Neonatal Resuscitation Program

NRP guidelines recommend a compression depth of one third to one half of the anteroposterior diameter of the chest to generate a pulse, at a ratio of three compressions to one breath.

From: Avery's Diseases of the Newborn (Eighth Edition) , 2005

Newborn Resuscitation

Anup Katheria , Neil N. Finer , in Avery's Diseases of the Newborn (Tenth Edition), 2018

Heart Rate

Previous NRP recommendations only required a snapshot of the heart rate every 30 seconds to determine whether it fell between two critical cut points (60 and 100 bpm) as defined in the guidelines. Even if the heart rate is being auscultated and manually tapped out by hand, it can be difficult for the leader of the resuscitation to recognize changes quickly. With the inclusion of pulse oximetry for high-risk deliveries, all resuscitation teams can now monitor the heart rate continuously as long as the oximeter is functioning (Kattwinkel et al., 2010). However, the pulse oximeter, while helpful, does not provide a reliable heart rate in the first few minutes of life. Importantly, this is a critical period when decisions, such as the need to begin PPV, must be made. Our group demonstrated that the median time to obtain the heart rate of very low birth weight newborns (<1500 g), by means of oximetry, was 67 seconds (interquartile range 50–93 seconds) (Gandhi et al., 2013).

ECG, which derives from the electrical activity of the heart, is not dependent on the circulation and so is less affected by the transitional state of the newborn. In trials comparing oximetry with ECG, early application of ECG electrodes during newborn resuscitation can provide the resuscitation team with a continuous reliable audible heart rate earlier, and its use may improve the timeliness of appropriate critical interventions when compared with pulse oximetry alone (Katheria et al., 2012; Mizumoto et al., 2012). In addition, heart rate measured by ECG has been found to be higher than that measured by oximetry particularly early in resuscitation when low signal messages occur (Narayen et al., 2015). The seventh edition of the NRP textbook suggests the use of ECG to provide a rapid and accurate estimation of heart rate (Perlman et al., 2015; NRP, 2016).

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Resuscitation in the Delivery Room

Jeffrey D. Merrill , Roberta A. Ballard , in Avery's Diseases of the Newborn (Eighth Edition), 2005

Initial Assessment

The NRP algorithm for resuscitation in the delivery room begins with an initial evaluation of the newborn (Fig. 28-6). Abnormalities in breathing, tone, and color as well as the presence of meconium or evidence of prematurity are indicative of the need for further resuscitation. One begins by placing the infant under a radiant heater, positioning the infant's head to open the airway, clearing upper airway secretions, and drying and stimulating the infant. A brief delivery of oxygen, blown over the face, may be given as necessary for cyanosis. It is important to remember that at birth, the newborn infant's lungs are normally full of fluid which is cleared by resorption into the pulmonary vascular system (Walters, 1978). Excessive suctioning of clear fluid from the nasopharynx is not helpful and may contribute to atelectasis. The infant is next quickly assessed for respiration, heart rate, and color. The presence of apnea or a heart rate of less than 100 beats/min indicates the need for positive-pressure ventilation.

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Respiratory Care of the Newborn

Robert DiBlasi RRT-NPS, FAARC , John T. Gallagher MPH, RRT-NPS, FAARC , in Assisted Ventilation of the Neonate (Sixth Edition), 2017

Resuscitation and Stabilization at Delivery

The NRP is a training program for providers of newborn resuscitation created by the AAP and the American Heart Association to provide a comprehensive stepwise algorithm for the assessment and resuscitation of the newborn infant at delivery. 1 A core feature of this algorithm is the provision of adequate respiratory support and establishing effective ventilation using a variety of resuscitation devices, while repeatedly assessing the patient's response to the support provided and adjusting the technique of respiratory support.

Furthermore, endotracheal intubation may be considered at several points during a resuscitation; however, the timing of intubation may be influenced by the skill and experience of the provider as well as the clinical circumstances. Potential indications for endotracheal intubation during delivery room resuscitation include (1) tracheal suctioning of meconium (this is no longer recommended by the NRP), (2) need for prolonged positive-pressure ventilation, (3) administration of prophylactic surfactant, (4) presence of obstructive upper airway lesions requiring an artificial airway, and (5) cases in which air distention of the gastrointestinal (GI) tract is undesirable, such as with congenital diaphragmatic hernia.

