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Positive pressure ventilation can be achieved with different types of bag-mask devices, which have different relative advantages and disadvantages. The process of bag mask ventilation in neonatal resuscitation is the same regardless of the device chosen:.

Suction: Mucus or secretions should be suction from the nose and mouth before starting positive pressure ventilation and as needed throughout the procedure. Position: Proper positioning is key to effective positive pressure ventilation. Likewise, the size of the mask used should be appropriate to the size of the baby.

Proper technique is important for achieving and maintaining a tight seal. On the other hand, it is important not to use excessive volume or pressure as this can cause barotrauma, or trauma to the lungs due to excessive pressures. Positive pressure ventilation has generally been effective if the baby makes bilateral breath sounds and demonstrates chest movement.

If positive pressure ventilation is not working, there are things to check, including the position of the mask you may be using and the position of the airway.

Increasing pressure and the suction on mouth or nose are other strategies to improve the effects of positive pressure ventilation. Research has also shown that applying surfactant, which is a substance that reduces surface tension, through a catheter, can improve positive airway pressure and minimize the requirement of mechanical ventilation Gopel et al.

Another time to think about using a laryngeal mask is when the facemask is not achieving positive-pressure ventilation and intubation is not feasible. However, there are a number of shortcomings associated with laryngeal masks that should also be considered before initiating their use, which include:.

Successful intubation requires a specifically trained professional, and one of these individuals should always be present at delivery, in case intubation is necessary. The placement of the intubation tube can also be confirmed by visualizing the tube between the vocal cords, and x-rays can be used to confirm the chest placement of the tube. Chest compressions increase the pressure within the thoracic cavity by compressing the heart against the spine, thereby reducing the volume within that space.

The effect is that blood should circulate to important organs of the body. The two-thumb technique is generally the best way to perform chest compressions Panel A.

You can locate the area where compressions should be performed by finding the xiphoid along the lower part of the rib cage. You can then place your thumbs above the xiphoid, on the sternum. During the compressions, you will want to ensure that chest movement occurs, and your thumb remains in contact with the chest.

Release all the pressure during the relaxation phase of compression, and the release should last longer in time than the downward compression. Finger compressions Panel B are acceptable, but less effective, generally. Epinephrine, or adrenaline, increases blood pressure and stimulates the heart. Epinephrine should be rapidly administered to a newborn through the umbilical vein if the heart rate has stayed below 60 beats per minute after 30 seconds of assisted ventilation.

Newborns should be given doses of epinephrine ranging from 0. After epinephrine is used, chest compressions and ventilations should be resumed for an additional minute. If a newborn is not responding to resuscitation and seems to be in shock, volume expansion can be undertaken with a volume expander. Volume expansion can be achieved with normal saline 0. If severe anemia is present, Type O, Rh-factor-negative blood is also acceptable.

This can be followed by a second dose, if needed. There are a number of things that should be prepared ahead of every single birth, to ensure efficient resuscitation procedures are implemented if resuscitation is required. The things to prepare include:. If resuscitation does not seem to be working, there are some special considerations that should be assessed. In many cases, complication relates to a constricted or blocked airway such aslaryngeal webs, cystic hygroma, or congenital goiter.

Practically speaking, the airway obstruction is usually in the nasal pharynx e. Babies do not normally breathe through their mouths unless they are crying. In a way, they can be considered obligate nose breathers. In the case of choanal atresia, however, the nasal airway is not fully patent open. This means that the baby can only breathe effectively through crying or with assistance. One clue to the existence of choanal atresia is the presence of meconium or mucus is in the nasal airway.

A suction catheter gently applied through the nares into the posterior pharynx can test for this condition. If the catheter cannot pass so that it is visible in the oral pharynx, you can assume that choanal atresia exists and an oral airway will be necessary. These congenital abnormalities essentially result in a blocked oral pharynx as opposed to a blocked nasal pharynx present in choanal atresia.

Intubation through the mouth is quite difficult in a child with Robin syndrome. Putting the baby on its stomach can push the tongue forward and open the airway. If that action is not adequate to improve the condition, a catheter can be used to open the airway. The neonate, and especially the premature infant, can develop one or more problems in the lungs that complicate neonatal resuscitation.

In the very premature infant, the lungs either cannot support respiration and oxygenation or can only do so marginally.

Artificial surfactant can help considerably in these cases by reducing surface tension in the alveoli and reducing pressures required to ventilate the lungs. Another form of lung malformation is pulmonary hypoplasia. In pulmonary hypoplasia which is more common in fetuses exposed to insufficient amounts of amniotic fluid during gestation , the lungs have simply not formed during fetal development. Less severe cases of pulmonary hypoplasia can be effectively treated with long-term intensive care, but children with severe cases of pulmonary hypoplasia often do not survive the neonatal period.

