Neonatal resuscitation programme, NRP

Detailed description of NRP

1. NEONATAL RESUSCITATION DR . LOKANATH REDDY JUNIOR RESIDENT DEPT. OF PAEDIATRICS KASTURBA MEDICAL COLLEGE MANIPAL

2. Neonatal Resuscitation History Overview and Principles of Resuscitation Initial steps of resuscitation Positive – Pressure ventilation Chest compressions Endotracheal tube intubation and LMA insertion Medications Special considerations Resuscitation of Preterm babies Ethics and Care at the end of life

3. Historical aspects For the past 40 yrs Fetal anoxia was one of the most investigated conditions affecting the newborn. Better understanding of the effect of certain conditions on fetus like placental disease and hemorrhage. It was then realized that obstruction to the airway immediately following birth should be the first concern in newborn resuscitation.

4. Historical aspects 18 th Century Scottish Obstetrician Blundell first used mechanical device for tracheal intubation in living newborn In 1920 Joseph B. DeLee introduced simple rubber catheter and glass trap to clear upper airways and stomach. In 1953 Apgar Score was given by Varginia Apgar . She is also the first to catheterise UA in newborn

5. Historical aspects 1966 national guidelines for resuscitation of adults was recommended by National Academy of Sciences. In 2000 the consensus document on advanced life support of the newborn converted the previously published advisory statements into a set of guidelines. In 2010 revised guidelines was published.

6. Bill keenan – Father of NRP  Professor of Pediatrics and Director of the Neonatology Department at Saint Louis University in St. Louis, Missouri.

7. Causes of Neonatal Mortality 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900

8. Overview and Principles WHY TO LEARN NEWBORN RESUSCITATION ? Birth asphyxia accounts for about 1/4 th of the 4 million neonatal deaths that occur each year worldwide. For many newborns resuscitation is not available Outcomes of these newborns can be improved with timely and effective resuscitation .

9. Overview and Principles Approximately 90% of newborns make smooth transition from intrauterine to extrauterine life requiring little or no assistance 10% of newborns need some assistance Only 1% require extensive resuscitation We must always be prepared to resuscitate, as even some of those with no risk factors will require resuscitation.

10. Overview and Principles ADULT vs. NEONATAL RESUSCITATION The sequence of resuscitation in adults is C-A-B But in newborns the sequence remains A-B-C as the etiology of neonatal compromise is nearly always a breathing difficulty AIRWAY(position and clear) BREATHING (stimulate to breathe) CIRCULATION (assess HR and oxygenation)

11. Newborn Resuscitation Pyramid Always needed Needed less frequently Rarely needed

12. Overview and Principles – Changes in newborn physiology

13. Overview and Principles – Changes in newborn physiology BEFORE BIRTH Oxygen supply by placental membranes No role of lungs. Fluid filled alveoli and constricted arterioles due to low Po2 in fetal blood.

14. Overview and Principles – Changes in newborn physiology Low Po2  constricted arterioles  increased pulmonary vascular resistance  shunting of blood from Pulmonary Artery  Ductus Arteriosus  Aorta.

15. Overview and Principles – Changes in newborn physiology AFTER BIRTH Baby cries  takes first breath  air enters alveoli  alveolar fluid gets absorbed  increased Po2  relaxes pulmonary arterioles  decreased PVR

16. Overview and Principles – Changes in newborn physiology Umbilical arteries constrict + clamp cord  closure of Umbilical Arteries and Umbilical Vein  increased SVR Decreased PVR + Increased SVR  functional closure of Ductus Arteriosus  increased blood flow into lungs  oxygenation  supply to body through aorta.

