PowerPoint Presentation Initial Steps

1
Neonatal Resuscitation Program

• Self-study
• NRP Textbook
• DVD Rom

2
Neonatal Resuscitation Program

• Written Exam
• 85 correct
• Retest once
• Megacode

3
NRP Prep Class

• Slides and Checkoffs
• Lesson 2
• Lesson 3
• Lesson 4
• Lesson 5

4
Lesson 2 INITIAL STEPS IN RESUSCITATION
Neonatal Resuscitation Program Slide Presentation
Kit
5
Initial Steps

• Lesson content
• Decide if resuscitation is needed
• Open airway and provide initial steps
• Manage if meconium present
• Provide free-flow oxygen when needed

6
Evaluating the Newborn
Immediately after birth, the following questions
must be asked
7
Initial Steps

• Provide warmth
• Position clear airway (as necessary)
• Dry, stimulate, reposition

8
Provide Warmth

• Prevent heat loss by
• Placing newborn under radiant warmer
• Drying thoroughly
• Removing wet towels

9
Dry, Stimulate to Breathe, Reposition
10
Opening the Airway

• Positioning on back or side, slightly extending
  neck
• Sniffing position aligns posterior pharynx,
  larynx, and trachea
• ?

Open the airway by positioning the newborn in a
sniffing position
11
Opening the Airway
12
Clear Airway No Meconium Present

• Bulb Syringe
• Suction mouth first, then nose
• M before N

13
Evaluation Respirations, Heart Rate, Color

• Decisions and actions during newborn
  resuscitation are based on

• Respirations
• Heart Rate
• Color

?
14
Tactile Stimulation

• Slapping or flicking the soles of the feet
• Gently rubbing the back, trunk, or extremities

?
15
Potentially Hazardous Forms of Stimulation

• Slapping back or buttocks
• Squeezing rib cage
• Forcing thighs onto abdomen
• Dilating anal sphincter
• Hot or cold compresses or baths
• Shaking

16
Evaluation Persistent Cyanosis, Apnea, or Heart
Rate lt100

• Continued use of tactile stimulation in an apneic
  newborn wastes valuable time. For persistent
  apnea, begin positive-pressure ventilation
  promptly

?
17
Central Cyanosis and Acrocyanosis
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Free-flow Oxygen

• Free-flow oxygen is indicated for central
  cyanosis
• Free-flow oxygen cannot be given reliably by a
  mask attached to a self-inflating bag

?
19
Free-Flow Oxygen Given Via Flow-Inflating Bag and
Mask
2-19A
20
Free-Flow Oxygen Given Via Oxygen Tubing
2-19B
21
FreeFlow Oxygen Given Via Oxygen Mask
2-19C
22
Initial Steps Meconium Present

• Newborn is not vigorous Suction the babys
  trachea before proceeding with any other steps
• Newborn is vigorous Suction the mouth and nose
  only, and proceed with resuscitation as required
• ?

23
Management of Meconium
24
Meconium Present and Newborn Vigorous

• If
• Respiratory effort strong, and
• Muscle tone good, and
• Heart rate greater than 100 beats per minute
  (bpm)
• Then
• Use bulb syringe or large-bore suction catheter
  to clear mouth and nose
• ?

25
Meconium Present and Newborn Not Vigorous

• Tracheal Suction
• Administer oxygen, monitor heart rate
• Insert laryngoscope, use 12F or 14F suction
  catheter to clear mouth
• Insert endotracheal tube into trachea
• Attach endotracheal tube to suction source
• Apply suction as tube is withdrawn
• Repeat as necessary

26
Suctioning Meconium
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End of Lesson 2
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Lesson 3 USE OF RESUSCITATION DEVICES FOR
POSITIVE-PRESSURE VENTILATION
Neonatal Resuscitation Program Slide Presentation
Kit
29
Use of Resuscitation Devices for
Positive-Pressure Ventilation

• Lesson Content
• When to ventilate
• Types of resuscitation devices
• Operation of each device
• Face-mask placement
• Troubleshooting resuscitation devices
• Evaluating ventilation

