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Background Objective Methods Results Conclusions Neonatal resuscitation airway training can be difficult as there is no feedback on the face mask technique. “JUNO” is a training respiratory function monitor that provides feedback on mask leak, ventilatory rate, and tidal volume.To evaluate whether the use of the JUNO improves face mask ventilation techniques in manikin models.We conducted an observational cross‐over study with our unit staff. Following instructions, each participant performed a single‐person technique, followed by a two‐person technique with no JUNO feedback. This was repeated with JUNO feedback visible. A similar sequence was performed both in term and preterm manikins, giving a total of 8 sequences. Each participant was instructed to perform 1 min of positive pressure ventilation providing 30 inflations/minute for all of the simulations. Each of the simulation data underwent a data cleaning process.Thirty‐eight subjects provided a total of 304 sequences of positive pressure ventilation. A total of 13 354 inflations were analyzed. The feedback group had significantly lower rates of inflations with leak >60%, lower rates of excessive tidal volumes, lower mean leak percentage, and a lower mean inspiratory tidal volumes. When analyzed based on the technique (single person and two‐person), similar positive results were noted in the “feedback group”, across all the strata of staff. All of the staff reported that JUNO improved their ventilation technique and would recommend it for staff training.The use of JUNO significantly improved mask ventilation consistently across manikin types, staff roles, and techniques (either single‐ or two‐person). [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation. Methods: The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019. Results: The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision‐making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial. Conclusion: Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit. [ABSTRACT FROM AUTHOR]

Objective  To investigate if the use of a visible respiratory function monitor (RFM) to use lower tidal volumes (Vts) during positive pressure ventilation (PPV) in the delivery room (DR) reduces the need of surfactant administration and invasive mechanical ventilation during the first 72 hours after birth of preterm infants <32 weeks' gestational age (GA). Study Design  Infants <32 weeks' GA (n  = 106) requiring noninvasive PPV were monitored with a RFM at birth and randomized to visible (n  = 54) or masked (n  = 52) display on RFM. Pulmonary data were recorded during the first 10 minutes after birth. Secondary analysis stratified patients by GA (<28, 28–29 +6 , or ≥30 weeks). Results  Median expiratory Vts during inflations were greater in the masked group (7 mL/kg) than in the visible group (5.8 mL/kg; p  = 0.001) same as peak inflation pressure (PIP) administered (21.5 vs. 19.7 cmH 2 O; p  < 0.001). Consequently, minute volumes were greater in the masked group (256 vs. 214 mL/kg/min; p  < 0.001), with no differences in respiratory rate. These differences were higher in those <30 weeks' GA. There was no difference in the need of surfactant administration or intubation during the first 72 hours of age. Conclusion  Using a RFM in the DR prevents the use of large Vt and PIP during respiratory support inflations, mostly in the more immature newborn infants, but with no other short-term benefits. [ABSTRACT FROM AUTHOR]

Aim: Facial measurements of preterm infants indicate that standard diameter facemasks used during positive pressure ventilation are too large, which may lead to mask leak and compromise resuscitation. We aimed to determine whether the use of a facemask that better complies with the dimensions of preterm faces, compared with a standard facemask, reduces facemask leak.Methods: Parallel group, randomised controlled trial. Preterm infants ≤32 weeks' gestation receiving facemask ventilation prior to intubation in the neonatal intensive care unit, and those 28-32+6 weeks' receiving facemask ventilation in the delivery room were eligible. Infants were randomised to receive ventilation via a standard (50mm) (control), or a smaller (35mm or 42mm) diameter facemask (intervention), stratified by gestation (≤26 weeks'; 35mm, 27-32+6; 42mm). The primary outcome was leak between the mask and the infants face.Results: Of 298 eligible infants, 139 were randomised and 131 were included in the final analysis; 66 in the intervention group and 65 in the control group. The median (IQR) leak was 42% (13-69%) in the intervention group compared with 39% (22-66%) in the control group P=0.43. The median (IQR) lowest oxygen saturation was similar in both groups [intervention 70% (34-93%) vs. control 71% (40-93%) P=0.75]. One infant crossed over from the intervention to the control group due to poor response to ventilation with the intervention facemask.Conclusions: Smaller facemasks did not reduce mask leak in preterm facemask ventilation. All facemasks had high leak, particularly in infants ≤26 weeks' gestation.Clinical Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12614000709640, www.anzctr.org.au. [ABSTRACT FROM AUTHOR]

