Reanimación Neonatal: Lección 3 USO DE INSTRUMENTOS DE REANIMACIÓN PARA SUMINISTRAR VENTILACIÓN A PRESIÓN POSITIVA
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Curso de Reanimación neonatal, lección 3 de 9. Lección 3: USO DE INSTRUMENTOS DE REANIMACIÓN PARA SUMINISTRAR VENTILACIÓN A PRESIÓN POSITIVA American Heart Association. American Academy of Pediatrics.
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Reanimación Neonatal: Lección 3 USO DE INSTRUMENTOS DE REANIMACIÓN PARA SUMINISTRAR VENTILACIÓN A PRESIÓN POSITIVA
- 1. Lección 3: USO DE INSTRUMENTOS DE REANIMACIÓN PARA SUMINISTRAR VENTILACIÓN A PRESIÓN POSITIVA
- 2. Uso De Instrumentos De Reanimación Para Suministrar Ventilación A Presión Positiva Contenido • Cuando ventilar • Tipos de instrumentos de reanimación • Operación de cada instrumento • Colocación de la máscara sobre la cara • Problemas de los dispositivos de reanimación • Evaluación de la ventilación 3-2
- 3. Indicaciones Para Ventilación Con Presión Positiva • Apnea/boqueos • Frecuencia cardíaca menor de 100 latidos por minuto aún si hay respiración • Cianosis persistente a pesar de suministrar oxígeno a flujo libre al 100% La ventilación de los pulmones es el paso más importante y mas efectivo en la reanimación cardiopulmonar de un neonato comprometido 3-3
- 4. Tipos De Instrumentos De Presión Positiva: • • • Bolsa autoinflable Bolsa inflada por flujo Reanimador con pieza en T 3-4
- 5. Bolsa Auto-Inflable Ventajas: • Siempre se expande después de ser apretada • Siempre está inflada • La válvula de liberación de presión hace que sea menos probable el baro y volutrauma 3-5
- 6. Bolsa Autoinflable Desventajas: • La bolsa funciona aún sin una fuente de gas; debe asegurarse que esté conectada al O2 • Requiere que haya una colocación hermética de la máscara sobre la cara del paciente • Necesita de un reservorio de oxígeno para proveer altas concentraciones • No puede ser usada para proporcionar oxígeno a flujo libre de manera confiable • No puede ser usada para proporcionar CPAP. No PEEP sin una válvula especial 3-6
- 7. Bolsa Inflada Por Flujo Ventajas: • Suministra entre 21% y 100% de oxígeno, dependiendo de la fuente • Es fácil determinar si está colocada herméticamente sobre la cara del paciente • Se puede utilizar para dar oxígeno a flujo libre de 21% a 100% 3-7
- 8. Bolsa Inflada Por Flujo Desventajas : Requiere de un cierre hermético Requiere de un cierre hermético entre la máscara y el paciente para permanecer inflada Requiere de una fuente de gas para inflarse Generalmente no tiene una válvula de seguridad • Usa una válvula de control de flujo para regular la presión/inflado 3-8
- 9. Reanimador con Pieza en “T” Ventajas: • • Suministro consistente de presión Control confiable de presión inspiratoria pico y presión positiva al final de la espiración. • Entrega confiable del 100% de oxígeno • El operador no se fatiga por el trabajo con la bolsa 3-9
- 10. Reanimador con Pieza en T Desventajas: • Requiere una fuente de gas comprimido • Requiere que haya una colocación hermética de la máscara sobre la cara del paciente • No se puede “sentir” la distensibilidad del pulmón • Requiere de presión antes de ser usada • Cambiar las presiones durante su uso es mas difícil 3-10
- 11. Respaldo De Urgencia: Bolsa Auto-inflable Considere tener siempre una bolsa autoinflable como respaldo en cualquier momento que se requiera llevar a cabo una reanimación, ya que puede fallar la fuente de gas comprimido o tener un mal funcionamiento el reanimador con pieza en T. 3-11
- 12. Características Generales De Los Instrumentos De Reanimación • Máscara de tamaño apropiado (acojinada, preferentemente de forma anatómica) • Capacidad variable de entrega de oxígeno hasta 90% a 100% • Control de la presión inspiratoria pico y del tiempo inspiratorio • Tamaño de la bolsa (200-750 mL) • Debe de tener por lo menos una medida de seguridad para prevenir presión excesiva 3-12
- 13. Instrumentos de Reanimación : Dispositivos de Seguridad Cada instrumento de reanimación debe tener: • Un manómetro de presión y una válvula de control de flujo y/o • Una válvula de liberación de presión (pop-off) 3-13
