Leccin 3: USO DE INSTRUMENTOS DE REANIMACION PARA VENTILACION CON PRESION POSITIVANeonatal Resuscitation Program Slide Presentation Kit

3-*Uso de Instrumentos de Reanimacin para ventilacin con Presin PositivaContenido de la LeccinCuando ventilarTipos de instrumentos de reanimacinFuncionamiento de cada dispositivo Colocacin de la mscara sobre la caraProblemas con los instrumentos de reanimacin Evaluando la ventilacin

3-*Indicaciones para Ventilacin con Presin PositivaApnea/jadeoFrecuencia cardaca menor de 100 latidos por minuto (lpm) an si esta respirando Cianosis persistente a pesar de oxgeno a flujo libre al 100%

La ventilacin de los pulmones es el nico paso ms importante y ms efectivo en la reanimacin cardiopulmonar de un infante comprometido

3-*Tipos de Instrumentos de Presin PositivaBolsa autoinflable Bolsa inflada por FlujoReanimador con pieza en T

3-*Bolsa autoinflableVentajas:Siempre se llena despus de ser apretada ySiempre esta inflada La vlvula de liberacin de presin (pop-off) hace que la sobre-ventilacin sea menos probable

3-*Bolsa auto inflableDesventajas:La bolsa funciona sin la necesidad de una fuente de gas; asegrese que el oxgeno este conectado. Requiere que se forme un sello hermtico entre la cara y la mscara para poder ventilar los pulmones Requiere de un reservorio de oxgeno para proveer altas concentraciones de oxgeno. No se puede administrar oxgeno a flujo libre a travs de la mscaraNo puede ser utilizada para CPAP. No se puede aplicar PEEP sin vlvula especial.

3-*Bolsa inflada por FlujoVentajas: Provee oxgeno del 21% al 100%, dependiendo de la fuente Es fcil evaluar sellado sobre la cara del beb. Puede ser utilizada para administrar oxgeno a flujo libre a travs de la mscara.

3-*Bolsa inflada por FlujoDesventajas:Requiere una fuente de gas comprimido. Requiere de un sello hermtico de la cara y mscara para mantenerse inflada. Requiere de una fuente de gas para inflarse. Si esta vaca luce como un globo desinflado. Usualmente no tiene una vlvula pop-off de seguridadUtiliza una vlvula de control de flujo para regular la presin/inflacin.

3-*Reanimador de pieza en TVentajas:Presin administrada es constante Control confiable de la presin inspiratoria pico y de la presin positiva la final de la espiracinAdministracin confiable de oxgeno al 100% No hay fatiga al ventilar

3-*Reanimador de pieza en TDesventajas:Requiere una fuente de gas comprimido La mscara deber formar una sello hermtico con la cara para ventilar los pulmones. La distensibilidad de los pulmones no puede ser percibidaRequiere que la presin se fije previo a su usoLos cambios de presin durante su uso son ms difciles.

3-*Considere tener una bolsa autoinflable disponible siempre que se requiera realizar una reanimacin como respaldo, en caso de que la fuente de gas comprimido falle o que el reanimador con pieza en T falle. Respaldo de Emergencia:Bolsa autoinflable

3-*Caractersticas Generales de los Instrumentos de ReanimacinMscaras de tamao apropiado (acolchonadas, se prefieren las mascarillas de forma anatmica)La capacidad de oxgeno es variable hasta 90%-100%Control de la presin inspiratoria pico y el tiempo inspiratorio.Tamao de la bolsa (200-750 mL)Dispositivos de seguridad para prevenir la administracin de presiones elevadas.