30
Indications for Positive-Pressure Ventilation

• Apnea/gasping
• Heart rate less than 100 beats per minute (bpm)
  even if breathing
• Persistent cyanosis despite 100 free-flow oxygen

Ventilation of the lungs is the single most
important and most effective step in
cardiopulmonary resuscitation of the
compromised infant
?
31
General Characteristics of Resuscitation Devices

• Appropriate-sized mask (cushioned, anatomically
  shaped mask preferred)
• Variable oxygen capability up to 90 to 100
• Control of peak inspiratory pressure and
  inspiratory time
• Size of bag (200-750 mL)
• Safety features to prevent high pressure delivery

32
Resuscitation DevicesSafety Features

• Every resuscitation device must have
• A pressure gauge and a flow-control valve and/or
• A pressure-release (pop-off) valve

?
33
Self-inflating bag
34
Self-inflating Bag

• An oxygen reservoir must be attached to deliver
  high concentrations of oxygen using a
  self-inflating bag
• Without reservoir and oxygen attached,
• the bag delivers only about 40 oxygen, which may
  be insufficient for neonatal resuscitation

?
35
Self-inflating Bag Control of Oxygen

• With reservoir, 90 to 100 oxygen delivered to
  patient

36
Self-inflating Bag Types of Oxygen Reservoirs
37
Self-inflating Bag

• Testing before use

38
Self-inflating Bag Pressure
Amount of pressure delivered depends on the
following 3 factors

• How hard the bag is squeezed
• Any leak between mask and newborns face
• Set point of pressure-release valve

39
Safety Features Self-inflating Bags With
Pressure-Release Valve
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Self-inflating Bag

• Advantages
• Always refills after being squeezed and
• Is always inflated
• Pressure release (pop-off) valve makes
  over-inflation less likely

?
41
Self-inflating Bag

• Disadvantages
• Bag will work without a gas source ensure that
  oxygen is connected
• Requires tight face-mask seal to inflate the
  lungs
• Requires oxygen reservoir to provide high
  concentration of oxygen
• Cannot give free-flow oxygen through the mask
• Cannot be used for CPAP. No PEEP without special
  valve

?
42
Flow-inflating bag
43
Flow-inflating Bag Potential Problems

• The bag will not inflate if
• The mask is not properly sealed over newborns
  mouth and nose
• There is a hole in the bag
• The flow-control valve is open too far
• The pressure gauge is missing or the port is not
  occluded
• ?

44
Flow-Inflating Bag Adjusting Oxygen Flow and
Pressure
45
Safety Features Flow-inflating Bag
46
Flow-inflating Bag

• Advantages
• Delivers 21 to 100 oxygen, depending on the
  source
• Easy to assess seal on the babys face
• Can be used to give free-flow oxygen through the
  mask

?
47
Flow-inflating Bag

• Disadvantages
• Requires a compressed gas source
• Requires a tight face-mask seal to remain
  inflated
• Requires a gas source to inflate. If empty, looks
  like deflated balloon
• Usually does not have a safety pop-off valve
• Uses a flow-control valve to regulate
  pressure/inflation

?
48
Oxygen Concentration During Positive-Pressure
Ventilation

• The Neonatal Resuscitation Program (NRP)
  recommends use of 100 oxygen when
  positive-pressure ventilation is required during
  neonatal resuscitation. However, research
  suggests that resuscitation with something less
  than 100 may be just as successful.
• If resuscitation is started with less than 100
  oxygen, supplemental oxygen up to 100 should be
  administered if there is no appreciable
  improvement within 90 seconds following birth.
• If oxygen is unavailable, use room air to deliver
  positive-pressure ventilation.

