Neonatal Resuscitation Program—What is New?

Sharad  Thora; VP  Goswami; Manju  Biswas

SECTION 1

1Neonatology2

Neonatal Resuscitation Program—What is New?1

Sharad Thora,

VP Goswami,

Manju Biswas

Introduction

The Neonatal Resuscitation Program (NRP) was first launched in 1987, as a learning program, the primary goal of which was to ensure that at least one person trained in neonatal resuscitation techniques was present at every hospital birth. As a continued learning process, this chapter brings changes in resuscitation practice and a new education methodology that transform the instructor from a “teacher” to a “learning facilitator”. The changes are both in program instructions and stepwise methodology.

Programmatic Changes

Instructor eligibility criteria: This includes physicians (MD, DO), registered nurses, respiratory therapists, and physician's assistants. Professionals who become NRP instructors have to maintain their instructor status through continuous ongoing online examination. Each instructor must teach at least two courses in the two years for which their instructor card is valid. Each current NRP instructor must own a personal copy of the NRP Instructor DVD: an interactive tool for facilitation of stimulation-based learning and complete the post-DVD education activity. For more information, visit www.aap.org/nrp and click on the ‘online examination’ option.

Provider course changes: There is no more renewal course, in addition with two new performance checklists. The learner must pass the online examination within 30 days before attending the in-person provider course. Provider course has three essential components: (1) cognitive skills (textbook content); (2) technical skills (hand-on practice and demonstration at skill stations); and (3) teamwork and communication skills (stimulation and debriefing).

Neonatal resuscitation changes: “Textbook of Neonatal Resuscitation, 6th Edition” focuses on practice recommendations to ensure adequate ventilation while avoiding lung injury, hypoxia and hyperoxia.

No longer “optional” items in the birth setting:

Compressed air source
Oxygen blender
Pulse oximetry
Laryngeal mask airway (LMA).

There are two levels of resuscitation care:

Routine care: For vigorous term babies with no maternal risk factor and those who responded to the initial steps, should not be separated from their mothers.
Postresuscitation care: For babies who have depressed breathing or activity and/or require supplemental oxygen, requiring frequent monitoring and evaluation.

Beginning of resuscitation of a term baby with room air (21% oxygen), for preterm infants, an ideal oxygen concentration is not known.
Use pulse oximetry during resuscitation.
Oxygen concentration is adjusted to achieve age-specific preductal oxygen saturation (right hand or wrist) targets as per norms.
A mnemonic for the learners to recall all steps (MRSOPA).
- M—Reapply the mask to ensure a good face mask seal.
- R—Reposition the head to ensure an open airway. Reattempt ventilation, if no bilateral breath sounds and no chest movements.
- S—Suction of the mouth and nose to ensure open airway.
- O—Open the infant's mouth with your finger to improve ventilation.
- Reattempt ventilation, if no breath sounds and no chest movements are there.
- P—Increase pressure of every breath until bilateral breath sounds and chest rise are evident.
- A—If still unsuccessful, use an alternate airway [endotracheal tube (ET) or LMA].
Endotracheal intubation procedure is now allowed for 30 seconds instead of 20 seconds. Intubation is recommended before chest compressions are performed. Administration of free-flow oxygen during intubation is no longer recommended if the baby is not breathing.
All the positive pressure ventilation devices should be equipped with pressure-monitoring devices.
Laryngeal mask airway placement has been added.
Oxygen concentration should be increased to 100% when chest compressions have to be performed.

Therapeutic Hypothermia

Infants with greater than or equal to 36 weeks’ gestational age and who meet the definite criteria for this therapy.
Initiated within 6 hours of birth.
Used only by centers with specialized programs equipped to provide the therapy.

Recommendations for the Management of a Preterm Infant (Table 1)

Increase the temperature of the delivery room and the area where the baby has to be resuscitated to 26°C. Place the infant under a radiant warmer.
Use plastic wraps for the babies delivered at less than 29 weeks’ gestational age.
Place a portable warming pad (exothermic mattress) under the layers of towels on the resuscitation table.

Withholding and Discontinuing Resuscitation

A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal in noninitiation and discontinuation of resuscitation:
- When gestation, birth weight or congenital anomalies are associated with almost certain early death and high morbidity among the survivors.
- In conditions associated with uncertain prognosis in which survival chances are borderline, with high morbidity rate, parental desires concerning initiation of resuscitation should be supported.