3-*Instrumentos de Reanimacin: Caractersticas de seguridad Todo instrumento de reanimacin debe tener: Un manmetro de presin y una vlvula de control de flujo y/o Una vlvula de liberacin de presin (pop-off)

3-*Caractersticas de Seguridad: Bolsas autoinflables con vlvulas de liberacin de presinClick on the image to play video

3-*Caractersticas de seguridad: Bolsa inflada por flujoClick on the image to play video

3-*Caractersticas de Seguridad: Reanimador con pieza en TClick on the image to play video

3-*Concentracin de oxgeno durante la ventilacin con presin positivaEl programa de Reanimacin Neonatal recomienda el uso de oxgeno al 100% cuando se requiere ventilacin con presin positiva durante la reanimacin neonatal. Sin embargo, las investigaciones sugieren que la reanimacin con un poco menos de 100% puede ser igual de exitoso. Si la reanimacin es iniciada con un poco menos de 100% de oxgeno, el oxgeno suplementario deber de ser administrado hasta un 100% si no se observa una mejora apreciable dentro de los primeros 90 segundos del nacimiento. Si no hay oxgeno disponible, utilice oxgeno a aire ambiente para administrar ventilacin con presin positiva.

3-*Instrumentos de Reanimacin: Oxgeno a Flujo libreNo puede ser administrado confiablemente a travs de una mscara con una bolsa autoinflable. Puede ser administrado confiablemente a travs de la mscara con una bolsa inflada por flujo o un reanimador con pieza en T.

3-*Bolsa y mscara: Mscaras del EquipoBordesAlmohadilladoNo-almohadilladoFormaRedondaForma anatmica TamaoPequeaGrande

3-* Bolsa y Mscara: EquipoLa mscara deber cubrirMentnBoca Nariz

3-*Preparacin para los Instrumentos de ReanimacinArmar el equipo Probar el equipo

3-*Lista de PreparacinEscoja el tamao de mscara apropiada Asegrese que la va area este librePosicione la cabeza del bebColquese a un lado del beb o la cabeza de l.

Antes de iniciar ventilacin con presin Positiva:

3-*Colocacin de la mscara sobre la caraNo force la mscara sobre la caraNo permita que sus manos o dedos descansen sobre los ojos No realice presin sobre la garganta (trquea)

Para mejorar el sello:Utilice una ligera presin hacia abajoPuede apretar gentilmente la mandbula hacia la mscara

3-*Sello cara-mscaraUn sello hermtico es requerido para que la bolsa inflada por flujo se infle. Un sello hermtico es requerido para ventilar los pulmones cuando se aprieta una bolsa autoinflable. Un sello hermtico es requerido para ventilar los pulmones cuando se ocluye el puerto del PEEP al utilizar el resucitador con pieza en TUn sello hermtico es esencial para lograr una presin positiva efectiva

3-*Mejora de la frecuencia cardiaca, color, respiraciones, tono, y saturacinSignos de Ventilacion Efectiva Signos de mejora en el Neonato

3-*Sobre ventilacin de los Pulmones

Se esta utilizando demasiada presinHay peligro de producir un neumotrax

Si el beb aparenta estar recibiendo respiraciones muy profundas

3-*Frecuencia de la Ventilacion:40 a 60 respiraciones por minutoClick on the image to play video

3-*El neonato no mejora y el trax no se esta expandiendo adecuadamentePosibles causasSello inadecuadoVa area bloqueadaNo suficiente presin Click on the image to play video

3-*Causas y Soluciones para Expansin Torcica InadecuadaCondicin AccionesSello inadecuado Reaplicar la mscara a la cara y levante la quijada hacia adelanteVa area bloqueada Reposicione la cabeza Verifique si hay secreciones; succione si estn presentes Ventile con la boca del recin nacido ligeramente abiertaNo suficiente presin Incremente la presin hasta que haya un movimiento torcico perceptible Considere la intubacin endotraqueal

3-*Ventilacin con Presin Positiva ContinuaLa distensin gstrica puede Elevar el diafragma, evitando la expansin pulmonar completaCausar regurgitacin y aspiracin

