helping baby to breath

8/12/2019 Helping Baby to Breath

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Mohammad Al maghayrehPrincess Rahma Teaching Hospital

Helping Babies Breathe


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A healthy first cry represents a babywith unlimited potent ial


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Golden minuteAt no other time in ones life will necessarycritical concepts in resuscitation have a potentiallifelong impact

A babys first cry is one of the most anticipatedand welcome sounds in all the world

A pp rop r iate in tervent ion s can m ake thedifference between l i fe or d eath , or n or m all i fe vs . l i fe of d isabi l i ty


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Inverted Pyramidof Neonatal Resuscitation

Medications

ChestCompressions

Positive-PressureVentilation

Initial Steps: Drying Warmth

Clearing the AirwayStimulation

Assessment at Birth and SimpleNewborn Care

All infants

Some infants

Few infants

Wall, Lee, Niermeyer et al. IJGO 2009

136 millionbabies born

Approx 10million babies

Approx 6million babies

< 1.4 millionbabies


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What Can Go Wrong DuringTransition

Inadequate ventilation; oxygen may not reachblood in lungsSystemic hypotension from excess blood loss

or neonatal hypoxia and ischemiaPulmonary arterioles may remain constrictedafter birth (PPHN)Lack of perfusion and oxygenation may causebrain damage or death


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Signs of a Compromised NewbornDepressed respiratorydrive

Poor muscle toneBradycardiaTachypnea

Persistent cyanosisLow blood pressure

Goodtone withcyanosis

Bad tonewith

cyanosis


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Perinatal Compromise

Primary Apnea Oxygen deprivationPeriod of attempted rapid breathingPrimary apnea and dropping HRWill improve with tactile stimulation


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Secondary ApneaContinued oxygendeprivation leads tosecondary apnea

Heart rate and bloodpressure fallSecondary apnea cannotbe reversed withstimulation

Assisted ventilation mustbe provided


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The Theme of Neonatalresuscitation

Circle ofEvaluationDecision

ActionTimely mannerTeam work


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TABCs

Temperature Airway

Suction secretions, assess for anomalies

Breathing Stimulate respiratory effort Tactile Bag-mask positive pressure ventilation (PPV)

Circulation Assess heart rate Chest compressions if PPV ineffective at restoring heart rate


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Term gestation

Breathing orcrying?

Good tone?

YES

ROUTINE CARE

Stays with mother Provide Warmth Clear Airway Dry Ongoing evaluation

Initial steps

NO

Evaluate HRRespirations

WarmthOpen AirwayDryStimulate


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NRP algorithm (2010)

HR below 100,gasping, or apnea?

PPV, Spo2monitoring

HR below100?

Take ventilation

corrective steps

Labored

breathing orpersistentcyanosis?

Clear airway,Spo2 monitoring,Consider CPAP

Post ResuscitationCare

YES

NO

NO

Yes

IneffectivePPV (MRSOPA)


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HR below 100?

Take ventilationcorrective steps

HR below 60 ?

Consider intubationChest compressionsCoordinate with PPV

HR below 60 ?

i.v. epinephrine

Take ventilationcorrective steps

Intu bate if no chestrise!

Consider-Hypovolemia

- Pneumothorax

yes

Yes

YesNo

No

Yes

Mask AdjustmentReposition headSuction upper airwayOpen mouth and lift JawPressure increaseAirway alternative


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Plan and prepare for birthEquipment check

before birth , you should askGestational age

Clear fluidHow many babiesOther risk factor

Need additional equipmentNeed more people


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Quick pre resuscitation checklistWarm, drySuctionAuscultate

OxygenateVentilateIntubateMedicateThermoregulate


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Plastic wrap in < 2 8 wks

Polythene wrap or bag up to their necks withoutdrying.

Infants should be kept wrapped until admission andtemperature check.


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Management of Meconium

2010

???


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Bag & mask ventilation in MSAF??

If attempted intubation isprolonged and unsuccessfull .

& if there is persistentbradycardia.


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Indications for PPV

ApneaGasping respirationsHeart rate < 100


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Positive Pressure Ventilation

When done appropriately, PPV should result inimprovement in heart rate and color Appropriate size mask and bag Self-inflating vs. flow-inflating bag Forming a good seal with mask Achieve adequate chest rise 40-60 breaths per minute


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Positive Pressure Ventilation

inflation pressure?

initial inflation pressure of

20 cm H2O

30 to 40 cm H2O may be required in some term babies

without spontaneous ventilation


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Effective Ventilation

Bilateral breath soundsChest movement (HR may rise without visiblechest movement, especially with preterm baby)Most important indicator of successful PPV isimproving heart rateUse lowest inflation pressure to maintain HR

above 100


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Ineffective PPV (MR SOPA)Mask AdjustmentReposition head