?
49
Resuscitation Devices Free-flow Oxygen

• Free-flow oxygen
• Cannot be given reliably though a mask with
  self-inflating bag
• Can be delivered reliably through the mask with
  flow-inflating bag or T-piece resuscitator

?
50
Bag and Mask Equipment Masks

• Rims
• Cushioned
• Non-cushioned
• Shape
• Round
• Anatomically shaped
• Size
• Small
• Large

51
Bag and Mask Equipment

• Mask should cover
• Tip of Chin
• Mouth
• Nose

52
Preparation for Resuscitation Device

• Assemble equipment
• Test equipment

53
Preparation Checklist
Before beginning positive-pressure ventilation

• Select appropriate-sized mask
• Be sure airway is clear
• Position babys head
• Position yourself at babys side or head

54
Positioning Mask on Face

• Do not jam mask down on face
• Do not allow fingers or hands to rest on eyes
• Do not put pressure on throat (trachea)

55
Positioning Mask on Face

• To improve face-mask seal,
• Use light downward pressure
• May gently squeeze mandible up toward mask

56
Face-Mask Seal
Airtight seal is essential to achieve effective
positive pressure

• Tight seal required for flow-inflating bag to
  inflate
• Tight seal required to inflate lungs when
  self-inflating bag squeezed

57
Signs of Effective Ventilation
Signs of adequate ventilation

• Improved heart rate, color, muscle tone

?
Signs of improvement in newborn

• Improved heart rate, color, breathing, tone, and
  saturation

58
Over-inflation of Lungs
If the baby appears to be receiving very deep
breaths,

• Too much pressure is being used
• Danger of producing a pneumothorax

59
Frequency of Ventilation

• 40 to 60 breaths per minute

60
Infant Not Improving and Chest Not Adequately
Expanding

• Possible causes
• Seal inadequate
• Airway blocked
• Not enough pressure

61
Causes and Solutions for Inadequate Chest
Expansion
Condition
Actions Inadequate seal
Reapply mask to face and lift jaw
forward Blocked airway
Reposition the headCheck for secretions
suction if present
Ventilate with the newborns
mouth slightly open Not enough pressure
Increase pressure until there is a perceptible
chest movement
Consider endotracheal intubation
?
62
Continued Positive-Pressure Ventilation
Orogastric tube should be inserted to relieve
gastric distention

• Gastric distention may
• Elevate diaphragm, preventing full lung expansion
• Cause regurgitation and aspiration

63
Insertion of Orogastric Tube

• Equipment
• 8F feeding tube
• 20-mL syringe

64
Insertion of Orogastric Tube

• Measuring correct length

65
Insertion of Orogastric Tube Technique

• Insert tube through mouth, rather than nose
  (resume ventilation)
• Attach 20-mL syringe and aspirate gently
• Remove syringe and leave tube end open to air
• Tape tube to newborns cheek

66
Newborn Not Improving

• Check oxygen, bag, seal, and pressure
• Is chest movement adequate?
• Is adequate oxygen being administered?
• Then,
• Consider endotracheal intubation
• Check breath sounds pneumothorax possible

67
Newborn Not Improving
Heart rate less than 60 despite 30 seconds of
positive-pressure ventilation
68
End of Lesson 3
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Neonatal Resuscitation Program Slide Presentation
Kit
Lesson 4 CHEST COMPRESSIONS
70
Chest Compressions

• Lesson content
• Indications for chest compressions
• Performance of chest compressions
• Coordination of chest compression with
  positive-pressure ventilation
• Stopping chest compressions

71
Chest Compressions

• Chest Compressions
• Temporarily increase circulation
• Must be accompanied by ventilation
• Should use 100 oxygen

72
Chest Compressions Indications

• Heart rate remains less than 60 beats per minute
  (bpm) despite 30 seconds of effective
  positive-pressure ventilation

?
73
Chest Compressions

• Compress the heart against the spine
• Increase intrathoracic pressure
• Circulate blood to vital organs, including the
  brain

?
74
Chest Compressions 2 People Needed

• One person compresses chest
• One person continues ventilation

75
Comparison of Chest Compression Techniques

• Thumb Technique (Preferred)
• Less tiring
• Better control of compression depth
• 2-Finger Technique
• Better for small hands
• Provides access to umbilicus for medications
• ?

76
Chest Compressions Positioning of Thumbs or
Fingers

• Run your fingers along the lower edge of the rib
  cage until you locate the xyphoid
• Place your thumbs or fingers on the sternum,
  above the xyphoid and on a line connecting the
  nipples
• ?