Se deber colocar una sonda Oro-gstrica para aliviar la distensin gstrica

3-*Colocacin de la Sonda Oro- gstrica

3-*El Recin Nacido no mejoraCorrobore el oxgeno, bolsa, sello y presinSon adecuados los movimientos torcicos?Se esta administrando oxgeno de forma adecuada?Entonces, Considere intubacin endotraquealCorrobore sonidos respiratorios; posible neumotrax

3-*Recien Nacido no mejora

Frecuencia cardiaca menor de 60 a pesar de 30 segundos de ventilacin con presin positiva

3-*Apndices: Descripcin de los Instrumentos de ReanimacinBolsas auto-inflables Bolsas infladas por flujoReanimador con pieza en T

Revise los instrumentos utilizados en su hospital

3-*Apndice A: Bolsas de reanimacin autoinflables: Partes Bsicas

Click on the image to play video

3-*Bolsa Auto inflable: Control de OxgenoUn reservorio de oxgeno deber ser colocado para administrar altas concentraciones de oxgeno al utilizar una bolsa autoinflableSin reservorio y sin el oxgeno, la bolsa administra solo 40% de oxigeno, que puede ser insuficiente para la reanimacin neonatal

Click on the image to play video

3-*Bolsa Autoinflable: Tipos de Reservorios de Oxgeno

3-*Bolsa AutoinflablePrubela antes de usarlaClick on the image to play video

3-*Bolsa Autoinflable: PresinCantidad de presin administradadepende de los siguientes 3 factores:Que tan fuerte se apriete la bolsa Cualquier fuga entre la mscara y la cara del bebPunto de liberacin de la vlvula de liberacin de presin

3-*Apndice B: Bolsas de Reanimacin infladas por FlujoClick on the image to play video

3-*Bolsa inflada por Flujo: Potenciales ProblemasLa bolsa no se va a inflar si La mscara no esta sellada apropiadamente sobre la boca y nariz del recin nacidoHay un agujero en la bolsaLa vlvula de control de flujo esta muy abiertaEl manmetro de la presin no est o el puerto no esta ocluido

3-*Bolsa Inflada por flujo: Ajustando el flujo de oxgeno y la presinClick on the image to play video

3-*Apndice C: Reanimador con pieza en TClick on the image to play video

3-*Preparando el Reanimador con pieza en T para su usoClick on the image to play video

3-*Reanimador con pieza en T: Ajustando los valores de Presin

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3-*Reanimador con Pieza en T: Problemas tcnicosClick on the image to play video

Final de la Leccin 3

Bolsa Autoinflable3-4A

Bolsa Inflada por Flujo3-4B

Reanimador con Pieza en TClick on the image to play video3-4C

Colocacin de la Mscara3-23A

Para mejorar el sello entre la cara y la mscara3-23B

**In Lesson 3 you will learnWhen to give positive-pressure ventilationThe similarities and differences among flow-inflating bags, self-inflating bags, and T-piece resuscitatorsThe operation of each device to provide positive-pressure ventilationThe correct placement of the masks on the newborns faceHow to test and troubleshoot devices used to provide positive-pressure ventilationHow to evaluate the success of positive-pressure ventilation

*If, after the initial steps, the baby is not breathing or is gasping, the heart rate is less than 100 bpm, or the color remains cyanotic despite 100% free-flow oxygen, the next step is to provide positive-pressure ventilation. This is a critically important skill and the single most important step in the resuscitation of the compromised newborn. The success of resuscitation may be dependent on the effectiveness of this procedure.

*There are 3 types of devices to give positive-pressure ventilation to newborns.The self-inflating bag inflates without a compressed gas source after it is squeezed. It remains inflated at all times.The flow-inflating bag is collapsed when not in use, and it looks like a deflated balloon. It inflates only when gas flows into the bag and the opening is sealed, as when the mask is placed tightly on a newborns face.The T-piece resuscitator works only when gas flows into it. The gas is directed to the environment or to the baby by occluding or releasing the opening on a T-shaped tube with your finger or thumb.