- 14. Dispositivos de Seguridad: Bolsa Autoinflable con Válvula de Liberación de Presión Click on the image to play video 3-14
- 15. Dispositivos de Seguridad: Bolsa Autoinflable Click on the image to play video 3-15
- 16. Dispositivos de Seguridad: Reanimador con Pieza en T Click on the image to play video 3-16
- 17. Concentración De Oxígeno Durante La Ventilación Con Presión Positiva • El Programa de Reanimación Neonatal (NRP) recomienda el uso de oxígeno al 100% cuando la ventilación con presión positiva es utilizada en la reanimación neonatal. Sin embargo, investigaciones sugieren que la reanimación con algo menos de 100% puede ser igualmente exitosa. • Si la reanimación es iniciada con menos de 100% de oxígeno y no hay mejoría evidente, debe suministrarse oxígeno al 100% dentro de los 90 segundos posteriores al nacimiento. • Si no hay oxígeno disponible, utilice ventilación con presión positiva con aire ambiente. 3-17
- 18. Instrumentos de Reanimación: Oxígeno a Flujo Libre: • No puede ser dado de manera confiable con máscara con una bolsa autoinflable • Puede ser dado de manera segura con máscara mediante el uso de bolsa inflada por flujo o reanimador con pieza en T 3-18
- 19. Bolsa y Máscara: Equipamiento Máscaras • Borde – Acojinado – No Acojinado • Forma – Redonda – Forma Anatómica • Tamaño – Pequeña – Grande 3-19
- 20. Bolsa y Máscara: Equipamiento La Máscara debe cubrir • Mentón • Boca • Nariz 3-20
- 21. Preparación Del Equipo De Reanimación • Ensamble el equipo • Pruebe el equipo 3-21
- 22. Lista de Comprobación Antes de empezar la ventilación con Presión Positiva: • Seleccione el tamaño adecuado de la máscara • Asegúrese que están despejadas las vías aéreas • Posicione la cabeza del bebé • Colóquese usted a un lado o a la cabeza del bebé 3-22
- 23. Colocando la Máscara en la Cara • No presione demasiado la máscara sobre la cara • No apoye los dedos o manos sobre los ojos del bebé • No presione la garganta (tráquea) Para mejorar el sellado de la máscara en la cara, • Use una ligera presión descendente • Presione cuidadosamente la mandíbula con la máscara 3-23
- 24. Sellado Máscara-Cara Un buen sellado es esencial para lograr una adecuada presión positiva • Es necesario un sellado hermético para que la bolsa inflada por flujo se infle • Un buen sellado es necesario para insuflar los pulmones cuando se comprima la bolsa autoinflable • Un reanimador con pieza en T no podrá insuflar los pulmones a menos que exista un sellado hermético 3-24
- 25. Signos de Ventilación Efectiva Signos de Ventilación adecuada: • Mejoría de la frecuencia cardíaca, coloración y tono muscular Signos de mejoría del recién nacido: • Mejor frecuencia cardíaca, coloración, respiración, tono, y saturación 3-25
- 26. Sobreinflado pulmonar Si el recién nacido parece tener una respiración muy profunda, • Se está usando demasiada presión • Existe riesgo de provocar neumotórax 3-26
- 27. Frecuencia de Ventilación: 40 a 60 respiraciones por minuto Click on the image to play video 3-27
- 28. El Neonato No Mejora Y No Se Observa Una Adecuada Expansión Del Tórax Causas probables • Sellado inadecuado • Obstrucción de vías aéreas • Presión insuficiente Click on the image to play video 3-28
- 29. Causas Y Soluciones Para Una Inadecuada Expansión Del Tórax Condición Acciones 1. Sellado inadecuado Recolocar la máscara en la cara. 2. Obstrucción de la vía aérea Reposicionar cabeza. Verificar secreciones; aspirar si tiene. Ventilar con la boca ligeramente abierta. 3. Presión insuficiente Incrementar presión hasta que haya una adecuada elevación y descenso del tórax. Considerar intubación endotraqueal. 4. Equipo no funcional Verificar o remplazar la bolsa. 3-29
- 30. Ventilación Con Presión Positiva Contínua Debe introducirse una sonda orogástrica para reducir la distensión gástrica La distensión gástrica puede: • Elevar el diafragma, evitando una expansión pulmonar completa • Provocar regurgitación y broncoaspiración 3-30
- 31. Instalación De La Sonda Orogástrica Equipo • Sonda de alimentación 8F • Jeringa de 20 mL 3-31
