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Department of Neonatology, Charité Universitätsmedizin, Berlin, Berlin, GermanyNewborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
The following guidelines for resuscitation at birth have been developed during the process that culminated in the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR, 2015).
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
The following are the main changes that have been made to the guidelines for resuscitation at birth in 2015:
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Support of transition: Recognising the unique situation of the baby at birth, who rarely requires ‘resuscitation’ but sometimes needs medical help during the process of postnatal transition. The term ‘support of transition’ has been introduced to better distinguish between interventions that are needed to restore vital organ functions (resuscitation) or to support transition.
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Cord clamping: For uncompromised babies, a delay in cord clamping of at least 1 min from the complete delivery of the infant, is now recommended for term and preterm babies. As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who require resuscitation at birth.
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Temperature: The temperature of newly born non-asphyxiated infants should be maintained between 36.5 °C and 37.5 °C after birth. The importance of achieving this has been highlighted and reinforced because of the strong association with mortality and morbidity. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.
•
Maintenance of temperature: At <32 weeks gestation, a combination of interventions may be required to maintain the temperature between 36.5 °C and 37.5 °C after delivery through admission and stabilisation. These may include warmed humidified respiratory gases, increased room temperature plus plastic wrapping of body and head, plus thermal mattress or a thermal mattress alone, all of which have been effective in reducing hypothermia.
•
Optimal assessment of heart rate: It is suggested in babies requiring resuscitation that the ECG can be used to provide a rapid and accurate estimation of heart rate.
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Meconium: Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. The emphasis should be on initiating ventilation within the first minute of life in non-breathing or ineffectively breathing infants and this should not be delayed.
•
Air/Oxygen: Ventilatory support of term infants should start with air. For preterm infants, either air or a low concentration of oxygen (up to 30%) should be used initially. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.
•
Continuous Positive Airways Pressure (CPAP): Initial respiratory support of spontaneously breathing preterm infants with respiratory distress may be provided by CPAP rather than intubation.
The guidelines that follow do not define the only way that resuscitation at birth should be achieved; they merely represent a widely accepted view of how resuscitation at birth can be carried out both safely and effectively (Fig. 7.1).
Fig. 7.1Newborn life support algorithm. SpO2: transcutaneous pulse oximetry, ECG: electrocardiograph, PPV: positive pressure ventilation.
The fetal-to-neonatal transition, which occurs at the time of birth, requires anatomic and physiological adjustments to achieve the conversion from placental gas exchange with intra-uterine lungs filled with fluid, to pulmonary respiration with aerated lungs. The absorption of lung fluid, the aeration of the lungs, the initiation of air breathing, and cessation of the placental circulation bring about this transition.
A minority of infants require resuscitation at birth, but a few more have problems with this perinatal transition, which, if no support is given, might subsequently result in a need for resuscitation. Of those needing any help, the overwhelming majority will require only assisted lung aeration. A tiny minority may need a brief period of chest compressions in addition to lung aeration. In a retrospective study, approximately 85% of babies born at term initiated spontaneous respirations within 10 to 30 s of birth; an additional 10% responded during drying and stimulation, approximately 3% initiated respirations following positive pressure ventilation, 2% were intubated to support respiratory function and 0.1% received chest compressions and/or adrenaline.
Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study.
Most of those, 8 per 1000, responded to mask inflation of the lungs and only 2 per 1000 appeared to need intubation. The same study tried to assess the unexpected need for resuscitation at birth and found that for low risk babies, i.e. those born after 32 weeks gestation and following an apparently normal labour, about 2 per 1000 (0.2%) appeared to need resuscitation or help with transition at delivery. Of these, 90% responded to mask ventilation alone while the remaining 10% appeared not to respond to mask inflation and therefore were intubated at birth. There was almost no need for cardiac compressions.
Resuscitation or support of transition is more likely to be needed by babies with intrapartum evidence of significant fetal compromise, babies delivering before 35 weeks gestation, babies delivering vaginally by the breech, maternal infection and multiple pregnancies.
Furthermore, caesarean delivery is associated with an increased risk of problems with respiratory transition at birth requiring medical interventions especially for deliveries before 39 weeks gestation.