Infants <28 weeks' gestation in need of inflations at birth were recorded with Respiratory Function Monitor. Two devices were used for resuscitation. Peak Inspiratory Pressure spikes were visible in all inflations with GE Panda and in none with Neo-Puff. There was no significant difference in mean Vte/kg between GE Panda and Neo-Puff. • Additional pressure "spikes" are being delivered with every positive pressure inflation with GE Panda T-piece resuscitaire • No significant differences were found in the tidal volume delivery between GE Panda and Neo-Puff, in non-compliant lung • There is a positive correlation between the tidal volume delivery and the "spike" duration [ABSTRACT FROM AUTHOR]

Background: A sustained inflation (SI) at birth in preterm babies may be ineffective unless the infants breathe. Gain in lung volume is associated with breathing during delivery room non-invasive management. Objective: To describe the breathing patterns of preterm infants during an SI and correlate to a calculated gain in lung volume. Methods: Retrospective observational study. Data collected from a respiratory function monitor during SI (25 cmH2O for 15 s then PEEP at 5 cmH2O) through a face mask in preterm infants (gestational age [GA] ≤ 31 weeks). Spontaneous breaths, inspiratory time (TI), inspiratory/expiratory tidal volume (Vti/Vte), and gain in lung volume were determined. Results: 30 SIs in 20 infants (mean GA 27 weeks; birth weight 825 g) were analysed and stratified in 2 groups according to spontaneous breathing: SIs without spontaneous breaths (apnoea: n = 11) and SIs with spontaneous breaths (breathing: n = 19). Mean GA was lower in the apnoea group versus the breathing group (25 vs. 27+5 weeks; p = 0.01). Mean birth weight was lower in the apnoea group versus the breathing group (683 vs. 860 g; p = ns). In the breathing group, the mean number of spontaneous breaths was 4 with a mean TI of 0.52 min, the mean Vti/kg was 5.9 mL/kg, and the mean Vt e was 2.7 mL/kg. The calculated mean gain in lung volume was 7.5 mL/kg in the apnoea group and 17.8 mL/kg in the breathing group (p = 0.039). Conclusions: Actively breathing infants during an SI at birth showed a gain in lung volume higher than apnoeic infants. Spontaneous breathing during SI seems to be related to GA. [ABSTRACT FROM AUTHOR]

Unlabelled: This study aimed to test the accuracy in volume measurements of three available respiratory function monitors (RFMs) for neonatal resuscitation and the effect of changing gas conditions. The Florian, New Life Box Neo-RSD (NLB Neo-RSD) and NICO RFM were tested on accuracy with volumes of 10 and 20 mL and on changes in volume measurements under changing gas conditions (oxygen level 21-100 % and from cold dry air (24 ± 2 °C) to heated humidified air (37 °C). Volume differences >10 % were considered clinically relevant. We found that the mean (SD) volume difference was clinically acceptable for all devices (10, 20 mL): Florian (+8.4 (1.2)%, +8.4 (0.5)%); NLB Neo-RSD (+5.8 (1.1)%, +4.3 (1.4)%); and NICO (-8.2 (0.9)%, -8.7 (0.8)%). Changing from cold dry to heated humidified air increased the volume difference using the Florian (cold dry air, heated humidified air (+5.2 (1.2)%, +12.2 (0.9)%) but not NLB Neo-RSD (+2.0(1.6)%, +3.4(2.8)%) and NICO (-2.3 % (0.8), +0.1 (0.6)%). Similarly, when using heated humidified air, increasing oxygen enlarged increased the volume difference using the Florian (oxygen 21 %, 100 %: +12.2(1.0)%, +19.8(1.1)%), but not NLB Neo-RSD (+0.2(1.9)%, +1.1(2.8)%) and NICO (-5.6(0.9)%, -3.7(0.9)%). Clinically relevant changes occurred when changing both gas conditions (Florian +25.7(1.7)%; NLB Neo-RSD +3.8(2.4)%; NICO -5.7(1.4)%).Conclusion: The available RFMs demonstrated clinically acceptable deviations in volume measurements, except for the Florian when changing gas conditions.What Is Known: •Respiratory function monitors (RFMs) are increasingly used for volume measurements during respiratory support of infants at birth. •During respiratory support at birth, gas conditions can change quickly, which can influence the volume measurements. What is new: •The available RFMs have clinically acceptable deviations when measuring the accuracy of volume measurements. •The RFM using a hot wire anemometer demonstrated clinically relevant deviations in volume measurements when changing the gas conditions. These deviations have to be taken into account when interpreting the volumes directly at birth. [ABSTRACT FROM AUTHOR]