Table 1 Comparisons for the changes in recommendations

Resuscitation steps	Recommendations (2005)	Recommendations (2010)
Assessment for the need of resuscitation	Four questions: 1. Gestation—term or not? 2. Amniotic fuid—clear or not? 3. Tone—good? 4. Breathing/crying?	Three questions: 1. Gestation—term or not? 2. Tone—good? 3. Breathing/crying?
Routine care (given if the answer to all the three questions is ‘Yes’)	• Provide warmth • Clear airway • Dry • Assess color	• Provide warmth • Assure open airway • Dry • Ongoing evaluation (color, activity and breathing)
Initial steps	• Provide warmth • Position; clear (if required) • Dry, stimulate, reposition	• Provide warmth • Open airway (no routine suction) • Dry, stimulate
Assessment (after initial steps and ongoing): • For the need of progressive steps after initial steps • Of heart rate	Look for three signs: 1. Respiration 2. Heart rate 3. Color Palpation of umbilical cord pulsation for 6 seconds and multiply by 10	Look for two signs: • Heart rate • Respiration (labored, unlabored, apnea, gasping) Auscultation of heart at pericardium is the most accurate
Positive pressure ventilation (PPV): • Indication for PPV • Assessment of efectiveness of resuscitation steps once PPV is started	Indications are (any one out of three): • Heart rate less than 100 beats/ minute • Apnea or gasping • Persistent central cyanosis despite free-fow oxygen Heart rate Color Respiration	Indications are (any one out of two): • Heart rate less than 100 beats/minute • Apnea or gasping Heart rate Color Respiration
Initial oxygen concentration for resuscitation in case of PPV	Term babies (< 37 weeks): • Start with 100% O₂ during PPV • If room air resuscitation is started, O₂ up to 100% should be given if no improvement within 90 seconds • In case of unavailability of O₂—start room air Preterm babies (< 32 weeks): • Start with oxygen between 21% and 100% • Advocates use of blender for graded O₂ • Pulse oximetry for targeting SpO₂—85–95%	Term babies (< 37 weeks): • Start with room air (21%) • No improvement in heart rate or oxygenation-use up to 100% to attain target saturations • Use blender for graded increase in delivered oxygen concentrations Preterm babies (< 32 weeks): • Initiate resuscitation using O₂ concentration between 30% and 90% • Uses blended air oxygen mixture judiciously guided by pulse oximetry
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Peripartum suctioning for neonates born through meconium-stained amniotic fuid	• No routine oropharyngeal and nasopharyngeal suction • Tracheal suction only in nonvigorous babies born through meconium-stained amniotic fuid (MSAF)	• No routine oropharyngeal and nasopharyngeal suction required • Tracheal suction of nonvigorous babies with MSAF still to be continued, though evidence for the same is conficting
Initial breath strategy positive pressure ventilation (PPV)	• No specific recommendations for short or long infating time • No specific recommendations for positive end-expiratory pressures (PEEP) • Guiding of PPV looking at chest rise and improvement in heart rate	• No specific recommendations for short or long infation time as evidence is conficting • Peak infation pressure (PIP)-for initial breaths 20-25 cm H₂O for term
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 or ventilation as per local practice
Airway management: • Confirmation of endotracheal tube placement • Laryngeal mask airway	Exhaled CO2 detection is recommended except in cardiac asystole where direct laryngoscopy may have to be done For near-term and term infants, greater than 2,500 g may be used with no defnite mention of indications	Exhaled CO2 detection is recommended except in cardiac asystole where direct laryngoscopy may have to be done. LMA may be used for infants greater than 2,000 g and more than 34 weeks in case bag and mask are inefective and tracheal intubation is unsuccessful or not feasible
Chest compression	• Ratio of compression is 3:1 • Two-thumb technique is better than two-fnger technique • The compression is applied at the lower one-third of the sternum • The depth of compression should be one-third of the anteroposterior diameter of the chest	• Ratio of compression is 3:1 unless cardiac etiology, where ratio of 15:2 may be considered • Two-thumb technique is better than two-fnger technique • The compression is applied at the lower one-third of the sternum • The depth of compression should be one-third of the anteroposterior diameter of the chest
Drugs • Naloxone	Naloxone is considered in case of infants born to mothers with a history of opioid exposure within 4 hours of delivery and there is persistent respiratory depression even after restoration of heart rate and color by efective PPV	• Naloxone is not recommended as a part of initial resuscitation in babies with respiratory depression • Focus needs to be on efective ventilation
Supportive care	• No sufcient evidence is recommended for the routine use of modest systemic or selective cerebral hypothermia after resuscitation in infants with suspected asphyxia • Avoid hyperthermia in such cases • Not recommendedy	• Therapeutic hypothermia (whole body or selective head cooling) recommended for infants more than 36 weeks with moderate to severe hypoxia ischemic encephalopathy as per the protocol used in major cooling trials with provision for monitoring for side-efects and long-term follow-up • For uncomplicated births, both term and preterm not requiring resuscitation—delay cord clamping by at least one minute

Discontinuing Resuscitative Efforts

In a newborn baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes. Beyond 10 minutes, resuscitation efforts should be continued in conditions such as presumed etiology of the arrest, the gestation of baby and parental desires about the acceptable risk of morbidity.

Neonatal Resuscitation Program (Flow chart 1)

Relevant perinatal history prior to the infant's birth:
- What is the gestational age?
- Is the amniotic fluid clear?
- How many babies are expected?
- Are there other risk factors?
When the infant is born, ask yourself these three questions:
- Is the newborn term?
- Is the newborn crying or breathing?
  
  Flow chart 1: Newborn resuscitation algorithm
  Abbreviations: PPV, positive pressure ventilation; CPAP, continuous positive airway pressure; IV, intravenous
  
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- Does the newborn have good muscle tone?
- No color assessment.

Chapter Notes

Neonatal Resuscitation Program—What is New?1