- 32. Instalación de Sonda Orogástrica Medición de la distancia correcta 3-32
- 33. Instalación De La Sonda Orogástrica: Técnica • Inserte la sonda a través de la boca y no por la nariz (reinicie la ventilación) • Coloque una jeringa de 20 mL y aspire delicadamente • Retire la jeringa y deje la sonda abierta para permitir la salida de aire • Fije la sonda con cinta adhesiva en la mejilla del recién nacido 3-33
- 34. El Recién Nacido No Mejora • Compruebe el oxígeno, bolsa, sellado y presión • ¿El movimiento del tórax es adecuado? • ¿Está siendo suministrado el oxígeno adecuadamente? • Entonces, – Considere intubación endotraqueal – Compruebe sonidos respiratorios; posible neumotórax 3-34
- 35. El Recién Nacido No Mejora La frecuencia cardíaca es menor de 60 a pesar de suministrar ventilación con presión positiva por 30 segundos 3-35
- 36. Apéndices: Descripción de los Instrumentos de Reanimación • • • Bolsas autoinflables Bolsas infladas por flujo Reanimadores con pieza en T Revise el equipo usado en su hospital 3-36
- 37. Apéndice A: Bolsas Autoinflables: Partes Básicas Click on the image to play video 3-37
- 38. Bolsa Autoinflable : Control del Oxígeno Debe instalársele un reservorio para poder suministrar concentraciones elevadas de oxígeno. Sin el reservorio solo se obtienen concentraciones de oxígeno de alrededor del 40%, y puede ser insuficiente para la reanimación neonatal. Click on the image to play video 3-38
- 39. Bolsa Autoinflable : Control del Oxígeno Con reservorio, se suministra al paciente 90% a 100% de oxígeno Click on the image to play video 3-39
- 40. Bolsa Autoinflable : Tipos de Reservorios de Oxígeno Extremo abierto Extremo cerrado con válvula 3-40
- 41. Bolsa Autoinflable Comprobación antes de usarlo Click on the image to play video 3-41
- 42. Bolsa Autoinflable : Presión La cantidad de presión suministrada, depende de cualquiera de los siguientes 3 factores: • Que tan fuerte se comprime la bolsa • Cualquier fuga entre la máscara y la cara del recién nacido • Punto de ajuste de la válvula de liberación de presión 3-42
- 43. Apéndice B: Bolsas Infladas por Flujo Click on the image to play video 3-43
- 44. Bolsa Inflada por Flujo : Problemas Potenciales La Bolsa no se inflará si • La máscara no se encuentra sellada apropiadamente en la boca y nariz del recién nacido • Existe un agujero en la bolsa • La válvula de control de flujo está muy abierta • El manómetro de presión no esta colocado o el puerto de salida no se ha bloqueado 3-44
- 45. Bolsa Inflada por Flujo : Ajuste del Flujo y la Presión de Oxígeno Click on the image to play video 3-45
- 46. Apéndice C: Reanimador con Pieza en T Click on the image to play video 3-46
- 47. Preparando El Reanimador Con Pieza En T Para Su Uso Click on the image to play video 3-47
- 48. Reanimador Con Pieza En T : Ajustando Los Parámetros De Presión Click on the image to play video 3-48
- 49. Reanimador con Pieza en T : Problemas Click on the image to play video 3-49
- 50. Fin de la Lección 3 3-50
- 52. Bolsa Inflada Por Flujo 3-4B
- 53. Reanimador Con Pieza En T Click on the image to play video 3-4C
- 54. Colocación De La Máscara 3-23A
- 55. Mejorando El Sellado CaraMáscara 3-23B
Editor's Notes
- In Lesson 3 you will learn When to give positive-pressure ventilation The similarities and differences among flow-inflating bags, self-inflating bags, and T-piece resuscitators The operation of each device to provide positive-pressure ventilation The correct placement of the masks on the newborn’s face How to test and troubleshoot devices used to provide positive-pressure ventilation How to evaluate the success of positive-pressure ventilation
- If, after the initial steps, the baby is not breathing or is gasping, the heart rate is less than 100 bpm, or the color remains cyanotic despite 100% free-flow oxygen, the next step is to provide positive-pressure ventilation. This is a critically important skill and the single most important step in the resuscitation of the compromised newborn. The success of resuscitation may be dependent on the effectiveness of this procedure.
