Overview
Definition:
Positive-pressure ventilation (PPV) using a T-piece resuscitator is a method of delivering breaths to a spontaneously breathing or apnoeic infant or child by generating positive pressure in the airway without requiring a mechanical ventilator
The T-piece device allows for the delivery of a set inspiratory pressure (PIP) and a variable positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP).
Epidemiology:
This technique is the cornerstone of neonatal resuscitation globally, employed in virtually all deliveries where infants require respiratory support
It is also utilized in pediatric intensive care units for infants and children experiencing respiratory distress or failure, particularly those with spontaneous respiratory efforts
Accurate incidence data is challenging as it is a standard procedure.
Clinical Significance:
Effective T-piece ventilation is critical for supporting cardiorespiratory function in neonates with respiratory distress, facilitating gas exchange, and preventing hypoxemia and hypoxia
In older infants and children, it can serve as a bridge to mechanical ventilation or provide non-invasive respiratory support
Proper setup and troubleshooting are essential to optimize oxygenation, ventilation, and minimize complications, directly impacting patient outcomes and examination readiness for DNB and NEET SS candidates.
Setup
Components:
Oxygen source (medical grade)
Air-oxygen blender (if needed for precise FiO2)
T-piece device (e.g., Laerdal Neopuff, Ambu Res-Q-Vac)
Face mask (appropriate size)
Reservoir bag (optional, for pre-oxygenation)
Pressure manometer
Flow meter.
Pre Use Checks:
Ensure all components are clean and functional
Check for leaks in the mask and tubing
Verify oxygen supply and flow
Test pressure gauge
Assemble the system correctly according to manufacturer instructions.
Setting Parameters:
Initial settings depend on patient age, weight, and clinical condition
For neonates, typical initial PIP is 20-25 cmH2O, and PEEP/CPAP is 5 cmH2O, with a respiratory rate of 40-60 breaths/min
For older children, settings are adjusted based on weight and clinical response
FiO2 is adjusted to achieve target SpO2.
Delivery Technique:
Apply the mask to the infant's face, ensuring a good seal
Initiate breaths by occluding the pressure relief port on the T-piece device for the desired duration (e.g., 0.5 seconds for a 3-second inspiratory time)
Release the port to allow exhalation
Monitor chest rise with each breath.
Troubleshooting
Inadequate Chest Rise:
Poor mask seal (reposition mask, ensure correct size)
Air leak (check mask fit, tubing connections)
Insufficient pressure (increase PIP, check manometer)
Obstruction (suction airway, reposition head/neck).
Poor Oxygenation:
Inadequate ventilation (optimize PIP, rate, seal)
Insufficient FiO2 (increase FiO2, check blender)
Pneumothorax (suspect, perform needle decompression if necessary)
Persistent pulmonary hypertension (consider nitric oxide, ECMO).
Air Leaks:
Mask leak (check fit, size, securing straps)
Tubing connection leak (ensure secure connections).
Excessive Pressure:
Pressure relief valve malfunction (check device function, replace if faulty)
Accidental over-occlusion of the port (train operators).
Patient Discomfort Or Fighting:
Need for adequate analgesia and/or sedation
Consider CPAP trial if spontaneously breathing
Ensure correct PEEP/CPAP settings.
Indications And Contraindications
Indications:
Apnea or gasping respirations
Bradycardia (HR < 100 bpm)
Hypoxemia requiring support
Respiratory distress syndrome
Meconium aspiration syndrome
Transient tachypnea of the newborn
Post-extubation support
Asynchronous breathing
Congenital diaphragmatic hernia (initial stabilization).
Contraindications:
Complete airway obstruction
Untreated pneumothorax (relative, requires chest tube)
Facial anomalies precluding mask seal
Untreated severe congenital anomaly incompatible with life
Complete cessation of spontaneous breathing without response to stimulation (may require intubation and PPV via ETT).
Special Considerations:
In neonates with congenital diaphragmatic hernia, initial PPV should be gentle (PIP 20-25 cmH2O, PEEP 3-5 cmH2O) with minimal FiO2 to avoid worsening air leak into the chest
Avoid mask ventilation in infants with choanal atresia (obligate nasal breathers).
Monitoring And Assessment
Clinical Monitoring:
Continuous assessment of chest rise
Respiratory rate and pattern
Heart rate
Color and oxygen saturation (SpO2).
Device Monitoring:
Ensure pressure manometer readings are within the target range
Monitor for audible leaks
Check for adequate tidal volume delivery (visible chest rise).
Gas Exchange:
Arterial or capillary blood gas analysis to assess oxygenation (PaO2), ventilation (PaCO2), and acid-base status
Target SpO2 for term neonates is 90-95% post-resuscitation
For preterm infants, target SpO2 may be lower initially.
Complication Monitoring:
Watch for signs of pneumothorax (sudden desaturation, unilateral absent breath sounds, tracheal deviation)
Monitor for gastric distension and potential aspiration
Assess for facial trauma or pressure necrosis from mask.
Key Points
Exam Focus:
Know the essential components of a T-piece resuscitator
Understand the initial settings for neonates (PIP, PEEP, rate, FiO2)
Be familiar with common troubleshooting scenarios and their management
Recognize the importance of mask seal and airway patency.
Clinical Pearls:
Always perform pre-use checks
A good mask seal is paramount for effective ventilation
If chest rise is inadequate, systematically check for leaks, obstruction, and adequate pressure
Prioritize suctioning and airway opening maneuvers before increasing ventilator pressures excessively.
Common Mistakes:
Over-ventilation leading to barotrauma or pneumothorax
Inadequate FiO2 leading to hypoxemia
Poor mask seal causing ineffective ventilation and gastric insufflation
Delay in intubation when mask ventilation fails to improve cardiorespiratory status.