C. Omar F. Kamlin

Improved techniques reduce face mask leak during simulated neonatal resuscitation: Study 2

Background: Techniques of positioning and holding neonatal face masks vary. Studies have shown that leak at the face mask is common and often substantial irrespective of operator experience. Aims: (1) To identify a technique for face mask placement and hold which will minimise mask leak. (2) To investigate the effect of written instruction and demonstration of the identified technique on mask leak for two round face masks. Method: Three experienced neonatologists compared methods of placing and holding face masks to minimise the leak for Fisher & Paykel 60 mm and Laerdal size 0/1 masks. 50 clinical staff gave positive pressure ventilation to a modified manikin designed to measure leak at the face mask. They were provided with written instructions on how to position and hold each mask and then received a demonstration. Face mask leak was measured after each teaching intervention. Results: A technique of positioning and holding the face masks was identified which minimised leak. The mean (SD) mask leaks before instruction, after instruction and after demonstration were 55% (31), 49% (30), 33% (26) for the Laerdal mask and 57% (25), 47% (28), 32% (30) for the Fisher & Paykel mask. There was no significant difference in mask leak between the two masks. Written instruction alone reduced leak by 8.8% (CI 1.4% to 16.2%) for either mask; when combined with a demonstration mask leak was reduced by 24.1% (CI 16.4% to 31.8%). Conclusion: Written instruction and demonstration of the identified optimal technique resulted in significantly reduced face mask leak.

Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure

Objective To evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP). Methods An open feasibility study of MIST was conducted at two sites. Infants were eligible for MIST if needing CPAP pressure ≥7 cm H2O and FiO2 ≥0.3 (25–28 weeks gestation, n=38) or ≥0.35 (29–32 weeks, n=23). Without premedication, a narrow-bore catheter was inserted through the vocal cords under direct vision. Surfactant (100 or 200 mg/kg Curosurf) was then instilled, followed by reinstitution of CPAP. Outcomes were compared between surfactant-treated infants and historical controls achieving the same CPAP and FiO2 thresholds. Results Surfactant was successfully administered via MIST in all cases, with a rapid and sustained reduction in FiO2 thereafter. For infants at 25–28 weeks gestation, need for intubation <72 h was diminished after MIST compared with controls (32% vs 68%; OR 0.21, 95% CI 0.083 to 0.55), with a similar trend at 29–32 weeks (22% vs 45%; OR 0.34, 95% CI 0.11 to 1.1). Duration of ventilation and incidence of bronchopulmonary dysplasia were similar, but infants receiving MIST had a shorter duration of oxygen therapy. Conclusion Surfactant delivery via a narrow-bore tracheal catheter is feasible and potentially effective, and deserves further investigation in clinical trials.

Breathing Patterns in Preterm and Term Infants Immediately After Birth

There is limited data describing how preterm and term infants breathe spontaneously immediately after birth. We studied spontaneously breathing infants ≥29 wk immediately after birth. Airway flow and tidal volume were measured for 90 s using a hot wire anemometer attached to a facemask. Twelve preterm and 13 term infants had recordings suitable for analysis. The median (interquartile range) proportion of expiratory braking was very high in both groups (preterm 90 [74–99] vs. term 87 [74–94]%; NS). Crying pattern was the predominant breathing pattern for both groups (62 [36–77]% vs. 64 [46–79]%; NS). Preterm infants showed a higher incidence of expiratory hold pattern (9 [4–17]% vs. 2 [0–6]%; p = 0.02). Both groups had large tidal volumes (6.7 [3.9] vs. 6.5 [4.1] mL/kg), high peak inspiratory flows (5.7 [3.8] vs. 8.0 [5] L/min), lower peak expiratory flow (3.6 [2.4] vs. 4.8 [3.2] L/min), short inspiration time (0.31 [0.13] vs. 0.32 [0.16] s) and long expiration time (0.93 [0.64] vs. 1.14 [0.86] s). Directly after birth, both preterm and term infants frequently brake their expiration, mostly by crying. Preterm infants use significantly more expiratory breath holds to defend their lung volume.

Assessing the effectiveness of two round neonatal resuscitation masks: study 1

Background: Positive pressure ventilation (PPV) via a face mask is an important skill taught using manikins. There have been few attempts to assess the effectiveness of different face mask designs. Aim: To determine whether leak at the face mask during simulated neonatal resuscitation differed between a new round mask design and the current most widely used model. Method: 50 participants gave PPV to a modified manikin designed to measure leak at the face mask. Leak was calculated from the difference between the inspired and expired tidal volumes. Results: Mask leak varied widely with no significant difference between devices; mean (SD) percentage leak for the Laerdal round mask was 55% (31) and with the Fisher & Paykel mask it was 57% (25). Conclusion: We compared a new neonatal face mask with an established design and found no difference in leak. On average the mask leak was >50% irrespective of operator experience or technique.