- There are 3 types of devices to give positive-pressure ventilation to newborns. The self-inflating bag inflates without a compressed gas source after it is squeezed. It remains inflated at all times. The flow-inflating bag is collapsed when not in use, and it looks like a deflated balloon. It inflates only when gas flows into the bag and the opening is sealed, as when the mask is placed tightly on a newborn’s face. The T-piece resuscitator works only when gas flows into it. The gas is directed to the environment or to the baby by occluding or releasing the opening on a T-shaped tube with your finger or thumb.
- The self-inflating bag, as its name implies, inflates automatically without a compressed gas source. It remains inflated at all times unless being squeezed. Peak inspiratory pressure (or peak inflation pressure) is controlled by how hard the bag is squeezed. The self-inflating bag has a pressure-release (pop-off) valve that opens if peak inspiratory pressures greater than 30 to 40 cm H2O are generated. This is a safety feature that makes over-inflation less likely.
- The self-inflating bag will work even if it is without a gas source, so make sure the bag is connected to an oxygen source. Positive end-expiratory pressure (PEEP) can be administered only if an additional valve is attached to the self-inflating bag. Continuous positive airway pressure (CPAP) while a patient is breathing spontaneously cannot be delivered reliably with a self-inflating bag. To achieve 90% to 100% oxygen administration when the bag is squeezed, a reservoir attachment is required. You cannot give free-flow oxygen through the mask of this bag.
- Flow-inflating bags deliver 100% oxygen directly to the patient and can be used to deliver free-flow oxygen through the mask. The bag will not inflate unless there is a tight seal against the baby’s face, making it easy to assess the quality of the seal.
- The flow-inflating bag is collapsed like a deflated balloon when not in use. It inflates only when a gas source is forced into the bag and the opening of the bag is sealed, as when a mask is placed tightly on a baby’s face. Peak inspiratory pressure is controlled by the flow rate of incoming gas, adjustment of the flow control valve, and how hard the bag is squeezed. Positive end-expiratory pressure (PEEP) or CPAP is controlled by an adjustable flow-control valve. A pressure manometer should be used to avoid excessive inflation pressure.
- The T-piece resuscitator is an old device that has been recently reintroduced into the delivery room. The T-piece resuscitator provides flow-controlled and pressure-limited ventilation or CPAP. Think of this device as a manually cycled mechanical ventilator. Peak inspiratory pressure and positive end-expiratory pressure (PEEP), or CPAP if desired, are manually set with adjustable controls. Intermittent inflating pressure is delivered when the operator alternately occludes and releases the opening on the device. This device can reliably deliver varying concentrations of oxygen up to 100% free-flow oxygen.
- The T-piece resuscitator will not work unless connected to a compressed gas source. This device requires a tight face-mask seal to deliver a breath. The device also requires some preparation time to assemble, turn on gas flow, and adjust the pressure limits appropriately. Because the pressures are set manually by the operator, changing inflation pressure during resuscitation is more difficult than with the other devices.
- The self-inflating bag can be used in any setting and without a gas source, making it immediately available for initiating neonatal resuscitation, even outside the obstetric/neonatal patient care area. Consider stocking a self-inflating bag and different size masks in your portable emergency resuscitation supplies to ensure that a neonatal positive-pressure device is available no matter where in the hospital you may be called upon to initiate newborn resuscitation.
- A variety of mask sizes, appropriate for newborns of different weights, should be available at every delivery. Cushioned, anatomically shaped masks are preferred. Term newborns who require positive-pressure ventilation at birth should be initially ventilated with a high concentration of oxygen (90%-100%). Bags used for newborns should have a volume of 200 to 750 mL. Term newborns require only 15 to 25 mL with each ventilation (5-8 mL/kg). To minimize complications resulting from high ventilation pressures, resuscitation devices should have certain safety features to prevent unwanted high pressures.