Suction upper airwayOpen mouth and lift JawPressure increaseAirway alternative


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When to usePULSE OXIMETRY

- Anticipated resuscitation

positive pressure respiration is administered

- When cyanosis is persistent

- When supplemental oxygen is administered


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Oximetry and Oxygen SupplyFor all compromising babies pulse oximetry should

be used to detect the preductal saturation and heartrate

28


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OXYGEN ASSESSMENT

Insufficient Excessive

oxygenation oxygenation

Harmful to neonate


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Chest Compressions

Compression of sternum 1/3 depth of APdiameter of chestIncrease O2 to 100%


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Chest CompressionsBegin chest compressions

when HR is below 60 despiteatleast 30 seconds of effective

PPVCoordinate with ppv at 1 :3

Two thumb method ispreferred

Provides more consistentpressureBetter control of compression


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Depress sternum to approximately onethird of the anterior-posterior diameterof the chest100% oxygen should be given withchest compressionsContinue chest compressions for 45-60seconds before stopping to evaluate theHR

Intubation is highly recommendedwith chest compressions


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Endotracheal Intubation


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Endotracheal Intubation: Indications

To suction trachea in presence of meconium whenthe baby is not vigorous

To improve efficacy of ventilation after severalminutes of bag-and-mask ventilationTo facilitate coordination of chest compressionsand ventilationTo administer epinephrine while IV access isbeing established

Limit attempt to 30 seconds


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Endotracheal Intubation:Radiographic Confirmation

Correct Incorrect


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Indications for EpinephrineHeart rate persists < 60 after

Initial steps [30 seconds]PPV [30 seconds]Chest compressions [ 45-60 seconds ]

Dosage given IV (UVC preferred) , orendotracheal ( higher dose given )


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Epinephrine Administration

Dilute 1:1000 concentration of epinephrine to1:10,000

Recommended concentration: 1:10,000Recommended route: IntravenouslyRecommended dose: 0.1 to 0.3 mL/kgRecommended preparation: 1:10,000 solution in 1 mL syringe

Recommended rate of administration: Rapidly

Consider endotracheal route ONLY while IV access being obtainedRecommended dose: 0.5 to 1mL/kgPrepare 1:10,000 solution in 3 mL syringe


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Epinephrine: Poor Response(Heart Rate < 60 bpm)

Recheck effectiveness of: VentilationChest compressionsEndotracheal intubationEpinephrine delivery

Consider possibility of hypovolemia


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Indications for Volume Administration No response to above resuscitation measures History of blood loss at delivery suggesting

hypovolemia

Infant appears to be in shock (pallor, poorperfusion, failure to respond appropriately toresuscitation efforts)

IV, 10-20 mL/kg, Normal saline, Ringers lactate,or O- blood


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Withhold / discontinue resuscitation?

Age of viability in your institution.Parental informed decision

In a newly born baby with no detectable heart rate, itis appropriate to consider stopping resuscitation if the

heart rate remains undetectable for 10 minutes


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Key Points

Resuscitation requires a rapid series ofassessments, interventions, and reassessments

Prompt initiation of respiratory support withpositive pressure ventilation by bag-mask is thekey to successful resuscitation of most infants

Always consider corrective steps in ventilationand hypovolemia and pneumothorax (othercauses)


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RecommendationRoutine intrapartum oropharyngeal and nasopharyngeal

suctioning for infants born with clear and/or meconium-stained amniotic fluid is not recommended.

If attempted intubation is prolonged or unsuccessful,mask ventilation should be implemented, particularly if

there is persistent bradycardia.The LMA should be considered during resuscitation ofthe newborn if face mask ventilation is unsuccessfuland tracheal intubation is unsuccessful or not feasible.


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Endotracheal Intubation

Tracheal suctioning for non-vigorousmeconium-stained newbornEffective PPV with bag and mask and no clinical

improvementPPV lasting more than a few minutesWhen chest compressions are needed

Special indications (diaphragmatic hernia, etc)


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Use of Oxygen

Resuscitation of term newborns should beginwith 21% oxygen

Resuscitation of preterm newborns may begin

with slightly higher oxygen It may take up to 10 minutes for a healthy

newbornto become well oxygenated on room air

Place oximeter (if available) and increase oxygengradually to meet target saturations


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Umbilical cord clampingFor healthy term infants delaying cord clampingfor at least one minute or until the cord stopspulsating following delivery improves iron statusthrough early infancy.

For preterm babies in good condition at delivery,delaying cord clamping for up to 3 min results inincreased blood pressure during stabilisation, alower incidence of intraventricular haemorrhageand fewer blood transfusions


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Most infants successfully transfer from intrauterine to extrauterine lifewithout any special assistance.

10 percent of newborns will need some intervention.

1 percent will require extensive resuscitative measures at birth.

personnel who are adequately trained should be readily available to

perform neonatal resuscitation at every birthing locationInfants who are more likely to require resuscitation can be identified bymaternal and neonatal risk factors

Care providers skilled in neonatal resuscitation should be present andequipment should be prepared prior to the birth of the high-risk infant.

Preterm infants are more likely to require resuscitation and developcomplications from resuscitation than term infants


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Please take good care of me!

Im the Future!

helping baby to breath

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