Infant Humidification Overview

Mechanisms of action for T-piece resuscitation

The T-piece connects to a face mask or other interface to deliver a flow regulated, pressure limited gas supply to the infant, enabling application of controlled initial inflation breaths.

Compared to other types of resuscitators such as self-inflating bags and flow-inflating bags, T-piece resuscitators provide consistent and controlled pressures independent of operator experience.^1,2 For this reason, current international resuscitation guidelines by ILCOR, NRP and ANZCOR recommend the use of a T-piece resuscitator when a gas source is available.^3-5 Providing consistent and controlled pressures with a T-piece resuscitator offers a range of benefits to neonates and infants.

Humidified T-piece resuscitation is a method of delivering warm, humidified gas to an infant during resuscitation, and may help to increase the incidence of normothermia on admission to the neonatal intensive care unit (NICU), compared to using cold and dry gas.^6,7 T-piece resuscitation provides a range of benefits that are associated with the safety and efficacy of resuscitation therapy.

Helps protect the lungs from injury

T-piece resuscitators have been designed to provide consistent and controlled PIP during resuscitation.

PIP is the maximum inspiratory pressure required to improve oxygenation without causing adverse effects. Delivering a controlled PIP is important as uncontrolled PIP that is too high may lead to lung injury, while under-inflating the lungs may not provide adequate gas exchange.

At birth, the lungs of preterm infants are uniquely susceptible to injury because they are structurally immature, surfactant-deficient, fluid-filled, and not supported by a stiff chest wall. Animal studies have demonstrated that lung injury can occur during resuscitation with just a few large manual inflations.^8,9 In immature animals, ventilation at birth with high tidal volumes associated with the generation of high PIP for a few minutes can cause lung injury, impaired gas exchange, and reduced lung compliance.¹⁰

infant resuscitation protect the lung injury

Data from measurements obtained from a resuscitation simulator while a F&P Neopuff was used by a qualified resuscitator.

Infant resuscitation maintains functional residual capacity

Establishes and maintains functional residual capacity

T-piece resuscitators deliver consistent and controlled PEEP, the residual pressure maintained at the end of expiration. Research suggests that adequate levels of PEEP may help to establish and maintain FRC during transition at birth.¹¹

Resuscitation guidelines recommend delivering PEEP whenever positive pressure ventilation is required in the delivery room.¹² On a T-piece resuscitator, PEEP can be set to the desired pressure and tested before use on a patient.

Research has shown that providing PEEP early during ventilation improves the response to surfactant, and may also reduce intubation rates in the delivery room and the incidence of lung injury.^13-15

Delivers consistent pressures independent of operator experience

Studies have investigated and compared operator performance with different resuscitators.

Resuscitation simulations have found that operator experience and level of training did not affect the pressures delivered during resuscitation when a Fisher and Paykel Healthcare Neopuff T-piece resuscitator was used. Also, for operators with no specific training in manual ventilation, use of the T-piece device has been advised, to control for excessive PIP and tidal volume.^1,2

Heated and humidified T-piece resuscitation promotes normothermia

Newborn infants are exposed to heat loss immediately following birth.

A meta-analysis found that the use of heated and humidified T-piece resuscitation in the delivery room resulted in significantly more infants with normothermia on NICU admission, compared to the use of cold and dry gas.⁶ Normothermia is defined as a rectal temperature between 36.5°C and 37.5°C.

The use of heated gas during delivery room stabilization has also been observed to reduce the rate of moderate hypothermia on admission to the NICU, with no increased risk of hyperthermia.⁷

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Roehr, C. C. et al. Manual ventilation devices in neonatal resuscitation: Tidal volume and positive pressure-provision. Resuscitation 81, 202–205 (2010). View abstract here.
Roehr, C. C., Kelm, M., Proquitté, H. & Schmalisch, G. Equipment and operator training denote manual ventilation performance in neonatal resuscitation. Am. J. Perinatol. 27, 753–758 (2010). View abstract here.
Liley, H. G., Mildenhall, L., Morley, P. & Resuscitation, on behalf of the A. N. Z. C. on. Australian and New Zealand Committee on Resuscitation Neonatal Resuscitation guidelines 2016. J. Paediatr. Child Health 53, 621–627 (2017). View abstract here.
American academy of pediatrics. Neonatal Resuscitation Program 7^th edn. (2019). View abstract here.
Wyckoff, MH. et al. Part 13: Neonatal Resuscitation. Circulation 132, S543–S560 (2015). View abstract here.
Meyer, M. P., Owen, L. S. & Te Pas, A. Use of heated humidified gases for early stabilization of preterm infants: a meta-analysis. Front. Pediatr. 6, 319(2018). View abstract here.
te Pas, A. B., Lopriore, E., Dito, I., Morley, C. J. & Walther, F. J. Humidified and heated air during stabilization at birth improves temperature in preterm infants. Pediatrics 125, e1427-32 (2010). View abstract here.
Björklund, L. J. et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr. Res. 42, 348 (1997). View abstract here.
Wada, K., Jobe, A. H. & Ikegami, M. Tidal volume effects on surfactant treatment responses with the initiation of ventilation in preterm lambs. J. Appl. Physiol. 83, 1054–1061 (1997). View abstract here.
Hillman, N. H. et al. Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am. J. Respir. Crit. Care Med. 176, 575–581 (2007). View abstract here.
Boon, A.W., Milner, A.D., Hopkin, I.E. Lung expansion, tidal exchange and formation of the functional residual capacity during resuscitation of asphyxiated neonates. J Pediatr. 95, 1031–1036 (1979). View abstract here.
John, K. et al. Part 15: Neonatal Resuscitation. Circulation 122, S909–S919 (2010). View abstract here.
Hartog, A., Gommers, D., Haitsma, J. J. & Lachmann, B. Improvement of lung mechanics by exogenous surfactant: effect of prior application of high positive end-expiratory pressure. Br. J. Anaesth. 85, 752–756 (2000). View abstract here.
Michna, J., Jobe, A. H. & Ikegami, M. Positive end-expiratory pressure preserves surfactant function in preterm lambs. Am. J. Respir. Crit. Care Med. 160, 634–639 (1999). View abstract here.
Gittermann, M. K., Fusch, C., Gittermann, A. R., Regazzoni, B. M. & Moessinger, A. C. Early nasal continuous positive airway pressure treatment reduces the need for intubation in very low birth weight infants. Eur. J. Pediatr. 156, 384–388 (1997). View abstract here.

Therapy Overview

T-piece resuscitation

Mechanisms of action for T-piece resuscitation

Helps protect the lungs from injury

Establishes and maintains functional residual capacity

Delivers consistent pressures independent of operator experience

Heated and humidified T-piece resuscitation promotes normothermia

View references