Oxygenation with T-Piece versus Self-Inflating Bag for Ventilation of Extremely Preterm Infants at Birth: A Randomized Controlled Trial

OBJECTIVE To investigate whether infants < 29 weeks gestation who receive positive pressure ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation (SpO₂) measurements at 5 minutes than infants ventilated with a self inflating bag (SIB). STUDY DESIGN Randomized, controlled trial of T-piece or SIB ventilation in which SpO₂ was recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with air. RESULTS Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB. At 5 minutes after birth, there was no significant difference between the median (interquartile range) SpO₂ in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to 67%]; P = .27). More infants in the T-piece group received oxygen during delivery room resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room. CONCLUSION There was no significant difference in SpO₂ at 5 minutes after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this study.

Crying and Breathing by Extremely Preterm Infants Immediately After Birth

We reviewed videos of 61 extremely preterm infants taken immediately after birth. The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are not apneic at birth.

Providing PEEP during neonatal resuscitation: Which device is best?

Aim:  The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self‐inflating bag with a positive end expiratory pressure (PEEP) valve, a T‐piece resuscitator (T‐piece) and a flow‐inflating bag to provide peak inflation pressure (PIP) and PEEP.

Ethical and legal aspects of video recording neonatal resuscitation

Neonatal resuscitation is a common and important intervention. It is also a stressful and sometimes chaotic experience. Recollections of events may be inaccurate and teaching and learning in such circumstances are difficult. Video can accurately document events during delivery room (DR) resuscitation; it can therefore be used to assess compliance with guidelines and the effect of interventions. In many hospitals photographs or video recordings of infants can only be made with written parental permission. It is difficult and may be inappropriate to prospectively obtain parental permission to video all DR resuscitations. When a high-risk delivery is imminent, parents are invariably anxious and mothers may be in pain or unwell. They may thus be unable to give permission appropriately. If previous permission is needed, it is only possible to record resuscitations where there is considerable advance warning. This seriously limits the applicability of the findings because infants born after an unanticipated emergency, likely to be the most ill and thus of most interest, are excluded. We wished to audit the care given to newborns in the DRs of our hospital. Here, we describe the ethical and legal issues we encountered before we commenced recording DR resuscitations at our hospital. Audit is the testing of current practice against previously established guidelines or benchmarks; this contrasts with research, which is aimed at the discovery of new knowledge that is intended ultimately to help establish guidelines. In general, previous informed consent of participants is a prerequisite for research, but not for audit. Quality assurance activities are an integral part of healthcare delivery.1 Healthcare providers recognise the need to ensure that their service is of a high quality and consistent with available resources; and that not to do so is unethical.2 First reported in the 1960s,3 videotaping emergency medical procedures has long …

Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation.

AIM Clinical assessment and end-tidal CO(2) (ETCO(2)) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO(2) detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO(2) detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement. METHODS We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO(2) detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not. RESULTS Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement. CONCLUSION Colorimetric CO(2) detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases.

Ventilation and Spontaneous Breathing at Birth of Infants with Congenital Diaphragmatic Hernia

OBJECTIVE To describe the interaction of spontaneous breaths, manual ventilation, and tidal volumes (V(T)) during stabilization of infants with congenital diaphragmatic hernia (CDH) in the delivery room. STUDY DESIGN We studied infants with CDH receiving respiratory support at birth. Airway pressure, flow, and volume were measured, and each breath or inflation was analyzed. Each V(T) was classified as a manual inflation, a spontaneous breath, or a spontaneous breath coinciding with manual inflation on the basis of the timing of the pressure and flow waves. RESULTS Twelve infants had 2957 breaths suitable for analysis, with spontaneous breathing in 11 infants (92%). The mean (+/-SD) proportion of manual inflations was 41% (+/-24%), spontaneous breaths 43% (+/-25%), spontaneous but coinciding with manual inflation 16% (+/-12%). V(T) was significantly different for spontaneous breaths (3.8 +/- 1.9 mL/kg), spontaneous breaths coinciding with manual inflation (4.7 +/- 2.5 mL/kg), and manual inflations alone (2.6 +/- 1.6 mL/kg). CONCLUSIONS Most infants with CDH breathed spontaneously, and manual ventilation was mostly asynchronous. We observed large differences in tidal volumes between spontaneous breaths, manual inflations, or where these coincided, with manual inflations having the lowest V(T). Monitoring the respiratory pattern of these infants could improve respiratory support.