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《心肺复苏指南》参考资料（英文版）Part 13 Neonatal Resuscitation Guidelines

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Part 13: Neonatal resuscitation guidelines The following guidelines are intended for practitioners is allotted to complete each step, reevaluate, and decide responsible for resuscitating neonates. They apply pri- whether to progress to the next step(see the Figure) marily to neonates undergoing transition from intrauterine to extrauterine life. The recommendations are also applicable to Anticipation of Resuscitation Need neonates who have completed perinatal transition and require Anticipation, adequate preparation, accurate evaluation, and resuscitation during the first few weeks to months following prompt initiation of support are critical for successful neona birth.Practitioners who resuscitate infants at birth or at any tal resuscitation. At every delivery there should be at least one time during the initial hospital admission should consider person whose primary responsibility is the newly born. This following these guidelines. The terms newborn and neonate person must be capable of initiating resuscitation, including re intended to apply to any infant during the initial hospi- administration of positive-pressure ventilation and chest com- talization. The term newly born is intended to apply specifi pressions. Either that person or someone else who is imme- cally to an infant at the time of birth diately available should have the skills required to perform a Approximately 10% of newborns require some assistance complete resuscitation, including endotracheal intubation and to begin breathing at birth. About 1% require extensive administration of medications. resuscitative measures. Although the vast majority of newly With careful consideration of risk factors, the majority of born infants do not require intervention to make the transition newborns who will need resuscitation can be identified before from intrauterine to extrauterine life, because of the large birth. If the possible need for resuscitation is anticipated, number of births, a sizable number will require some degree additional skilled personnel should be recruited and the of resuscitation necessary equipment prepared. Identifiable risk factors and Those newly born infants who do not require resuscitation the necessary equipment for resuscitation are listed on the cangenerallybeidentifiedbyarapidassessmentoftheNeonatalResuscitationProgramwebsitewww.aaporg/nrp. following 4 characteristics If a preterm delivery(<37 weeks of gestation) is expected. special preparations will be required. Preterm babies have Was the baby born after a full-term gestation? lat may be more difficult to ventilate and Is the amniotic fluid clear of meconium and evidence of also more vulnerable to injury by positive-pressure ventila infection? tion. preterm babies also have immature blood vessels in the Is the baby breathing or crying? brain that are prone to hemorrhage: thin skin and a Does the baby have good muscle tone? surface area, which contribute to rapid heat loss; increased If the answer to all 4 of these questions is"yes,the baby susceptibility to infection; and increased risk of hypovolemic oes not need resuscitation and should not be separated from shock caused by small blood volume d the mother. The baby can be dried, placed directly on the Initial Steps mothers chest, and covered with dry linen to maintain The initial steps of resuscitation are to provide warmth by temperature. Observation of breathing, activity, and color should be ongoing placing the baby under a radiant heat source, position the head in If the answer to any of these assessment questions is"no, a"sniffing" position to open the airway, clear the airway with a bulb syringe or suction catheter, and dry the baby and stimulate there is general agreement that the infant should receive one breathing. Recent studies have examined several aspects of these or more of the following 4 categories of action in sequence: initial steps. These studies are summarized below. A Initial steps in stabilization (provide warmth, position, Temperature Control Very low birth weight(<1500 g)preterm babies are likely to C Chest compressions become hypothermic despite the use of traditional techniques D. Administration of epinephrine and/or volume expansion for decreasing heat loss (LOE 5). 2 For this reason it is recommended that additional warming techniques be used The decision to progress from one category to the next is such as covering the baby in plastic wrapping(food-grade, determined by the simultaneous assessment of 3 vital signs: heat-resistant plastic) and placing him or her under radiant respirations, heart rate, and color. Approximately 30 seconds heat( Class lla: LOE 23. 