Neonatal Breathing Assessment

Aka: Neonatal Breathing Assessment

1. See Also
   1. Newborn Resuscitation
   2. Neonatal Airway Assessment
   3. Neonatal Circulation Assessment
   4. Neonatal Perfusion Assessment
   5. Neonatal Distress Causes
2. Background
   1. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR
3. Protocol
   1. Spontaneous Respirations
      1. Neonatal Circulation Assessment
   2. No Respirations or gasping (secondary apnea) or Heart Rate <100/min
      1. Positive Pressure Ventilations with Oxygen starting at 21% and titrating up
      2. Provide ventilations at rate of 40-60 per minute
         1. Count as "Breath - two - three"
         2. During CPR, Compressions to PPV ratio is 3:1
      3. Peak inspiratory pressure (PIP)
         1. Started at 20-25cm H2O
         2. Some infants may require 30-40 cm H2O
      4. Ventilate for 15-30 seconds before next assessment
         1. Continue PPV until Heart Rate >100/min and adequate spontaneous respirations
      5. Monitoring: Continuous pulse oximetry (targeted pulse oximetry values)
         1. At 1 minute of life: >60%
         2. At 3 minutes of life >70%
         3. At 5 minutes of lifer >80%
         4. At 10 minutes of life >85%
      6. Consider Orogastric Tube for prolonged PPV
      7. Perform Neonatal Circulation Assessment
4. Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate)
   1. Adjust mask to obtain adequate seal
   2. Adjust head and neck position to reposition airway (sniffing position is ideal)
   3. Suction mouth and nose for secretions
   4. Open mouth slightly and move jaw forward
      1. Place index and middle finger inside mouth hooking behind central lower gums and gently lift upward
   5. Increase peak inspiratory pressure (PIP) enough to move chest (may require 30-40 cm H2O)
      1. May require blocking pop-off valve
   6. Consider intubation (see below)
5. Management: Pediatric intubation
   1. Indications
      1. Prolonged Positive Pressure Ventilations >2-3 minutes
      2. Ineffective Bag Valve Mask ventilation
      3. Tracheal suctioning for thick meconium in a non-vigorous newborn
      4. Diaphragmatic Hernia suspected
      5. Birth weight below 1500 grams (EGA under 30-31 weeks)
   2. Devices
      1. Endotracheal Tube intubation
         1. Weight 1 kg: 2.5 mm Endotracheal Tube
         2. Weight 2 kg: 3.0 mm Endotracheal Tube
         3. Weight 3 kg: 3.5 mm Endotracheal Tube
      2. Laryngeal mask airway (LMA) size 1 (gestational age >34 weeks or weight >2kg)
   3. Confirmation
      1. Exhaled carbon dioxide detector or end-tidal CO2 (etCO2) monitor changes from purple to yellow if in trachea
6. References
   1. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
   2. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
   3. Raghuveer (2011) Am Fam Physician 83(8): 911-8