Although it is sometimes possible to predict the need for resuscitation or stabilisation before a baby is born, this is not always the case. Any newborn may potentially develop problems during birth, therefore, personnel trained in newborn life support should be easily available for every delivery. In deliveries with a known increased risk of problems, specially trained personnel should be present with at least one person experienced in tracheal intubation. Should there be any need for intervention, the care of the baby should be their sole responsibility. Local guidelines indicating who should attend deliveries should be developed, based on current practice and clinical audit. Each institution should have a protocol in place for rapidly mobilising a team with competent resuscitation skills for any birth. Whenever there is sufficient time, the team attending the delivery should be briefed before delivery and clear role assignment should be defined. It is also important to prepare the family in cases where it is likely that resuscitation might be required.
A structured educational programme, teaching the standards and skills required for resuscitation of the newborn is therefore essential for any institution or clinical area in which deliveries may occur. Continued experiential learning and practice is necessary to maintain skills.
Planned home deliveries
Recommendations as to who should attend a planned home delivery vary from country to country, but the decision to undergo a planned home delivery, once agreed with medical and midwifery staff, should not compromise the standard of initial assessment, stabilisation or resuscitation at birth. There will inevitably be some limitations to resuscitation of a newborn baby in the home, because of the distance from further assistance, and this must be made clear to the mother at the time plans for home delivery are made. Ideally, two trained professionals should be present at all home deliveries; one of these must be fully trained and experienced in providing mask ventilation and chest compressions in the newborn.
Equipment and environment
Unlike adult cardiopulmonary resuscitation (CPR), resuscitation at birth is often a predictable event. It is therefore possible to prepare the environment and the equipment before delivery of the baby. Resuscitation should take place in a warm, well-lit, draught free area with a flat resuscitation surface placed below a radiant heater (if in hospital), with other resuscitation equipment immediately available. All equipment must be regularly checked and tested.
When a birth takes place in a non-designated delivery area, the recommended minimum set of equipment includes a device for safe assisted lung aeration and subsequent ventilation of an appropriate size for the newborn, warm dry towels and blankets, a sterile instrument for cutting and clamping the umbilical cord and clean gloves for the attendant and assistants. Unexpected deliveries outside hospital are most likely to involve emergency services that should plan for such events.
Timing of clamping the umbilical cord
Cine-radiographic studies of babies taking their first breath at delivery showed that those whose cords were clamped prior to this had an immediate decrease in the size of the heart during the subsequent three or four cardiac cycles. The heart then increased in size to almost the same size as the fetal heart. The initial decrease in size could be interpreted as the significantly increased pulmonary blood flow following the decrease in pulmonary vascular resistance upon lung aeration. The subsequent increase in size would, as a consequence, be caused by the blood returning to the heart from the lung.
Brady et al drew attention to the occurrence of a bradycardia apparently induced by clamping the cord before the first breath and noted that this did not occur in babies where clamping occurred after breathing was established.
Studies of delayed clamping have shown an improvement in iron status and a number of other haematological indices over the next 3–6 months and a reduced need for transfusion in preterm infants.
A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints.
A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints.
A systematic review on delayed cord clamping and cord milking in preterm infants found improved stability in the immediate postnatal period, including higher mean blood pressure and haemoglobin on admission, compared to controls.
Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial.
Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial.
No human studies have yet addressed the effect of delaying cord clamping on babies apparently needing resuscitation at birth because such babies have been excluded from previous studies.
Delaying umbilical cord clamping for at least 1 min is recommended for newborn infants not requiring resuscitation. A similar delay should be applied to preterm babies not requiring immediate resuscitation after birth. Until more evidence is available, infants who are not breathing or crying may require the umbilical cord to be clamped, so that resuscitation measures can commence promptly. Umbilical cord milking may prove an alternative in these infants although there is currently not enough evidence available to recommended this as a routine measure.
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
Umbilical cord milking produces improved short term haematological outcomes, admission temperature and urine output when compared to delayed cord clamping (>30 s) in babies born by caesarean section, although these differences were not observed in infants born vaginally.
Naked, wet, newborn babies cannot maintain their body temperature in a room that feels comfortably warm for adults. Compromised babies are particularly vulnerable.