4: LOE 45.6 LOE 57). Temperature must be monitored closely because of the slight but described (LOE 2) risk of hyperthermia with this technique. Other ( Circulation.2005;112:Iv-188-v-195.) 2005 American Heart Association techniques to maintain temperature during stabilization of the baby in the delivery room(eg, drying and swaddling, This special supplement to Circulation is freely available http://www.circulationaha.org ing pads, increased environmental temperature, placing the baby skin-to-skin with the mother and covering both with a DOI: 10.1161/CIRCULATIONAHA. 105.166574 blanket) have been used (loe 8). .9 but they have not been 1V-188

Part 13: Neonatal Resuscitation Guidelines The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily to neonates undergoing transition from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. The terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth. Approximately 10% of newborns require some assistance to begin breathing at birth. About 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large number of births, a sizable number will require some degree of resuscitation. Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 4 characteristics: ● Was the baby born after a full-term gestation? ● Is the amniotic fluid clear of meconium and evidence of infection? ● Is the baby breathing or crying? ● Does the baby have good muscle tone? If the answer to all 4 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby can be dried, placed directly on the mother’s chest, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” there is general agreement that the infant should receive one or more of the following 4 categories of action in sequence: A. Initial steps in stabilization (provide warmth, position, clear airway, dry, stimulate, reposition) B. Ventilation C. Chest compressions D. Administration of epinephrine and/or volume expansion The decision to progress from one category to the next is determined by the simultaneous assessment of 3 vital signs: respirations, heart rate, and color. Approximately 30 seconds is allotted to complete each step, reevaluate, and decide whether to progress to the next step (see the Figure). Anticipation of Resuscitation Need Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least one person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.1 With careful consideration of risk factors, the majority of newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. Identifiable risk factors and the necessary equipment for resuscitation are listed on the Neonatal Resuscitation Program website: www.aap.org/NRP. If a preterm delivery (37 weeks of gestation) is expected, special preparations will be required. Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock caused by small blood volume. Initial Steps The initial steps of resuscitation are to provide warmth by placing the baby under a radiant heat source, position the head in a “sniffing” position to open the airway, clear the airway with a bulb syringe or suction catheter, and dry the baby and stimulate breathing. Recent studies have examined several aspects of these initial steps. These studies are summarized below. Temperature Control Very low birth weight (1500 g) preterm babies are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss (LOE 5).2 For this reason it is recommended that additional warming techniques be used, such as covering the baby in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat (Class IIa; LOE 23,4; LOE 45,6; LOE 57). Temperature must be monitored closely because of the slight but described (LOE 2)4 risk of hyperthermia with this technique. Other techniques to maintain temperature during stabilization of the baby in the delivery room (eg, drying and swaddling, warming pads, increased environmental temperature, placing the baby skin-to-skin with the mother and covering both with a blanket) have been used (LOE 8),8,9 but they have not been (Circulation. 2005;112:IV-188-IV-195.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166574 IV-188

