help baby to breath

8/12/2019 help baby to breath

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Helping Babies Breathe


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A healthy first cry represents a baby

with unlimited potential


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Golden minuteAt no other time in ones life will necessary critical

concepts in resuscitation have a potential lifelongimpactA babys first cry is one of the most anticipated and

welcome sounds in all the world

Appropriate interventions can make the differencebetween life or death, or normal life vs. life of

disability !"#$ % '& (


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Inverted Pyramidof Neonatal Resuscitation

edications

ChestCompressions

Positive-PressureVentilation

Initial Steps: Drying,Warmth, Clearing theAiray, Stimulation

Assessment at !irth andSimple "e#orn CareAll infantsAll infants

Some infantsSome infants

Few infantsFew infants

Wall, Lee, Niermeyer et al. IJGO 2009

136 million

babies born

Approx 10

million babies

Approx 6 million

babies

< 1.4 million

babies


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What Can Go Wrong DuringWhat Can Go Wrong During

TransitionTransition

Inadequate ventilation; oxygen may not reachInadequate ventilation; oxygen may not reachblood in lungsblood in lungs

Systemic hypotension from excess blood loss orSystemic hypotension from excess blood loss or

neonatal hypoxia and ischemianeonatal hypoxia and ischemiaPulmonary arterioles may remain constricted afterPulmonary arterioles may remain constricted after

birth PP!"#birth PP!"#

$ac% of perfusion and oxygenation may cause$ac% of perfusion and oxygenation may cause

brain damage or deathbrain damage or death


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Signs of a Compromised NewbornSigns of a Compromised Newborn&epressed respiratory&epressed respiratory

drivedrive

Poor muscle tonePoor muscle tone'radycardia'radycardia

(achypnea(achypnea

Persistent cyanosisPersistent cyanosis$ow blood pressure$ow blood pressure

GoodGood

tone withtone with

cyanosiscyanosis

Bad toneBad tonewithwith

cyanosiscyanosis


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Perinatal CompromisePerinatal Compromise

Primary ApneaPrimary Apnea)xygen deprivation)xygen deprivationPeriod of attempted rapid breathingPeriod of attempted rapid breathingPrimary apnea and dropping !*Primary apnea and dropping !*+ill improve with tactile stimulation+ill improve with tactile stimulation


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Secondary ApneaSecondary Apnea,ontinued oxygen,ontinued oxygendeprivation leads todeprivation leads tosecondary apneasecondary apnea

!eart rate and blood!eart rate and bloodpressure fallpressure fallSecondary apnea cannot beSecondary apnea cannot be

reversed with stimulationreversed with stimulationAssisted ventilation mustAssisted ventilation must

be providedbe provided


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The Theme of Neonatalresuscitation

ircle of!valuation"ecision

ActionTimely mannerTeam wor#


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TABs

Temperature Airway

Suction secretions- assess for anomalies

Breathing Stimulate respiratory effort (actile

'ag.mas% positive pressure ventilation PP/#

irculation Assess heart rate ,hest compressions if PP/ ineffective at restoring heart rate


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Term gestation

Breathing orcrying$

%ood tone$

&!'

R()TIN! AR!

Stays with motherProvide +armth,lear Airway&ry)ngoing evaluation

Initial steps

N(

!valuate HRRespirations

*armth(pen Airway

"ry 'timulate


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NP algorithm !"#$#(

HR below +,,-gasping- or apnea$

PP.- 'po/ monitoring

HR below +,,$

Ta#e ventilation

corrective steps

0abored breathingor persistent

cyanosis$

lear airway-'po/ monitoring-onsider PAP

Post Resuscitation are

YES

NO

NO

Yes

Ineffecti%e

PP& !'

S(PA)


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HR below +,,$

(a%e ventilation correctivesteps

HR below 60$

onsider intubationhest compressions

oordinate with PP.

HR below 60$

i.v. epinephrine

Ta#e ventilation

corrective stepsIntubate if no chest rise!

onsider.Hypovolemia

.Pneumothora1

yes

Yes

YesNo

No

Yes

Mask Adjustment

Reposition head

Suction upper airway

Open mouth and lift JawPressure increase

Airway alternative


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Plan and prepare for birth

!2uipment chec# before birth - you should as#

%estational age

lear fluidHow many babies

(ther ris# factor

Need additional e2uipment

Need more people


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*uic+ pre resuscitation chec+list

*arm- dry'uctionAuscultate

(1ygenate.entilateIntubate3edicate

Thermoregulate


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Plastic wrap in 4 /5w#s

Polythene wrap or bag up to their necks

without drying.

Infants should be kept wrapped until

admission and temperature check.


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'anagement of 'econium

0121

333


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,ag - mas+ %entilation . in 'SA/??

If attempted intubation is

prolonged and unsuccessfull

0

- if there is persistent

bradycardia0


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Indications for PP.

Apnea%asping respirationsHeart rate 4 +,,


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Positi%e Pressure &entilation

*hen done appropriately- PP. should result inimprovement in heart rate and color Appropriate si4e mas% and bag

Self.inflating vs5 flow.inflating bag

Forming a good seal with mas%

Achieve adequate chest rise

61.71 breaths per minute


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Positi%e Pressure &entilation

inflation pressure?

initial inflation pressure of

"# cm 1"(

2# to 3# cm 1"( may be re4uired in some term

babies without spontaneous %entilation


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5ffecti%e &entilation

'ilateral breath sounds

,hest movement !* may rise without visible

chest movement- especially with preterm baby#

8ost important indicator of successful PP/ isimproving heart rate

9se lowest inflation pressure to maintain !*

above 211


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Ineffective PP. 63R '(PA3as# Ad7ustmentReposition head