17. Overview and Principles – Changes in newborn physiology WHAT CAN GO WRONG ? Compromise of uterine or placental blood flow  deceleration of FHR (1 st clinical sign) Weak cry  inadequate ventilation to push the alveolar fluid In utero hypoxia  Meconium passage may block the airways Fetal blood loss (abruption)  Systemic Hypotension Fetal Hypoxia/ischemia  poor cardiac contractility & fetal bradycardia  Systemic Hypotension Pulmonary arterioles remain constricted  PPHN

18. C onsequences of interrupted transition Low muscle tone Respiratory depression (apnoea / gasping) Tachypnea Bradycardia Hypotension Cyanosis

19. C hanges due to oxygen deprivation Rapid breathing Irregular Gasping If the baby does not begin breathing immediately after being stimulated, he or she is likely In secondary apnea and will require PPV

20. Primary Apnea Stimulation Secondary Apnea Effective Positive pressure ventilation Myocardium is depressed Chest compressions, medications C hanges due to oxygen deprivation

21. E quipment required Suction Catheter Oral mucus sucker Radiant warmer

22. TRANSPORT INCUBATOR

23. INITIAL STEPS OF RESUSCITATION

24. Initial steps of resuscitation Term / Preterm ? Term: smooth transition Preterm : stiff, under-developed lungs, insufficient muscle strength, can’t maintain temperature Breathing/Crying ? Watch baby’s chest Gasping is a series of deep, single or stacked inspirations that occur presence of hypoxia/ischemia. Treated as apnea.

25. I nitial steps Good tone ? Term: flexed extremities Preterm/sick: flaccid/limp, extended extremities

26. I nitial steps Provide warmth : Radiant warmer, don’t cover with towels. Position head and clear airway as necessary Dry and stimulate the baby to breathe, reposition

27. P osition “ SNIFFING DOG ”

28. C lear airway Suction mouth first, then nose “M” before “N” To prevent aspiration of mouth contents

29. Clear airway Vigorous if Good tone Good Cry/ Breathing HR> 100/min

30. M econium, non-vigorous baby Insert Laryngoscope Clear Mouth and posterior pharynx using 12F/14F catheter Insert ET tube Attach ET tube to meconium aspirator and suction source Apply suction and remove slowly Count 1-1000,2-1000,3-1000, withdraw Repeat if HR is < 100

31. D ry ,Reposition, Stimulate Stimulate : Flicking the soles/ drying & rubbing the back

32. E valuation Respirations Heart rate: Best is auscultation, alternatively pulsations at base of cord is felt. Count for 6s and “x”10 Oxygenation by oximeter

33. B reathing If Apneic or HR < 100 bpm: Provide positive-pressure ventilation,spo2 monitoring. If breathing, and heart rate is >100 bpm but baby is cyanotic, give supplemental oxygen, spo2 monitoring. If cyanosis persists, provide positive-pressure ventilation If respiratory distress is persistent , consider CPAP and connect oximeter

34. Supplemental oxygen Free flow oxygen Oxygen mask Flow inflating bag T- piece resuscitator Oxygen tubing held close to baby’s nose CPAP provided with Flow inflating bag T-piece resuscitator Start with room air and increase to maintain target SpO2 Time Target Spo2 1min 60-65% 2min 65-70% 3min 70-75% 4min 75-80% 5min 80-85% 10min 85-95%

35. F ree-flow oxygen given via oxygen tubing

36. MASK Flow Inflating Bag T-Piece Resuscitator

37. P ositive pressure ventilation Ventilation of the lungs is the single most and most effective step in newborn resuscitation Indications: Gasping/apnea HR < 100/min SpO2 remains below target values despite free flow supplemental oxygen increased to 100%.

