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Precision Resuscitation: Calibrating the T-Piece Device — A Clinical Guide to Neopuff™ Setup and Operation for Neonatologists

Dra. Marcela M Marques
📄 Download the full clinical reference (PDF)Download PDF

Key takeaways

  • Initial gas flow rate for the Neopuff should be set at 10 L/min (or 8 L/min if using cylinders).
  • The maximum pressure relief valve should be set at 50 cm H2O to prevent barotrauma.
  • Peak inspiratory pressure (PIP) should be set at 25–30 cm H2O for infants ≥32 weeks (term) and 20–25 cm H2O for preterm infants <32 weeks.
  • Positive end expiratory pressure (PEEP) should be set at 5–8 cm H2O, but must be re-checked if flow rate is increased from 8 to 10 L/min to avoid a dangerously high PEEP.
  • Effective ventilation is confirmed by heart rate rising above 100/minute, a slight rise of the chest and upper abdomen with each inflation, and improved oxygenation — not simply by achieving the set PIP on the manometer.

References

  • Wood, et al. (2008). Archives of Disease in Childhood, Fetal & Neonatal Edition 93: p. F231
  • Morley, Schmoelzer & Davis, 2009
Cover page showing a Neopuff infant resuscitator device with mask, tubing, and oxygen line, titled Precision Resuscitation: Calibrating the T-Piece Device.

Precision Resuscitation:

Calibrating the T-Piece Device

A Clinical Guide to Neopuff™ Setup and Operation for Neonatologists

Based on the Victorian Newborn Resuscitation Project (NeoResus) & ANZCOR Guidelines.
Textbook of Neonatal Resuscitation, 9th Edition

The components of the Neopuff

Diagram showing the four components of the Neopuff system: gas supply, patient supply line with T-piece and mask, gas supply line, and test lung, arranged around the Neopuff device.

The components of the Neopuff

  • Gas supply
  • Patient supply line with T-piece & mask
  • Gas supply line
  • Test lung

Anatomy of the Neopuff Interface

Labeled diagram of the Neopuff interface identifying the manometer, maximum pressure relief, maximum inspiratory pressure, gas connection, gas outlet, T-piece, and face masks.

Anatomy of the Neopuff Interface

  • Manometer
  • Maximum pressure Relief
  • Maximum inspiratory pressure
  • Gas connection
  • Gas outlet
  • T-Piece
  • Face masks of all sizes

Anatomy of the Neopuff Interface

Detailed diagram with descriptions of each Neopuff component including gas inlet, gas outlet, manometer, maximum pressure relief, inspiratory pressure control, and T-piece.

Anatomy of the Neopuff Interface

  • Gas Inlet: Connects to the primary oxygen/air blender.
  • Gas Outlet: Connects to the patient supply line.
  • Manometer: Displays real-time circuit pressure.
  • Maximum Pressure Relief: The hidden safety valve to prevent barotrauma.
  • Inspiratory Pressure Control: The main dial to set target PIP.
  • T-Piece: The patient interface where PEEP is regulated via the top cap.

Setting up the Neopuff

Text page listing required equipment and initial recommended settings for gas flow rate, maximum pressure relief valve, peak inspiratory pressure, and PEEP for the Neopuff.

Setting up the Neopuff

you will need:

  • A compressed gas source;
  • A gas supply line (green oxygen tubing) with the plastic connector (supplied);
  • The patient supply line (tubing & T-piece);
  • A test lung.

Initial recommended settings

Gasflow rateSet at 10 L/min (8L/min if using cylinders)
Maximum pressure relief valveSet at 50 cm H2O
Peak inspiratory pressure (PIP)Set at 25 – 30 cm H2O (>= 32 weeks)
Set at 20 – 25 cm H2O (preterm < 32 weeks)
Positive end expiratory pressure (PEEP)Set at 5-8 cm H2O

ANZCOR 2021, Guideline 13.4, p.2
Textbook of Neonatal Resuscitation, 9th Edition

Setting up the Neopuff: 6 steps

Step-by-step flowchart listing six steps to set up the Neopuff device, from connecting gas lines to achieving a good mask seal.