Some of the more common causes of impaired lung function can be reversed with timely bedside or surgical procedures, assuming they are detected in the early neonatal period. For example, many babies who require neonatal resuscitation are born with a pneumothorax or develop one during resuscitation particularly ventilation. In pneumothorax is the presence of air in the pleural space, between the chest wall and the outside of the lungs. A pneumothorax causes substantial respiratory distress and is diagnosed through trans illumination of the chest cavity, the absence of lung sounds of one of the chest, or a portable chest x-ray if needed.

A pneumothorax can be treated with needle thoracostomy where the placement of a catheter to evacuate the air in the pleural space. Pleural effusions and congenital diaphragmatic hernias are rare, but potentially treatable causes of poor lung function in the neonate.

A pleural effusion is treated in much the same way as a pneumothorax, releasing fluid instead of air. A baby with congenital diaphragmatic hernia is usually diagnosed by ultrasound prior to delivery. However in women who have not had routine prenatal screenings, the hernia may go undiagnosed until delivery.

The baby can be stabilized with separate tubes in the trachea and stomach until pediatric surgery can repair the hernia. Women who received opioid analgesics during delivery or women who are actively intoxicated with illicit opioids may deliver infants with substantial levels of opioids in their systems.

In these cases, the problem with respiration is not an impaired airway or a pulmonary problem, but the drive to breathe is depressed. When this occurs, the baby can be ventilated until the opioids had been metabolized.

Naloxone, an opioid antagonist, should be avoided in babies of women with opioid abuse problems or on methadone treatment because the drug can cause withdrawal seizures in the neonate. Several types of congenital heart malformation can interfere with circulation, but few of them manifest in the newly born infant. Providers may consider a congenital heart problem after ventilation has proved fruitless. This requires specialist diagnostic and management skills that are outside the purview of neonatal resuscitation.

Once the newborn has been successfully resuscitated, the baby is moved to post-resuscitation care. As such, neonates who require resuscitation are usually moved to the neonatal intensive care unit for close monitoring.

Blood pressure : Hypotension is the most likely cardiovascular result of resuscitation. Monitoring heart rate and blood pressure are the best ways to determine if hypotension is an issue for newborns who have been resuscitation. Volume replacement and inotrope administration are relevant interventions in the case of hypotension.

Electrolytes : Hyponatremia and hypocalcemia are common in recently resuscitated newborns. Standard treatment is to reverse deficits with intravenous supplementation. When possible, acidosis acidemia should be treated with increased ventilation drawing off carbon dioxide from the lungs Sodium bicarbonate can be given in cases of extreme or persistent metabolic acidosis, but it should be used with extreme caution since it is caustic, irritates blood vessels, and can actually decrease pH in cells.

Blood glucose : Hypoglycemia is a concern in the post-resuscitation period. Central nervous system function : Seizures, apnea, and other neurological issues can result from resuscitation. Therapeutic hypothermia and anticonvulsants are potential interventions for brain disturbances resulting from resuscitation.

Pulmonary function : A number of lung complications can arise because of resuscitation. These complications include pulmonary hypertension, meconium aspiration syndrome, pneumonia, pneumothorax, transient tachypnea, and surfactant deficiency especially in premature infants. Maintaining proper oxygenation and ventilation, delaying feedings, using antibiotics, taking x-rays, and using surfactant therapy are all interventions that can help with specific lung complications.

Delaying feedings and providing intravenous fluids and parenteral nutrition are potential ways to intervene with these issues. Renal function : Acute tubular necrosis is the most common kidney complication resulting from resuscitation.

This condition can be identified by monitoring urine output and serum electrolytes. Infection and blood cell counts : Complete blood cell counts CBCs can be used to diagnose anemia low red blood cell count , thrombocytopenia low platelet count , and infection elevated white blood cell count, usually with elevated body temperature.

Pneumonia is the likely culprit of infection in the neonate, either from aspiration that occurred during resuscitation or from infection that is present congenitally. Click here to order. Log-in to see your price. The NRP, 8th Edition, introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. The NRP Steering Committee made the decision to offer 2 course options so that the NRP providers could excel in the course material most relevant to their role and personnel resources during newborn resuscitation.

Neonatal Resuscitation eBook Collection for Institutions - An annual site license to the Neonatal Resuscitation eBook Collection gives your entire organization unlimited access to this essential collection. Jeanette has worked as a staff nurse, clinical nurse specialist, manager, and outreach coordinator in a variety of settings, including community hospitals and major medical centers.

She has served as a nurse consultant for the American Academy of Pediatrics Neonatal Resuscitation Program NRP Steering Committee since , is co-editor of the Textbook of Neonatal Resuscitation and creates many of the education materials for the program.

Jeanette is a nurse author and editor and provides consultation and program development for simulation-based resuscitation training across the United States. Privacy Statement Terms of Use. Create an Account Log In.

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