Project 27/28: inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland.
Factors influencing morbidity and mortality in infants with severe respiratory distress syndrome treated with single or multiple doses of a natural porcine surfactant.
The temperature of newly born non-asphyxiated infants should be maintained between 36.5 °C and 37.5 °C after birth. For each 1 °C decrease in admission temperature below this range there is an associated increase in mortality by 28%.
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
World Health Organization: Department of Reproductive Health and Research (RHR). Thermal protection of the newborn: a practical guide (WHO/RHT/MSM/97.2). Geneva; 1997.
Dry the term baby immediately after delivery. Cover the head and body of the baby, apart from the face, with a warm and dry towel to prevent further heat loss. Alternatively, place the baby skin to skin with mother and cover both with a towel.
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
World Health Organization: Department of Reproductive Health and Research (RHR). Thermal protection of the newborn: a practical guide (WHO/RHT/MSM/97.2). Geneva; 1997.
If the baby needs support in transition or resuscitation then place the baby on a warm surface under a preheated radiant warmer.
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All babies less than 32 weeks gestation should have the head and body of the baby (apart from the face) covered with polyethylene wrapping, without drying the baby beforehand, and also placed under a radiant heater.
In addition, babies <32 weeks gestation, may require a combination of further interventions to maintain the temperature between 36.5 °C and 37.5 °C after delivery through admission and stabilisation. These may include warmed humidified respiratory gases,
Alternatively, well newborns >30 weeks gestation may be dried and nursed with skin to skin contact or kangaroo mother care to maintain their temperature whilst they are transferred.
Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns.
Skin-to-skin contact may reduce negative consequences of “the stress of being born”: a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg.
They should be covered and protected from draughts.
Whilst maintenance of a baby's temperature is important, this should be monitored in order to avoid hyperthermia (>38.0 °C). Infants born to febrile mothers have a higher incidence of perinatal respiratory depression, neonatal seizures, early mortality and cerebral palsy.
However, individual components of the score, namely respiratory rate, heart rate and tone, if assessed rapidly, can identify babies needing resuscitation, (and Virginia Apgar herself found that heart rate was the most important predictor of immediate outcome).
Furthermore, repeated assessment particularly of heart rate and, to a lesser extent breathing, can indicate whether the baby is responding or whether further efforts are needed.
Breathing
Check whether the baby is breathing. If so, evaluate the rate, depth and symmetry of breathing together with any evidence of an abnormal breathing pattern such as gasping or grunting.
Heart rate
Immediately after birth the heart rate is assessed to evaluate the condition of the baby and subsequently is the most sensitive indicator of a successful response to interventions. Heart rate is initially most rapidly and accurately assessed by listening to the apex beat with a stethoscope
Feeling the pulse in the base of the umbilical cord is often effective but can be misleading because cord pulsation is only reliable if found to be more than 100 beats per minute (bpm)
which is better assessed using pulse oximetry if possible. A healthy baby is born blue but starts to become pink within 30 s of the onset of effective breathing. Peripheral cyanosis is common and does not, by itself, indicate hypoxaemia. Persistent pallor despite ventilation may indicate significant acidosis or rarely hypovolaemia. Although colour is a poor method of judging oxygenation, it should not be ignored: if a baby appears blue, check preductal oxygenation with a pulse oximeter.
Tone
A very floppy baby is likely to be unconscious and will need ventilatory support.
Tactile stimulation
Drying the baby usually produces enough stimulation to induce effective breathing. Avoid more vigorous methods of stimulation. If the baby fails to establish spontaneous and effective breaths following a brief period of stimulation, further support will be required.
Classification according to initial assessment
On the basis of the initial assessment, the baby can be placed into one of three groups:
There is no need for immediate clamping of the cord. This baby requires no intervention other than drying, wrapping in a warm towel and, where appropriate, handing to the mother. The baby will remain warm through skin-to-skin contact with mother under a cover, and may be put to the breast at this stage. It remains important to ensure the baby's temperature is maintained.
Dry and wrap. This baby will usually improve with mask inflation but if this does not increase the heart rate adequately, may rarely also require ventilations.