Positive-pressure ventilation should be initiated during neonatal resuscitation when the infant is bradycardic (heart rate less than 100) or apneic despite stimulation or when there is persistent hypoxemia despite supplemental oxygen administration. 1 Under these circumstances, positive-pressure ventilation should be initially provided with a resuscitation bag and mask or T-piece resuscitator. Ultimately, intubation for positive-pressure ventilation should be considered if bag and mask ventilation is ineffective or if the need for prolonged positive-pressure ventilation is anticipated.

One of the most recent advances in manual ventilation of the newborn has been the introduction of the sustained lung inflation. 175 The process involves using one of the resuscitation devices previously discussed to administer a single high pressure to the infant's lungs in an effort to better establish the functional residual capacity. The pressure is sustained for a designated amount of time and then reduced to a standard CPAP level to assist spontaneous breathing. This maneuver remains controversial, but emerging evidence suggests that such a maneuver may decrease the need for mechanical ventilation in the first few days of life. 176,177

Infants born with congenital diaphragmatic hernia frequently require positive-pressure ventilation at delivery because of respiratory distress with cyanosis. Provision of positive-pressure ventilation with bag and mask will drive large amounts of air into the upper GI tract, causing distention of a bowel that has herniated into the chest. Such bowel distention will cause further lung compression and compromise respiratory function. For this reason, infants with diaphragmatic hernia should be promptly intubated in the delivery room if resuscitation is required. 1 Some clinicians also advise that these infants should be paralyzed with a muscle relaxant to prevent spontaneous breathing from causing bowel distention. An orogastric tube should also be placed to evacuate any air that does enter the stomach. The diagnosis of diaphragmatic hernia is often confirmed by antenatal ultrasound studies and should be suspected in any infant with a scaphoid abdomen, unilaterally diminished breath sounds, and persistent respiratory distress.

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Oxyhemoglobin Saturation Targets in Newborns and the Role of Automated Oxygen Delivery Systems

Payam Vali MD , Satyan Lakshminrusimha MBBS, MD, FAAP , in Updates on Neonatal Chronic Lung Disease, 2020

Supplemental Oxygen in the Resuscitation of Preterm Infants

The current NRP guidelines recommend resuscitation of preterm infants to begin at 21%–30% O2 and that FIO2 should be titrated to maintain SpO2 within the same target range as defined for full-term newborns. 24 Studies comparing initiation of supplemental oxygen at different FIO2 in the resuscitation of preterm infants have demonstrated that 21% O2 is not sufficient to achieve the target SpO2 ranges and that most infants need approximately 30% O2 by the time of stabilization. 49–53 Possible mechanisms that may explain the need for higher FIO2 in premature infants in the delivery room include (1) an underdeveloped airspace-capillary interface, (2) immature fluid-filled lungs in the canalicular stage of development, (3) pulmonary vascular smooth muscle cells that are less responsive to oxygen, and (4) surfactant deficiency 1 (Fig. 14.3).

Fig. 14.3. Infographic describing characteristics of premature infants that explain the need for supplemental oxygen in the delivery room.

Inadequateventilation or mask leak can cause hypoxia and worsen bradycardia. Conversely, too much oxygen can lead to hyperoxia and oxidative stress. GPx, glutathione peroxidase; IVH, intraventricular hemorrhage; SOD, superoxide dismutase.

 Copyright Satyan Lakshminrusimha.

A meta-analysis including approximately 500 premature infants from eight studies comparing high versus low oxygen use in the delivery room showed no difference in death or major morbidities (intraventricular hemorrhage [IVH], BPD, ROP, and patent ductus arteriosus). 54 A Cochrane review including 914 infants from 10 trials, also, concluded no evidence of an effect from the use of a lower rather than a higher initial oxygen concentration targeted to SpO2 on mortality or other newborn health outcomes. 55 One study showed an increased mortality rate in infants born at <28 weeks' gestation resuscitated with lower (0.21) rather than higher (1.0) initial FIO2. However, the study only enrolled 292 out of the 1976 intended subjects owing to loss of equipoise in using 100% O2, 56 and, therefore, the findings of increased mortality based on a non-prespecified post hoc analysis need to be interpreted with caution. Analysis of data from 768 preterm infants (<32 weeks' gestation) showed that regardless of the initial FIO2, infants who did not reach an SpO2 of 80% by 5   min of age were at significantly increased risk of bradycardia, IVH, and death. 57 Whether these findings can be explained by the failure to reach an SpO2 >80% owing to inadequate oxygen use or the inherent clinical instability of the infants is uncertain and needs to be examined in randomized trials.