Aim Resuscitation guidelines recommend 90 chest compressions ( CCs) and 30 inflations ( INFs) per minute for neonatal cardiopulmonary resuscitation ( nCPR). We hypothesised that auditory prompts would help coordinate these actions. Our aim was to investigate the effect of musical prompts during nCPR training on adherence to recommended CC and INF rates and on the quality of delivered INFs. Methods A simulation study was conducted employing 30 experienced neonatal staff, a respiratory function monitor and a neonatal manikin. The effects of five different auditory prompts on adherence to recommended rates of CC and INF were tested against baseline (no music). The five auditory prompts (popular musical tunes) were investigated in random order. Quality of INFs was assessed by comparing the peak inflation pressures ( PIP), positive end-expiratory pressures ( PEEP), percentage mask leak and tidal volumes ( VT). Results Mean baseline rates at which CCs and INFs were delivered were 80 ( SD 6) per minute and 28 ( SD 2) per minute, respectively. Listening to auditory prompts had varying effects on CC and INF delivery rates. For CCs, a significant difference to baseline was found only when participants listened to ABBA's ' SOS', with 86 ( SD 7) per minute ( P = 0.04). For INFs, we found a statistically significant improvement to baseline rate only for ' SOS', with 29 ( SD 2) per minute ( P = 0.04), and there was no significant difference in INF quality among the auditory prompts. Conclusions Musical prompts can help with adherence to recommended CC and INF rates but do not improve the quality of INFs during nCPR training. The lasting effect of auditory prompts as musical mnemonics on nCPR performance in vivo needs to be established. [ABSTRACT FROM AUTHOR]

Background: Less invasive surfactant administration (LISA) on the neonatal unit reduces the need for mechanical ventilation and bronchopulmonary dysplasia (BPD).Aims: To assess the immediate and longer-term efficacy of LISA to prematurely born infants in the delivery-room.Study Design: A case control study with inborn historical controls matched for gestational age, birthweight and gender to each LISA infant.Subjects: Infants born between 26+0 weeks and 34+6 weeks of gestational age.Outcome Measures: Respiratory function monitoring before and after LISA and need for mechanical ventilation within 72 h of birth.Results: Ninety-nine infants, median gestational age of 32+4(range:27+0-34+6) weeks, were prospectively recruited. The respiratory rate and inspired oxygen (FiO2) decreased two minutes after LISA and there was a reduction in the FiO2 requirement at two hours post birth. Compared to historical controls, LISA administration was associated with a reduction in the need for mechanical ventilation within 72 h after birth (20.2% versus 56.6% p < 0.001) the incidence of moderate to severe BPD (8.2% versus 20.2%, p = 0.02) and the median costs of neonatal intensive care stay (£1218 versus £2436, p = 0.03) and total neonatal unit stay (£12,888 versus £17,240, p = 0.04). A high FiO2 in the delivery-room pre-LISA (median 0.75 versus 0.60, p = 0.02) was associated with LISA failure, that is mechanical ventilation within 72 h of birth.Conclusions: LISA to prematurely born infants in the delivery-room was associated with reductions in the need for mechanical ventilation and costs of care, but was less successful in those with initial, more severe respiratory disease. [ABSTRACT FROM AUTHOR]