Setting up the Neopuff: 6 steps

  1. Connect the gas supply line to the gas inlet and the patient supply line to the gas outlet
  2. Attach a test lung to the patient supply line and turn the gas flow to 8 -10 L/min
  3. Check the maximum pressure relief valve is set to 50 cm H2O (adjust as necessary)
  4. Set the peak inspiratory pressure (PIP) to 25 – 30 cm H2O (term) or 20 –25 cm H2O (preterm)
  5. Set the positive end expiratory pressure (PEEP) to 5 – 8 cm H2O
  6. Create a good seal between the infant’s face and the face mask using the

    Adjusting the maximum pressure

    Diagram showing steps to adjust the maximum pressure relief dial on the Neopuff device to 50 cm H2O.

    Adjusting the maximum pressure

    Once the inspiratory pressure control dial is fully open:

    • Occlude the PEEP cap on the patient T-piece with your thumb.
    • Open the cap covering the maximum pressure relief dial.
    • Turn the maximum pressure relief dial clockwise or anti-clockwise to adjust the maximum pressure to 50 cm H2O.
    • Close the maximum pressure relief cap.

    4. Set the peak inspiratory pressure (PIP)

    Illustration of the Neopuff Infant Resuscitator control panel with instructions for setting peak inspiratory pressure.

    4. Set the peak inspiratory pressure (PIP)

    • Occlude the PEEP cap on the end of the patient T-piece with your thumb.
    • Turn the inspiratory pressure control anti-clockwise (several times) to decrease the pressure from 50 cmH2O down to the recommended PIP:

    20–25 cm H2O for a premature infant or 25–30 cm H2O for a term infant.

    • The set PIP is displayed on the manometer when the PEEP cap on the patient T-piece is occluded.

    If the test lung is unavailable, occlude the gas outlet to the patient with your palm and the opening of the T-piece with your finger, then proceed to calibrate the PIP.

    5. Set the positive end expiratory pressure (PEEP)

    Photograph of a hand adjusting the PEEP cap on the patient T-piece with instructions for setting PEEP to 5 cm H2O.

    5. Set the positive end expiratory pressure (PEEP)

    Set the PEEP by turning the cap on the patient T-piece clockwise or anti-clockwise until a PEEP of 5 cm H2O is displayed on the manometer.

    Caution: If the PEEP has been set on a flow rate of 8 L/min, any increase in the flow rate will result in a dangerously high increase in PEEP. (Morley, Schmoelzer & Davis, 2009)

    If you increased the flow rate to 10 L/min, then re-set and re-check the PEEP.

    6. Create a good seal between the infant’s face & the mask

    Two photographs showing correct hand technique to create a seal between a resuscitation mask and an infant's face, with instructions on ventilation rate and signs of effective ventilation.

    6. Create a good seal between the infant’s face & the mask

    Occlude the PEEP cap using your thumb or finger for 0.5 seconds, then release for 0.5 seconds.

    This will provide a ventilation rate of 60 inflations per minute.

    Effective ventilation is confirmed by three signs:

    • An increase in the heart rate above 100/minute.
    • A slight rise of the chest and upper abdomen with each inflation.
    • An improvement in oxygenation.

    Achieving the set PIP on the manometer is not sign of effective ventilation.

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    Frequently asked questions

    What are the initial recommended gas flow rate settings for the Neopuff?

    Set the gas flow rate at 10 L/min, or 8 L/min if using cylinders.

    What PIP settings should be used for term versus preterm infants on the Neopuff?

    For infants ≥32 weeks (term), set PIP at 25–30 cm H2O; for preterm infants <32 weeks, set PIP at 20–25 cm H2O.

    How do you set the maximum pressure relief valve on the Neopuff?

    With the inspiratory pressure control dial fully open, occlude the PEEP cap on the patient T-piece with your thumb, open the cap covering the maximum pressure relief dial, and turn it clockwise or anti-clockwise to adjust the maximum pressure to 50 cm H2O, then close the cap.

    Why is it important to re-check PEEP after adjusting the gas flow rate on the Neopuff?

    If PEEP was set at a flow rate of 8 L/min, increasing the flow rate to 10 L/min will result in a dangerously high increase in PEEP, so PEEP must be re-set and re-checked after any flow rate increase.

    How do you confirm effective ventilation when using the Neopuff, and is reaching the set PIP sufficient?

    Effective ventilation is confirmed by three signs: an increase in heart rate above 100/minute, a slight rise of the chest and upper abdomen with each inflation, and an improvement in oxygenation. Achieving the set PIP on the manometer is not a sign of effective ventilation.

    Dra. Marcela M Marques
    Written by
    Neonatologist & pediatric intensivist · CRM 12807/DF
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