A review of 45 international clinical practice guidelines on current recommendations for oxygen management of preterm infants in the delivery room identified 17 guidelines that recommend initiating resuscitation at an FIO2 of 0.21–0.3, 8 that recommend an FIO2 of 0.21, 9 that recommend an FIO2 of 0.3, 6 that recommend an FIO2 of 0.3–0.4, and 1 country each that recommend 0.21–1.0, 0.21–0.4, and 0.3–0.5. 58 Recommendations for five-minute SpO2 targets ranged from 70% to 90%. Until stronger evidence from ongoing and future randomized trials are reported, it is reasonable to initiate resuscitation of preterm infants with low FIO2 (<0.4) and adjust oxygen concentration to maintain the NRP-recommended SpO2 target goals.

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Neonatology

Philip Roth MD, PhD , in Pediatric Secrets (Fifth Edition), 2011

39 Should 100% O2 or room air be used in neonatal resuscitation?

The guidelines of the Neonatal Resuscitation Program (NRP) recommend use of 100% O 2 when PPV is required in the resuscitation of full-term infants. However, there is a growing body of data showing that 21% O2 (room air) is just as effective as 100% O2 and less likely to cause reperfusion injuries following asphyxia. Therefore, one may choose to start with 21% O2 but be prepared to increase to 100% if the infant has not shown clinical improvement in 90 seconds. In the case of preterm infants, especially those born before 32 weeks' gestational age, who are especially vulnerable to hyperoxic injury, initial oxygen concentration for resuscitation should begin between 21% and 100% O2—perhaps 30%—and be titrated based on achieving saturations higher than 85%, a rise toward 90% saturation over several minutes, and saturations that do not exceed 95%. Failure to achieve these goals and/or a rapid increase in heart rate to greater than 100 beats/minute should prompt the resuscitator to increase to 100% O2 until adequate oxygenation is achieved.

Richmond S, Goldsmith JP: Air or 100% oxygen in neonatal resuscitation, Clin Perinatol 33:11–27, 2006.

Ten VS et al and Matsiukvich D: Room air or 100% oxygen for resuscitation of infants with perinatal depression, Curr Opin Pediatr 21:188–193, 2009.

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Fetus With Critical Heart Disease—Bridging to Birth

Ryan Loftin MD , Miguel DeLeon MD , in Critical Heart Disease in Infants and Children (Third Edition), 2019

Support for Lower Levels of Newborn Care—Undiagnosed Cardiac Defects

Tertiary care centers can support their referral areas by providing NRP courses and offering cardiac education to assess for clinical signs of a heart defect. In addition to education, tertiary centers can provide to their referral areas algorithms on how to stabilize the baby with a cardiac defect as soon as feasible. Prostaglandin is an essential medication for the treatment of cyanotic heart defects and should be readily available for the appropriate patients. Providing education on mixing and dosing the medication, along with instruction for indication and administration, would be beneficial in care of the baby with a cyanotic heart defect.

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Delivery Room Stabilization, and Respiratory Support

Louise S. Owen MBChB, MRCPCH, FRACP, MD , ... Peter G. Davis MBBS, MD, FRACP , in Assisted Ventilation of the Neonate (Sixth Edition), 2017

Training

All health providers working with newborns should complete a standardized neonatal resuscitation training course. Examples include the Neonatal Resuscitation Program, developed by the American Academy of Pediatrics and the American Heart Association, and the Newborn Life Support course organized by the U.K. Resuscitation Council. Using adult education principles, these programs focus on the cognitive, technical, and teamwork skills required to resuscitate a newborn in the hospital. Other courses teach similar skills for births occurring outside the typical delivery room setting. By simulating both common and unusual neonatal emergencies, providers can identify weaknesses in their skills and develop proficiency. Although a participant's knowledge and skills improve after a resuscitation course, both have been demonstrated to decay rapidly over time. 21,22 Without deliberate practice, providers are unlikely to acquire and maintain competence with infrequently used technical skills such as tracheal intubation and emergency vascular access. Even basic assisted ventilation skills have been shown to decay within months of course completion. 22 The ideal frequency of retraining has not been established; however, several studies have shown that low-intensity/high-frequency practice, as short as 6   minutes every month, may improve skill retention. 23,24