*The self-inflating bag, as its name implies, inflates automatically without a compressed gas source. It remains inflated at all times unless being squeezed. Peak inspiratory pressure (or peak inflation pressure) is controlled by how hard the bag is squeezed. The self-inflating bag has a pressure-release (pop-off) valve that opens if peak inspiratory pressures greater than 30 to 40 cm H2O are generated. This is a safety feature that makes over-inflation less likely. *The self-inflating bag will work even if it is without a gas source, so make sure the bag is connected to an oxygen source. Positive end-expiratory pressure (PEEP) can be administered only if an additional valve is attached to the self-inflating bag. Continuous positive airway pressure (CPAP) while a patient is breathing spontaneously cannot be delivered reliably with a self-inflating bag. To achieve 90% to 100% oxygen administration when the bag is squeezed, a reservoir attachment is required. You cannot give free-flow oxygen through the mask of this bag.*Flow-inflating bags deliver 100% oxygen directly to the patient and can be used to deliver free-flow oxygen through the mask. The bag will not inflate unless there is a tight seal against the babys face, making it easy to assess the quality of the seal.*The flow-inflating bag is collapsed like a deflated balloon when not in use. It inflates only when a gas source is forced into the bag and the opening of the bag is sealed, as when a mask is placed tightly on a babys face. Peak inspiratory pressure is controlled by the flow rate of incoming gas, adjustment of the flow control valve, and how hard the bag is squeezed. Positive end-expiratory pressure (PEEP) or CPAP is controlled by an adjustable flow-control valve. A pressure manometer should be used to avoid excessive inflation pressure. *The T-piece resuscitator is an old device that has been recently reintroduced into the delivery room. The T-piece resuscitator provides flow-controlled and pressure-limited ventilation or CPAP. Think of this device as a manually cycled mechanical ventilator.

Peak inspiratory pressure and positive end-expiratory pressure (PEEP), or CPAP if desired, are manually set with adjustable controls. Intermittent inflating pressure is delivered when the operator alternately occludes and releases the opening on the device. This device can reliably deliver varying concentrations of oxygen up to 100% free-flow oxygen.*The T-piece resuscitator will not work unless connected to a compressed gas source. This device requires a tight face-mask seal to deliver a breath. The device also requires some preparation time to assemble, turn on gas flow, and adjust the pressure limits appropriately. Because the pressures are set manually by the operator, changing inflation pressure during resuscitation is more difficult than with the other devices.*The self-inflating bag can be used in any setting and without a gas source, making it immediately available for initiating neonatal resuscitation, even outside the obstetric/neonatal patient care area. Consider stocking a self-inflating bag and different size masks in your portable emergency resuscitation supplies to ensure that a neonatal positive-pressure device is available no matter where in the hospital you may be called upon to initiate newborn resuscitation.*A variety of mask sizes, appropriate for newborns of different weights, should be available at every delivery. Cushioned, anatomically shaped masks are preferred.

Term newborns who require positive-pressure ventilation at birth should be initially ventilated with a high concentration of oxygen (90%-100%). Bags used for newborns should have a volume of 200 to 750 mL. Term newborns require only 15 to 25 mL with each ventilation (5-8 mL/kg).

To minimize complications resulting from high ventilation pressures, resuscitation devices should have certain safety features to prevent unwanted high pressures.*Ventilation of a newborn with excessive pressure (and/or volume) could overinflate the lungs, thus causing rupture of the alveoli and a resulting air leak or pneumothorax. Any resuscitation device, whether flow-inflating, self-inflating, or T-piece resuscitator, should be equipped with one or both of the safety features to prevent the development of excessive pressure.*Self-inflating bags should have a pressure-release (pop-off) valve, which is generally set to 30 to 40 cm H2O. If pressures greater than 30 to 40 cm H2O are generated, the valve opens, limiting the pressure being transmitted to the baby.

