Frequently Asked Questions

Jump to: Resuscitation, Invasive Ventilation, Nasal High Flow

Infant Respiratory Resuscitation

Resuscitation
Infant Respiratory Invasive

Invasive Ventilation
Infant Respiratory Nasal High Flow

Nasal High Flow


Resuscitation

  • Neopuff can provide manual inflation breaths (positive pressure ventilation - PPV) and positive pressure support (positive end-expiratory pressure - PEEP) to the patient’s lungs.
  • It can be used in any clinical setting where an infant weighing less than 10 kg (22 lb) needs help to breathe. This may include the labor and delivery rooms, operating theaters, birthing units, NICU, special-care nurseries, emergency departments, pediatric ICU and hospital wards.
  • Neopuff is only to be used by those trained in infant resuscitation, and with reference to resuscitation guidelines and the Neopuff T-piece resuscitation system user instructions.
  • PEEP protects against lung injury and distal airway collapse at the end of expiration, so it improves oxygenation and helps to establish and maintain functional residual capacity.1,2 After an inflation without PEEP, lung volume is lost, the airways collapse, and an infant can be at risk of atelectrauma (damage to the alveoli due to shear stress caused by their repeated collapsing and reopening during the inflations that follow).
  • International neonatal resuscitation guidelines suggest that PEEP is especially beneficial during the provision of positive pressure support to preterm infants, and that it should be used if available.3,4
  • Rates of approximately 30 to 60 breaths per minute are recommended by most international guidelines. These match the typical respiratory rates of healthy newborns. To match the natural breathing pattern of term and preterm infants, the inspiratory time while delivering PPV should be 1 second or less.4
  • The Neopuff T-piece resuscitator can deliver controlled inflations that can be applied to various resuscitation strategies, such as providing longer inflations at the start of resuscitation. However, there is uncertainty around the potential harm or benefit of longer inflations of 1 to 10 seconds, which is why they are used mainly in research studies and are not currently recommended.3,4
  • Peak inspiratory pressure (PIP): International guidelines3,4 suggest pressures of 20 to 30 cm H2O as initial settings. Pressures should be adjusted up or down according to response. A rising heart rate is a sign that effective ventilation is being delivered.
    • PIP is set using the PIP control on the Neopuff T-piece resuscitator.
  • Positive end-expiratory pressure (PEEP): When providing positive pressure ventilation (PPV) to newborns, a minimum of 5 to 6 cmH2O is suggested by international guidelines.3,4
    • PEEP pressure is set by adjusting the PEEP cap on the T-piece circuit.
  • A flow rate of 8 to 10 L/minute is typically used during resuscitation. It is rarely necessary to change the gas flow above the standard rate during resuscitation. If the flow rate is changed, the pressure (PIP and PEEP) settings should be checked again before use.
  • The maximum pressure relief valve is a safety feature of the Neopuff which limits the achievable circuit pressure and prevents the accidental delivery of an excessively high PIP. This valve is factory set at a pressure of 40 cmH2O and can be increased if higher pressures are required.
  • The classic (900RD010) and ergonomic (RD1300-10) T-piece circuits have a universal connection and can be connected directly to any T-piece resuscitator that meets the gas- powered resuscitator standard ISO 10651-5:2006. The humidified T-piece circuit (900RD110) should only be used with the F&P Neopuff T-piece resuscitator and the F&P MR850 Humidifier.
  • F&P resuscitation masks have a 15 mm (0.59”) conical male fitting, and can be connected to common resuscitation devices, including many self-inflating and flow-inflating bags, as well as to non-F&P T-piece circuits which conform to ISO 10651-5:2006.
  • Neopuff can be set up in advance of its use. However, it should be checked immediately before every resuscitation to ensure the device is functioning correctly and has the correct PIP, PEEP and safety limit pressure settings. Follow the instructions for use.
  • F&P resuscitation masks and T-piece circuits are designed for single-patient use. We recommend you follow hospital protocols regarding infection control and the disposal of consumables.
  • The gas supply lines (900RD008 and 900RD009) are reusable products.
  • It is recommended that they are checked periodically for cracks, leaks and other damage. If the gas supply lines are not damaged, the maximum use time should be determined by hospital protocols.