Dry and wrap. This baby will then require immediate airway control, lung inflation and ventilation. Once this has been successfully accomplished the baby may also need chest compressions, and perhaps drugs.
Preterm babies may be breathing and showing signs of respiratory distress in which case they should be supported initially with CPAP.
There remains a very rare group of babies who, though breathing with a good heart rate, remain hypoxaemic. This group includes a range of possible diagnoses such as cyanotic congenital heart disease, congenital pneumonia, pneumothorax, diaphragmatic hernia or surfactant deficiency.
Newborn life support
Commence newborn life support if initial assessment shows that the baby has failed to establish adequate regular normal breathing, or has a heart rate of less than 100 min−1 (Fig. 7.1). Opening the airway and aerating the lungs is usually all that is necessary. Furthermore, more complex interventions will be futile unless these two first steps have been successfully completed.
Airway
Place the baby on his or her back with the head in a neutral position (Fig. 7.2). A 2 cm thickness of the blanket or towel placed under the baby's shoulder may be helpful in maintaining proper head position. In floppy babies application of jaw thrust or the use of an appropriately sized oropharyngeal airway may be essential in opening the airway.
The supine position for airway management is traditional but side-lying has also been used for assessment and routine delivery room management of term newborns but not for resuscitation.
Suction is needed only if the airway is obstructed. Obstruction may be caused by particulate meconium but can also be caused by blood clots, thick tenacious mucus or vernix even in deliveries where meconium staining is not present. However, aggressive pharyngeal suction can delay the onset of spontaneous breathing and cause laryngeal spasm and vagal bradycardia.
Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial.
For over 30 years it was hoped that clearing meconium from the airway of babies at birth would reduce the incidence and severity of meconium aspiration syndrome (MAS). However, studies supporting this view were based on a comparison of suctioning on the outcome of a group of babies with the outcome of historical controls.
Lightly meconium stained liquor is common and does not, in general, give rise to much difficulty with transition. The much less common finding of very thick meconium stained liquor at birth is an indicator of perinatal distress and should alert to the potential need for resuscitation. Two multi-centre randomised controlled trials showed that routine elective intubation and tracheal suctioning of these infants, if vigorous at birth, did not reduce MAS
Hence intrapartum suctioning and routine intubation and suctioning of vigorous infants born through meconium stained liquor are not recommended. A small RCT has recently demonstrated no difference in the incidence of MAS between patients receiving tracheal intubation followed by suctioning and those not intubated.
The presence of thick, viscous meconium in a non-vigorous baby is the only indication for initially considering visualising the oropharynx and suctioning material, which might obstruct the airway. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction.
The emphasis should be on initiating ventilation within the first minute of life in non-breathing or ineffectively breathing infants and this should not be delayed. If suctioning is attempted use a 12–14 FG suction catheter, or a paediatric Yankauer sucker, connected to a suction source not exceeding −150 mmHg.
After initial steps at birth, if breathing efforts are absent or inadequate, lung aeration is the priority and must not be delayed (Fig. 7.3). In term babies, respiratory support should start with air.
Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
The primary measure of adequate initial lung inflation is a prompt improvement in heart rate. If the heart rate is not improving assess the chest wall movement. In term infants, spontaneous or assisted initial inflations create a functional residual capacity (FRC).
The pressure required to aerate the fluid filled lungs of newborn babies requiring resuscitation is 15–30 cm H2O (1.5–2.9 kPa) with a mean of 20 cm H2O.
Efficacy of the intervention can be estimated by a prompt increase in heart rate or observing the chest rise. If this is not obtained it is likely that repositioning of the airway or mask will be required and, rarely, higher inspiratory pressures may be needed. Most babies needing respiratory support at birth will respond with a rapid increase in heart rate within 30 s of lung inflation. If the heart rate increases but the baby is not breathing adequately, ventilate at a rate of about 30 breaths min−1 allowing approximately 1 s for each inflation, until there is adequate spontaneous breathing.
