Cara Gugurkan Kandungan Awal Kehamilan 1 bulan (087776558899)
Ldsc3
1. Lesson 3: USE OFLesson 3: USE OF
RESUSCITATIONRESUSCITATION
DEVICES FORDEVICES FOR
POSITIVE-POSITIVE-
PRESSUREPRESSURE
VENTILATIONVENTILATION
Neonatal Resuscitation Program Slide Presentation Kit
The American Academy of Pediatrics is not responsible for any changes or modifications to this program
made by the Neonatal Resuscitation Training Team of Latter-day Saint Charities.
This program, as modified, may not be distributed in the United States.
2. 3-2
Use of Resuscitation Devices forUse of Resuscitation Devices for
Positive-Pressure VentilationPositive-Pressure Ventilation
Lesson ContentLesson Content
• When to ventilateWhen to ventilate
• Types of resuscitation devicesTypes of resuscitation devices
• Operation of each deviceOperation of each device
• Face mask placementFace mask placement
• Troubleshooting resuscitation devicesTroubleshooting resuscitation devices
• Evaluating ventilationEvaluating ventilation
p. 3-1
3. 3-3
Indications for Positive-Indications for Positive-
Pressure VentilationPressure Ventilation
• Apnea/gaspingApnea/gasping
• Heart rate less than 100 beats per minuteHeart rate less than 100 beats per minute
(bpm) even if breathing(bpm) even if breathing
• Persistent cyanosis despite 100% free-flowPersistent cyanosis despite 100% free-flow
oxygenoxygen
Ventilation of the lungs is the single mostVentilation of the lungs is the single most
important and most effective step inimportant and most effective step in
cardiopulmonary resuscitation of thecardiopulmonary resuscitation of the
compromised infantcompromised infant
p. 3-4
4. 3-4
Types of Positive-PressureTypes of Positive-Pressure
DevicesDevices
• Self-inflating bagSelf-inflating bag
• Flow-inflating bagFlow-inflating bag
p. 3-5
5. 3-5
General Characteristics ofGeneral Characteristics of
Resuscitation DevicesResuscitation Devices
• Appropriate-sized mask (cushioned,Appropriate-sized mask (cushioned,
anatomically shaped mask preferred)anatomically shaped mask preferred)
• Variable oxygen capability up to 90% to 100%Variable oxygen capability up to 90% to 100%
• Control of peak inspiratory pressure andControl of peak inspiratory pressure and
inspiratory timeinspiratory time
• Size of bag (200-750 mL)Size of bag (200-750 mL)
• Safety features to prevent high pressureSafety features to prevent high pressure
deliverydelivery
p. 3-10, 3-11
6. 3-6
Self-inflating BagSelf-inflating Bag
Advantages:Advantages:
• Always refills after being squeezedAlways refills after being squeezed
• Is always inflatedIs always inflated
• Pressure release (pop-off) valve makes over-Pressure release (pop-off) valve makes over-
inflation less likelyinflation less likely
p. 3-7
7. 3-7
Self-inflating BagSelf-inflating Bag
DisadvantagesDisadvantages::
• Bag will work without a gas source; ensureBag will work without a gas source; ensure
that oxygen is connectedthat oxygen is connected
• Requires tight face-mask seal to inflate theRequires tight face-mask seal to inflate the
lungslungs
• Requires oxygen reservoir to provide highRequires oxygen reservoir to provide high
concentration of oxygenconcentration of oxygen
• Cannot give free-flow oxygen through theCannot give free-flow oxygen through the
maskmask
• Cannot be used for CPAP. No PEEP withoutCannot be used for CPAP. No PEEP without
special valvespecial valve
p. 3-7
8. 3-8
Self-inflating Bag: Control ofSelf-inflating Bag: Control of
OxygenOxygen
An oxygen reservoir must beAn oxygen reservoir must be
attached to deliver highattached to deliver high
concentrations of oxygenconcentrations of oxygen
using a self-inflating bagusing a self-inflating bag
Without reservoir and oxygenWithout reservoir and oxygen
attached, the bag deliversattached, the bag delivers