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Temperature Regulation

W. Alan Hodson , in Avery's Diseases of the Newborn (Tenth Edition), 2018

Delivery Room Environment

Hypothermia soon after birth has been associated with increased morbidity and mortality, prompting organizations such as the Neonatal Resuscitation Program and the World Health Organization to stress the importance of preventing early postnatal hypothermia ( Lapcharoensap and Lee, 2016). The maternal temperature at delivery should be noted on the baby's birth record, along with an axillary temperature. The room temperature should be kept at 28oC. Ideally, a preheated gel mattress, with a warm bassinette, warm blankets, and a radiant heat source should be in place. Immediate drying, swaddling (once stabilized), and placement of a cap will reduce evaporative heat loss. The full-term newborn will maintain a normal body temperature with appropriate clothing and blankets in an environment of at least 24oC. Preterm newborns need additional protection from heat losses, including higher ambient temperature and the use of plastic wraps (without drying). Early SSC, once the infant has been stabilized, can be very effective in preventing hypothermia—particularly in resource-limited settings.

Delayed umbilical cord clamping in very preterm newborns has raised concern regarding thermal management. However, a metaanalysis of several studies done in newborns of less than 32 weeks' GA was reassuring, with no differences noted in admission temperature (Backes et al., 2014).

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PULMONARY CARE

JOSEPH R. HAGEMAN MD, FCCM , ... HARRIET HAWKINS RN, CCRN , in Assisted Ventilation of the Neonate (Fourth Edition), 2003

TECHNIQUES

There are a number of methods for performing endotracheal intubation in newborns, but the technique outlined in the NRP textbook should be considered the technique of choice 1 and "a common sense approach." 27 The steps are as follows, with other acceptable techniques included in parentheses:

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Stabilize the baby's head in the "sniffing position." A shoulder roll placed under the shoulders can help to maintain the baby's head in the correct position.

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Deliver free-flow oxygen during the procedure and suction the mouth and pharynx before sliding the blade into the mouth.

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Slide the laryngoscope over the right side of the tongue, pushing the tongue to the left side of the mouth, and advance the blade until the tip lies just beyond the base of the tongue.

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Lift the blade up slightly; raise the entire blade, not just the tip. The blade should be placed in the vallecula and, as the blade is raised, the epiglottis and the glottis with the vocal cords should be visualized. (Some clinicians slide the blade and raise the epiglottis to visualize the vocal cords.)

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Look for anatomic landmarks; suction as necessary for visualization.

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If the vocal cords are closed, wait for them to open. Insert the tip of the tube until the vocal cord guide is at the level of the vocal cords.

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Hold the tube firmly against the baby's hard palate while removing the laryngoscope once the tube has been placed. Hold the tube while removing the stylet as well.

The procedure should be completed in 20 seconds. This does not include setting up all of the equipment and getting the team together to help with the resuscitation. 1 Heart rate and pulse oximetry should be monitored during the intubation procedure and the infant ventilated with bag and mask. Recovery should be allowed between intubation attempts. The practitioner can improve O2 tension during intubation by taping a suction catheter connected to a low-flow O2 source along the laryngoscope blade. 28 Other investigators have maintained a flow of O2 (3 to 5 L/min) through the endotracheal tube during intubation in an attempt to prevent drastic changes in oxygenation. At least two laryngoscopes have been designed with an O2 port alongside the blade 29 .

There is no apparent consensus on the use of medications such as atropine, succinylcholine, or pancuronium bromide before intubation. In some respects, atropine could be helpful in decreasing the volume of secretions and blocking a bradycardia secondary to a vagal response, and a muscle relaxant might be helpful in decreasing movement of the baby.

Nasotracheal Intubation

Nasotracheal intubation may be more time consuming and technically more difficult than orotracheal intubation for the less experienced practitioner. A nasotracheal tube is inserted into one of the nares and guided into the posterior pharynx along the floor of the nose. A laryngoscope is placed into the mouth and the glottis is visualized. A Magill forceps is held in the right hand and introduced into the mouth along the right side of the laryngoscope blade. The nasotracheal tube is grasped a short distance from its tip with the forceps. The tip of the tube is elevated until it is at the level of the glottis and is advanced between the vocal cords and into the trachea. An assistant may be needed to grasp the exterior (or distal) end of the endotracheal tube and assist with its advancement. Care should be exercised in using the Magill forceps so that the soft tissues of the oropharynx are not damaged. Experienced operators may successfully accomplish nasotracheal intubation without the Magill forceps. In addition, cooling a Murphy tube with a predetermined bend prior to intubation may facilitate the procedure.