Adequate passive ventilation is usually indicated by either a rapidly increasing heart rate or a heart rate that is maintained faster than 100 beats min−1. If the baby does not respond in this way the most likely cause is inadequate airway control or inadequate ventilation. Look for passive chest movement in time with inflation efforts; if these are present then lung aeration has been achieved. If these are absent then airway control and lung aeration has not been confirmed. Mask leak, inappropriate airway position and airway obstruction, are all possible reasons, which may need correction.
Without adequate lung aeration, chest compressions will be ineffective; therefore, confirm lung aeration and ventilation before progressing to circulatory support.
Some practitioners will ensure airway control by tracheal intubation, but this requires training and experience. If this skill is not available and the heart rate is decreasing, re-evaluate the airway position and deliver inflation breaths while summoning a colleague with intubation skills. Continue ventilatory support until the baby has established normal regular breathing.
Sustained inflations (SI) > 5 s
Several animal studies have suggested that a longer SI may be beneficial for establishing functional residual capacity at birth during transition from a fluid-filled to air-filled lung.
Sustained pressure-controlled inflation or intermittent mandatory ventilation in preterm infants in the delivery room? A randomized, controlled trial on initial respiratory support via nasopharyngeal tube.
which demonstrated that initial SI reduced the need for mechanical ventilation. However, no benefit was found for reduction of mortality, bronchopulmonary dysplasia, or air leak. One cohort study
suggested that the need for intubation was less following SI. It was the consensus of the COSTR reviewers that there was inadequate study of the safety, details of the most appropriate length and pressure of inflation, and long-term effects, to suggest routine application of SI of greater than 5 s duration to the transitioning newborn.
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
Sustained inflations >5 s should only be considered in individual clinical circumstances or in a research setting.
Air/Oxygen
Term babies
In term infants receiving respiratory support at birth with positive pressure ventilation (PPV), it is best to begin with air (21%) as opposed to 100% oxygen. If, despite effective ventilation, there is no increase in heart rate or oxygenation (guided by oximetry wherever possible) remains unacceptable, use a higher concentration of oxygen to achieve an adequate preductal oxygen saturation.
Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. In press.
Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
The administered oxygen concentration should be titrated to achieve acceptable pre-ductal oxygen saturations approximating to the 25th percentile in healthy term babies immediately after birth (Fig. 7.4).
Fig. 7.4Oxygen saturations (3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles) in healthy infants at birth without medical intervention. Reproduced with permission from.
In a meta-analysis of seven randomized trials comparing initiation of resuscitation with high (>65%) or low (21–30%) oxygen concentrations, the high concentration was not associated with any improvement in survival,
Modern pulse oximetery, using neonatal probes, provides reliable readings of heart rate and transcutaneous oxygen saturation within 1–2 min of birth (Fig. 7.4).
A reliable pre-ductal reading can be obtained from >90% of normal term births, approximately 80% of those born preterm, and 80-90% of those apparently requiring resuscitation, within 2 min of birth.
Pulse oximetry should be used to avoid excessive use of oxygen as well as to direct its judicious use (Figs. 7.1 and 7.4). Transcutaneous oxygen saturations above the acceptable levels should prompt weaning of any supplemental oxygen.
Positive end expiratory pressure
All term and preterm babies who remain apnoeic despite initial steps must receive positive pressure ventilation after initial lung inflation. It is suggested that positive end expiratory pressure (PEEP) of ∼5 cm H2O should be administered to preterm newborn babies receiving PPV.
Two human newborn RCTs demonstrated no improvement in mortality, need for resuscitation or bronchopulmonary dysplasia they were underpowered for these outcomes.
The blow-off valves of self-inflating bags are flow-dependent and pressures generated may exceed the value specified by the manufacturer if compressed vigorously.
Target inflation pressures, tidal volumes and long inspiratory times are achieved more consistently in mechanical models when using T-piece devices than when using bags,
although the clinical implications are not clear. More training is required to provide an appropriate pressure using flow-inflating bags compared with self-inflating bags.
A self-inflating bag, a flow-inflating bag or a T-piece mechanical device, all designed to regulate pressure or limit pressure applied to the airway can be used to ventilate a newborn. However, self-inflating bags are the only devices, which can be used in the absence of compressed gas but cannot deliver continuous positive airway pressure (CPAP) and may not be able to achieve PEEP even with a PEEP valve in place
have been used but there is no evidence that they affect outcomes. Neither additional benefit above clinical assessment alone, nor risks attributed to their use have so far been identified. The use of exhaled CO2 detectors to assess ventilation with other interfaces (e.g., nasal airways, laryngeal masks) during PPV in the delivery room has not been reported.