only about 40% oxygen,only about 40% oxygen,
which may be insufficient forwhich may be insufficient for
neonatal resuscitationneonatal resuscitation
Click on the image to play videoClick on the image to play video
p. 3-45
9. 3-9
Self-inflating Bag: Control ofSelf-inflating Bag: Control of
OxygenOxygen
With reservoir, 90% toWith reservoir, 90% to
100% oxygen delivered100% oxygen delivered
to patientto patient
Click on the image to play videoClick on the image to play video
p. 3-45
11. 3-11
Self-inflating Bag: PressureSelf-inflating Bag: Pressure
• How hard the bag is squeezedHow hard the bag is squeezed
• Any leak between mask and newborn’sAny leak between mask and newborn’s
faceface
• Set point of pressure-release valveSet point of pressure-release valve
Amount of pressure delivered dependsAmount of pressure delivered depends
on the following 3 factors:on the following 3 factors:
p. 3-47
12. 3-12
Safety Features: Self-inflating BagsSafety Features: Self-inflating Bags
With Pressure-Release ValveWith Pressure-Release Valve
Click on the image to play videoClick on the image to play video
p. 3-11
13. 3-13
Oxygen Concentration DuringOxygen Concentration During
Positive-Pressure VentilationPositive-Pressure Ventilation
• The Neonatal Resuscitation Program (NRP)The Neonatal Resuscitation Program (NRP)
recommends use of 100% oxygen when positive-recommends use of 100% oxygen when positive-
pressure ventilation is required during neonatalpressure ventilation is required during neonatal
resuscitation. However, research suggests thatresuscitation. However, research suggests that
resuscitation with something less than 100% may beresuscitation with something less than 100% may be
just as successful.just as successful.
• If resuscitation is started with less than 100% oxygen,If resuscitation is started with less than 100% oxygen,
supplemental oxygen up to 100% should besupplemental oxygen up to 100% should be
administered if there is no appreciable improvementadministered if there is no appreciable improvement
within 90 seconds following birth.within 90 seconds following birth.
• If oxygen is unavailable, use room air to deliverIf oxygen is unavailable, use room air to deliver
positive-pressure ventilation.positive-pressure ventilation.
p. 3-14
14. 3-14
Free-flow OxygenFree-flow Oxygen
• CANNOT be given reliably though aCANNOT be given reliably though a
mask with self-inflating bagmask with self-inflating bag
• Can be given with an oxygen maskCan be given with an oxygen mask
or oxygen tubingor oxygen tubing
p. 3-15
15. 3-15
Bag and Mask: EquipmentBag and Mask: Equipment
Face Mask CharacteristicsFace Mask Characteristics
• RimsRims
– CushionedCushioned
– Non-cushionedNon-cushioned
• ShapeShape
– RoundRound
– Anatomically shapedAnatomically shaped
• SizeSize
– SmallSmall
– LargeLarge
p. 3-16
16. 3-16
Bag and Mask: EquipmentBag and Mask: Equipment
Mask should coverMask should cover
• Tip of ChinTip of Chin
• MouthMouth
• NoseNose
p. 3-16
19. 3-19
Preparation ChecklistPreparation Checklist
• Select appropriate-sized maskSelect appropriate-sized mask
• Be sure airway is clearBe sure airway is clear
• Position baby’s headPosition baby’s head
• Position yourself at baby’s side or headPosition yourself at baby’s side or head
Before beginning positive-pressureBefore beginning positive-pressure
ventilation:ventilation:
p. 3-18, 3-19
20. 3-20
Positioning Mask on FacePositioning Mask on Face
• Do not jam mask down on faceDo not jam mask down on face
• Do not allow fingers or hands to rest on eyesDo not allow fingers or hands to rest on eyes
• Do not put pressure on throat (trachea)Do not put pressure on throat (trachea)
To improve face-mask seal,To improve face-mask seal,
• Use light downward pressureUse light downward pressure
