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Clinicians and Educators

Airway management and mask ventilation

Technique is the key when using resuscitation devices to inflate tiny lungs at birth.

While all nurses, midwives and doctors are required to be trained and undergo annual certification in neonatal resuscitation, for the majority of clinicians an actual resuscitation is rarely encountered. Any neonatal resuscitation is a highly stressful and tense situation. If a clinician is confident in their skills, it enables them to concentrate on achieving the optimal outcome for the patient.

A sound theoretical understanding of the reasoning behind the different medical interventions taken in neonatal resuscitation provides a good basis for a clinician. This must be combined with proficient manual skills such as airway positioning and mask technique. Resuscitation scenarios, run by senior staff such as Nurse Educators, provide a key opportunity for more junior clinicians to hone their skills. For maximum value, multiple scenarios should be run to allow clinicians to assume a different role in each subsequent scenario, such as taking the lead in provision of bag and mask ventilation or intubating the patient.

Proper technique in manual ventilation is the key for effective neonatal resuscitation, delivering the optimal volume of gas to oxygenate the infant while protecting the delicate respiratory structures. The Australian and New Zealand Committee on Resuscitation (ANZCOR) Guidelines list a clear set of evidence-based procedures to follow in the event of a neonatal resuscitation. In the event of drying and stimulation failing to establish effective respiration in the newly born infant, positive pressure ventilation is the first intervention to be commenced. The Guidelines point to heart rate (heart rate greater than 100/min) as being the primary indicator of adequate resuscitation. Adequate chest wall movement is advised as another measure of the effectiveness of ventilation.

While too little chest wall movement is a sign of possible insufficient ventilation, clinicians should also be aware of the potential for trauma to the lungs associated with excessive ventilatory volumes. Limiting the potential for damage is the reasoning behind the use of the manometer on the self-inflating bag, and the Peak Inflating Pressure (PIP) valve on the T-piece resuscitator. However, as the ANZCOR Guidelines themselves state, "measured PIP does not correlate well with volume delivered in the context of changing respiratory mechanics". Clinicians should be careful about watching and limiting excessive chest wall movement of the newborn. To this end, research into neonatal ventilation is demonstrating that babies ventilated with volume-targeted modes of ventilation are more likely to survive free of lung damage.

The video below, "How to resuscitate a newborn baby" by Medical Aid Films, effectively conveys some of the main technical points to consider when resuscitating an infant.

Manual ventilation devices

Current devices used to inflate newborn lungs at birth are manual devices with no user feedback. The correct technique (mask hold, head position, delivered breath volume) is difficult to master and requires ongoing education. We rely on the user’s and trainer's  perception of chest movement as an estimate of adequate lung ventilation. Current training/annual accreditation programs do not have quantitative methods of assessing mask ventilation skill levels.

Not all devices are equal.

The self inflating bag (SIB or BVM) is the most common device used worldwide for newborn resuscitation. Over or under inflation with SIB (squeeze distance) during resuscitation of just a few breaths can have life long consequences for child, mother and family. Research into the performance of various brands of SIB used on newborns worldwide showed large variability in delivered ventilation for the same squeeze distance. Some models were shown to be dangerous and not fit for their stated purpose. This is despite being listed with the local medical device regulatory authority and compliance to international standards. Subsequently local health authorities issued a warning advising against the use of some brands (NSW Health warning).

The use of manikins in training

Use of manikins in resuscitation training programs is an established method of teaching mask ventilation but they have their limitations. Faulty manikins with internal leak due to age and tears from intubation training are not easy to detect. Internal leak combined with fixed internal lung compliance, lack of different baby manikin sizes as well as poor SIB performance can give a false user perception as to the squeeze distance required of the SIB to see a chest rise. This perception taught in training may in real resuscitation lead to over delivery of volume. Educators should be aware of this when instructing clinicians in the use of manual ventilation devices. When combined with the adrenaline induced tendency to over-inflate in an actual resuscitation, there is significant potential for error.

The ResusRight RTM

We are currently developing a resuscitation training monitor (RTM) aimed at addressing many of the issues we have seen clinicians encounter in a training or clinical setting. The ResusRight RTM provides breath by breath visual feedback to users and trainers on mask leak and expired tidal volume. This boosts user confidence and provides a higher level of training fidelity. This ability to benchmark individual assessment sessions and provide on the fly instructions to users to optimize their ventilation technique (mask hold and SIB squeeze) has not been previously available. 
The ResusRight RTM not only provide a new level of confidence in resuscitation training but it can also confirm functionality and efficacy of the SIB, T-piece resuscitator and manikin.

We currently have a survey out aimed at getting responses from nurses, midwives, doctors and paramedics on their experience with neonatal resuscitation (actual and training). If you fall into this category we would love to hear from you!

View the survey here!

Resource list

ANZCOR Guidelines 13.4 - Airway Management and Mask Ventilation of the Newborn Infant

Self-inflating bags: Testing the safety of different brands

NSW Health self-inflating bag Safety Alert

T-piece resuscitators: How do they compare?

The efficacy of respiratory monitoring in neonatal resuscitation

Ventilator-delivered mask ventilation compare with manual mask ventilation in a manikin model

T-piece resuscitator: is mask leak related to watching the pressure dial?

Monitoring Neonatal resuscitation...why is it needed?