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:

Weeks Gestation	SpO2	Alarms High  Low
<30	85%	93	80
30-34	88%	93	83
35-39	91%	96	86
40 or >	94%	99	89

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.

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