Depth of Tube Insertion

In addition to direct visualization of the tube as it passes through the glottis, there are a number of different suggested "rules of thumb" for initial estimation of proper depth of tracheal tube placement. These rules use the centimeter markings on the side of a standard Murphy tube to gauge the depth of placement. The most common rule uses birthweight and a simple formula, the rule of 7-8-9. An endotracheal tube is advanced 7 cm to the lip for a 1-kg infant, 8 cm for a 2-kg infant, and 9 cm for a 3-kg infant. The rule of 7-8-9 is not appropriate for infants with hypoplastic mandibles (e.g., those with Pierre Robin syndrome) or short necks (e.g., those with Turner syndrome). 30 Similarly, nasotracheal tube insertion can be governed by adding 1 cm to the 7-8-9 rule.

Determination of Placement

Determination of placement of the endotracheal tube after intubation is determined first clinically and then by chest radiograph. Clinical determination includes the following:

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Improvement or maintenance of heart rate in the normal range

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Good color, pulses, and perfusion after the intubation

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Good bilateral chest wall movement with each breath

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Equal breath sounds heard over both lung fields

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Breath sounds heard much louder over the lung fields than are heard over the stomach

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No gastric distention with ventilation

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Presence of vapor in the tube during exhalation

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Direct visualization by laryngoscope of the tube passing between the vocal cords

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Presence of exhaled CO2 as determined by a CO2 detector and/or an end-tidal CO2 monitor or capnography 31

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Tip to lip measurement: Add 6 to the newborn's weight in kilograms (rule of "7-8-9")

The chest radiograph can demonstrate that the tube is in the mid trachea. The position can be confirmed by following both of the mainstem bronchi back to the carina and cephalad to the tip of the tube. 1 Occasionally a lateral radiograph is necessary to confirm placement in the trachea.

Tube Fixation

Secure fixation of the endotracheal tube is important, not only to prevent accidental extubation but also to minimize tube movement during ventilation and other interventions such as suctioning or chest physiotherapy (CPT). Accidental extubation and repeated intubations have been demonstrated to be associated with the development of subglottic stenosis, as well as increased mortality. 12, 13 The likelihood of accidental extubation also has been found to be associated with younger gestational age, higher level of consciousness, higher volume of secretions, and slippage of the tube. 32 It also is clear that there is no consensus as to which tube fixation method is most effective. The technique shown in Figure 6-4 represents a modification of the method described by Gregory 33 and is similar to what is used at the authors' institutions. The exception is that tincture of benzoin is no longer used, especially in "micropremies." Also, some of these techniques can be used to secure nasotracheal tubes (Fig. 6-5) without the use of tincture of benzoin. Several devices for fixation of neonatal endotracheal tubes are available from various manufacturers.

Alternative to Endotracheal Intubation: Use of the Laryngeal Mask Airway

The laryngeal mask airway (LMA) has been available for a number of years as an alternative to endotracheal intubation in babies, infants, children, and adults. 7 It is mentioned but not recommended for routine use in the new NRP textbook, 1 and a variety of papers discuss its use in various clinical scenarios, including the following:

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In neonatal resuscitation of term and preterm infants (size 1 LMA) (see Fig. 4-9)

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In the difficult airway, such as in the Robin sequence, and other situations when micrognathia is profound

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As an aid to endotracheal intubation

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As an aid in flexible endoscopy

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In surgical cases in place of endotracheal intubation 34–37

The success rate of insertion of the LMA has been reported to be greater than 90% in a number of descriptive studies of small series of infants and children 38 (see Chapter 23 for further discussion of LMA use).

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Resuscitation

M. Gary Karlowicz MD, FAAP , ... Jay P. Goldsmith MD, FAAP , in Assisted Ventilation of the Neonate (Fifth Edition), 2011

Personnel

At least one person skilled in initiating newborn resuscitation should be present at every delivery. This person should be trained in the AHA-AAP NRP or a similar program. Renewal of training is required every 2 years. At least two persons are required for resuscitation of a severely depressed neonate, one to ventilate and intubate, if necessary, and another to monitor heart rate and perform chest compressions, if indicated. When extensive resuscitation (including medication administration) is anticipated, a team of three to five persons with designated roles is recommended, including one person to record events and a designated team leader. With multiple gestation delivery, a separate team should be present for each infant.

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