In some self-inflating bags, the pressure-release valve can be temporarily occluded or bypassed to allow high pressure to be administered. This is usually not necessary, but can be done to ventilate a newborns non-aerated lungs when the usual pressures are not effective, especially with the first few breaths. Many self-inflating bags also are equipped with a port to attach to a pressure gauge.*Flow-inflating bags have a flow-control valve that can be adjusted to deliver the desired peak pressure and positive end-expiratory pressure (PEEP). A pressure manometer attached to the bag will allow proper adjustment of the valve.*The T-piece resuscitator has 2 controls to adjust the inspiratory pressure. The inspiratory pressure control sets the amount of pressure desired during a normal assisted breath. The maximum pressure relief control is a safety feature that prevents the pressure from exceeding a preset value (usually 40 cm H2O, but adjustable). Excessive pressure can also be avoided by watching the circuit pressure gauge.*One hundred percent oxygen should be used when positive-pressure ventilation is required during resuscitation of term babies. Some studies suggest that resuscitation with 21% oxygen (air) is just as successful as resuscitation with 100% oxygen. Prolonged exposure to 100% oxygen following perinatal asphyxia may have deleterious effects. However, supplemental oxygen during resuscitation may result in more rapid restoration of tissue oxygen and perhaps less permanent tissue damage. Some clinicians will elect to start resuscitation using less than 100% oxygen. If one chooses to start resuscitation with room air, it is recommended that oxygen be used if there is no improvement within 90 seconds following birth.*Free-flow oxygen cannot be given reliably with a self-inflating bag-and-mask device. The oxygen flow entering a self-inflating bag will normally be diverted to the air inlet, through its attached oxygen reservoir, and then evacuated out the end of the oxygen reservoir or out a valve that is attached to the reservoir.

A flow-inflating bag and mask or T-piece resuscitator can be used to deliver free-flow oxygen. The mask should be loosely placed on the face, allowing some gas to escape around the edges. When using a flow-inflating bag, it should not inflate when used for this purpose. *Resuscitation masks have rims that are either cushioned or non-cushioned. Advantages of a cushioned-rim mask areConforms more easily to the shape of the newborns face making it easier to form a sealRequires less pressure to obtain a sealLess chance of damaging a newborns eyes if the mask is incorrectly positioned

A non-cushioned rim can cause several problems.More difficult to obtain a seal because it does not easily conform to the shape of the newborns faceIt can damage the eyes if the mask is improperly positionedIt can bruise the babys face if the mask is applied too firmly

Masks also come in 2 shapes: round and anatomically shaped.

Anatomically shaped masks fit the contours of the face when placed on the face with the most pointed part fitting over the nose.*For the mask to be the correct size, as pictured in this slide, the rim will cover the tip of the chin, the mouth, and the nose, but not the eyes.

If the mask is too large, it may cause eye damage.

If the mask is too small, it will not cover the mouth and nose and may occlude the nose.*The bag or resuscitation device should be assembled and connected to oxygen so that it will provide the necessary 90% to 100% concentration, if needed. If a self-inflating bag is used, be sure the oxygen reservoir is attached. If a T-piece resuscitator is used, set the pressure settings according to the recommendations in the appendices of this lesson.

Once the equipment has been selected and assembled, check to make sure the resuscitation device is functioning properly. Bags that have cracks or tears, valves that stick or leak, or masks that are cracked or deflated must not be used.*Before beginning positive-pressure ventilation, check the following:The mask should cover the mouth, nose, and the tip of the chin, but not the eyes.Suction the mouth and nose to be certain there is no obstruction.The newborns neck should be extended slightly to maintain an open airway. One way to accomplish this is to place a small roll under the shoulders.Position yourself at the side or head of the newborn to use the resuscitation device effectively. This position allows you to hold the mask on the newborns face comfortably. The mask may be swiveled on the bag or T-piece resuscitator for optimal fit to the face and to your position. If using a bag, it must be positioned so that it does not block your view of the newborns chest since you need to be able to observe movement of the newborns chest during ventilation.*Care should be taken in holding the mask on the newborns face. Observe the following precautions.*An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs.