• May gently squeeze mandible up toward maskMay gently squeeze mandible up toward mask
p. 3-20
21. 3-21
Face Mask SealFace Mask Seal
An airtight seal is essential to achieveAn airtight seal is essential to achieve
effective positive pressure andeffective positive pressure and
inflate the lungs when the bag isinflate the lungs when the bag is
squeezedsqueezed
p. 3-21
22. 3-22
• Increasing heart rateIncreasing heart rate
• Improving colorImproving color
• Spontaneous breathingSpontaneous breathing
• Improving muscle toneImproving muscle tone
Signs of Effective VentilationSigns of Effective Ventilation
• Improved heart rate, color, muscle toneImproved heart rate, color, muscle tone
Signs of adequate ventilation:Signs of adequate ventilation:
Signs of improvement in newborn:Signs of improvement in newborn:
p. 3-21, 3-23
23. 3-23
Over-inflation of LungsOver-inflation of Lungs
• Too much pressure is being usedToo much pressure is being used
• Danger of producing a pneumothoraxDanger of producing a pneumothorax
If the baby appears to be receiving veryIf the baby appears to be receiving very
deep breathsdeep breaths
p. 3-22
24. 3-24
Frequency of Ventilation:Frequency of Ventilation:
40 to 60 breaths per minute40 to 60 breaths per minute
Click on the image to play videoClick on the image to play video p. 3-22
25. 3-25
Infant Not Improving and ChestInfant Not Improving and Chest
Not Adequately ExpandingNot Adequately Expanding
Possible causesPossible causes
• Seal inadequateSeal inadequate
• Airway blockedAirway blocked
• Not enough pressureNot enough pressure
Click on the image to play videoClick on the image to play video
p. 3-23
26. 3-26
Causes and Solutions forCauses and Solutions for
Inadequate Chest ExpansionInadequate Chest Expansion
ConditionCondition ActionsActions
Inadequate sealInadequate seal Reapply mask to face and lift jawReapply mask to face and lift jaw
forwardforward
Blocked airwayBlocked airway Reposition the headReposition the head
Check for secretions; suction ifCheck for secretions; suction if
presentpresent
Ventilate with the newborn’s mouthVentilate with the newborn’s mouth
slightly openslightly open
Not enough pressureNot enough pressure Increase pressure until there is aIncrease pressure until there is a
perceptible chest movementperceptible chest movement
Consider endotracheal intubationConsider endotracheal intubation
p. 3-24
27. 3-27
Continued Positive-PressureContinued Positive-Pressure
VentilationVentilation
Gastric distention mayGastric distention may
• Elevate diaphragm, preventing full lungElevate diaphragm, preventing full lung
expansionexpansion
• Cause regurgitation and aspirationCause regurgitation and aspiration
Orogastric tube should be inserted toOrogastric tube should be inserted to
relieve gastric distentionrelieve gastric distention
p. 3-26
28. 3-28
Insertion of Orogastric TubeInsertion of Orogastric Tube
EquipmentEquipment
• 8F feeding tube8F feeding tube
• 20-mL syringe20-mL syringe
p. 3-27
29. 3-29
Insertion of Orogastric TubeInsertion of Orogastric Tube
Measuring correct lengthMeasuring correct length
p. 3-27
30. 3-30
Insertion of Orogastric Tube:Insertion of Orogastric Tube:
TechniqueTechnique
• Insert tube through mouth, rather thanInsert tube through mouth, rather than
nose (resume ventilation)nose (resume ventilation)
• Attach 20-mL syringe and aspirate gentlyAttach 20-mL syringe and aspirate gently
• Remove syringe and leave tube endRemove syringe and leave tube end
open to airopen to air
• Tape tube to newborn’s cheekTape tube to newborn’s cheek
p. 3-28
31. 3-31
Newborn Not ImprovingNewborn Not Improving
• Check oxygen, bag, seal, and pressureCheck oxygen, bag, seal, and pressure
• Is chest movement adequate?Is chest movement adequate?