Face mask versus nasal prong
A reported problem of using the facemask for newborn ventilation is mask leak caused by a failure of the seal between the mask and the face.
To avoid this some institutions are using naso-pharyngeal prongs to deliver respiratory support. Two randomised trials in preterm infants have compared the efficacy and did not find any difference between the methods.
The laryngeal mask airway can be used in resuscitation of the newborn, particularly if facemask ventilation is unsuccessful or tracheal intubation is unsuccessful or not feasible. The LMA may be considered as an alternative to a facemask for positive pressure ventilation among newborns weighing more than 2000 g or delivered ≥34 weeks gestation.
One recent unblinded RCT demonstrated that following training with one type of LMA, its use was associated with less tracheal intubation and neonatal unit admission in comparison to those receiving ventilation via a facemask.
There is limited evidence, however, to evaluate its use for newborns weighing <2000 gram or delivered <34 weeks gestation. The laryngeal mask airway may be considered as an alternative to tracheal intubation as a secondary airway for resuscitation among newborns weighing more than 2000 g or delivered ≥34 weeks gestation.
Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials.
The LMA is recommended during resuscitation of term and preterm newborns ≥34 weeks gestation when tracheal intubation is unsuccessful or not feasible. The laryngeal mask airway has not been evaluated in the setting of meconium stained fluid, during chest compressions, or for the administration of emergency intra-tracheal medications.
Tracheal tube placement
Tracheal intubation may be considered at several points during neonatal resuscitation:
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When suctioning the lower airways to remove a presumed tracheal blockage.
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When, after correction of mask technique and/or the baby's head position, bag-mask ventilation is ineffective or prolonged.
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When chest compressions are performed.
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Special circumstances (e.g., congenital diaphragmatic hernia or to give tracheal surfactant).
The use and timing of tracheal intubation will depend on the skill and experience of the available resuscitators. Appropriate tube lengths based on gestation are shown in Table 1.
Tracheal tube placement must be assessed visually during intubation, and positioning confirmed. Following tracheal intubation and intermittent positive-pressure, a prompt increase in heart rate is a good indication that the tube is in the tracheobronchial tree.
and neonatal studies suggest that it confirms tracheal intubation in neonates with a cardiac output more rapidly and more accurately than clinical assessment alone.
However, neonatal studies have excluded infants in need of extensive resuscitation. False positives may occur with colorimetric devices contaminated with adrenaline (epinephrine), surfactant and atropine.
Poor or absent pulmonary blood flow or tracheal obstruction may prevent detection of exhaled CO2 despite correct tracheal tube placement. Tracheal tube placement is identified correctly in nearly all patients who are not in cardiac arrest
; however, in critically ill infants with poor cardiac output, inability to detect exhaled CO2 despite correct placement may lead to unnecessary extubation. Other clinical indicators of correct tracheal tube placement include evaluation of condensed humidified gas during exhalation and presence or absence of chest movement, but these have not been evaluated systematically in newborn babies.
Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm tracheal placement in neonates with spontaneous circulation.
Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
Initial respiratory support of all spontaneously breathing preterm infants with respiratory distress may be provided by CPAP, rather than intubation. Three RCTs enrolling 2358 infants born at <30 weeks gestation demonstrated that CPAP is beneficial when compared to initial tracheal ventilation and PPV in reducing the rate of intubation and duration of mechanical ventilation without any short term disadvantages.
Circulatory support with chest compressions is effective only if the lungs have first been successfully inflated. Give chest compressions if the heart rate is less than 60 beats min−1 despite adequate ventilation. As ventilation is the most effective and important intervention in newborn resuscitation, and may be compromised by compressions, it is vital to ensure that effective ventilation is occurring before commencing chest compressions.
The most effective technique for providing chest compressions is with two thumbs over the lower third of the sternum with the fingers encircling the torso and supporting the back (Fig. 7.5).
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