38. Positive pressure ventilation Peak inspiratory pressure (PIP) : Pressure delivered with each breath, such as the pressure at the end of a squeeze of resuscitation bag or at the end of breath with a T – piece resuscitator Positive end – expiratory pressure (PEEP) : The gas pressure which remains in the system between breaths, such as during relaxation and before the next squeeze

39. Positive pressure ventilation Continuous positive airway pressure(CPAP) : Same as PEEP, but used when the baby is breathing spontaneously and not receiving PPV. It is pressure in the system at the end of spontaneous breath when a mask is held tightly on baby’s face but the bag is not being squeezed. Rate: The number of assisted breaths given per minute

40. Self Inflating bag Flow Inflating Bag T-Piece Resuscitator DEVICES USED

41. Self inflating bag Flow inflating bag T- Piece resuscitator Does not require Compressed Gas source for inflation of Bag Requires Compressed Gas Source for inflating the bag Requires Compressed Gas Source for inflating the bag Functions even without a proper seal Does not work without proper seal Does not work without proper seal PIP/Ti How hard & Long the bag in squeezed Flow of incoming gas and how hard & long the bag is squeezed Can be set exactly manually PEEP Only if additional valve is attached Given by adjusting flow control valve Can be set exactly manually CPAP/Free flow O2 Cannot be delivered Given by adjusting flow control valve Can be set exactly manually Safety Features Pop-Off Valve Pressure gauge Pressure gauge Maximum Pressure relief valve Pressure gauge

42. M ask Appropriate Sizes Mask should Rest on Chin Cover Mouth & Nose

43. Suction & Position Cup the chin in the mask and then cover the nose Light Pressure on mask to create a seal Anterior pressure on posterior rim of mandible

44. F requency of ventilation: 40 to 60 breaths per minute Start With 21% ( higher in preterm's) oxygen and increase according to target Saturation Initial Pressure at 20mmH2O

45. Ensure Effective PPV Most Important sign is the rising of HR Improvement in Oxygen Saturation Equal and adequate breath sounds B/L Good Chest rise

46. E valuation Heart rate Oxygenation by oximeter If heart rate <100 bpm

47. Ventilation corrective steps Corrective steps Action M Mask Adjustment Ensure Good seal of mask on face R Reposition airway Sniffing Position S Suction Mouth and nose If secretions present O Open mouth Ventilate with baby mouth slightly open and lift the jaw forward P Pressure increase Gradually increase the pressure every few breaths A Airway alternative Consider ET or Laryngeal mask airway

48. PPV continued more than several minutes Place an OG tube, Suction gastric contents and leave the end open.

49. E valuation If heart rate <60 bpm despite adequate ventilation for 30 seconds,

50. C hest compressions Indications : HR <60/min despite at least 30 sec of effective PPV Strongly c onsider Endotracheal intubation at this point as it ensures adequate ventilation and facilitates the coordination of ventilation and chest compressions

51. Chest compressions Rationale: HR<60/min despite PPV indicates very low O2 levels and significant acidosis  depressed myocardium  no blood in lungs to get oxygenated(supplied by PPV) Chest compressions + effective ventilation (ET/PPV)  oxygenation of blood  recovery of myocardium to function spontaneously  HR increases  O2 supply to brain increases

52. Chest compressions Principle: Rhythmic compressions of sternum that Compress the heart against the spine Increases intrathoracic pressure Circulate blood to vital organs Chest compressions  compresses heart & increased Intrathoracic pressure  blood pumped into arteries Pressure released  blood enters heart from veins

53. Chest compressions Positions : Chest compressions are of little value unless the lungs are effectively ventilated 2 persons are required 1 – chest compressions provider should have access to the chest with his hands positioned correctly 2 – Ventilation provider should be at head end to maintain effective mask-face seal or to stabilize ET tube

54. Chest compressions Technique: Thumb technique: 2 thumbs depress the sternum, hands encircle the torso and the fingers support the spine. Preferred technique 2 – Finger technique: Tips of middle & index/ring finger of one hand compresses sternum, other hand supports the back.

55. Chest compressions Thumb technique is preferred as Better control of depth of compression Can provide pressure consistently Superior in generating peak systolic and coronary arterial perfusion pressure.