• Is adequate oxygen being administered?Is adequate oxygen being administered?
• Then,Then,
– Consider endotracheal intubationConsider endotracheal intubation
– Check breath sounds; pneumothorax possibleCheck breath sounds; pneumothorax possible
p. 3-29, 3-30
32. 3-32
Newborn Not ImprovingNewborn Not Improving
Heart rate less than 60 despite 30Heart rate less than 60 despite 30
seconds of positive-pressure ventilationseconds of positive-pressure ventilation
p. 3-30
33. 3-33
NRT Key Point!NRT Key Point!
It is all about ventilation!It is all about ventilation!
• Bag and mask ventilation is the mostBag and mask ventilation is the most
important skill we teachimportant skill we teach
• Proper bag and mask ventilation will saveProper bag and mask ventilation will save
thousands of babies’ livesthousands of babies’ lives
• Practice, practice, practicePractice, practice, practice
• Assess effectivenessAssess effectiveness
39. 3-39
Resuscitation Devices:Resuscitation Devices:
Safety FeaturesSafety Features
Every resuscitation device must have:Every resuscitation device must have:
• A pressure gauge and a flow-controlA pressure gauge and a flow-control
valve and/orvalve and/or
• A pressure-release (pop-off) valveA pressure-release (pop-off) valve
p. 3-11
41. 3-41
Flow-inflating BagFlow-inflating Bag
Disadvantages:Disadvantages:
• Requires a compressed gas sourceRequires a compressed gas source
• Requires a tight face-mask seal to remainRequires a tight face-mask seal to remain
inflatedinflated
• Requires a gas source to inflate. If empty,Requires a gas source to inflate. If empty,
looks like deflated balloonlooks like deflated balloon
• Usually does not have a safety pop-off valveUsually does not have a safety pop-off valve
• Uses a flow-control valve to regulateUses a flow-control valve to regulate
pressure/inflationpressure/inflation
p. 3-8
42. 3-42
Flow-inflating BagFlow-inflating Bag
Advantages:Advantages:
• Delivers 21% to 100% oxygen, depending onDelivers 21% to 100% oxygen, depending on
the sourcethe source
• Easy to assess seal on the baby’s faceEasy to assess seal on the baby’s face
• Can be used to give free-flow oxygen throughCan be used to give free-flow oxygen through
the maskthe mask
p. 1-2
44. 3-44
T-piece ResuscitatorT-piece Resuscitator
Advantages:Advantages:
• Consistent delivery of pressureConsistent delivery of pressure
• Reliable control of peak inspiratory andReliable control of peak inspiratory and
positive end-expiratory pressurepositive end-expiratory pressure
• Reliable delivery of 100% oxygenReliable delivery of 100% oxygen
• No fatigue from baggingNo fatigue from bagging
p. 3-9
45. 3-45
T-piece ResuscitatorT-piece Resuscitator
Disadvantages:Disadvantages:
• Requires compressed gas sourceRequires compressed gas source
• Must have tight face-mask seal to inflateMust have tight face-mask seal to inflate
lungslungs
• Compliance of the lung cannot be “felt”Compliance of the lung cannot be “felt”
• Requires pressure to be set prior to useRequires pressure to be set prior to use
• Changing pressures during use is moreChanging pressures during use is more
difficultdifficult
p. 3-9
46. 3-46
Resuscitation Devices:Resuscitation Devices:
Free-flow OxygenFree-flow Oxygen
Free-flow oxygenFree-flow oxygen
• Cannot be given reliably though a maskCannot be given reliably though a mask
with self-inflating bagwith self-inflating bag
• Can be delivered reliably through theCan be delivered reliably through the
mask with flow-inflating bag or T-piecemask with flow-inflating bag or T-piece
resuscitatorresuscitator
p.3-15
47. 3-47
Consider having a self-inflating bagConsider having a self-inflating bag
available as a backup whereveravailable as a backup wherever
resuscitation may be needed, in case aresuscitation may be needed, in case a
compressed gas source fails or the T-compressed gas source fails or the T-
piece device malfunctions.piece device malfunctions.
