Assisted ventilation by facemask at a rate of 40 to 60 breaths per minute is recommended. Oxygen saturation is monitored by pulse oximetry. Supplemental oxygen can be given in graduated, rising percentages to maintain oxygen saturation values within a normal range per minute of life. Adequate ventilation is best indicated by an improved heart rate. Colorimetric end-tidal carbon dioxide (ETC02) monitoring placed between the positive-pressure device and facemask serves as a helpful adjunct for detection of successful gas exchange during mask ventilation (Weiner, 2016).
If the heart rate remains � 100 bpm after 5 to 10 positive pressure breaths, the attempted ventilation is inadequate and corrective steps must be taken. These can be remembered by the pneumonic MR. SOPA (Table 32-1). The two most common problems are mask leak due to an inefective seal and malposition of the airway (Schmolzer, 2011). If corrective steps do not improve the heart rate, either intubation with an endotracheal tube or placement of a laryngeal mask airway is required.
If mask ventilation is inefective or prolonged, an alternative airway is placed. For tracheal intubation, a laryngoscope with a straight blade-size 0 for a preterm newborn and size 1 for a term neonate-is used. Gentle cricoid pressure may be useful. An increasing heart rate and ETC02 detection after several breaths are the primary methods of conirming intubation of the trachea and not the esophagus. One can also look for symmetrical chest wall motion; auscultate for equal breath sounds, especially in the axillae; and auscultate for the absence of breath sounds or gurgling over the stomach.
The Newborn 609
Once in place, the tube is used for tracheal suctioning only for a suspected obstructed airway. Otherwise, an appropriate positive-pressure device is attached to the endotracheal tube. Air pufs are delivered at a rate of 40 to 60 per minute with a force adequate to stabilize the heart rate. In term infants, opening pressures of 30 to 40 cm H20 typically will expand the alveoli without causing barotrauma. Once the lung is inflated, less pressure is typically needed (20 to 25 cm
H20). For preterm infants, pressures of 20 to 25 cm
Term?
Good tone?
Breathing/crying?
H20 are typically used. An increase in heart rate and peripheral oxygen saturation (Sp02) levels within acceptable ranges reflect a positive response.
FIGURE 32-2 Algorithm for resuscitation of the newborn based on the International Liaison Committee on Resuscitation scientific review and recommended by the American Academy of Pediatrics and American Heart Association (Perlman, 2015; Wyckoff, 2015). bpm = beats per minute; CPAP = continuous positive airway pressure; ECG = electrocardiogram; ETT = endotracheal tube; HR = heart FIGURE 32-3 Correct use of bag-and-mask ventilation. The head rate; IV = intravenous; PPV = positive-pressure ventilation; Sp02= should be in a sniffing position with the tip of the nose pointing to peripheral oxygen saturation; UVC = umbilical venous catheter. the ceiling. The neck should not be hyperextended.
Epinephrine measures (American Academy of Pediatrics, 2017). s shown in Table 32-2, each of five easily identiiable characteristics