Effective ventilation: The most critical intervention for successful delivery room resuscitation

doi:10.1016/j.siny.2018.04.001

Seminars in Fetal and Neonatal Medicine

Volume 23, Issue 5, October 2018, Pages 340-346

https://doi.org/10.1016/j.siny.2018.04.001 Get rights and content

Abstract

Lung aeration is the critical first step that triggers the transition from fetal to postnatal cardiopulmonary physiology after birth. When an infant is apneic or does not breathe sufficiently, intervention is needed to support this transition. Effective ventilation is therefore the cornerstone of neonatal resuscitation. In this article, we review the physiology of cardiopulmonary transition at birth, with particular attention to factors the caregiver should consider when providing ventilation. We then summarize the available clinical evidence for strategies to monitor and perform positive pressure ventilation in the delivery room setting.

Introduction

Lung liquid clearance and aeration is the critical first step that initiates a series of cardiopulmonary events needed for successful newborn transition at birth [1]. When an infant is insufficiently breathing or apneic, this transition fails and prompt intervention is needed in order to avoid (further) hypoxia and ischemic insults. Thus, effective ventilation is the cornerstone of resuscitation after birth [2]. Whereas resuscitation is defined as the process of reviving someone from unconsciousness or apparent death, most infants only need to be stabilized with respiratory support to restore breathing. It is rare for newborns to require extensive resuscitation measures after birth, and in most cases this is because effective ventilation has not been established [3].

Although effective ventilation is the most critical step in newborn resuscitation, current recommendations are largely based on historical practice, evidence from animal models, and dogma. Very little clinical evidence exists to support the current approach to ventilation, in terms of inflation time and pressures used to clear lung liquid, aerate the lung, and establish gas exchange. Our understanding of the mechanisms regulating lung aeration and maintaining the functional residual capacity is largely informed by experimental studies of animal models using phase-contrast X-ray imaging [4]. This knowledge provides a physiologic rationale to approach respiratory support in newborn infants after birth.

In the first part of this review, we discuss the physiological mechanisms of cardiopulmonary transition that the caregiver should consider when providing ventilation at birth. We then review the existing clinical evidence for providing positive pressure ventilation (PPV) in the delivery room setting.

Section snippets

The physiology of newborn transition and how this alters during neonatal resuscitation

In the last decade, there has been renewed interest in performing experimental and observational human studies in neonatal transition and resuscitation at birth. Several recent reviews provide a comprehensive summary of the current knowledge [[4], [5], [6]]. For the purpose of this review we describe the most important features that caregivers need to take into account when an infant fails transition and requires intervention.

Clinical evidence for the most effective methods to provide ventilation in the delivery room

Initial recommendations for PPV were grounded in historical practice, not clinical evidence. In recent years, many observational studies and clinical trials have focused on identifying the most effective methods to provide PPV in the delivery room setting. Here we discuss residual questions related to delivery room PPV and review the available clinical evidence for each.

Conclusion

Establishing lung aeration and ventilation is the most critical phase of newborn transition after birth. Respiratory interventions to support this transition should be individualized based on several factors, such as the infant's underlying physiology, the phase of lung aeration, and the infant's response to resuscitation. As there are limited data to identify one best method of providing PPV, providers should be aware of the strengths and limitations of the available techniques, monitoring,

Conflicts of interest

The authors are both investigators on the ongoing SAIL trial (Sustained Aeration of Infant Lungs), Clinicaltrials.gov Identifier NCT02139800 and MONITOR trial (Monitoring Neonatal Resuscitation) trial, Clinicaltrials.gov Identifier NCT NCT03256578.

Funding sources

Dr Foglia is supported by an NICHD Career Development Award (K23HD084727). Dr te Pas is recipient of an NWO innovational research incentives scheme (VIDI 91716428).