Also, a flow-inflating bag will not stay inflated without a good face-mask seal, and, therefore, you will not be able to squeeze the bag to create the desired pressure.

With a self-inflating bag or a T-piece resuscitator, you will not be able to deliver positive pressure unless there is a good face-mask seal. This can be determined by watching for chest movement with each inspiration.*The best indications that the mask is sealed and the lungs are being adequately inflated are improvements in heart rate, color, and muscle tone. If these signs are not improving, you should look for the presence of chest movement with each positive-pressure breath and have an assistant listen to both sides of the lateral areas of the chest with a stethoscope to assess breath sounds. Abdominal movement due to air entering the stomach may be mistaken for effective ventilation.

The lungs of a fetus are filled with fluid, while the lungs of a newborn must be filled with air. To establish a gaseous volume (functional residual capacity) in a newly born baby, the first breaths often require higher pressures and longer inflation times than with subsequent breaths. It is helpful to monitor pressure with a pressure gauge to avoid high lung volumes and airway pressures. You should ventilate the lungs with the lowest pressure required to improve heart rate, color, and muscle tone.*If the baby appears to be receiving very deep breaths from positive-pressure ventilation, the lungs are being overinflated. Too much pressure is being used and there is danger of producing a pneumothorax. Remember that the volume of a newborn breath is much smaller than the amount of gas in the resuscitation bag.One tenth of a 240-mL self-inflating bagOne thirtieth of a 750-mL flow-inflating bag

Abdominal movement may be due to air entering the stomach and should not be mistaken for effective ventilation.*During the initial stages of resuscitation, breaths should be delivered at a rate of 40 to 60 breaths per minute or slightly less than once a second. If you squeeze the bag or occlude the PEEP cap of the T-piece resuscitator on Breathe and release while you say Two, Three, you probably are ventilating at a proper rate.

Check the 4 signs for improvement (rising heart rate, improving color, spontaneous breathing, and improving tone) after 30 seconds of administering positive-pressure ventilation. As the heart rate increases toward normal, ventilation should be continued at a rate of between 40 and 60 breaths per minute. With improvement, the newborn should become pink and muscle tone should improve.

When the heart rate stabilizes above 100 bpm, reduce the rate and pressure of assisted ventilation until you see effective spontaneous respiration. When color improves, supplemental oxygen can also be weaned as tolerated. If the heart rate remains below 60 bpm, you need to proceed to the next step of chest compressions, as described in the next lesson.*If the heart rate, muscle tone, and color do not improve, check to see if the chest is moving with each positive-pressure breath. If the chest is not expanding adequately and there are poor breath sounds, it may be due to one of the following reasons:

Seal is inadequate. You may hear or feel air escaping from around the mask. Reapply the mask to the face and try to form a better seal while using a little more pressure on the rim of the mask.Airway is blocked. Check the newborns position and extend the neck a bit farther. Check the mouth or oropharynx and nose for secretions and suction if necessary. Try ventilating with the newborns mouth slightly open.Not enough pressure given. If you are not providing enough pressure to move the lungs, increase the pressure. If using a resuscitation device with a pressure gauge, the pressure limit may have to be increased. If using a bag with a pressure-release valve, increase the pressure until the valve actuates.Malfunctioning equipment, including a torn bag, a faulty flow-control valve, or an improper connection, also may be the cause of inadequate chest expansion.