'uction upper airway(pen mouth and lift 8 awPressure increase

Airway alternative


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When to use

P67S5 (8I'5T9

- Anticipated resuscitation

positive pressure respiration is administered

- hen cyanosis is persistent

- hen supplemental o!ygen is administered


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(:imetry and (:ygen SupplyFor all compromising babies pulse oximetry should be

used to detect the preductal saturation and heart rate

28


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(89G5N ASS5SS'5NT

Insufficient "!cessive

o!ygenation o!ygenation

#armful to neonate

h i


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hest ompressions

ompression of sternum +9: depth of AP diameter ofchest

Increase (/ to +,,;


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Chest Compressions

Begin chest compressions when

HR is below ?inger Techni2ueBetter for small handsProvides access to umbilicus for

medications


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Depress sternum to approimately one

third of the anterior!posterior diameter

of the chest

"##$ oy%en should &e %iven with

chest compressions

'ontinue chest compressions for ()!*#

seconds &efore stoppin% to evaluate the

+R

,ntu&ation is hi%hly recommended

with chest compressions


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5ndotracheal Intubation


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5ndotracheal Intubation; Indications

(o suction trachea in presence of meconium when thebaby is not vigorous

(o improve efficacy of ventilation after severalminutes of bag.and.mas% ventilation

(o facilitate coordination of chest compressions andventilation

(o administer epinephrine while I/ access is beingestablished

-imit attempt to .# seconds


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5ndotracheal Intubation;

adiographic Confirmation

Correct IncorrectCorrect Incorrect


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Indications for !pinephrine

Heart rate persists 4


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5pinephrine Administration

Dilute 1:1000 concentration of epinephrine toDilute 1:1000 concentration of epinephrine to

1:10,0001:10,000

eco!!ended concentration: 1:10,000eco!!ended concentration: 1:10,000

eco!!ended route: Intra"enouslyeco!!ended route: Intra"enously

eco!!ended dose: 0#1 to 0#$ !%&'(eco!!ended dose: 0#1 to 0#$ !%&'(

eco!!ended preparation: 1:10,000 solution in 1 !% syrin(eeco!!ended preparation: 1:10,000 solution in 1 !% syrin(e

eco!!ended rate of ad!inistration:eco!!ended rate of ad!inistration: RapidlyRapidly

Consider endotracheal route )*%+ while I access -ein( o-tainedConsider endotracheal route )*%+ while I access -ein( o-tained

eco!!ended dose: 0#. to 1!%&'(eco!!ended dose: 0#. to 1!%&'(

/repare 1:10,000 solution in $ !% syrin(e/repare 1:10,000 solution in $ !% syrin(e

i h i


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5pinephrine; Poor esponse

!1eart ate < =# bpm(

Rechec# effectiveness of=

/entilation

,hest compressions

:ndotracheal intubation

:pinephrine delivery

onsider possibility of hypovolemia


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Indications for &olume Administration

No response to above resuscitation measures History of blood loss at delivery suggesting

hypovolemia

Infant appears to be in shoc# 6pallor- poor perfusion-failure to respond appropriately to resuscitationeffortsD

I.- +,>/, m09#g- Normal saline- Ringers lactate- or(> blood


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Withhold > discontinue resuscitation?

Age of viability in your institution5

Parental informed decision

In a newly born baby with no detectable heart rate- it isappropriate to consider stopping resuscitation if the heart

rate remains undetectable for+,minutes


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Eey Points

Resuscitation re2uires a rapid series of assessments-interventions- and reassessments

Prompt initiation of respiratory support with positivepressure ventilation by bag>mas# is the #ey tosuccessful resuscitation of most infants

Always consider corrective steps in ventilation andhypovolemia and pneumothora1 6other causesD


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RecommendationRoutine intrapartum oropharyngeal and nasopharyngeal

suctioning for infants born with clear and9or meconium>stainedamniotic fluid is not recommendedF

If attempted intubation is prolonged or unsuccessful- mas#ventilation should be implemented- particularly if there is

persistent bradycardiaFThe 03A should be considered during resuscitation of thenewborn if face mas# ventilation is unsuccessful and trachealintubation is unsuccessful or not feasibleF


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5ndotracheal Intubation

(racheal suctioning for non.vigorous

meconium.stained newborn

:ffective PP/ with bag and mas% and no clinical

improvementPP/ lasting more than a few minutes

+hen chest compressions are needed

Special indications diaphragmatic hernia- etc#


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6se of (:ygen

*esuscitation of term newborns should begin with02 oxygen

*esuscitation of preterm newborns may begin with

slightly higher oxygen It may ta%e up to 21 minutes for a healthy newborn

to become well oxygenated on room air

Place oximeter if available# and increase oxygengradually to meet target saturations


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6mbilical cord clamping

For healthy term infants delaying cord clamping for atleastone minute or until the cord stops pulsatingfollowing delivery improves iron status through earlyinfancy5

For preterm babies in good condition at delivery-delaying cord clampingfor up to : min results inincreased blood pressure during stabilisation- a lowerincidence of intraventricular haemorrhage and fewer

blood transfusions


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3ost infants successfully transfer from intrauterine to e1trauterine life withoutany special assistanceF

+, percent of newborns will need some interventionF

+ percent will re2uire e1tensive resuscitative measures at birthF

personnel who are ade2uately trained should be readily available to perform

neonatal resuscitation at every birthing location GInfants who are more li#ely to re2uire resuscitation can be identified by

maternal and neonatal ris# factors

are providers s#illed in neonatal resuscitation should be present and e2uipmentshould be prepared prior to the birth of the high>ris# infantF

GPreterm infants are more li#ely to re2uire resuscitation and developcomplications from resuscitation than term infants


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Im the Future!

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