lV-190 Circulation December 13. 2005 cerebral injury. Hyperthermia should Conversely there are also concerns about tissue ided(Class IIb). The goal is to achieve normothermia Studies from oxygen deprivation during and after asphyxia. avoid iatrogenic hyperthermia (LOE 6)27-31 examining blood pressure, cerebral perfusion, and various biochemical measures of cell damage Clearing the Airway of Meconium in asphyxiated animals resuscitated with 100% oxygen versus Aspiration of meconium before delivery, during birth, or 21% oxygen(room air) have shown conflicting results. One during resuscitation can cause severe aspiration pneumonia. (LOE 2)32 study of preterm infants(<33 weeks of gestation) One obstetrical technique to try to decrease aspiration has exposed to 80% oxygen found lower cerebral blood flow been to suction meconium from the infants airway after delivery of the head but before delivery of the shoulders Some animal data(LOE 6)27 indicated the opposite effec en when ed with those stabili (intrapartum suctioning). Although some studies (Loe 3: reduced blood pressure and cerebral perfusion with 21% 4 6, 7)suggested that intrapartum suctioning might be effec- oxygen(room air) versus 100% oxygen. Meta-analysis of 4 tive for decreasing the risk of aspiration syndr ome. suds human studies(LOE 1)33.34 showed a reduction in mortality quent evidence from a large multicenter randomized trial rate and no evidence of harm in infants resuscitated with (LOE 1)8 did not show such an effect. Therefore, room air versus those resuscitated with 100%o oxygen, al recommendations no longer advise routine intrapartum or though these results should be viewed with caution because pharyngeal and nasopharyngeal suctioning for infants born to of significant methodological concerns mothers with meconium staining of amniotic fluid( Class I) Supplementary oxygen is recommended whenever Traditional teaching (LOE 5)- recommended that positive-pressure ventilation is indicated for resuscitation meconium-stained infants have endotracheal intubation im- free-flow oxygen should be administered to babies who ar mediately following birth and that suction be applied to the breathing but have central cyanosis( Class Indeterminate) endotracheal tube as it is withdrawn. Randomized controlled The standard approach to resuscitation is to use 100%0 )5.2 have shown that this practice offers no oxygen. Some clinicians may begin resuscitation with benefit if the infant is vigorous( Class D). a vigorous infant is defined as one who has strong respiratory efforts, good with no supplementary oxygen (ie, room air). There is muscle tone, and a heart rate >100 beats per minute(bpm evidence that employing either of these practices during Endotracheal suctioning for infants who are not vigorous resuscitation of neonates is reasonable. If the clinician begins should be performed immediately after birth(Class resuscitation with room air, it is recommended that supple- mentary oxygen be available to use if there is no appreciable Periodic Evaluation at 30-Second Intervals improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available After the immediate postbirth assessment and administration of initial steps, further resuscitative efforts should be guide positive-pressure ventilation should be administered with room air(Class Indeterminate) by simultaneous assessment of respirations, heart rate, and color. After initial respiratory efforts the newly born infant Administration of a variable concentration of oxygen should be able to establish regular respirations that are guided by pulse oximetry may improve the ability to achieve sufficient to improve color and maintain a heart rate >100 normoxia more quickly. Concerns about potential oxidant bpm. Gasping and apnea indicate the need for assisted injury should caution the clinician about the use of excessive ventilation.23 Increasing or decreasing heart rate can also oxygen, especially in the premature infant. provide evidence of improvement or deterioration Positive- Pressure ventilation A newly born infant who is uncompromised will achieve If the infant remains apneic or gasping, if the heart rate and maintain pink mucous membranes without administration remains <100 bpm 30 seconds after administering the initial of supplementary oxygen. Evidence obtained with continuous steps, or if the infant continues to have persistent central oximetry, however, has shown that neonatal transition is a gradual process. Healthy babies born at term may take >10 cyanosis despite administration of supplementary oxygen, start positive-pressure inutes to achieve a preductal oxygen saturation >95%o and nearly I hour to achieve postductal saturation >95% (LOE Initial Breaths and Assisted Ventilation 5).24-26 Central cyanosis is determined by examining the face, In term infants, initial inflations--either spontaneous or trunk, and mucous membranes. Acrocyanosis(blue color of assisted--create a functional residual capacity (LOE 5) The optimum pressure, inflation time, and flow rate required is not a reliable indicator of hypoxemia but may indicate to establish an effective functional residual capacity have not her conditions, such as cold stress. Pallor or mottling may been determined. Average initial peak inflating pressures of be a sign of decreased cardiac output, severe anemia, hypo- 30 to 40 cm H2o (inflation time undefined)usually success- emia, hypothermia, fully ventilate unresponsive term infants(LOE 5).36.38 40-43 Assisted ventilation rates of 40 to 60 breaths per minute are Administration of Oxygen commonly used, but the relative efficacy of various rates has There are concerns about the potential adverse effects of not been investigated. 100% oxygen on respiratory physiology and cerebral circu The primary measure of adequate initial ventilation is lation and the tial tissue damage from oxygen free prompt improvement in heart rate. Chest wall movement