Background: Neonatal resuscitation training is considered to be multifarious and includes manual ventilation as an essential competence for any health-care provider. Usually, ventilation is applied with self-inflating bags (SIBs). These devices have been shown to produce highly variable, operator-dependent peak inspiratory pressures (PIPs) and tidal volumes (VT). Excessive PIP and VT contribute to lung injury. We studied a simple tool to improve resuscitation skills. Objective: The objectives of this study were to train health-care providers to avoid excessive PIP and VT by visualizing these values by using a respiratory function monitor (RFM) and to study the sustainability of such a training. Material and methods: Previously untrained medical professionals were educated and trained to ventilate a neonatal preterm manikin. PIP and VT were measured with an RFM. Graphical representations of the measurements were displayed during training, but the RFM was blinded during subsequent recordings. Participants were reassessed directly after training and 1 month later. Results: In total, 37 participants were trained and assessed three times during the study. Median PIPs (range) were 32.3 (4.1-44) cm H2O before training, 17.8 (9.6-23.6) cm H2O directly after training (P<0.05), and 18.7 (7.5-41.6) cm H2O 1 month later, and the values remained low, compared with before training (P<0.05). Median VTs were 6.7 (4.2-44) mL before training, 3.5 (1.8-7.3) mL directly after training (P<0.05), and 4.1 (1.9-9.7 mL) 1 month after training (P<0.05). Conclusion: Using a SIB, untrained staff produced excessive PIP and VT. Training with a simple RFM significantly reduced the occurrence of excessive PIP and VT. The effect was sustained for at least 1 month. [ABSTRACT FROM AUTHOR]

Abstract: Maintenance of upper airway patency remains a cornerstone of adequate airway management. Although various opening manoeuvres are recommended by neonatal resuscitation guidelines, none of these have been well evaluated in newly born infants. The aim of this article was to review the available literature about airway opening manoeuvres in newborn infants. We reviewed books, resuscitation manuals and articles from 1860 to the present with the search terms “Infant, Newborn”, “airway management”, “airway manoeuvres”, “chin lift”, “jaw thrust”, “neutral position”, “shoulder roll”, “neonatal resuscitation”, “positive pressure respiration” and “continuous positive airway pressure”. Only human studies were included. During mask PPV, jaw thrust appears to be more effective in achieving a patent upper airway and might help to reduce airway obstruction. The additional application of chin lift might reduce leak during mask ventilation. However given the lack of available data these conclusions remains speculative and further research in this area is required. [Copyright &y& Elsevier]

Purpose: Reduced mortality for infants born at less than 30 weeks' gestation after prophylactic surfactant administration has led many to advocate routine intubation and administration of surfactant in all infants at risk of respiratory distress syndrome. However, surfactant administration is associated with adverse events including bradycardia, changes in cerebral blood flow and endotracheal tube obstruction. The aim of this study was to analyse respiratory function immediately before and after surfactant administration in the delivery room. Methods: We reviewed video recordings of the initial resuscitation in the delivery room of infants born at less than 32 weeks' gestation between February 2007 and March 2010. Positive pressure ventilation was delivered with either a Neopuff T-piece or self-inflating bag. Respiratory parameters were recorded with a respiratory function monitor (RFM). Each RFM recording was analysed for 30 s before and 2 min after surfactant administration. Results: Of 230 infants recorded during the study period 16 infants received surfactant in the delivery room. Their mean (standard deviation, SD) gestation and birth weight were 25 (1) weeks and 757 (249) g, respectively. Complete airway obstruction was seen in 4/16 (25%) infants. The median (interquartile range, IQR) duration of this obstruction was 16 (8-27) s. The median (IQR) expired tidal volume before surfactant delivery was 8.0 (5.2-11.2) mL/kg compared to 4.6 (4.1-7.3) mL/kg ( p = 0.03) after surfactant administration. Conclusion: Substantial tidal volume changes occur before, during and after surfactant administration in the delivery room. Complete airway obstruction is common. Monitoring respiratory function during this procedure may help to assess the delivered tidal volume and airway pressures after surfactant treatment. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Clinical assessment and end-tidal CO2 (ETCO2) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO2 detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO2 detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement. Methods: We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO2 detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not. Results: Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement. Conclusion: Colorimetric CO2 detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases. [Copyright &y& Elsevier]

