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SCOPE

DISEASE/CONDITION(S)

Respiratory distress syndrome, respiratory failure, prematurity, cardiopulmonary resuscitation.

GUIDELINE OBJECTIVE(S)

Review best practice of stabilization for premature infants at birth. Review best practice of resuscitation when positive pressure and/or cardiac compressions are required.

BRIEF BACKGROUND

Newborn babies, and especially premature newborns, are at risk for requiring resuscitation. This risk is highest on the day of birth when the newborn makes the cardiorespiratory transition to extrauterine life. Some have called the day a preterm baby is born the most dangerous of its life. In the delivery room, 4−10% of all term and late preterm newborns will receive positive-pressure ventilation (PPV), but only 1 to 3 per 1000 will receive chest compressions or emergency medications. Of those who are sick and require admission to the neonatal intensive care unit (NICU), resuscitation outside of the delivery room may still be needed. The incidence of infants who receive cardiopulmonary resuscitation (CPR) in the NICU is 1−6% of all admissions.

The great majority of neonates who require resuscitation require this because of respiratory failure or decompensation, whether at delivery or later during NICU admission. Therefore, the American Heart Association and American Academy of Pediatrics, through the Neonatal Resuscitation Program (NRP), have long emphasized that ventilation of the lungs is the single most important step in neonatal resuscitation. Stabilization of the respiratory system must be the primary focus for intervention in nearly every baby at birth and during periods of decompensation later in the initial hospitalization. Stabilization of the respiratory system of premature babies has shifted in recent years from primarily intubation and subsequent surfactant administration to stabilizing with continuous positive airway pressure (CPAP). CPAP with selective surfactant use is superior to routine intubation and surfactant administration with continued ventilation by the endotracheal tube (ETT) for prevention of bronchopulmonary dysplasia (BPD) and death. Preterm infants treated with early CPAP alone are not at increased risk of adverse outcomes. Several trials have demonstrated that babies as preterm as 24 weeks can be stabilized on CPAP without intubation, PPV, or surfactant. Thus the spontaneously breathing preterm newborn should always be stabilized on CPAP if possible.

If the baby is not breathing (apnea), is gasping, or has a heart rate below 100 beats per minute, then PPV is required for these signs of ineffective ventilation. Knowing how to provide effective ventilation of the lungs is the foundation for resuscitation skills in the delivery room and NICU. The purpose of ventilation is to aerate the lungs and displace fetal lung fluid and then to maintain functional residual capacity. It should be appreciated that giving an adequate tidal volume with each PPV breath is needed to accomplish this. However, devices used in the delivery room for PPV do not measure tidal volumes. Rather the resuscitation team uses heart rate response and level of chest rise to judge if ...

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