slideshow widget

Wednesday, September 28, 2011

Everything you need to know about the Neopuff

Introduction to the NeoPuff:

The need to perform positive pressure ventilation (PPV) on neonates is rare.  In fact, statistics show that about 90% of infants make the transition to extra-uterine life with no problem.  The other 10% will need resuscitation, with 1% requiring an extensive work-up.

In the past PPV has been performed with an AMBU-bag, and rate and depth of breaths determined by a steady hand.  New evidence shows that using AMBU-bags on neonates is too risky, and many hospitals, including ours, are making the transition to using a NeoPuff instead of AMBU-bag.

What can a NeoPuff be used for?

  • Blowby oxygen
  • PPV
  • CPAP
How to get NeoPuff ready for use? (Must be completed when birth expected)
  1. Check manometer reads zero with no gas flow. (If not, call RT)
  2. Make sure patient supply line is connected to outlet port
  3. Make sure a T-piece is connected to the patient supply line
  4. Turn on air & oxygen tanks (not needed if air & oxygen connected to wall source)
  5. Connect test lung to T-piece
  6. Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
  7. Check for desired oxygen (recommended setting is 40% FiO2)
  8. Place finger over PEEP valve.  Pressure manometer should read 20cwp. 
  9. While still occluding PEEP valve, turn PIP valve clockwise as far as it can go.  It should not go higher than 40.  If it does go to step 10.  If not, go to step 11
  10. Continue occluding PEEP valve.  Remove cap from Maximum Pressure control knob.  Turn knob until Maximum Pressure set at 40 (or as desired)*
  11. Close cap that so Maximum Pressure knob is covered
  12. Turn PIP** knob to set desired PIP (We like to use 20cwp)
  13. Adjust PEEP cap to desired PEEP level.  We like to use 5 CWP.  The PEEP cap is located on the T-Piece
  14. Turn off gas supply from flowmeter on NeoPuff
  15. If used, make sure you turn off the air and oxygen tanks (otherwise you’ll have to replace them when they go empty)
  16. Make sure neonatal resuscitation mask is in the basket
  17. Remove test lung from patient circuit
  18. If used, check oxygen and air tanks and replace as necessary
  19. Failure to complete any of the above steps may cause unacceptable delays in resuscitating newborns.
*The factory setting of the Maximum Pressure Relief is 40 cwp. This is to prevent the PIP from being adjusted over 40 cwp.  Likewise, resuscitation above 40 cwp cannot be achieved unless the Maximum Pressure Relief valve is adjusted.  So long as no one does this, step 10 above can be skipped.

**PIP is Peak Inspiratory Pressure.  This is the pressure given for each breath. 

How to get NeoPuff ready when you need it NOW?

  • Turn on oxygen and air tanks (not necessary if O2 & air plugged into wall outlet)
  • Turn flowmeter on NeoPuff to 8lpm (or 5-10lpm)
  • Make sure PIP is set at 20
  • Make sure PEEP is set at 5
  • Make sure FiO2 is set to 40%
  • Fit neonatal resuscitation mask to the T-Piece
  • Now it is ready for the impending delivery.  Hopefully you won’t need it.
Blowby oxygen:  If the infant is breathing yet continues to be blue or otherwise requires oxygen, the NeoPuff can be used to blow oxygen past the patient’s face (an AMBU-bag cannot be used to give blowby oxygen) 

  • Place mask (or that end of the tubing) close to baby’s mouth and/nose (no not place the mask on the baby's face, just NEAR the face)
  • Occlude PEEP valve with your finger and hold it there
  • Oxygen should now be blowing by the patient’s face
  • Adjust oxygen as required to maintain desired SpO2 (see below)
How to give PPV with NeoPuff? 

If the infant is not breathing adequately, or the heart rate dips below 100, you should do the following:

  • Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT).
  • Resuscitate by placing and removing thumb over the PEEP cap to allow inspiration and expiration. 
    • Inhalaiton occurs when you place thumb over the PEEP cap
    • Exhalation occurs when you remove thumb from PEEP cap
  • Give 40-60 breaths per minute (recommended by NRP)
  • Do this until HR > 100 and patient breathing adequately
How do you know PPV is working?

  • Heart rate increases
  • Improved Color
  • Spontaneous respirations
  • Increased muscle tone
If the NeoPuff appears to not be working:

  • Check equipment
  • Make sure have good seal
  • Make sure PIP is adequate
  • Check respirations
  • Reposition infant
How to give CPAP with NeoPuff?

If infant heart rate is above 100 and breathing remains labored, CPAP may be trialed:

  • Place mask over the baby’s mouth and/nose (or fit patient T-piece to ETT)
  • Do not place finger over hte PEEP valve and hold
  • This will allow patient to breath spontaneously while providing CPAP (PEEP)
  • Verify it is working by observing the pressure manometer: during exhalation the hand should point to your dialed in PEEP setting.  
Why use the NeoPuff to give PPV rather than an AMBU-bagBag?

  • Evidence shows the NeoPuff is the best way to ventilate neonates
  • Less pressure (prevents pneumo)
  • Consistent Pressure (prevents Hyaline Membrane Disease*)
  • Bags should be available for backup only
  • I-Time and Rate controlled by finger instead of whole hand
  • Less stress on caregiver (don’t have to worry about giving too much or too little pressure)
*Evidence shows that inconsistent pressures from AMBU-bags actually cause bruising in the neonate airway and can result in further complications for newborns making them extremely difficult to treat.  The Neopuff gives constant, equal breaths that are much easier for the infant.

Fallacies about using Neo-Puff to give PPV: 

Many medical care practitioners are afraid to use the Neo-Puff because they are used to “feeling” each breath go into the baby with their hands by squeezing the bag. When using the Neo-Puff you will not “feel” the breath go in. 