Abstract: Background: Current neonatal resuscitation guidelines recommend using visual assessment of chest wall movements to guide the choice of inflating pressure during positive pressure ventilation (PPV) in the delivery room. The accuracy of this assessment has not been tested. We compared the assessment of chest rise made by observers standing at the infants’ head and at the infants’ side with measurements of tidal volume. Methods: Airway pressures and expiratory tidal volume (V Te) were measured during neonatal resuscitation using a respiratory function monitor. After 60s of PPV, resuscitators standing at the infants’ head (head view) and at the side of the infant (side view) were asked to assess chest rise and estimate V Te. These estimates were compared with V Te measurements taken during the previous 30s. Result: We studied 20 infants who received a mean (SD) of 23 (4) inflations during the 30s. Some observer felt unable to assess chest rise both from the head view (6/20) and from the side view (3/20). Observers from both head and side tended to underestimate tidal volume by 3.5mL and 3.3mL respectively. Agreement between clinical assessment and measured V Te was generally poor. Conclusion: During mask ventilation, resuscitators were unable to accurately assess chest wall movement visually from either head or side view. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Clinical assessment and end-tidal CO2 (ETCO2) detectors are routinely used to verify correct endotracheal tube (ETT) placement. However, ETCO2 detectors may mislead clinicians by failing to correctly identify placement of an ETT under a variety of circumstances. A flow sensor measures and displays gas flow in and out of an ETT. We compared endotracheal flow sensor recordings with a colorimetric CO2-detector (Pedi-Cap®) to detect endotracheal intubation in a preterm sheep model of neonatal resuscitation. Methods: Six preterm lambs were intubated and ventilated immediately after delivery. At 5min the oesophagus was also intubated with a similar tube. The endotracheal tube and oesophageal tubes were attached to a Pedi-Cap® and flow sensor in random order. Two observers, blinded to the positions of the tubes, used a ETCO2 detector and the flow sensor recording to determine whether the tube was in the trachea or oesophagus. The experiment was repeated 10 times for each animal. In the last three animals (30 recordings) the number of inflations required to correctly identify the tube placement was noted. Results: The Pedi-Cap® and the flow sensor correctly identified tube placement in all studies. Thus, the sensitivity, specificity, and positive and negative predictive values of both devices were 100%. At least three, and up to 10, inflations were required to identify tube location with the Pedi-Cap® compared to one or two inflations with the flow sensor. Conclusion: A flow sensor correctly identifies tube placement within the first two inflations. The Pedi-Cap® required more inflations to correctly identify tube placement. [Copyright &y& Elsevier]

Abstract: Background: Excessive peak inspiratory pressures (PIP) and high tidal volumes (Vt) during manual ventilation can be detrimental to the neonatal lung. We compared the influence of different manual ventilation devices and individual professional experience on the extent of applied Vt and PIP in simulated neonatal resuscitation. Material and methods: One hundred and twenty medical professionals were studied. An intubated mannequin (equivalent to 1.0kg neonate) was ventilated using two different devices: a self-inflating bag and a T-piece resuscitator. Target value was a PIP of 20cm H2O. Applied PIP and the resulting Vt were recorded continuously using a respiratory function monitor (CO2SMO+, Novametrix, USA). Results: Vt and PIP provision was significantly higher in SI-bags, compared to T-piece devices: median (interquartile range) PIP 25.6 (18.2) cm H2O vs 19.7 (3.2) cm H2O (p <0.0005), and Vt 5.1(3.2) ml vs Vt 3.6 (0.8) ml (p <0.0005) respectively. The intersubject variability of Vt and PIP provision was distinctly higher in SI-bags, compared to T-piece devices. Professional experience had no significant impact on the level and the variability of Vt or PIP provided. Conclusion: Use of T-piece devices guarantees reliable and constant Vt and PIP provision, irrespective of individual, operator dependent variables. Methods to measure and to avoid excessive tidal volumes in neonatal resuscitation need to be developed. [Copyright &y& Elsevier]