77
Chest Compressions Thumb Technique

• Thumbs compress sternum
• Fingers support back
  

78
Chest Compressions Thumb Technique

• Apply pressure during compression on the sternum,
  releasing pressure to allow chest recoil and
  ventilation

79
Chest Compressions 2-Finger Technique

• Tips of middle finger and index or ring finger of
  one hand compress sternum
• Other hand supports back

80
Chest Compressions Compression Pressure and Depth

• Depress sternum one third of the
  anterior-posterior diameter of chest

81
Chest Compressions Technique

• Duration of downward stroke shorter than duration
  of release

82
Chest Compressions Complications

• Laceration of liver
• Broken ribs

83
Chest Compressions Coordination With Ventilation
?
84
Chest Compressions Coordination With Ventilation

• One cycle of 3 compressions and 1 breath takes 2
  seconds
• The breathing rate is 30 breaths per minute and
  the compression rate is 90 compressions per
  minute. This equals 120 events per minute
• ?

85
Chest Compressions Stopping Compressions

• After 30 seconds of compressions and ventilation,
  stop and check heart rate
• ?

86
Chest Compressions Heart Rate Remains Less than
60 bpm

• Check adequacy of ventilation
• Consider intubation if not already done
• Insert an umbilical catheter to give epinephrine
• ?

87
End of Lesson 4
88
Lesson 5 ENDOTRACHEAL INTUBATION
Neonatal Resuscitation Program Slide Presentation
Kit
89
Endotracheal Intubation

• Lesson content
• Indications for intubation
• Equipment selection and preparation
• Laryngoscope use and endotracheal tube insertion
• Determination of tube placement
• Suctioning meconium from trachea
• Positive-pressure ventilation via endotracheal
  tube

90
Endotracheal Intubation Indications

• To suction trachea in presence of meconium when
  the newborn is not vigorous
• To improve efficacy of ventilation after several
  minutes of bag-and-mask ventilation or
  ineffective bag-and-mask ventilation
• To facilitate coordination of chest compressions
  and ventilation
• To administer epinephrine while IV access is
  being established

?
91
Endotracheal Intubation Special Indications

• Extreme Prematurity
• Surfactant Administration
• Suspected Diaphragmatic Hernia

A person experienced in endotracheal intubation
should be immediately available to assist at
every delivery. ?
92
Endotracheal Intubation Equipment and Supplies

• Equipment should be clean, protected from
  contamination

93
Characteristics of Endotracheal Tubes

• Sterile, disposable
• Uniform diameter (not tapered)
• Centimeter marks and vocal cord guides helpful
• Uncuffed

94
Endotracheal Tube Appropriate Size

• Select tube size based on weight and gestational
  age
• Consider shortening tube to 13 to 15 cm
• Stylet optional

Tube Size (mm) Weight
Gestational Age (inside diameter)
(g) (wks) 2.5
Below 1,000 Below 28
3.0 1,000-2,000
28-34 3.5
2,000-3,000 34-38 3.5-4.0
Above 3,000 Above 38 ?
95
Preparation of Laryngoscope

• Supplies
• The correct-sized laryngoscope blade
• No. 0 for preterm newborns
• No. 1 for term newborns
• ?
• Check laryngoscope light
• Adjust suction source to 100 mm Hg
• Use large suction catheter (greater than or equal
  to 10F) for oral secretions
• Have small catheter for suctioning endotracheal
  tube

96
Preparation for Intubation

• Prepare resuscitation device and mask
• Turn on oxygen
• Get stethoscope
• Cut tape or prepare endotracheal tube stabilizer

97
Assisting During Intubation

• The assistant for the procedure should
• Ensure equipment available, prepared
• Correctly position baby, stabilize head
• Provide free-flow oxygen
• Provide suction
• Hand endotracheal tube to intubator
• Apply cricoid pressure if asked

98
Assisting During Intubation

• The assistant for the procedure should
• Provide positive-pressure ventilation between
  attempts
• Connect endotracheal tube to resuscitation device
• Connect CO2 detector
• Auscultate heart rate to assess improvement
• Note CO2 detector color change
• Auscultate breath sounds and observe chest
  movement
• Help secure tube