- Ventilation of a newborn with excessive pressure (and/or volume) could overinflate the lungs, thus causing rupture of the alveoli and a resulting air leak or pneumothorax. Any resuscitation device, whether flow-inflating, self-inflating, or T-piece resuscitator, should be equipped with one or both of the safety features to prevent the development of excessive pressure.
- Self-inflating bags should have a pressure-release (pop-off) valve, which is generally set to 30 to 40 cm H2O. If pressures greater than 30 to 40 cm H2O are generated, the valve opens, limiting the pressure being transmitted to the baby. In some self-inflating bags, the pressure-release valve can be temporarily occluded or bypassed to allow high pressure to be administered. This is usually not necessary, but can be done to ventilate a newborn’s non-aerated lungs when the usual pressures are not effective, especially with the first few breaths. Many self-inflating bags also are equipped with a port to attach to a pressure gauge.
- Flow-inflating bags have a flow-control valve that can be adjusted to deliver the desired peak pressure and positive end-expiratory pressure (PEEP). A pressure manometer attached to the bag will allow proper adjustment of the valve.
- The T-piece resuscitator has 2 controls to adjust the inspiratory pressure. The inspiratory pressure control sets the amount of pressure desired during a normal assisted breath. The maximum pressure relief control is a safety feature that prevents the pressure from exceeding a preset value (usually 40 cm H2O, but adjustable). Excessive pressure can also be avoided by watching the circuit pressure gauge.
- One hundred percent oxygen should be used when positive-pressure ventilation is required during resuscitation of term babies. Some studies suggest that resuscitation with 21% oxygen (air) is just as successful as resuscitation with 100% oxygen. Prolonged exposure to 100% oxygen following perinatal asphyxia may have deleterious effects. However, supplemental oxygen during resuscitation may result in more rapid restoration of tissue oxygen and perhaps less permanent tissue damage. Some clinicians will elect to start resuscitation using less than 100% oxygen. If one chooses to start resuscitation with room air, it is recommended that oxygen be used if there is no improvement within 90 seconds following birth.
- Free-flow oxygen cannot be given reliably with a self-inflating bag-and-mask device. The oxygen flow entering a self-inflating bag will normally be diverted to the air inlet, through its attached oxygen reservoir, and then evacuated out the end of the oxygen reservoir or out a valve that is attached to the reservoir. A flow-inflating bag and mask or T-piece resuscitator can be used to deliver free-flow oxygen. The mask should be loosely placed on the face, allowing some gas to escape around the edges. When using a flow-inflating bag, it should not inflate when used for this purpose.
- Resuscitation masks have rims that are either cushioned or non-cushioned. Advantages of a cushioned-rim mask are Conforms more easily to the shape of the newborn’s face making it easier to form a seal Requires less pressure to obtain a seal Less chance of damaging a newborn’s eyes if the mask is incorrectly positioned A non-cushioned rim can cause several problems. More difficult to obtain a seal because it does not easily conform to the shape of the newborn’s face It can damage the eyes if the mask is improperly positioned It can bruise the baby’s face if the mask is applied too firmly Masks also come in 2 shapes: round and anatomically shaped. Anatomically shaped masks fit the contours of the face when placed on the face with the most pointed part fitting over the nose.
- For the mask to be the correct size, as pictured in this slide, the rim will cover the tip of the chin, the mouth, and the nose, but not the eyes. If the mask is too large, it may cause eye damage. If the mask is too small, it will not cover the mouth and nose and may occlude the nose.
- The bag or resuscitation device should be assembled and connected to oxygen so that it will provide the necessary 90% to 100% concentration, if needed. If a self-inflating bag is used, be sure the oxygen reservoir is attached. If a T-piece resuscitator is used, set the pressure settings according to the recommendations in the appendices of this lesson. Once the equipment has been selected and assembled, check to make sure the resuscitation device is functioning properly. Bags that have cracks or tears, valves that stick or leak, or masks that are cracked or deflated must not be used.