However, every study so far completed comparing the Neo-Puff to PPV overwhelmingly supports using the Neo-Puff to the Ambu-Bag.  The Neonatal Resuscitation program (NRP) highly recommends we get over our fear of the Neo-Puff and use them. 

Oxygenating Neonates:

When using our AMBU-bags you have to give 100% oxygen.  The NeoPuff allows you to adjust the FiO2 from 21% to 100%.

A growing number of literatures have proven you shouldn’t use 100% oxygen for newborn infants.  New studies show that high levels of oxygen -- even for term babies -- can be detrimental to the short term and possibly even long term health of newborns.

Several studies have linked 100% oxygen (even for as little as ONE minute) to:
  • Leukemia
  • Cancer
  • Cellular death
  • Infection
  • Delayed development of oxygen sensing tissues
  • Oxygen radical disease of neonate
It is for this reason that 40% is the recommended starting point for FiO2.  If needed, this can be titrated as appropriate for the patient, or as recommended by physician.

Pay attention to oxygen sats, don’t just leave baby at 100% SpO2.  With Baby less than 30 weeks, Spo2 should be kept <90, the concern is early eye development.  Plus scientists are not sure if primie organs should be rapidly exposed to too much oxygen too fast; when in utero they were developing in a SpO2 of 60% or less. 

Some hospitals are currently doing a study of using 21% on all newborns.  It is now believed that it’s not oxygen that stimulates a baby to take its first breath, but heat, stimulation, and PPV.  So some hospitals have gone to 21% FiO2 already.  

Benefits of lowering oxygen Sats:

  • Increased neurological function
  • Decreased Retinopathy of Prematurity
  • Decreased Chronic lung disease
  • Increased weight gain
  • Decreased Infection 
  • Decreased Ventilator days
  • Decreased Oxygen days
  • Decreased Length of stay
  • Decreased neonate mortality rate by 30-40%
However, if a baby is not responding to 40% FiO2 after 90 seconds, you should increase to 100%

The recommended goals of oxygenation:

High  Low
40 or >

  1. Achieve Sat gradually (increasing PO2 too fast has potential to cause harm)
  2. Decrease FiO2 as Sats rise > 95%
  3. If HR not rising, check for correct ventilation
  4. Increase to 100% FiO2 if no improvement after 90 seconds
  5. Do not chase saturations, fluctuations in sats is normal (better to bounce low than to bounce high
  6. SPO2 should not exceed 95% unless suspect Persistent Pulmonary Hypertension
Benefits of CPAP for neonates: (PEEP and CPAP is the same thing)

  • Always keeps little air in lungs to make next breath easier.
  • If HR >100 and breathing remains labored, then you can try CPAP. 
    1. Keeps small amount of air in lungs
    2. Keeps alveoli open, and prevents alveoli from collapsing
    3. Improves oxygenation
    4. Makes next breath easier
Conclusion:  So you can see the NeoPuff is proven to be a safe and effective method of providing blowby oxygen, PPV and CPAP for neonates.  It’s also easy to set up, requires only one finger to use, and takes away the stress of squeezing the bag too hard.  In this regard, a well educated caregiver will realize it’s actually easier to use than an AMBU-bag.



Anonymous said...

Thanks so much! We are transitioning to the Neopuff and it was helpful.

Anonymous said...

Thank you for the info. Never heard of it before the other day. I know that this will help me in the future. Is there an age cutoff for using this?

Rick Frea said...

I don't know about a specific age cutoff. I have used it in the ER for a 3 weeker in the ER. It's much easier, safer, and less stressful than bagging such a little baby.

Anonymous said...

Can you supply cpap for the baby while he/she breathes on her own? IE 5/peep only?

Rick Frea said...

Yes. You just hold the mask over the patient (tight seal) and this will provide CPAP. I've done it and it works great. To see if it's working you just watch the pressure manometer, because the hand will bob up to 5 CPAP with each exhalation.

Anonymous said...

I appreciate this information but please use caution with the CPAP instruction to "Place finger over PEEP valve and hold".
The Neopuff is a flow dependent infant resuscitator that delivers
breaths manually with controlled and accurate PIP and PEEP during
resuscitations and transports. PEEP is maintained continuously by
rotating the PEEP cap (valve) found in the patient circuit. CPAP is
delivered by setting the PEEP to a numerical value and not occluding the
aperture on top of the peep cap (valve). PIP is set with the
“INSPIRATORY PRESSURE CONTROL” knob. Inspiration is produced when the
user occludes with user’s thumb the PEEP cap aperture found on top of
the PEEP cap (valve). Expiration occurs when thumb is removed.
Inspiratory time and respiratory rate are dependent upon user technique.
The Neopuff delivers non-humidifed gas.

rn2bsn said...

** It is imperative that the aperture on top of the peep cap (valve) is
not continuously occluded. This would result in a prolonged inspiratory
hold potentially leading to a pneumothorax.

bonedish said...

Is anyone experiencing problems ventilating babies in a delivery setting?
My facility has experienced several issues with getting initial opening pressures with the Neopuff - even after assuring that there is a good seal, no other airway occlusion and increasing the PIP, increasing flow, etc. In these instances, it has caused a slight delay in which we have to revert back to using the flow-inflating bags.
Any input would be most valuable. Thanks!

Rick Frea said...

Is it all your neopuffs, or just one in particular? If it's one, then maybe there is an internal problem with the machine, and it's in need of maintenance. Another place you might want to research (or ask your question) is Go down to community and click on discussion. You can scroll the other Q and A's, or you can ask your own question. I have learned a lot in this community.

sripriya kannan said...

Thanks for the information... ... specially those on Niceneotech

shanthi d said...

Thanks for the information...... specially those on Infant Resuscitator