  • The gas supply lines can be cleaned externally using a detergent-based solution (maximum 2% in water), ensuring the manufacturer’s directions for use of the cleaning agents are followed. If the breathing tube becomes excessively soiled, or soiled internally, it should be replaced.
  • The Neopuff T-piece resuscitator should be checked before every use to ensure that the device (including its gas supply line) is functioning correctly. Follow the Neopuff T-piece resuscitator user instructions.
  • Dispose of the gas supply lines according to hospital protocols.
  • A good mask seal with minimal leak is important to achieve effective ventilation. International resuscitation guidelines recommend that an appropriately sized face mask should cover the mouth and nose but not the eyes and that it should not overlap the chin.
  • The Fisher & Paykel Healthcare resuscitation mask range comprises five sizes to fit a range of patients. The masks are designed to be soft and pliable, with a transparent surface that allows breath condensate to be observed. Available diameters: 35 mm (1.37”) (RD803-10), 42 mm (1.65”) (RD804-10), 50 mm (1.97”) (RD805-10), 60 mm (2.36”) (RD806-10) and 72 mm (2.83”) (RD807-10).
  • International resuscitation guidelines do not provide recommendations on which type of neonatal resuscitation mask (round vs. anatomical) should be used. Emphasis is instead placed on the correct size, hold and positioning of the mask.
  • O’Shea et al. (2016) showed that round masks with an external diameter of 35 mm/1.37” and 45 mm/1.77” were suitable for preterm infants of < 29 weeks PMA (weighing <1000 g/2.2 lb) and 29-33 weeks PMA (weighing 1000-2500 g/2.2-5.5 lb) respectively.5
  • You can find out more about mask size and hold when using the F&P Healthcare range of resuscitation masks here.
  • No; the use of a nasal cannula to provide ventilatory support with Neopuff is not recommended. Neopuff should only be used with an approved interface, such as a resuscitation mask or endotracheal tube.
  • A good seal over the nose and mouth, with minimal leak, is important for establishing effective ventilation. Inadequate seal of the cannula in the nares, and an open mouth, reduces the pressures that can be delivered, which might lead to ineffective ventilation.
  • Use of a nasal cannula designed to deliver other respiratory therapies compromises the Neopuff’s ability to provide controlled and consistent pressures, due to increased resistance to flow. In addition, the pressures displayed on the manometer might not accurately reflect the pressures delivered to the infant’s lungs.
  • The placement of a filter between the T-piece and resuscitation mask is not advised. F&P Healthcare recommends extreme caution when using filters in unapproved or improvised ways. Resistance to flow, filtration efficiency in different conditions, instrumental dead space, flow dynamics through the system and the potential for gas-trapping are just some of the important safety factors healthcare professionals should consider. Because of these altered parameters, the pressures displayed on the Neopuff manometer may not accurately reflect the pressures delivered to the baby’s lungs.
  • Guidelines say that warming strategies, including the use of warmed, humidified inspired gases as a warming aid, may be used to prevent hypothermia in very preterm infants. The latest European Resuscitation Council guidelines further state that the use of warmed humidified respiratory gases should be considered for preterm infants of £ 32 weeks’ gestation who are receiving respiratory support at birth.3
  • HHG can be delivered using the Neopuff T-piece resuscitator, MR850 Humidifier, MR290 or MR225 humidification chamber, and the F&P Humidified Resuscitation T-piece Circuit (900RD110). Follow the set-up and operation user instructions.
  • To allow for adequate warm-up time, the MR850 Humidifier should be turned on (in Invasive mode) 30 minutes before the resuscitation, as per the MR850 user instructions.
  • It is possible to provide humidified resuscitation using the 900RD110 circuit during transport from the delivery room to NICU. If no power is available and the humidifier is switched off, the humidity will drop below the recommended level (33 mg/L) within 10 to 20 minutes, depending on the gas flow rate and ambient temperature. Condensation will therefore start to form.
  • The published randomized controlled trials by te Pas et al. (2010) and McGrory et al. (2018) describe protocols for providing HHG during stabilization at birth.6,7
  • The bench test by Farley et al. (2013) describes a protocol in the laboratory setting.8
 