- Before beginning positive-pressure ventilation, check the following: The mask should cover the mouth, nose, and the tip of the chin, but not the eyes. Suction the mouth and nose to be certain there is no obstruction. The newborn’s neck should be extended slightly to maintain an open airway. One way to accomplish this is to place a small roll under the shoulders. Position yourself at the side or head of the newborn to use the resuscitation device effectively. This position allows you to hold the mask on the newborn’s face comfortably. The mask may be swiveled on the bag or T-piece resuscitator for optimal fit to the face and to your position. If using a bag, it must be positioned so that it does not block your view of the newborn’s chest since you need to be able to observe movement of the newborn’s chest during ventilation.
- Care should be taken in holding the mask on the newborn’s face. Observe the following precautions.
- An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs. Also, a flow-inflating bag will not stay inflated without a good face-mask seal, and, therefore, you will not be able to squeeze the bag to create the desired pressure. With a self-inflating bag or a T-piece resuscitator, you will not be able to deliver positive pressure unless there is a good face-mask seal. This can be determined by watching for chest movement with each inspiration.
- The best indications that the mask is sealed and the lungs are being adequately inflated are improvements in heart rate, color, and muscle tone. If these signs are not improving, you should look for the presence of chest movement with each positive-pressure breath and have an assistant listen to both sides of the lateral areas of the chest with a stethoscope to assess breath sounds. Abdominal movement due to air entering the stomach may be mistaken for effective ventilation. The lungs of a fetus are filled with fluid, while the lungs of a newborn must be filled with air. To establish a gaseous volume (functional residual capacity) in a newly born baby, the first breaths often require higher pressures and longer inflation times than with subsequent breaths. It is helpful to monitor pressure with a pressure gauge to avoid high lung volumes and airway pressures. You should ventilate the lungs with the lowest pressure required to improve heart rate, color, and muscle tone.
- If the baby appears to be receiving very deep breaths from positive-pressure ventilation, the lungs are being overinflated. Too much pressure is being used and there is danger of producing a pneumothorax. Remember that the volume of a newborn breath is much smaller than the amount of gas in the resuscitation bag. One tenth of a 240-mL self-inflating bag One thirtieth of a 750-mL flow-inflating bag Abdominal movement may be due to air entering the stomach and should not be mistaken for effective ventilation.
- During the initial stages of resuscitation, breaths should be delivered at a rate of 40 to 60 breaths per minute or slightly less than once a second. If you squeeze the bag or occlude the PEEP cap of the T-piece resuscitator on “Breathe” and release while you say “Two, Three,” you probably are ventilating at a proper rate. Check the 4 signs for improvement (rising heart rate, improving color, spontaneous breathing, and improving tone) after 30 seconds of administering positive-pressure ventilation. As the heart rate increases toward normal, ventilation should be continued at a rate of between 40 and 60 breaths per minute. With improvement, the newborn should become pink and muscle tone should improve. When the heart rate stabilizes above 100 bpm, reduce the rate and pressure of assisted ventilation until you see effective spontaneous respiration. When color improves, supplemental oxygen can also be weaned as tolerated. If the heart rate remains below 60 bpm, you need to proceed to the next step of chest compressions, as described in the next lesson.
- If the heart rate, muscle tone, and color do not improve, check to see if the chest is moving with each positive-pressure breath. If the chest is not expanding adequately and there are poor breath sounds, it may be due to one of the following reasons: Seal is inadequate. You may hear or feel air escaping from around the mask. Reapply the mask to the face and try to form a better seal while using a little more pressure on the rim of the mask. Airway is blocked. Check the newborn’s position and extend the neck a bit farther. Check the mouth or oropharynx and nose for secretions and suction if necessary. Try ventilating with the newborn’s mouth slightly open. Not enough pressure given. If you are not providing enough pressure to move the lungs, increase the pressure. If using a resuscitation device with a pressure gauge, the pressure limit may have to be increased. If using a bag with a pressure-release valve, increase the pressure until the valve actuates. Malfunctioning equipment, including a torn bag, a faulty flow-control valve, or an improper connection, also may be the cause of inadequate chest expansion.
- This chart is a summary of steps to follow if the baby does not improve and adequate chest expansion is not observed. Also make sure the equipment is functioning correctly. Replace the resuscitation bag, if necessary. If you still are unable to obtain physiologic improvement and adequate chest movement after going through this sequence, endotracheal intubation and positive-pressure ventilation through the endotracheal tube are usually required.
