The 2015 AHA Neonatal Resuscitation Guidelines update provides recommendations for several changes: 1. Positive pressure ventilation for preterm infants should include PEEP of 5cmH2O. Laryngeal masks are recommended when intubation is not feasible for infants >34 weeks. 2. Initiation of resuscitation for preterm infants should use low oxygen (21-30%) titrated to target saturation rather than high oxygen. Term infants should be initiated with room air. 3. Chest compressions are indicated if the heart rate is <60/minute despite ventilation. The 2-thumb technique is preferred for compressions. 4. Assessment of heart rate response is the best measure

1. Neonatal Resuscitation 2015 AHA Guidelines
Update for CPR
www.pediatrics.org/cgi/doi/10.1542/peds.2015-3373G
doi:10.1542/peds.2015-3373G
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3. Steps of resuscitation:
1. Initial steps in stabilization.
2. Ventilate and oxygenate-O2 administration and
monitoring,PPV,PEEP,advanced airways.
3. Initiate chest compressions.
4. Administer epinephrine and/or volume.
5. Witholding and discontinuation of resuscitation.

5. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Positive
pressure
ventilation
•No mention
about SIP
•PEEP
admisnitered in
resuscitation of
prterm.
•Routine application
of sustained infaltion
pressure>5 sec not
recommended.
•PPV when
administered to
Preterm,use of PEEP-
5cm is suggested.
Class 2b
Class 2b
•3 RCT, 2 cohort
studies demonstrated
a benefit of SIP for
reducing need for
mechanical
ventilation,no benefit
was found for
reduction of mortality,
BPD, or air leak.
•PPV delivered with
flow infalting,self
infalting bag or T
piece resucitator.
•Needs additition
of PEEP valve to
self infalting bag
• 2 RCT suggested
that addition of
PEEP during
delivery
room resuscitation
of preterm
newborns resulted
in no improvement
in mortality.

6. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Positive
pressure
ventilation
•No mention
about monitors
and exhaled CO2
in face mask
ventilation.
•A laryngeal
mask should be
considered
during
resuscitation if
facemask
ventilation is
unsuccessful
and tracheal
intubation is
unsuccessful or
•Use and effectivness
of respiratory
mechanics monitors
and exhaled CO2
monitors not
established.
•A laryngeal mask is
recommended during
resuscitation of term
and
preterm newborns at
34 weeks or more of
gestation when
tracheal intubation is
unsuccessful or is not
feasible
Class 2b
Class 2b
•Prevent excessive
pressures and tidal
volume and
exhaled CO2
monitors may help
assess
that actual gas
exchange is
occurring
during face-mask
PPV attempts-
effictivness not
established
•Use of the
laryngeal mask
has not been
evaluated during
chest
compressions or for
administration of
emergency
medications

7. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Positive
pressure
ventilation
Spontaneously
breathing
preterm infants
who have
respiratory
distress may be
supported with
CPAP or with
intubation and
mechanical
ventilation.
CPAP: Spontaneously
breathing preterm
infants
with respiratory
distress may be
supported with CPAP
initially rather
than routine
intubation for
administering PPV .
Class 2b 3 RCT enrolling
2548 preterms-
Starting CPAP
resulted in
decreased rate of
intubation in the
delivery room,
decreased duration
of ventilation with
reduction of death
and BPD, and no
significant increase
in air leak or severe
IVH.

8. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
O2 in
Preterm
infants
•Recommended
that whether
born at term or
preterm, should
be an oxygen
saturation value
in the
interquartile
range of
preductal
saturations.
•<35 wks GA begin
resuscitation with low
O2{21%-30%}
•Titrate according to
preductal SpO2.
•Initiating
resuscitation
of preterm newborns
with high oxygen
(65% or greater) is not
recommended
Class 1,LOE B-R
Class III
Meta-analysis of
7 RCT-initiation
with high oxygen
(65% or greater)
and low oxygen
(21- 30%)
showed no
improvement in
survival to
hospital
discharge with
the use of high
oxygen.

9. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
O2 in term
infants
Initiating
resuscitation
with air or a
blended
oxygen and
titrating the
oxygen
concentration
to achieve an
SpO2 in the
target range
as described
above using
pulse
oximetry .
Initiate resuscitation
with air (21% )
Supplementary
oxygen may be
administered
and titrated to
achieve a preductal
oxygen saturation
approximating the
interquartile
range measured in
healthy
term infants after
vaginal birth at sea
leve

10. • PPV-Flow infalting,self infalting or T piece resuscitator.
• When administeringPPV for preterm provide PEEP of 5cm .
• Initiate PPV in room air for Term and Fio2 21-30% for
preterm infants.
• LMA can be used >34 wk GA infant when intubation is not
successful.
• CPAP rather than routine intubation for spontaneously
breathing preterm infants with respiratory distress

11. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Chest
compression
Indicated for a
heart rate that
is <60 per
minute despite
adequate
ventilation with
supplementary
oxygen for 30
seconds.
Compressions
should be
delivered on
the lower third
of the sternum
to a depth of
approximately
one third of the
A-P diameter of
the chest .
If the heart rate is less
than 60/min despite
adequate ventilation
(via endotracheal
tube if possible), chest
compressions are
indicated
Compressions are
delivered on the
lower third of the
sternum to a depth of
approximately one
third of the anterior-
posterior diameter of
the chest.
Class 2b No change in
recommendation

12. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Chest
compression
•The 2 thumb–
encircling
hands
technique is
recommended
for performing
chest
compressions
in newly born
infants .
• The 2-finger
technique may
be preferable
when access to
the umbilicus is
required during
insertion of an
umbilical
catheter.
2-thumb technique
generates higher
blood pressures
and coronary
perfusion pressure
with less rescuer
fatigue, the 2
thumb–encircling
hands technique is
suggested as the
preferred
Method
2-thumb technique
can be continued
from the head of the
bed while the
umbilicus is accessed
for insertion of an
umbilical catheter, the
2-finger technique is
no longer needed.
Class 2b

13. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Chest
compression
Same 3:1 where gas
exchange is nearly
always the primary
cause of
cardiovascular
collapse, but
rescuers may consider
using higher ratios
(eg, 15:2) if the arrest
is believed to be of
cardiac origin
Class 2b

14. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Chest
compression
If the baby is
bradycardic (HR
<60 per
minute) after
90 seconds of
resuscitation
with a lower
concentration
of oxygen, O2
concentration
should be
increased to
100% until
recovery of a
normal heart
rate .
•Endorses increasing
the oxygen
concentration to
100% whenever chest
compressions are
Provided
•Supplementary
oxygen concentration
should be weaned as
soon as the heart rate
recovers
Class 2b
Class 1
Animal evidence
show no advantage
to 100% oxygen
during CPR.
By the time
resuscitation
of a newborn infant
has reached the
stage of chest
compressions,
efforts to achieve
return of
spontaneous
circulation using
effective ventilation
with low
concentration
oxygen should have
been attempted

15. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Chest
compression
•HR used for
assesment of
ROSC.
•Current measure for
determining
successful progress in
neonatal resuscitation
is to assess the heart
rate response.
Class 2b • ET CO2 monitoring
and pulse oximetry,
useful techniques to
determine return of
spontaneous circulation
occurs.
•In asystolic/
bradycardic neonates,
routine use of any
device such as ETCO2
monitors or pulse
oximeters for detection
of ROSC, is not
recommended as
their usefulness for this
purpose in neonates
has not been well
Established.

16. • Chest compression if HR<60 despite adequate ventilation.
• Compression delivered over lower third of sternum.
• Compression to ventilation ratio of 3:1.
• 2 thumb and 2 finger technique.
• 2 finger technique no longer recommended.
• Use 100% O2 whenever compressions are administered.
• Assesment of HR is best measure to assess progress, use of ET CO2
and oximetry not routinely recommended.

17. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Induced
Therapeutic
Hypothermia
Resource-
Limited Areas
Should be
administered
under clearly
defined
protocols
similar to those
used in
published
clinical trials
and in facilities
with the
capabilities for
multidisciplinar
y care and
longitudinal
follow-up
Use of therapeutic
hypothermia in
resource limited
settings may be
considered and
offered under clearly
defined
protocols .
Class 2b

18. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Guidelines for
Withholding
and
Discontinuing
•Not indicated-
almost certain
death and
unaccepatable
high morbidity.
•Nearly always
indicated-High
rate of survival
and acceptable
morbidity.
•Borderline-
survival
borderline and
morbidity is
relatively
high,parental
desires should
be supported.
•For GA<25
wks,consider
accuracy of GA, the
presence or absence
of chorioamnionitis,
and the level of care
available .
•Decision to be
influenced by region-
specific guidelines.
No new data
have Been
published that
would justify a
change to these
guidelines as
published in
2010.

19. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Guidelines
for
Withholding
and
Discontinuing
In a newly
born baby
with no
detectable
heart rate, it
is appropriate
to consider
stopping
resuscitation
if the heart
rate remains
undetectable
for 10
minutes .
Infants with an Apgar
score of 0 after 10
minutes of
resuscitation, if the
heart rate remain
undetectable, it may
be reasonable
to stop assisted
ventilations.
Class 2b Decision to
continue or
discontinue
resuscitative
efforts must be
individualized-
etiology,GA,
associated
complications,
role of
hypothermia .

20. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Provider
training:
2010
Guidelines
suggested
that
simulation
should
become a
standard
component in
neonatal
resuscitation
training
Suggested that
neonatal
resuscitation task
training occur
more frequently than
the current 2-year
interval.

21. TOPIC NRP 2010 NRP 2015 LOE COMMENTS
Instructor
training:
None Instructors be
trained using
timely,
objective
structured, and
individually
targeted verbal
and/or
written feedback .

22. Unchanged Recommendations:
TOPIC RECOMMENDATION
Temperature control Resuscitation should be performed with
temperature-controlling interventions.
Clearing the airway when amniotic fluid is
clear
Routine suctioning is not recommended
Assessment of need of oxygen therapy
and monitoring of oxygen therapy
Oximetry should be used to monitor if any
neonate needs PPV, with persistent
central cyanosis persists and with the use
of supplementary oxygen.
Initial breaths and assisted ventilation An initial inflation pressure of 20 cm
water is adequate; some term babies may
require up to ≥30 to 40 cm water. Rate of
giving PPV- 40 to 60 per minute.

23. Unchanged Recommendations:
TOPIC RECOMMENDATIONS
Endotracheal tube placement Exhaled CO2 detection is most reliable.
Chest compressions Coordinated chest compressions and PPV should be
done if heart rate<60 per
minute after establishing effective ventilation
Epinephrine IV dose - 0.01 to 0.03 mg/kg of 1:10 000
epinephrine. For an endotracheal route
- 0.05 to 0.1 mg/kg
Volume Expansion Volume expansion when blood loss is
known/suspected.Dose - 10 mL/kg of
isotonic crystalloid solution or blood, may be
repeated.

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