Neonatal Breathing Assessment

Aka: Neonatal Breathing Assessment

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II. Background

  1. Positive Pressure Ventilation (PPV) is single most important step in newborn CPR

III. Protocol: Neonatal Breathing Assessment (Resuscitation, NRP)

  1. Spontaneous Respirations
    1. Goto Neonatal Circulation Assessment
  2. No Respirations or gasping (secondary apnea) or Heart Rate <100/min
    1. Positive Pressure Ventilations (PPV via bag-valve-mask) with Oxygen starting at 21% and titrating up
      1. Attach Oxygen Saturation to right hand (pre-ductal) within 1-2 minutes of starting PPV
      2. Avoid hyperoxygenation due to associated worse outcomes (titrate based on expected O2 Sat for minutes of life as listed below)
    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) from right hand (pre-ductal)
      1. At 1 minute of life: >60%
      2. At 2 minutes of life >65%
      3. At 3 minutes of life >70%
      4. At 4 minutes of life >75%
      5. At 5 minutes of life >80%
      6. At 10 minutes of life >85%
    6. Consider Orogastric Tube for prolonged PPV
    7. Perform Neonatal Circulation Assessment

IV. Causes: Acute Newborn Respiratory Distress or Inadequate Respirations

  1. Transient Tachypnea
  2. Meconium Aspiration Syndrome
  3. Respiratory Distress Syndrome in the Newborn
  4. Persistent Pulmonary Hypertension of the Newborn
  5. CNS Conditions resulting in apnea or Bradypnea

V. Signs

  1. Respiratory Distress
    1. Tachypnea (newborn Respiratory Rate >60/min)
    2. Nasal flaring
    3. Grunting
    4. Intercostal retractions
  2. Respiratory Failure
    1. Apnea or Bradypnea
    2. Gasping respirations
    3. Irregular respiratory pattern

VI. Management: Inadequate Positive Pressure Ventilation (no chest rise, no increase in Heart Rate)

  1. Adjust bag-valve-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)
  7. Consider RAM Nasal Cannula
    1. Allows for Positive Pressure Ventilation via Nasal Cannula (and mouth closed)

VII. Management: Neonatal intubation

  1. Indications
    1. Tracheal Suctioning for thick meconium in a non-vigorous newborn
    2. Prolonged Positive Pressure Ventilations >2-3 minutes
    3. Ineffective Bag Valve Mask Ventilation
    4. Heart Rate persistently <100 bpm
    5. Chest Compressions initiated (i.e. Heart Rate <60 bpm)
    6. Diaphragmatic Hernia suspected (or other Congenital Anomaly affecting intubation)
    7. Birth weight below 1500 grams (EGA under 30-31 weeks)
  2. Devices
    1. Mnemonics 0123 and 789 and 60
      1. Straight Blade 0 for a 1-2 kg newborn with an uncuffed 3-0 ET Tube
      2. ET Tube depth is 6+ wtKg (7 cm for 1 kg, 8 cm for 2 kg, 9 cm for 3 kg)
      3. Respiratory Rate 40-60 per minute
    2. 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
    3. 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

VIII. References

  1. Bhalla (2014) Crit Dec Emerg Med 28(1): 2-11
  2. Diggs, Mok and Collyer (2026) Crit Dec Emerg Med 40(5): 27-37
  3. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
  4. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
  5. Raghuveer (2011) Am Fam Physician 83(8): 911-8 [PubMed]

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