- Newborns requiring positive-pressure ventilation with a mask for longer than several minutes should have an orogastric tube inserted and left in place. During positive-pressure ventilation, gas is forced into the oropharynx, where it is free to enter the trachea and the esophagus. Some gas will be forced into the stomach. Gas forced into the stomach will interfere with ventilation by preventing full expansion of the lungs and may cause regurgitation and aspiration of contents. This problem may be relieved by the insertion of an orogastric tube.
- The equipment you will need to place an orogastric tube during ventilation includes an 8F feeding tube and a 20-mL syringe.
- Always measure the length of the tube needed for insertion. The length of the inserted tube should be equal to the distance from the bridge of the nose to the earlobe, and earlobe to a point halfway between the xyphoid process (the lower tip of the sternum) and the umbilicus. Note the centimeter mark at this place on the tube.
- The tube will not interfere with the face-mask seal if an 8F feeding tube is used and the tube exits from the side of the mask over the soft area of the newborn’s cheek. A larger tube may make it difficult to obtain a seal, particularly in premature infants. A smaller tube can easily be occluded by secretions. Ventilation can be continued once the tube is inserted and before aspiration with the syringe.
- Check for adequacy of chest expansion, and use a stethoscope to listen for bilateral breath sounds. Is the face-mask seal tight? Is the airway blocked? Is the resuscitation equipment working properly? Is adequate pressure being used? Is adequate oxygen being administered? Is oxygen tubing attached to the device and to an oxygen source? If using the self-inflating bag, is the oxygen reservoir attached? If using a tank (rather than wall oxygen), is there oxygen in the tank? Is gas flowing through the flowmeter?
- Positive-pressure ventilation with a mask generally is not as effective as positive-pressure ventilation through an endotracheal tube. A mask does not seal on the face as tightly as an endotracheal tube seals in the larynx. If you have checked all of the factors listed on the preceding slide and chest movement is still unsatisfactory, or if you don’t hear good breath sounds bilaterally, usually it will be necessary to insert an endotracheal tube. Also, additional complications, such as pneumothorax, may have occurred. If the newborn’s condition continues to deteriorate or fails to improve, and the heart rate is less than 60 beats per minute despite 30 seconds of adequate positive-pressure ventilation, the next step is to begin chest compressions.
- This next section reviews the device(s) used for the administration of positive-pressure ventilation to newborns. You will be responsible to know how to operate, test, and troubleshoot devices used for resuscitation of newborns in your hospital.
- The self-inflating bag has 7 basic parts. Oxygen inlet: a small nipple to which oxygen tubing is attached. In the self-inflating bag, the oxygen tube does not need to be attached for the bag to function. Oxygen reservoir: appliance that can be placed over the bag’s air inlet to allow 100% oxygen to collect, thus preventing the oxygen from being diluted with room air. Air inlet: a 1-way valve that may be located at either end of the bag through which gas inflows after compression. Pressure gauge or pressure gauge attachment site (optional): a small hole or projection near the patient outlet to measure pressure given to the patient. The hole must be plugged or a manometer attached, or gas will leak through the opening, preventing adequate pressure from being generated. Pressure release (pop-off) valve: prevents excessive pressure buildup in the bag. Valve assembly: positioned between the bag and the patient outlet. When the bag is squeezed during ventilation, the valve opens, releasing oxygen and air to the patient. When the bag reinflates, the valve is closed. This prevents the patient’s exhaled air from entering the bag and being re-breathed. Patient outlet: place where gas exits from the bag to the baby and where the mask or endotracheal tube attaches.
- Newborns who require resuscitation with assisted ventilation at birth may require a high concentration of oxygen (90% to 100%). Air drawn into a self-inflating bag through the air inlet dilutes the concentration of oxygen in the bag. As a result, the concentration of oxygen actually received by the patient is greatly reduced to about 40%.
- High concentrations of oxygen can be achieved with a self-inflating bag by using an oxygen reservoir. The reservoir is an appliance that can be placed over the bag’s air inlet.
- There are several different types of oxygen reservoirs, but they all perform the same function. Some have open ends, and others have a valve that allows some air to enter the reservoir.