56. Chest compressions For small chests with thumbs overlapped

57. Chest compressions

58. Chest compressions 2- finger technique

59. Chest compressions

60. Chest compressions Depth : 1/3 rd of the anter0posterior diameter of chest. Duration of downward stroke should be shorter than the duration of release Do not lift the fingers off the chest

61. Chest compressions Complications: Laceration of liver Breakage of ribs

62. Chest compressions Coordination of chest compressions and ventilation: Avoid giving compression and ventilation simultaneously 1 breathe after every 3 compressions Ratio is 1 : 3 or 30: 90 per minute One cycle: 2 sec, 3Compresssions + 1 ventilation 1 minute : 30 cycles or 120 events (90 compressions + 30 breaths)

63. Chest compressions When to stop chest compressions? Reassess after 45-60 sec, if HR > 60/min stop chest compressions and increase breaths to 40-60 per minute. If HR is not improving… Insert an umbilical catheter and give IV epinephrine

64. E ndotracheal I ntubation

65. Endotracheal Intubation WHEN TO CONSIDER INTUBATION ? Indications in resuscitation Baby is floppy, not crying, and preterm HR < 100/min, gasping/apnea HR < 100/min inspite of PPV HR < 60/min No adequate chest rise and no clinical improvement If chest compressions are needed, intubation provides better coordination and efficacy of PPV To administer drugs

66. Endotracheal Intubation WHEN TO CONSIDER INTUBATION ? Special conditions Meconium aspiration if baby is depressed in which it is the first step to be done Extreme Prematurity Surfactant administration Suspected diaphragmatic hernia

67. Endotracheal Intubation- Equipment and supplies Laryngoscope with extra blades and bulbs Straight blades Term – 1 Preterm – 0 Extremely preterm - 00

68. ET tube sizes Weight GA(weeks) Tube size(mm) (internal diameter) Below 1 kg 28 2.5 1-2 kg 28-34 3.0 2-3 kg 34-38 3.5 >3kg >38 3.5- 4.00

69. ET tube – Uniform diameter, uncuffed

70. ET tube – Vocal cord guide

71. Procedure… Position

72. Position

73. P osition

74. Position

75. CRICOID PRESSURE SUCTIONING

76. Endotracheal Intubation: Anatomic Landmarks

77. Procedure

78. Add 6 to baby’s wt. Wt Depth of insertion < 750g 6cm 1kg 7cm 2kg 8cm 3kg 9cm 4kg 10cm F ixing ET tube

79. C onfirm position Watching the tube passing between cords Watching for chest movements Listening for breath sounds ( Axilla and stomach) Colourimeter/Capnography ( Can also be used for PPV with mask or LMA Improvement in HR and Spo2 Vapour Condensing inside tube

80. Laryngeal Mask Airway LMA

81. M edications - Adrenaline Mechanism of action : Increases systemic vascular resistance Increases coronary artery perfusion pressure Improves blood flow to myocardium and restores depleted ATP Indications : If HR remains < 60/min even after 30 sec of effective ventilation preferably after intubation and atleast another 45-60 sec of coordinated chest compressions and effective ventilation

82. Medications - Adrenaline Administration : Intravenous (recommended) Endotracheal Preparation and dosage: Adrenaline vial 1ml = 1mg (1:1000 solution) Dilute with NS to make 1:10,000 solution (1ml = 100 mcg) IV : 0.1-0.3 ml/kg = 10-30 mcg/kg ET : 0.5 – 1 ml/kg = 50-100 mcg/kg Give rapidly – as quickly as possible Can repeat every 3-5 minutes

83. M edications – volume expanders Indications: Bradycardia not improving with adrenaline Placenta previa / Abruption Volume Expanders: Normal saline (recommended) Ringer lactate Dosage: 10 ml/kg Route : Umbilical vein Rate: over 5-10 min , rapid infusion may cause IVH in <30 weeks babies

