Programul de Reanimare Neonatal. Kit de Slide-uriAcademia American de Pediatrie nu este responsabil de nici una din modificrile aduse acestui program de Echipa de Training in Reanimarea Neonatal a Later-day Saints Charities. Acest program, modificat astfel, nu poate fi distribuit n Statele UniteLecia 3: UTILIZARE DISPOZITIVELOR DE REANIMARE PENTRU VENTILAIA CU PRESIUNE POZITIV

Utilizarea Dispozitivelor de Reanimare pentru Ventilaia cu Presiune PozitivConinutul lecieiCnd se ventileazTipuri de dispozitive de reanimareAdministrarea oxigenuluiPlasarea mtii facialeRezolvarea problemelor la dispozitivele de reanimareEvaluarea ventilaieip. 71

Indicaii pentru Ventilaia cu Presiune PozitivApnee/gaspingFrecvena cardiac sub 100 bti pe minut (bpm) chiar dac respirCianoz persistent n ciuda administrrii oxigenului 100% n flux liber

Ventilaia plmnilor este singurul cel mai important i cel mai eficient pas n reanimarea cardiopulmon a nou-nscutului compromisp. 74

Termeni Referitori la Ventilaia cu Presiune Pozitiv

Presiunea Inspiratorie (Peak inspiratory pressure (PIP) : Presiunea administrat la fiecare respiraie la sfritul compresiei Presiunea Pozitiv la Sfritul Expirului (Positive end-expiratory pressure (PEEP): presiunea gazului n timpul relaxrii, nainte de urmtoarea compresiePresiune pozitiv continu n cile aeriene (Continuous positive airway pressure (CPAP): Aceeai ca i PEEP, dar copilul respir spontanFrecvena: Numrul de respiraii asistate

p. 74

Tipuri de dispozitive de presiune pozitivBalonul autogonflabil Balonul de anestezieResuscitator cu pies n T

p. 75-77Acest curs va discuta doardespre balonul autogonflabil.

Balonul autogonflabilAvantaje:Se reumple mereu dup comprimare Se destinde fr surs de gaz sub presiuneValva de supra presiune (supapa) face hiper- inflaia mai puin probabil p. 77-78

Balonul autogonflabilDezavantaje:Necesit contact strns ntre masc i fa pentru a destinde plmniiNecesit un rezervor de oxigen pentru a furniza concentraii mari de oxigenNu se poate administra oxigen n flux liber prin mascNu poate fi folosit pentru CPAP. Nu asigur PEEP fr o valv specialp. 77-78

Caracteristici Generale ale Dispozitivelor de ResuscitareMti de mrime potrivitCapabilitate pentru concentraii variabile de oxigen de la 21% la 100% (blender de oxigen recomandat)Control al PIP, PEEP i timp inspiratorDimensiuni corespunztoare ale balonului (200-750 mL) Caracteristici de siguranp. 79-81

Caracteristici de Siguran: Balonul Autogonflabil

p. 82Valva de suprapresiune (supapa) setat la 30-40 cm H2OIndicator de presiune sau manometruFacei click pe imagine pentru video

Deasemeneambuntirea coloraiei Respiraia spontanmbuntirea tonusului muscularSemne de Eficien a VentilaieiCel mai important indicator al succesului VPP (ventilaie cu presiune pozitiv) este frecvenacardiac n cretere.p. 85

Controlul OxigenuluiReanimarea cu aer atmosferic poate fi realizat cu balonul autogonflabil neataat la sursa de oxigen

O concentraie de aproximativ 40% oxigen poate fi atins cu un balon fr rezervor, conectat la oxigen 100% (reglai debitul

Tipuri de Rezervoare de Oxigenp. 119

Caracteristici ale Mtilor FacialePentru a asigura ventilaie eficient, mtile trebuie s fie capitonate i de mrime corect.Trebuie s acopereVrful brbieiGuraNasul

p. 88

List de Verificare a Materialelor Alegei masca de mrime potrivitAsamblai i testai balonul i mascaAsigurai-v c sunt libere cile aerieneAezai capul n poziia de adulmecareStai la capul copilului sau lateralnainte de a ncepe ventilaia cu presiune pozitiv:p. 88-90

Poziionarea Mtii pe FaNu apsai tare masca pe faNu lsai degetele sau mna sprijinite pe ochiNu punei presiune asupra gtului (traheei)