*This chart is a summary of steps to follow if the baby does not improve and adequate chest expansion is not observed. Also make sure the equipment is functioning correctly. Replace the resuscitation bag, if necessary. If you still are unable to obtain physiologic improvement and adequate chest movement after going through this sequence, endotracheal intubation and positive-pressure ventilation through the endotracheal tube are usually required.*Newborns requiring positive-pressure ventilation with a mask for longer than several minutes should have an orogastric tube inserted and left in place. During positive-pressure ventilation, gas is forced into the oropharynx, where it is free to enter the trachea and the esophagus. Some gas will be forced into the stomach. Gas forced into the stomach will interfere with ventilation by preventing full expansion of the lungs and may cause regurgitation and aspiration of contents. This problem may be relieved by the insertion of an orogastric tube.*Always measure the length of the tube needed for insertion. The length of the inserted tube should be equal to the distance from the bridge of the nose to the earlobe, and earlobe to a point halfway between the xyphoid process (the lower tip of the sternum) and the umbilicus. Note the centimeter mark at this place on the tube.*Check for adequacy of chest expansion, and use a stethoscope to listen for bilateral breath sounds.

Is the face-mask seal tight? Is the airway blocked?Is the resuscitation equipment working properly?Is adequate pressure being used?Is adequate oxygen being administered?Is oxygen tubing attached to the device and to an oxygen source? If using the self-inflating bag, is the oxygen reservoir attached? If using a tank (rather than wall oxygen), is there oxygen in the tank? Is gas flowing through the flowmeter?

*Positive-pressure ventilation with a mask generally is not as effective as positive-pressure ventilation through an endotracheal tube. A mask does not seal on the face as tightly as an endotracheal tube seals in the larynx. If you have checked all of the factors listed on the preceding slide and chest movement is still unsatisfactory, or if you dont hear good breath sounds bilaterally, usually it will be necessary to insert an endotracheal tube. Also, additional complications, such as pneumothorax, may have occurred. If the newborns condition continues to deteriorate or fails to improve, and the heart rate is less than 60 beats per minute despite 30 seconds of adequate positive-pressure ventilation, the next step is to begin chest compressions.*This next section reviews the device(s) used for the administration of positive-pressure ventilation to newborns. You will be responsible to know how to operate, test, and troubleshoot devices used for resuscitation of newborns in your hospital.*The self-inflating bag has 7 basic parts. Oxygen inlet: a small nipple to which oxygen tubing is attached. In the self-inflating bag, the oxygen tube does not need to be attached for the bag to function.Oxygen reservoir: appliance that can be placed over the bags air inlet to allow 100% oxygen to collect, thus preventing the oxygen from being diluted with room air.Air inlet: a 1-way valve that may be located at either end of the bag through which gas inflows after compression.Pressure gauge or pressure gauge attachment site (optional): a small hole or projection near the patient outlet to measure pressure given to the patient. The hole must be plugged or a manometer attached, or gas will leak through the opening, preventing adequate pressure from being generated.Pressure release (pop-off) valve: prevents excessive pressure buildup in the bag.Valve assembly: positioned between the bag and the patient outlet. When the bag is squeezed during ventilation, the valve opens, releasing oxygen and air to the patient. When the bag reinflates, the valve is closed. This prevents the patients exhaled air from entering the bag and being re-breathed.Patient outlet: place where gas exits from the bag to the baby and where the mask or endotracheal tube attaches.*Newborns who require resuscitation with assisted ventilation at birth may require a high concentration of oxygen (90% to 100%).

Air drawn into a self-inflating bag through the air inlet dilutes the concentration of oxygen in the bag. As a result, the concentration of oxygen actually received by the patient is greatly reduced to about 40%.