The following table summarizes the various protocols used and/or tested for the provision of HHG during resuscitation.
 
 
Study Volume of water in humidifier chamber Warm-up time Flow rate used
Te Pas AB et al. (2010) 20 mL approx. 3 minutes 8 L/minute
McGrory L et al. (2018) 50 mL Switched on for im- mediate use (did not use a set warm-up period) Not specified
Farley RC et al. (2013) 30 mL approx. 8 minutes 10 L/minute
 
Our FAQs should not replace any information or guidelines as stated in the product user instructions or local hospital procedures.
References


Invasive Ventilation

Condensation can occur in the breathing circuits used with the MR850 Humidifier for several reasons. Some of these are listed below. They can be resolved by making a few small adjustments to the setup.
  • Environmental conditions – exposure of the breathing circuits to external heating or cooling, such as the presence of an air conditioning system or a draft from an open window.
  • Incorrect setup of the F&P 850 humidification system.
  • Loose connections in the circuit setup.
Please refer to our brochure, F&P 850 System - Managing Condensation, for more information about how to manage these factors.
  • If using the MR850 humidifer, ensure that it is set to Invasive mode.
  • When using the F&P 950™ humidifier, the device will automatically switch to Neonatal mode when the neonatal circuit is connected.
  • For incubators with an air temperature > 34 °C (93°F) use the unheated extension and place the temperature probe just outside the incubator.
  • For incubators with an air temperature < 34°C (93°F) and for infant radiant warmers, remove the unheated extension and place the temperature probe in the patient-end probe port located near the patient swivel Y-piece.
  • When using an infant warmer or open bedspace, the unheated extension should not be used as it may result in increased levels of condensate, depending on the temperature of the environment around the circuit.
  • The unheated extension should not be used during kangaroo care.
Note: Ensure the temperature probe is in the correct position depending on whether the unheated extension is used. This is important as incorrect probe placement may cause inaccurate temperature readings of the circuit due to external heating, such as that from an infant warmer.
 
* An unheated extension does not come with the F&P 950 neonatal circuit because it is not required when the circuit has built-in Thermadapt™ technology.
  • F&P filters (RT016, RT019, RT020) are not intended for use with F&P infant invasive ventilation circuits.
  • For pediatric/neonatal ventilators that do not have an inherent expiratory filter and vent to the atmosphere, a disposable filter may be used.
    • Ensure the filter has 15 mm connections to facilitate secure connections, which help to minimize dead space and optimize ventilator performance.
    • Use only regulatory agency-approved filters. They have been tested in accordance with internationally recognized standards for filtration efficiency against bacteria and viruses.
    • Be aware that the filtration efficiency of filters changes with operation. Check the settings on the ventilator periodically and replace filters as per the manufacturer’s specification.
    • If you choose to use a filter with our infant invasive ventilation circuits, consider that resistance to flow and filter volume may affect ventilator performance.
For further information on the use of inspiratory/expiratory filters with invasive ventilation circuits, please visit Viral and Bacterial Filtration of F&P Healthcare Filters and F&P Evaqua™ 2 Circuits.
F&P humidification systems are suitable for use with a broad range of ventilators and flow sources. Most F&P infant invasive circuits include an adapter kit suitable for a range of ventilator models. Contact your local F&P representative for more information on ventilator-to-circuit compatibility.
Yes; any excess condensate that forms in the circuit can be drained back into the water chamber to avoid unnecessary circuit breaks.
The patient’s own pathogens may be present within the closed circuit. These may be present in condensate which can be drained back to the chamber. However, water vapor generated at the chamber cannot carry pathogens to the patient. Please refer to the information here for clarification around particle size.
Always follow your hospital protocols and the ventilator or nebulizer manufacturer user instructions. Using the appropriate adapter, e.g., RT010 or OPT016, it is possible to introduce medications into the gas path. F&P recommends placing the adapter as close to the patient as possible to reduce potential interference with the humidifier system. Remove the adapter after administering any medication.
Infant circuit kits for the MR850 contain multiple adapters for various clinical scenarios. This includes the RT062 Luerlock adapter, which can be inserted to allow NO delivery, and regular monitoring while using an F&P system. Extra adapters are also available as separate components.
 
If using the F&P 950 Humidifier, there is a specific kit for delivery of NO (950X08), which contains the required adaptors and a short unheated extension.
The benefits of heated, humidified respiratory support is well established within the clinical literature across the care continuum. These benefits are maximized when respiratory gases are delivered as close as possible to body temperature and pressure, in a saturated state. For this reason, F&P recommends that the humidifier be set to Invasive mode whenever delivering
support to neonates and infants. A wide range of heated and humidified solutions are available from F&P, including solutions for T-piece resuscitation, noninvasive respiratory support (such as bubble CPAP and NHF) and invasive ventilation.
The benefits of heating and humidifying gases for respiratory support are still relevant during therapeutic hypothermia of the neonate. Guidelines, including a 2021 publication on behalf of the Newborn Brain Society, typically recommend continuing with routine practice of respiratory care during the cooling period, including delivery of heated, humidified gases at normothermic levels.1-3
 
Our FAQs should not replace any information or guidelines as stated in the product user instructions or local hospital procedures.
References


Nasal High Flow

NHF is a flow-based therapy designed to be an open system. Typically, it consists of a flow source to blend air and oxygen, a heated humidifier to heat and humidify the gas mixture, and a circuit and unsealed interface to deliver humidified gas to the patient.1
The level of pressure generated on NHF is dependent on a range of factors including flow rate and nare occlusion.2 Physiological studies have demonstrated pharyngeal pressure that is similar to, or below, the pressure generated during continuous positive airway pressure (CPAP).3 Data from systematic reviews has found that NHF is associated with no increased risk of adverse events such as barotrauma, compared to CPAP.4
Medical gases are typically cold and extremely dry, and exposing the airway to these conditions has negative implications for both airway reactivity and lung mechanics.5
 
Adding heat and humidity to respiratory gases prior to inspiration reduces the burden on the airway to condition inspired gas to body temperature and pressure, saturated (BTPS). This has numerous beneficial effects, including optimized mucociliary function,6,7 reduction of respiratory effort,6 and promoting the conservation of energy for growth and development.
 