- To check the operation of a self-inflating bag, block the mask or patient outlet with the palm of your hand and squeeze the bag. A manometer is not necessary. Do you feel pressure against your hand? Can you force the pressure-release valve open? Does the pressure gauge (if present) register 30 to 40 cm H2O pressure when the pressure-release valve opens? If not, check for a crack or leak in bag. Check to see if the pressure gauge is missing, if the pressure-release valve is missing or stuck closed, and whether the patient outlet is sufficiently blocked.
- The amount of pressure delivered by a self-inflating bag is not dependent on the flow of oxygen entering the bag. When you seal the mask on the newborn’s face (or connect the bag to an endotracheal tube), there will be no change in the inflation of the self-inflating bag.
- The flow-inflating bag has 4 parts. Flow-control valve: provides an adjustable leak that allows pressure to be regulated in the bag. Oxygen inlet: oxygen from a compressed source enters the bag. Pressure manometer attachment site: allows for attachment of manometer to indicate the amount of pressure being used to ventilate the newborn. Patient outlet: oxygen exits from the bag to the patient. The pressure manometer alerts you to the amount of pressure being used to ventilate the newborn. If the flow-inflating bag has a connecting site for a pressure manometer, a manometer must be attached to the site, or the attachment site will be a source of leak and the bag will not inflate properly.
- The inflation of a flow-inflating bag depends on a sealed system. If the bag does not inflate, check for potential problems, such as those mentioned here.
- When using a flow-inflating bag, inflate the bag with compressed gas (oxygen, air, or blended). Once the gas enters the bag, it is not diluted and the concentration of oxygen you put in the bag is the same concentration given to the patient. Once you seal the mask on the newborn’s face, all of the oxygen coming from the wall or tank will be directed to the bag and out the flow-control valve. This will cause the bag to inflate. Pressure in the bag can be adjusted by adjusting the flowmeter to regulate how much gas enters the bag (usually at least 5 L/min) or by adjusting the flow-control valve, regulating how much gas escapes from the bag.
- There are 6 parts to a flow-controlled, pressure-limited T-piece resuscitator. Oxygen (gas) inlet: where gas from a compressed source enters the resuscitator. Patient (gas) outlet: where gas exits the resuscitator to the patient T-piece where the mask or endotracheal tube attaches. Inspiratory pressure control: used to set desired peak inspiratory pressure. Patient T-piece with positive end-expiratory pressure (PEEP) cap: the mask or endotracheal tube attaches to the T-piece and the PEEP cap is used to set the positive end-expiratory pressure, if needed. Circuit pressure gauge: used to set and monitor peak inspiratory pressure, positive end-expiratory pressure, and maximum circuit pressure. Maximum pressure relief control: controls desired maximum pressure by occluding the PEEP cap and turning the maximum pressure relief control to the maximal pressure limit.
- Assemble the parts of the T-piece resuscitator as instructed by the manufacturer. Attach a test lung to the patient outlet (provided by manufacturer). Connect the device to the gas source (this will be tubing either from 100% oxygen source or a blender that permits adjustment of oxygen concentration).
- Adjust the pressure settings as follows: Adjust the flowmeter to regulate how much gas flows into the resuscitator (5-15 L/min recommended). Set the maximum circuit pressure by occluding the PEEP cap with your finger and adjusting the maximum pressure relief dial to a selected value (40 cm H2O recommended). Set the desired peak inspiratory pressure by occluding the PEEP cap with your finger and adjusting the inspiratory pressure control to a selected peak inspiratory pressure. Set the positive end-expiratory pressure by removing your finger from the PEEP cap and adjusting the PEEP cap to the desired setting (0-5 cm H2O is recommended). Remove the test lung and attach a face mask or be prepared to attach to an endotracheal tube. The respiratory rate is controlled by intermittently occluding the PEEP cap.
- If the baby doesn’t improve or the desired peak pressure is not reached, The mask may not be properly sealed on the baby’s face. The gas supply may not be connected or of sufficient flow. The maximum circuit pressure, peak inspiratory pressure, or positive end-expiratory pressure may be incorrectly set. Free-flow oxygen can be given reliably with the T-piece resuscitator if you occlude the PEEP cap and hold the mask loosely over the baby’s face.
- The inflation of a flow-inflating bag depends on a sealed system. If the bag does not inflate, check for potential problems, such as those mentioned here.