*There are several different types of oxygen reservoirs, but they all perform the same function. Some have open ends, and others have a valve that allows some air to enter the reservoir.*To check the operation of a self-inflating bag, block the mask or patient outlet with the palm of your hand and squeeze the bag. A manometer is not necessary.Do you feel pressure against your hand?Can you force the pressure-release valve open?Does the pressure gauge (if present) register 30 to 40 cm H2O pressure when the pressure-release valve opens? If not, check for a crack or leak in bag. Check to see if the pressure gauge is missing, if the pressure-release valve is missing or stuck closed, and whether the patient outlet is sufficiently blocked.*The amount of pressure delivered by a self-inflating bag is not dependent on the flow of oxygen entering the bag. When you seal the mask on the newborns face (or connect the bag to an endotracheal tube), there will be no change in the inflation of the self-inflating bag.*The flow-inflating bag has 4 parts.Flow-control valve: provides an adjustable leak that allows pressure to be regulated in the bag.Oxygen inlet: oxygen from a compressed source enters the bag.Pressure manometer attachment site: allows for attachment of manometer to indicate the amount of pressure being used to ventilate the newborn.Patient outlet: oxygen exits from the bag to the patient.

The pressure manometer alerts you to the amount of pressure being used to ventilate the newborn. If the flow-inflating bag has a connecting site for a pressure manometer, a manometer must be attached to the site, or the attachment site will be a source of leak and the bag will not inflate properly.*The inflation of a flow-inflating bag depends on a sealed system. If the bag does not inflate, check for potential problems, such as those mentioned here.*When using a flow-inflating bag, inflate the bag with compressed gas (oxygen, air, or blended). Once the gas enters the bag, it is not diluted and the concentration of oxygen you put in the bag is the same concentration given to the patient. Once you seal the mask on the newborns face, all of the oxygen coming from the wall or tank will be directed to the bag and out the flow-control valve. This will cause the bag to inflate. Pressure in the bag can be adjusted by adjusting the flowmeter to regulate how much gas enters the bag (usually at least 5 L/min) or by adjusting the flow-control valve, regulating how much gas escapes from the bag.*There are 6 parts to a flow-controlled, pressure-limited T-piece resuscitator.Oxygen (gas) inlet: where gas from a compressed source enters the resuscitator.Patient (gas) outlet: where gas exits the resuscitator to the patient T-piece where the mask or endotracheal tube attaches.Inspiratory pressure control: used to set desired peak inspiratory pressure.Patient T-piece with positive end-expiratory pressure (PEEP) cap: the mask or endotracheal tube attaches to the T-piece and the PEEP cap is used to set the positive end-expiratory pressure, if needed.Circuit pressure gauge: used to set and monitor peak inspiratory pressure, positive end-expiratory pressure, and maximum circuit pressure.Maximum pressure relief control: controls desired maximum pressure by occluding the PEEP cap and turning the maximum pressure relief control to the maximal pressure limit.*Assemble the parts of the T-piece resuscitator as instructed by the manufacturer.

Attach a test lung to the patient outlet (provided by manufacturer).

Connect the device to the gas source (this will be tubing either from 100% oxygen source or a blender that permits adjustment of oxygen concentration).

*Adjust the pressure settings as follows:

Adjust the flowmeter to regulate how much gas flows into the resuscitator (5-15 L/min recommended).Set the maximum circuit pressure by occluding the PEEP cap with your finger and adjusting the maximum pressure relief dial to a selected value (40 cm H2O recommended).Set the desired peak inspiratory pressure by occluding the PEEP cap with your finger and adjusting the inspiratory pressure control to a selected peak inspiratory pressure.Set the positive end-expiratory pressure by removing your finger from the PEEP cap and adjusting the PEEP cap to the desired setting (0-5 cm H2O is recommended).Remove the test lung and attach a face mask or be prepared to attach to an endotracheal tube. The respiratory rate is controlled by intermittently occluding the PEEP cap.*If the baby doesnt improve or the desired peak pressure is not reached,The mask may not be properly sealed on the babys face.The gas supply may not be connected or of sufficient flow.The maximum circuit pressure, peak inspiratory pressure, or positive end-expiratory pressure may be incorrectly set.

Free-flow oxygen can be given reliably with the T-piece resuscitator if you occlude the PEEP cap and hold the mask loosely over the babys face.******