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Introducing a novel respiratory function monitor for neonatal resuscitation training
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A respiratory function monitor (RFM) gives immediate feedback, allowing clinicians to adjust face mask ventilation to correct leak or inappropriate tidal volumes. We audited the satisfaction of clinicians with a neonatal resuscitation training package, incorporating a novel RFM.
This was a mixed-methods study conducted at The Royal Women’s Hospital, Melbourne, Australia. Clinicians were approached to complete a neonatal resuscitation training session. Participants watched a training video, then provided ventilation to term and preterm manikins first without, and then with, the RFM. Clinicians completed a survey after the session and undertook a follow-up session three months later. The primary outcome was participant satisfaction with the RFM. Secondary outcomes included participants’ self-assessment of face mask leak and tidal volumes when using the RFM.
Fifty clinicians completed both the initial and follow-up session. Participants reported high levels of satisfaction with the RFM for both term and preterm manikins: on a scale from 0, meaning “not at all”, and 100, meaning “yes, for all resuscitations”, the median response (interquartile range, IQR) was 82 (74–94) vs 81.5 (69–94.5). Levels of satisfaction were similar for less experienced and more experienced clinicians: median (IQR) 83 (77–93) vs 81 (71.5–95) respectively. When using the monitor, clinicians accurately self-assessed that they achieved leak below 30% and tidal volumes within the target range at least 80% of the time.
Clinicians of all experience levels had a high level of satisfaction with a training package including a novel RFM.
Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors
2024, Resuscitation Plus
Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth.
A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression.
Between 11/7/22–12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.
The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns.
Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.
Carbon dioxide monitoring during neonatal stabilisation at delivery (COSTA-Neo)-multi centre observational study
2023, Resuscitation
The data is evolving on exhaled carbon dioxide (ECO₂) levels for preterm infants requiring stabilisation.
To establish the trends of ECO₂ levels during the first 10 minutes of stabilisation in preterm infants at birth.
We conducted a multi-centre, prospective observational study. We included all preterm infants ≤ 32 weeks needing stabilisation. We recorded blinded ECO₂ using Masimo Rad-97^TM Pulse oximeter with Capnography. We used the first 10 minutes of ECO₂, pulse rate (PR) and oxygen saturation (SpO₂) data from pulse oximeter for our analysis. We collected stabilisation and clinical details. Ethics approval and informed consent was obtained.
We recruited 150 preterm infants, with data of 131 babies available for analysis. Median (and interquartile range) birth gestational age and birth weight were 28 (26.5–30) weeks and 1110 (800–1422.5) grams. All infants received positive end expiratory pressure (PEEP). In addition, 91 (69%) received positive pressure inflations, 34 (26%) received only PEEP and 34 (26%) were intubated within the first 10 minutes of life. Using bootstrapping, the 50% confidence interval for ECO₂ at 5 minutes was estimated to range from 3.042 kPa^† to 3.328 kPa and has minimal change after 5 minutes. ECO₂ appeared earlier than any valid PR and SpO₂ data with median time difference of 16 (2–22) s) and 14 (0–20) s respectively.
We have provided trends of ECO₂ in preterm infants needing stabilisation during the first 10 minutes of life. ECO₂ appeared at least as early as any valid PR and earlier than SpO₂.
Use of laryngeal mask for neonatal resuscitation in Brazil: A national survey
2023, Resuscitation Plus
Citation Excerpt :
These results were expected because specific training for the use of LMA as an option for PPV was introduced by the BNRP only in August 2022. Training healthcare workers how to insert the LMA is much faster and easier than training them how to use tracheal intubation.29,30 In addition, studies show that brief training results in high rates of success on the first attempt of use of LMA because of ease of insertion and effectiveness of ventilation.31–33
The International Liaison Committee on Resuscitation suggests using the laryngeal mask airway (LMA) as an alternative to the face mask for performing positive pressure ventilation (PPV) in the delivery room in newborns ≥34 weeks. Because not much is known about the health professionals’ familiarity in using LMA in Brazil, this study aimed to describe the health professionals’ knowledge and practice of using LMA, who provide neonatal care in the country.
An online questionnaire containing 29 questions was sent to multi-healthcare professionals from different regions in the country through email and social media groups (WhatsApp®, Instagram®, Facebook®, ^and LinkedIn®). The participants anonymously answered the questions regarding their knowledge and expertise in using LMA to ventilate newborns in the delivery room.
We obtained 749 responses from all the regions in Brazil, with 80% from health professionals working in public hospitals. Most respondents were neonatologists (73%) having > 15 years of clinical practice. Among the respondents, 92% recognized the usefulness of LMA for performing PPV in newborns, 59% did not have specific training in LMA insertion, and only 8% reported that they have already used LMA in the delivery room. In 90% of the hospitals, no written protocol was available to use LMA; and in 68% of the hospitals, LMA was not available for immediate use.
This nationwide survey showed that most professionals recognize the usefulness of LMA. However, the device is scarcely available and underused in the routine of ventilatory assistance for newborns in delivery rooms in Brazil.
Respiratory monitoring during neonatal resuscitation using a supraglottic airway device vs. a face mask
2022, Resuscitation
Citation Excerpt :
Still, it is challenging to perform, and the implementation of neonatal resuscitation educational programs show discordant results.9,10 The major obstacles to effective FM ventilation are mask leakage,11–14 airway obstruction,5 and unnecessary pauses during PPV.15 The current evidence suggests that neonatal laryngeal mask airway and supraglottic airway (SGA) are a safe alternative to face mask ventilation (FMV).16–18
To evaluate the respiratory function of asphyxiated infants resuscitated with i-gel supraglottic airway (SGA) vs. face mask (FM) in a low-resource setting.
In this sub-study from the NeoSupra trial, respiratory function during the first 60 inflations was evaluated in 46 neonates (23 with SGA and 23 with FM) at the Mulago National Referral Hospital, Uganda. The primary outcome was the mask leak (%). The secondary outcomes included inspired (VTi) and expired (VTe) tidal volumes, and heart rate response to ventilation.
Median mask leak was 40% (IQR 22–52) with SGA and 39% (IQR 26–62) with FM (p = 0.38). Median VTe was 7.8 ml/kg (IQR 5.6–10.2) with SGA and 7.3 ml/kg (IQR 4.8–11.9) with FM (p = 0.84), while median VTi was 15.4 ml/kg (IQR 11–4-17.6) with SGA and 15.9 ml/kg (IQR 9.0–22.6) with FM (p = 0.68). A shorter time was needed to achieve heart rate > 100 bpm in SGA (median 13 s IQR 9–15) with respect to FM arm (median 61, IQR 33–140) (p = 0.0002).
Respiratory function was not statistically different between neonates resuscitated with SGA vs. FM. SGA was associated with faster heart rate recovery compared to FM in the subgroup of neonates with bradycardia. Further research is needed to investigate possible advantages of SGA on respiratory function at birth.
Sustained Inflation Versus Intermittent Positive Pressure Ventilation for Preterm Infants at Birth: Respiratory Function and Vital Sign Measurements
2021, Journal of Pediatrics
To characterize respiratory function monitor (RFM) measurements of sustained inflations and intermittent positive pressure ventilation (IPPV) delivered noninvasively to infants in the Sustained Aeration of Infant Lungs (SAIL) trial and to compare vital sign measurements between treatment arms.
We analyzed RFM data from SAIL participants at 5 trial sites. We assessed tidal volumes, rates of airway obstruction, and mask leak among infants allocated to sustained inflations and IPPV, and we compared pulse rate and oxygen saturation measurements between treatment groups.
Among 70 SAIL participants (36 sustained inflations, 34 IPPV) with RFM measurements, 40 (57%) were spontaneously breathing prior to the randomized intervention. The median expiratory tidal volume of sustained inflations administered was 5.3 mL/kg (IQR 1.1-9.2). Significant mask leak occurred in 15% and airway obstruction occurred during 17% of sustained inflations. Among 34 control infants, the median expiratory tidal volume of IPPV inflations was 4.3 mL/kg (IQR 1.3-6.6). Mask leak was present in 3%, and airway obstruction was present in 17% of IPPV inflations. There were no significant differences in pulse rate or oxygen saturation measurements between groups at any point during resuscitation.
Expiratory tidal volumes of sustained inflations and IPPV inflations administered in the SAIL trial were highly variable in both treatment arms. Vital sign values were similar between groups throughout resuscitation. Sustained inflation as operationalized in the SAIL trial was not superior to IPPV to promote lung aeration after birth in this study subgroup.
Clinicaltrials.gov: NCT02139800.