99
Endotracheal Intubation Limiting Hypoxia During
Intubation

• Pre-oxygenate with positive-pressure ventilation
  (unless intubating to suction meconium)
• Deliver free-flow oxygen during intubation
• Limit attempts to 20 seconds

100
Endotracheal Intubation Upper Airway Anatomy
101
Endotracheal Intubation Anatomic Landmarks
102
Endotracheal Intubation Positioning the Newborn
103
Endotracheal Intubation Always Hold the
Laryngoscope in the Left Hand
?
104
Endotracheal IntubationStep 1 Preparation for
Insertion

• Stabilize the newborns head in the sniffing
  position
• Deliver free-flow oxygen during the procedure
• ?

105
Endotracheal Intubation Step 2 Insert
Laryngoscope

• Slide the laryngoscope over right side of the
  tongue
• Push tongue to left side of mouth
• Advance blade until the tip lies just beyond the
  base of the tongue
• ?

106
Endotracheal Intubation Step 3 Lift Blade

• Lift the blade slightly
• Raise the entire blade, not just the tip
• Visualize pharyngeal area
• Do not use rocking motion
• ?

107
Endotracheal Intubation Step 4 Visualize
Landmarks

• Look for landmarks. Vocal cords should appear as
  vertical stripes on each side of the glottis or
  as an inverted letter V
• Applying downward pressure on cricoid may help
  bring glottis into view
• Suction, if necessary, for visualization
• ?

108
Endotracheal Intubation Step 5 Inserting Tube

• Insert the tube into the right side of the mouth
  with the curve of the tube lying in the
  horizontal plane
• If the cords are closed, wait for them to open
• Insert the tip of the endotracheal tube until the
  vocal cord guide is at the level of the cords
• Limit attempts to 20 seconds

?
109
Endotracheal IntubationStep 6 Remove
Laryngoscope

• Hold the tube firmly against the babys palate
  while removing the laryngoscope
• Hold the tube in place while removing the stylet
  if one was used

?
110
Suctioning Meconium via Endotracheal Tube

• Connect endotracheal tube to meconium aspirator
  and suction source
• Occlude suction port to apply suction
• Gradually withdraw endotracheal tube
• Repeat intubation and suction as necessary until
  newborns heart rate indicates that
  positive-pressure ventilation is needed

111
Suctioning Meconium via Endotracheal Tube

• Suction for only 3 to 5 seconds as tube is
  withdrawn
• If no meconium is recovered, proceed to
  resuscitation
• If meconium is recovered, check heart rate

• No significant bradycardia ? Reintubate, suction
  again if needed
• Significant bradycardia ? Administer
  positive-pressure ventilation

112
Endotracheal IntubationChecking Tube Position

• Signs of correct tube position
• Improved vital signs (heart rate, color, and
  activity)
• Presence of exhaled CO2 as determined by CO2
  detector
• Breath sounds over both lung fields but decreased
  or absent over stomach
• No gastric distention with ventilation
• ?

113
Endotracheal IntubationChecking Tube Position
Additional signs of correct tube placement

• Vapor in the tube during exhalation
• Chest movement with each breath
• Chest x-ray confirmation if the tube is to remain
  in place past initial resuscitation
• Direct visualization of tube passing between
  vocal cords
• ?

114
CO2 Detection

• Pull paper tab
• Indicator will change from purple to yellow to
  indicate that tube is in trachea

115
Endotracheal Intubation Checking Tube Position

• The tube is not likely in the trachea if
• Newborn remains cyanotic and bradycardic
• CO2 detector does not indicate exhaled CO2
• No breath sounds over lungs
• Abdomen becomes distended
• Air noises over stomach
• No mist in endotracheal tube
• Chest not moving symmetrically with
  positive-pressure breaths

116
Endotracheal IntubationTube Location in Trachea
117
Endotracheal Intubation Tube Location in
Trachea
Tip-to-lip measurement
Babies weighing less than 750 g may require only
6 cm insertion ?
118
Endotracheal IntubationRadiographic Confirmation
?
Correct
Incorrect
119
End of Lesson 5