Emergency Backup:Emergency Backup:
Self-Inflating BagSelf-Inflating Bag
p.3-5
50. 3-50
Safety Features: T-pieceSafety Features: T-piece
ResuscitatorResuscitator
Click on the image to play videoClick on the image to play video
p.3-12
51. 3-51
Face Mask SealFace Mask Seal
• Tight seal required for flow-inflating bag toTight seal required for flow-inflating bag to
inflateinflate
• Tight seal required to inflate lungs when self-Tight seal required to inflate lungs when self-
inflating bag squeezedinflating bag squeezed
• Tight seal required to inflate lungs when PEEPTight seal required to inflate lungs when PEEP
cap occluded using the T-piece resuscitatorcap occluded using the T-piece resuscitator
Airtight seal is essential to achieveAirtight seal is essential to achieve
effective positive pressureeffective positive pressure
p. 3-21
52. 3-52
Appendices: Description ofAppendices: Description of
Resuscitation DevicesResuscitation Devices
• Self-inflating bagsSelf-inflating bags
• Flow-inflating bagsFlow-inflating bags
• T-piece resuscitatorsT-piece resuscitators
Review devices used in your hospitalReview devices used in your hospital
p. 3-44
53. 3-53
Appendix B: Flow-inflatingAppendix B: Flow-inflating
Resuscitation BagsResuscitation Bags
Click on the image to play videoClick on the image to play video p. 3-48
54. 3-54
Flow-inflating Bag: PotentialFlow-inflating Bag: Potential
ProblemsProblems
The bag will not inflate ifThe bag will not inflate if
• The mask is not properly sealed overThe mask is not properly sealed over
newborn’s mouth and nosenewborn’s mouth and nose
• There is a hole in the bagThere is a hole in the bag
• The flow-control valve is open too farThe flow-control valve is open too far
• The pressure gauge is missing or the port isThe pressure gauge is missing or the port is
not occludednot occluded
p. 3-50
55. 3-55
Appendix C: T-piece ResuscitatorAppendix C: T-piece Resuscitator
Click on the image to play videoClick on the image to play video
p. 3-54
56. 3-56
Preparing the T-piecePreparing the T-piece
Resuscitator for UseResuscitator for Use
Click on the image to play videoClick on the image to play video
p. 3-55
57. 3-57
T-piece Resuscitator: AdjustingT-piece Resuscitator: Adjusting
Pressure SettingsPressure Settings
Click on the image to play videoClick on the image to play video
p. 3-55
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.
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.
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.
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.
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.
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.
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.
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.
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.
We cannot overemphasize this lesson. Being able to perform and assess effective bag and mask ventilation will save lives. Our ability to teach this skill to others is equally important. Practice is the key. Practice every situation you can think of that involves ventilation. Teach how to assess effective ventilation and what to do if there is no improvement in heart rate and no chest movement. Remember, in the delivery room, we often need to reposition the mask, clear the airway of secretions, open the airway by repositioning the head, and use higher positive pressure in those initial breaths. Practice this over and over again.
Begin your skills practice with the basic skills and increase to the more technical skills.
Begin with simple scenarios and move to more complex mega codes.
Remember, most resuscitations are successful because of effective initial steps and bag and mask ventilation.
Everyone needs a cheerleader! Look for what the students are doing well, then offer suggestions for improvement.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