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Effective ventilation: The most critical intervention for successful delivery room resuscitation

Abstract

Introduction

Section snippets

The physiology of newborn transition and how this alters during neonatal resuscitation

Clinical evidence for the most effective methods to provide ventilation in the delivery room

Conclusion

Conflicts of interest

Funding sources

Semin Fetal Neonatal Med

Respir Physiol

J Pediatr

Resuscitation

J Pediatr

Clin Perinatol

Resuscitation

J Pediatr

Resuscitation

Early Hum Dev

Resuscitation

Resuscitation

Resuscitation

Resuscitation

neonatology

Resuscitation

Increase in pulmonary blood flow at birth; role of oxygen and lung aeration

J Physiol (London)

Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

Circulation

Cardiopulmonary resuscitation in the delivery room. Associated clinical events

Arch Pediatr Adolesc Med

Respiratory transition in the newborn: a three-phase process

Arch Dis Child Fetal Neonatal Ed

Cardiovascular transition at birth: a physiological sequence

Pediatr Res

Inspiration regulates the rate and temporal pattern of lung liquid clearance and lung aeration at birth

J Appl Physiol

Clearance of liquid from lungs of newborn rabbits

J Appl Physiol

Elevated airway liquid volumes at birth: a potential cause of transient tachypnea of the newborn

J Appl Physiol

Vagal denervation inhibits the increase in pulmonary blood flow during partial lung aeration at birth

J Physiol (London)

The role of lung inflation and sodium transport in airway liquid clearance during lung aeration in newborn rabbits

Pediatr Res

Mechanism of stimulation of type J pulmonary receptors

J Physiol (London)

The effect of oxygen content during an initial sustained inflation on heart rate in asphyxiated near-term lambs

Arch Dis Child Fetal Neonatal Ed

The timing of umbilical cord clamping at birth: physiological considerations

Matern Health Neonatol Perinatol

Fetal lung liquid: a major determinant of the growth and functional development of the fetal lung

Clin Exp Pharmacol Physiol

Influence of upper respiratory tract on liquid flow to and from fetal lungs

J Appl Physiol

Laryngeal closure impedes non-invasive ventilation at birth

Arch Dis Child Fetal Neonatal Ed

Fetal breathing movements

Lesions in the upper lateral pons abolish the hypoxic depression of breathing in unanaesthetized fetal lambs in utero

J Physiol (London)

Hyperoxemia profoundly alters breathing pattern and arouses the fetal sheep

J Dev Physiol

The effect of 10% O2 on the continuous breathing induced by O2 or O2 plus cord occlusion in the fetal sheep

J Dev Physiol

Effect of supplemental oxygen on reinitiation of breathing after neonatal resuscitation in rat pups

Pediatr Res

The effect of 10% O₂ on the continuous breathing induced by O₂ or O₂ plus cord occlusion in the fetal sheep