progression of cerebral injury. Hyperthermia should be avoided (Class IIb). The goal is to achieve normothermia and avoid iatrogenic hyperthermia. Clearing the Airway of Meconium Aspiration of meconium before delivery, during birth, or during resuscitation can cause severe aspiration pneumonia. One obstetrical technique to try to decrease aspiration has been to suction meconium from the infant’s airway after delivery of the head but before delivery of the shoulders (intrapartum suctioning). Although some studies (LOE 315; 416,17) suggested that intrapartum suctioning might be effective for decreasing the risk of aspiration syndrome, subsequent evidence from a large multicenter randomized trial (LOE 1)18 did not show such an effect. Therefore, current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid (Class I). Traditional teaching (LOE 5)19–21 recommended that meconium-stained infants have endotracheal intubation immediately following birth and that suction be applied to the endotracheal tube as it is withdrawn. Randomized controlled trials (LOE 1)15,22 have shown that this practice offers no benefit if the infant is vigorous (Class I). A vigorous infant is defined as one who has strong respiratory efforts, good muscle tone, and a heart rate 100 beats per minute (bpm). Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth (Class Indeterminate). Periodic Evaluation at 30-Second Intervals After the immediate postbirth assessment and administration of initial steps, further resuscitative efforts should be guided by simultaneous assessment of respirations, heart rate, and color. After initial respiratory efforts the newly born infant should be able to establish regular respirations that are sufficient to improve color and maintain a heart rate 100 bpm. Gasping and apnea indicate the need for assisted ventilation.23 Increasing or decreasing heart rate can also provide evidence of improvement or deterioration. A newly born infant who is uncompromised will achieve and maintain pink mucous membranes without administration of supplementary oxygen. Evidence obtained with continuous oximetry, however, has shown that neonatal transition is a gradual process. Healthy babies born at term may take 10 minutes to achieve a preductal oxygen saturation 95% and nearly 1 hour to achieve postductal saturation 95% (LOE 5).24–26 Central cyanosis is determined by examining the face, trunk, and mucous membranes. Acrocyanosis (blue color of hands and feet alone) is usually a normal finding at birth and is not a reliable indicator of hypoxemia but may indicate other conditions, such as cold stress. Pallor or mottling may be a sign of decreased cardiac output, severe anemia, hypovolemia, hypothermia, or acidosis. Administration of Oxygen There are concerns about the potential adverse effects of 100% oxygen on respiratory physiology and cerebral circulation and the potential tissue damage from oxygen free radicals. Conversely there are also concerns about tissue damage from oxygen deprivation during and after asphyxia. Studies (LOE 6)27–31 examining blood pressure, cerebral perfusion, and various biochemical measures of cell damage in asphyxiated animals resuscitated with 100% oxygen versus 21% oxygen (room air) have shown conflicting results. One (LOE 2)32 study of preterm infants (33 weeks of gestation) exposed to 80% oxygen found lower cerebral blood flow when compared with those stabilized using 21% oxygen. Some animal data (LOE 6)27 indicated the opposite effect, ie, reduced blood pressure and cerebral perfusion with 21% oxygen (room air) versus 100% oxygen. Meta-analysis of 4 human studies (LOE 1)33,34 showed a reduction in mortality rate and no evidence of harm in infants resuscitated with room air versus those resuscitated with 100% oxygen, although these results should be viewed with caution because of significant methodological concerns. Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to babies who are breathing but have central cyanosis (Class Indeterminate). The standard approach to resuscitation is to use 100% oxygen. Some clinicians may begin resuscitation with an oxygen concentration of less than 100%, and some may start with no supplementary oxygen (ie, room air). There is evidence that employing either of these practices during resuscitation of neonates is reasonable. If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air (Class Indeterminate). Administration of a variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly. Concerns about potential oxidant injury should caution the clinician about the use of excessive oxygen, especially in the premature infant. Positive-Pressure Ventilation If the infant remains apneic or gasping, if the heart rate remains 100 bpm 30 seconds after administering the initial steps, or if the infant continues to have persistent central cyanosis despite administration of supplementary oxygen, start positive-pressure ventilation. Initial Breaths and Assisted Ventilation In term infants, initial inflations—either spontaneous or assisted—create a functional residual capacity (LOE 5).35–41 The optimum pressure, inflation time, and flow rate required to establish an effective functional residual capacity have not been determined. Average initial peak inflating pressures of 30 to 40 cm H2O (inflation time undefined) usually successfully ventilate unresponsive term infants (LOE 5).36,38,40–43 Assisted ventilation rates of 40 to 60 breaths per minute are commonly used, but the relative efficacy of various rates has not been investigated. The primary measure of adequate initial ventilation is prompt improvement in heart rate. Chest wall movement IV-190 Circulation December 13, 2005

Part 13: Neonatal Resuscitation Guidelines / v-19 should be assessed if heart rate does not improve. The initial and improves lung compliance and gas exchange (Loe peak inflating pressures needed are variable and unpredict- 6).60., 6 Evidence from case series in human infants indicates able and should be individualized to achieve an increase in that most apneic preterm infants can be ventilated with an heart rate and/or movement of the chest with each breath. If initial inflation pressure of 20 to 25 cm H]O, although some inflation pressure is being monitored, an initial inflation infants who do not respond require a higher pressure ( LOE pressure of 20 cm HO may be effective, but 230 to 40 5).62,63 cm HO may be required in some term babies without When ventilating preterm infants after birth, excessive spontaneous ventilation( Class IIb). If pressure is not moni- chest wall movement may indicate large-volume lung infla- tored, the minimum inflation required to achieve an increase tions, which should be avoided. Monitoring of pressure may in heart rate should be used. There is insufficient evidence to help to provide consistent inflations and avoid unnecessary recommend an optimum inflation time. In summary, assisted high pressures( Class IIb). If positive-pressure ventilation entilation should be delivered at a rate of 40 to 60 breaths required, an initial inflation pressure of 20 to 25 cm H_0 is per minute( Class Indeterminate: LOE 8)to promptly achieve adequate for most preterm infants( Class Indeterminate). If or maintain a heart rate >100 bpm prompt improvement in heart rate or chest movement is not obtained, higher pressures may be needed. If it is necessary to Devices Effective ventilation can be achieved with a flow-inflating continue positive-pressure ventilation, application of PEEP bag, a self-inflating bag, or with a T-piece(LoE 44.45 LOE may be beneficial( Class Indeterminate). Continuous 5"). A T-piece is a valved mechanical device designed to airway pressure in spontaneously breathing preterm control flow and limit pressure. The pop-off valves after resuscitation may also be beneficial63 self-inflating bags are flow-dependent, and pressures gener Indeterminate ). ated may exceed the value specified by the manufacturer Endotracheal Tube placement (LOE 6). 47 Target inflation pressures and long inspiratory Endotracheal intubation may be indicated at several points times are more consistently achieved in mechanical models during neonatal resuscitation when T devices are used rather than bags (LOE 6), 8 although the clinical implications are not clear. To provide When tracheal suctioning for meconium is required the desired pressure, healthcare providers need more training If bag-mask ventilation is ineffective or prolonged in the use of flow-inflating bags than with self-inflating bags When chest compressions are performed (LOE 6)49 A self-inflating bag, a flow-inflating bag, or a .When endotracheal administration of medications is T-piece can be used to ventilate a newborn( Class IIb) desired Laryngeal mask airways(LMAs)that fit over the laryngeal .For special resuscitation circumstances, such as congenital inlet have been shown to be effective for ventilating newly diaphragmatic hernia or extremely low birth weight born near-term and full-term infants(LOE 250 and LOE 55) (<1000g) There is limited (LoE 5)52.53 data on the use of these devices in small preterm infants. Data from 3 case series(LOE The timing of endotracheal intubation may also depend on 5)51. 