These benefits are maximized when inspired air is delivered at BTPS (37 °C, 44 mgH2O/L).6
 
The necessity of heated humidification during noninvasive respiratory support increases with use of higher flow rates. For this reason, hospital protocols and guidelines suggest that
humidification always be used when delivering flow > 2 L/min in infants and children, and > 1 L/ min for neonates.8
Neonates (Newborns up to 1 month)*
Data from neonatal randomized control trials (RCTs) and guidance from clinical experts suggest a starting flow rate between 4 and 6 L/min.9–12
The body of noninvasive literature suggests three pathways for implementing NHF and CPAP in the NICU:
 
  1. Post-extubation: A Cochrane Review by Wilkinson et al. found that compared to CPAP, neonates on NHF experienced a significant reduction to rates of nasal trauma, and no difference in rate of treatment failure, re-intubation and other adverse outcomes i.e. pneumothorax and bronchopulmonary dysplasia (BPD).4,9-11
  1. Alternative to prolonged CPAP: Expert consensus suggests NHF may be a suitable alternative to CPAP for neonates who require prolonged periods of noninvasive respiratory support. At the clinician’s discretion, NHF may be considered as an alternative when the patient is stable on CPAP.4,13
  1. Primary respiratory support: A recent systematic review concludes NHF (with rescue CPAP available) may be considered for primary respiratory support in preterm infants.9,12,14-17
 
The weight of clinical evidence for NHF is for infants ³ 28 weeks GA. Therefore, CPAP remains the gold standard for smaller preterm infants.
Infants and Children (1 month - 12 years)*
2 L/kg/min (for those between 3 and 12.5 kg (7-28 lb)) has demonstrated physiological and clinical efficacy in this population.18–21 For infants > 12.5 kg (28 lb), a weight-banding approach is suggested,22 which can vary between hospital protocols.
In a large multicenter randomized controlled trial conducted by Franklin et al. (2018) (the PARIS trial), the use of Optiflow Junior to deliver NHF therapy to infants with bronchiolitis early during the hospital admission, resulted in a significant reduction to escalation of care due to treatment failure, compared with standard oxygen therapy.18,23-25
Mayfield et al. (2014)25 observed that an improvement to simple physiological parameters, such as heart rate, respiratory rate, and work of breathing within 60 minutes, is a likely predictor of therapy success, while no improvement is a likely indicator for therapy escalation.25 This approach has been further supported by the body of NHF literature.
Franklin et al. (2018) is the largest NHF RCT to date.18 It was conducted using Fisher & Paykel Healthcare’s NHF system (Airvo 2 and Optiflow Junior) at flow rates of 2 L/kg/min in the emergency department and throughout the hospital. The protocol for this study is freely available and can be accessed here.
Product FAQs
Flow rate
(L/min)
MR850
RT330
F&P 950™
N40
Airvo™ 2
900PT561
OJR410
XS
0.5-8 0.5-10 N/A
OJR412
S
0.5-9 0.5-10
OJR414
M
0.5-10 0.5-11
OJR416
L
0.5-23 N/A 2-20
OJR418
XL
0.5-25 2-25
OJR520
XXL
1-36 10-50
To select an appropriate cannula size, ensure a gap is visible between the prongs and the patient’s nostrils and that the prongs are not causing a seal.
No; Wigglepads can be purchased as a spare if you need to replace them. Wigglepads replacement product codes:
 
Part No Description Quantity
WJR110 Wigglepad 2 Replacement (XS,S) 2/pack (20 in each box)
WJR112 Wigglepad 2 Replacement (M, L, XL) 2/pack (20 in each box)
WJR114 Wigglepad 2 Replacement (XXL) 20/box
The F&P WigglewiNGTM can be used in conjunction with the Optiflow Junior 2 and Optiflow Junior 2+ range to stabilize an NG tube to the patient, while maintaining the ability to remove or reposition the interface if necessary.
 
WigglewiNG product codes:
 
 
Part No Description Quantity
WJR210 WigglewiNG (XS,S) 10/box
WJR212 WigglewiNG (M, L, XL) 10/box
WJR214 WigglewiNG (XXL) 10/box
*Patient populations defined by the FDA
Our FAQs should not replace any information or guidelines as stated in the product user instructions or local hospital procedures.
References