Elsevier

Resuscitation

Volume 49, Issue 3, June 2001, Pages 299-305
Resuscitation

Comparison of methods of bag and mask ventilation for neonatal resuscitation

https://doi.org/10.1016/S0300-9572(01)00311-2Get rights and content

Abstract

Background: There are a variety of manual bagging devices used for neonatal resuscitation. To our knowledge, there has been no comparison of the ability of different operators to utilize such devices for the delivery of predetermined inspiratory and end-expiratory pressures. In addition, the use of prolonged inflation may be of benefit for infants who require bag and mask ventilation, and there has been no evaluation of the ability of a variety of operators to reliably deliver such breaths using currently available equipment. Methods: We utilized a neonatal manikin (Laerdal Armonk, NY) with a functional larynx and lungs, and a clear cushioned mask (Owens-BriGam, Morganton, NC). We studied a latex-free disposable anesthesia type bag (Model 5126 Vital Signs, Totawa, NJ), a Jackson-Rees (JR) type anesthesia bag (Model E191 Anesthesia Associates, San Marcos, CA) fitted with a Norman elbow and a flow-control tail-piece (Dupaco, Oceanside, CA), and the Neopuff (Fisher and Paykel, Auckland, New Zealand), an FDA approved mechanical device that is flow-controlled and pressure-limited, specifically designed to facilitate neonatal resuscitation. The ventilating pressures were continuously recorded throughout the process. We evaluated neonatal nurses, neonatal nurse practitioners, neonatal staff and fellows, pediatric residents and neonatal respiratory therapists. Results: The peak inspiratory pressure (PIP) was significantly different between operators using either anesthesia bag, P<0.001. Similar results were found for positive end-expiratory pressure (PEEP) with a significant difference among the operator groups, P<0.001. All the differences in post hoc analysis were between the therapists and the other groups, P<0.05. Therapists produced significantly higher pressures than the other groups for both PIP and PEEP (P<0.001). The PIP was similar for all groups using the Neopuff device. The PIP and PEEP delivered by the Neopuff differed from the other two devices independent of the operators (P<0.05). On post hoc analysis, there was a significant difference between the disposable anesthesia bag and Neopuff for both PIP and PEEP for the therapists, whereas among the non-therapists, there was a difference in PIP with the JR device producing a greater PIP (26.6±3.8 cmH2O) compared with the Neopuff and disposable anesthesia bag (24.8±1.1 cmH2O, 24.8±4.3 cmH2O). The level of PEEP was significantly different among all three devices for the non-therapists (1.3±1.6 cmH2O, Disposable; 2.9±1.2 cmH2O, JR; 4.7±0.5 cmH2O, Neopuff; P<0.05). Only the therapists were able to consistently deliver PEEP with the anesthesia bags, whereas all operators could generate the target PEEP with the Neopuff (P<0.05). We compared the pressure delivered during the first second to the pressure delivered during the fifth second during prolonged 5-s inflations. The absolute differences between the first and fifth second for the Neopuff versus the anesthesia bags were significantly different with a median of 7.1 cmH2O for the anesthesia bags compared with 0.2 cmH2O for the Neopuff, P<0.001, reflecting the difficulty in obtaining and maintaining the target inflation pressures. Conclusions: Our experience suggests that the Neopuff, a purpose-built neonatal resuscitator ventilator, facilitates the delivery of the desired airway pressures while maximizing the operators ability to obtain and maintain a patent airway, and facilitates the delivery of prolonged inflations. Further research is required to determine the clinical benefit of end-expiratory pressure and prolonged inflations in neonatal resuscitation.

