10 (-0.48 to 0.69,
P = 0.73)) or T-piece (15.68 (14.75–16.60, P = 0.59)) was used.
Participants adapted to compliance changes by adjusting infla-
tion pressure more effectively when delivered volume was dis-
played. The effect of compliance changes on PEEP was not
measured. In our study, participants were able to view
the pressure they were generating but not the tidal volume
delivered.
A limitation of our study is that we tested one model of
T-piece, self-inflating bag with PEEP valve or flow-inflating bag.
Other models of these devices may perform differently.
We tested participants’ ability to ventilate a mannequin
model. Our findings may not replicate exactly the clinical
setting. We used a respiratory function monitor to measure PIP,
PEEP and tidal volume during our study. Future research could
be directed at determining if a respiratory function can assist
clinicians when using resuscitation devices in the delivery room.
In resource-poor countries where a reliable gas supply is not
available, a self-inflating bag fitted with a PEEP valve may be
used with air for ventilating infants with PEEP. Our study and
those from other researchers measuring the qualities of resus-
citation devices continue to show how important it is for resus-
citators to be thoroughly trained in the use of whichever device
is available to them.
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JA Dawson et al.
Conclusion
The self-inflating bag with PEEP valve, flow-inflating bag and
T-piece were able to provide PIP and PEEP. However, the flow-
inflating bag provided the least PEEP with the greatest variation.
The T-piece was the most accurate and consistent. The leak was
lowest with the self-inflating bag and highest with the flow-
inflating bag, but all had wide variation.
Acknowledgements
We thank the staff at RWH, Melbourne for participating in this
study.
Funding
JAD and COFK received RWH postgraduate scholarships. PGD
has an NHMRC practitioner fellowship. PGD and CJM hold an
NHMRC Program Grant No. 384100 which partially funded this
work.
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Positive end expiratory pressure in neonates
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