54.55 shows that the use of the LMA can provide effective the skill and experience of the available providers ventilation in a time frame consistent with current resuscita- After endotracheal intubation and administration of inter mittent positive pressure, a prompt increase in heart rate is the tion guidelines, although the babies being studied were not best indicator that the tube is in the tracheobronchial tree and being resuscitated. A randomized controlled trial (LOE 2)50 found no clinically significant difference between the use of providing effective ventilation (LOE 5)64 Exhaled CO2 de- he LMa and endotracheal intubation when bag-mask venti tection is effective for confirmation of endotracheal tube lation was unsuccessful. It is unclear whether this study car placement in infants, including very low birth weight infants be generalized because the LMa was inserted b (LOE 5).65-6s A positive test result(detection of exhaled CO2) providers. Case reports (LoE 556-s5s suggest that when in patients with adequate cardiac output confirms placement bag-mask ventilation has been unsuccessful and endotracheal of the endotracheal tube within the trachea, whereas intubation is not feasible or is unsuccessful, the LMA may negative test result (ie, no CO, detected) strongly suggests provide effective ventilation. There is insufficient evidence to esophageal intubation(Loe 5).65,67 Poor or absent pulmonary support the routine use of the LMA as the primary airway blood flow may give false-negative results (ie, no CO2 device during neonatal resuscitation, in the setting of detected despite tube placement in the trachea), but endotra- meconium-stained amniotic fluid, when chest compressions cheal tube placement is correctly identified in nearly all required, in very low birth weight babies, or for delivery patients who are not in cardiac arrest(LOE 7). A false of emergency intratracheal medications(Class Indeterminate negative result may also lead to unnecessary extubation in critically ill infants with poor cardiac output. Assisted Ventilation of Preterm Infants Other clinical indicators of correct endotracheal tube place Evidence from animal studies (Loe 6)59 indicates that pre- nent are evaluation of condensed humidified gas during term lungs are easily injured by large-volume inflation exhalation and the presence or absence of chest movement, mmediately after birth. Additional animal studies (Loe but these have not been systematically evaluated in neonates 6)60, 6I indicate that when positive-pressure ventilation is Endotracheal tube placement must be assessed visually dur- applied immediately after birth, the inclusion of positive ing intubation and by confirmatory methods after intubation end-expiratory pressure(PEEP) protects against lung injury if the heart rate remains low and is not rising. Except for

should be assessed if heart rate does not improve. The initial peak inflating pressures needed are variable and unpredictable and should be individualized to achieve an increase in heart rate and/or movement of the chest with each breath. If inflation pressure is being monitored, an initial inflation pressure of 20 cm H2O may be effective, but 30 to 40 cm H2O may be required in some term babies without spontaneous ventilation (Class IIb). If pressure is not monitored, the minimum inflation required to achieve an increase in heart rate should be used. There is insufficient evidence to recommend an optimum inflation time. In summary, assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute (Class Indeterminate; LOE 8) to promptly achieve or maintain a heart rate 100 bpm. Devices Effective ventilation can be achieved with a flow-inflating bag, a self-inflating bag, or with a T-piece (LoE 444,45; LOE 546). A T-piece is a valved mechanical device designed to control flow and limit pressure. The pop-off valves of self-inflating bags are flow-dependent, and pressures generated may exceed the value specified by the manufacturer (LOE 6).47 Target inflation pressures and long inspiratory times are more consistently achieved in mechanical models when T-piece devices are used rather than bags (LOE 6),48 although the clinical implications are not clear. To provide the desired pressure, healthcare providers need more training in the use of flow-inflating bags than with self-inflating bags (LOE 6).49 A self-inflating bag, a flow-inflating bag, or a T-piece can be used to ventilate a newborn (Class IIb). Laryngeal mask airways (LMAs) that fit over the laryngeal inlet have been shown to be effective for ventilating newly born near-term and full-term infants (LOE 250 and LOE 551). There is limited (LOE 5)52,53 data on the use of these devices in small preterm infants. Data from 3 case series (LOE 5)51,54,55 shows that the use of the LMA can provide effective ventilation in a time frame consistent with current resuscitation guidelines, although the babies being studied were not being resuscitated. A randomized controlled trial (LOE 2)50 found no clinically significant difference between the use of the LMA and endotracheal intubation when bag-mask ventilation was unsuccessful. It is unclear whether this study can be generalized because the LMA was inserted by experienced providers. Case reports (LOE 5)56–58 suggest that when bag-mask ventilation has been unsuccessful and endotracheal intubation is not feasible or is unsuccessful, the LMA may provide effective ventilation. There is insufficient evidence to support the routine use of the LMA as the primary airway device during neonatal resuscitation, in the setting of meconium-stained amniotic fluid, when chest compressions are required, in very low birth weight babies, or for delivery of emergency intratracheal medications (Class Indeterminate). Assisted Ventilation of Preterm Infants Evidence from animal studies (LOE 6)59 indicates that preterm lungs are easily injured by large-volume inflations immediately after birth. Additional animal studies (LOE 6)60,61 indicate that when positive-pressure ventilation is applied immediately after birth, the inclusion of positive end-expiratory pressure (PEEP) protects against lung injury and improves lung compliance and gas exchange (LOE 6).60,61 Evidence from case series in human infants indicates that most apneic preterm infants can be ventilated with an initial inflation pressure of 20 to 25 cm H2O, although some infants who do not respond require a higher pressure (LOE 5).62,63 When ventilating preterm infants after birth, excessive chest wall movement may indicate large-volume lung inflations, which should be avoided. Monitoring of pressure may help to provide consistent inflations and avoid unnecessary high pressures (Class IIb). If positive-pressure ventilation is required, an initial inflation pressure of 20 to 25 cm H2O is adequate for most preterm infants (Class Indeterminate). If prompt improvement in heart rate or chest movement is not obtained, higher pressures may be needed. If it is necessary to continue positive-pressure ventilation, application of PEEP may be beneficial (Class Indeterminate). Continuous positive airway pressure in spontaneously breathing preterm infants after resuscitation may also be beneficial63 (Class Indeterminate). Endotracheal Tube Placement Endotracheal intubation may be indicated at several points during neonatal resuscitation: ● When tracheal suctioning for meconium is required ● If bag-mask ventilation is ineffective or prolonged ● When chest compressions are performed ● When endotracheal administration of medications is desired ● For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight (1000 g) The timing of endotracheal intubation may also depend on the skill and experience of the available providers. After endotracheal intubation and administration of intermittent positive pressure, a prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation (LOE 5).64 Exhaled CO2 detection is effective for confirmation of endotracheal tube placement in infants, including very low birth weight infants (LOE 5).65–68 A positive test result (detection of exhaled CO2) in patients with adequate cardiac output confirms placement of the endotracheal tube within the trachea, whereas a negative test result (ie, no CO2 detected) strongly suggests esophageal intubation (LOE 5).65,67 Poor or absent pulmonary blood flow may give false-negative results (ie, no CO2 detected despite tube placement in the trachea), but endotracheal tube placement is correctly identified in nearly all patients who are not in cardiac arrest (LOE 7).69 A falsenegative result may also lead to unnecessary extubation in critically ill infants with poor cardiac output. Other clinical indicators of correct endotracheal tube placement are evaluation of condensed humidified gas during exhalation and the presence or absence of chest movement, but these have not been systematically evaluated in neonates. Endotracheal tube placement must be assessed visually during intubation and by confirmatory methods after intubation if the heart rate remains low and is not rising. Except for Part 13: Neonatal Resuscitation Guidelines IV-191

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