Sumàrio

Introdução: Existe no mercado uma grande variedade de dispositivos para ventilação manual de recém nascidos. Que tenhamos conhecimento nunca houve nenhum estudo comparativo destes vários dispositivos no que diz respeito á utilização por diferentes operadores e a sua capacidade para administrar pressão inspiratória predefinida e pressão no final da expiração. Para além disso os recém nascidos podem beneficiar com uma insuflação prolongada e também a capacidade de o fazer usando os vários equipamentos nunca foi estudado. Método: Utilizamos um manequim neonatal (Laerdal Armonk, NY) com pulmões e laringe e uma máscara facial almofadada transparente (Owens-BriGam, Morganton, NC). Estudamos vários tipos de dispositivo de ventilação: Balão sem látex irrecuperável (Model 5126 Vital Signs, Totawa, NJ); Um balão tipo Jackson Rees (Model E191 Anesthesia Associates, San Marcos, CA) e o Neopuff (Fisher and Paykel, Aukland, New Zealand). Este ultimo é um dispositivo especificamente desenhado para facilitar a reanimação neonatal, controlado por fluxo e limitado por pressão e aprovado pela FDA. Foram registadas de forma contı&#x0301;nua as pressões de ventilação. Foram avaliados vários operadores: enfermeiros e enfermeiros em treino de neonatologia; Internos complementares de Pediatria, Especialistas de Pediatria e ainda cinesioterapeutas neonatais. Resultados: As pressões de pico inspiratórias (PPI) foram diferentes entre os operadores usando qualquer dos dispositivos (p<0.001). O mesmo aconteceu com a pressão positiva no fim da expiração (PEEP) (p<0.001). Os cinesioterapeutas originaram pressões maiores, PPI e PEEP, que os outros operadores (p<0.001). A PPI foi igual para todos os operadores usando o Neopuff. A PPI e PEEP resultantes do uso do Neopuff foi independente do operador. O nı&#x0301;vel de PEEP foi diferente entre os 3 dispositivos para os não cinesioterapeutas (1.3±1.6 cmH2O, balão irrecuperável; 2.9±1.2 cmH2O, JR; 4.7±0.5, Neopuff; p<0.05). Apenas os cinesioterapeutas conseguiram gerar PEEP de forma consistente com os balões anestésicos enquanto todos o conseguiram fazer com o Neopuff (p<0.05). Comparamos a pressão ao primeiro e quinto segundos na insuflação de 5 segundos. As diferenças entre o Neopuff e os outros dispositivos foram significativamente diferentes com uma mediana de 0.2 e 7.2 cm H2O respectivamente (p<0.001), refletindo a dificuldade em manter as pressões de insuflação alvo. Conclusões: A nossa experiência sugere que o Neopuff facilita a administração da pressão desejada, maximizando a capacidade do operador e facilitando a administração de insuflações prolongadas. Mais investigação é necessária para determinar o beneficio clı&#x0301;nico da PEEP e da insuflação prolongada na reanimação neonatal.

Section snippets

Background

At the present time, the need for resuscitation is greater in the neonate than in any other age group. The Neonatal Resuscitation Program (NRP) was developed by the American Academy of Pediatrics and the American Heart Association and endorsed in 1987 and revised thereafter [1]. The course has been widely taught in the United States and has become the standard of care in newborn resuscitation. Competency in the course material is demonstrated by successful completion of a written and

Methods

We utilized a neonatal manikin (Laerdal Armonk, NY) with a functional larynx and lungs, and placed the manikin on a flat table at the height of the resuscitation radiant warmers in our delivery areas. A clear cushioned mask (Owens-BriGam, Morganton, NC) was chosen to be the correct size for this manikin. Flow dependent anesthesia bags attached to wall-mounted flow meters identical to those utilized for neonatal resuscitation in our hospital were placed next to the manikin with the

Results

We evaluated five pediatric residents, five nurses, four neonatologists, six neonatal fellows, two neonatal nurse practitioners and five neonatal respiratory therapists. There were no significant differences in the rate of ventilation between groups of operators and anesthesia bags, and these results will not be presented. The PIP was significantly different between operators using either anesthesia bag, P<0.001. Similar results were found for PEEP with a significant difference among the

Discussion

Our results have demonstrated that the bag and mask ventilation skills of a group of operators, as assessed on a neonatal manikin, vary by individuals and training. In our unit, the respiratory therapists attend all high-risk deliveries and have historically taken a principal role in providing the bag and mask ventilation in the delivery area. Their ability to produce more consistent peak pressures and PEEP reflects their continued exposure and experience, and familiarity with the devices.

Conclusion

We believe that further research needs to be performed to evaluate the use of CPAP and PEEP, and the use of prolonged inflations as part of the initial resuscitation of neonates, involving not only the use of these modalities, but evaluating the most optimal equipment to provide such support. Our experience suggests that the Neopuff, a unique neonatal resuscitator ventilator, facilitates the delivery of desired airway pressures while allowing the operators to use both hands to attempt obtain

Acknowledgements

The authors wish to thank all of our respiratory therapists, neonatologists and fellows, neonatal nurse practitioners and nurses who participated in this evaluation. We also thank Chris Hutchinson of Fischer and Paykel for providing the Neopuff for this evaluation.

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