84. Resuscitation of preterms Additional resources , additional personnel, additional thermoregulation strategy Portable warming pad Polyethylene Plastic wrap (< 29wk) Prewarmed transport incubator Use of Oxymeter , blender to target Spo2 85%- 95% Use Lower PIP 20-25 cm of H2O during PPV Consider giving CPAP Consider Surfactant

85. Post Resuscitation Care Avoid hyperthermia, consider therapeutic hypothermia within 6 hrs for >36wks and E/O Acute perinatal HIE Monitor for Apnea, bradycardia, BP, SPo2 &Urine output. Monitor B. Sugars, electrolytes , Hematocrit , Platelets, ABG Maintain adequate oxygenation & support ventilation as needed

86. Post Resuscitation Care Delay feeds, Start IV fluids, consider parenteral nutrition Consider inotropes , fluid bolus Ensure adequate ventilation before giving sodium bicarbonate(only in severe metabolic acidosis)

87. Special considerations Choanal atresia – oral Airway Pierre Robin : place prone , 12F Et through nose with tip in post pharynx Laryngeal web, cystic hygroma, Cong. Goiter- ET/tracheostomy Pneumothorax : Percutaneous needle aspiration Pleural effusion : Percutaneous needle aspiration Congenital Diaphragmatic hernia

88. Ethical issues Meeting and discussing with parents and documenting the conversation. Where GA ( < 23wks ), B.wt ( < 400g) and / or Cong. Anomalies are associated with certainly early death and unacceptably high morbidity among rare survivors resuscitation is not indicated After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (no heart beat and no respiratory effort).

89. CHANGES IN 2010

90. Resuscitation step Recommendations (2005) Recommendations (2010) Comments/LOE Assessment Four questions • Amniotic fluid- clear or not? Three questions • Gestation-term or not? • Tone- Good? • Breathing /Crying? However, tracheal suction of nonvigorous babies with (MSAF) still to be continued Assessment ( after initial steps ) Look for 3 signs • Hear rate • Color • Respiration Look for 2 signs • Heart rate • Respiration( Labored, unlabored, apnea, gasping) HR Palpation of umbilical cord pulsation Auscultation of heart at the precordium is the most accurate LOE4

91. Resuscitation step Recommendations (2005) Recommendations (2010) Comments/LOE Oxygenation Pulse oximetry recommended for only preterm < 32weeks with need for PPV pulse oximetry for both term and preterm Target saturation (pre-ductal) Not defined Target SpO2 ranges provided as a part of algorithm

92. Initial oxygen concentration for resuscitation in case of PPV Term babies(≥ 37 weeks) • Start with 100% O2 during PPV • In case non availability of O2- start room air resuscitation Preterm babies(<32weeks) Start with oxygen concentration between 21-100% Term babies (≥ 37 weeks) LOE-2 • Start with room air (21%) •use higher concentration by graded increase up to 100% to attain target saturations Preterm(<32weeks) • Initiate resuscitation using O2 concentration between 30-90% Initial breath strategy Positive pressure ventilation (PPV) No specific PIP recommendation • No specific recommendation for PEEP • Guiding of PPV looking at chest rise and improvement in heart rate PIP- for initial breaths 20-25 cm H2O for preterm and 30-40 cm H2O for some term babies • PEEP for preterm infants, if provided with T-piece or flow inflating bags (LOE 5)

93. CPAP in delivery room Suggested for preterm babies ( < 32 weeks) with respiratory distress Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP Therapeutic Hypothermia No sufficient evidence recommended for infants ≥ 36weeks with moderate to severe HIE

94. Summary Doing the simple things better is probably the most cost-effective policy. Resuscitation can come as complete surprise So be prepared for resuscitation. It may take several hours to learn but it should be implemented over seconds. Practice makes one perfect.

95. References Neonatal resuscitation Textbook 6 th ed. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900 Park’s Textbook of Preventive and Social Medicine , K. park 21 st Edition .