Pentru a mbunti contactul mtii cu faaFolosii presiune uoar n josPutei mpinge uor mandibula n sus ctre mascp. 91

Ct de mult Presiune de Inflaie?

ncepei cu presiunea inspiratorie de 20 cm H20. Cnd masca e etan i plmnii sunt n mod adecvat destini se vor observa: creterea frecvenei cardiace a copilului zgomote respiratorii ce se aud bilateral micri toracice vizibile (nou-nscut la termen)p. 92

Controlul Presiunii

Puterea comprimrii balonuluiOrice scurgere ntre masc i faa nou-nscutuluiPunctul limit al supapei de presiuneCantitatea de presiune administrat prin balonul autogonflabil depinde de urmtorii 3 factori:p. 121

Hiper-inflaia pulmonar

Se folosete prea mult presiuneExist pericolul de a produce pneumotoraxDac nou-nscutul pare s primeasc respiraii foarte profundep. 93

Copilul nu se amelioreazPosibile cauzeEtaneizare incorectCi respiratorii blocatePresiune insuficient

p. 93Nu se mbuntesc frecvena cardiac i coloraia dup 5-10 respiraiiNu se aud zgomote respiratoriiNu se vd micri toraciceFacei click pe imagine pentru video

mbuntirea ventilaiei cu masc i balon (MR SOPA) Pai corectori M ajustai Masca R Repoziionai cile respiratorii S aspirai Secreiile din gur i nas O Open mouth. Deschidei gura copilului P cretei Presiunea A Alternativa pentru calea Aerian

p. 95

Frecvena ventilaiei:40 - 60 respiraii pe minut

Facei click pe imagine pentru videop. 95

Pn n acest moment ai.

Iniiat VPP 20 cm H2O, 40-60 resp/min Chemat ajutor Crescut oxigenul dac a fost nevoie Asistentul a ascultat zgomotele respiratorii i a vizualizat micrile respiratorii Iniiat MR SOPA

p. 98

Copilul nu se amelioreaz

FC este < 60 bpm dup 30 secunde de VPP eficient

Cretei oxigenul pn la 100% Luai serios n considerare intubaia traheal Chemai persoane cu expertiz suplimentar ncepei masajul cardiac

p. 98

Copilul se amelioreaz parial

FC > 60 bpm dar < 100 bpm: Cretei oxigenul pn la 100% Luai n considerare introducerea unei sonde orogastrice Luai n considerare scaderea presiunii inspiratorii dac expansiunea toracelui pare prea mare Asigurai eficiena ventilaiei i reevaluai la fiecare 30 secunde Verificai zgomotele respiratorii pentru a identifica un posibil pneumotoraxp. 98

Ventilaia cu presiune pozitiv continuDistensia gastric poate:Ridica diafragmul, mpiedicnd expansiunea pulmonar complet Provoca regurgitaia i aspiraiaSonda orogastric trebuie introdus pentru a rezolva distensia gastric.p. 99

Introducerea sondei orogastriceEchipament: sond de gavaj 8F i sering 20-mL Msurarea lungimii corecte:p. 100

Introducerea sondei orogastrice: Introducei sonda prin gur, mai degrab dect pe nas (reluai ventilaia)Ataai seringa de 20-mL i aspirai uornlturai seringa i lsai captul sondei deschis pentru aerFixai sonda pe obrazul nou-nscutuluip. 101

Cnd se oprete ventilaiaFrecvena cardiac este peste 100 bpmRespiraii spontane susinuteOxigenul suplimentar este retras dup toleran

p. 102

Sfritul Leciei 3

Diapozitive Opionale

1 minut 60-65% 2 minute 65-70% 3 minute 70-75% 4 minute 75-80% 5 minute 80-85%10 minute 85-95% Folosirea Oxigenului n timpul Reanimriincepei reanimarea cu oxigen 21% .Dac sunt disponibile pulsoximetru i blender, reglai oxigenul pt a atinge urmtoarele SpO2 dup natere: p. 85

Balonul Auto-Gonflabil3-4Ap. 75

Balonul Destins de Flux3-4Bp. 76

Resuscitatorul cu Pies n TFacei click pe imagine pentru video3-4Cp. 77

Balonul AutogonflabilTestarea balonului nainte de folosire

Facei click pe imagine pentru videop. 78

mbuntirea Etaneitii ntre Fa i Masc3-23Bp. 91

Balonul de anestezieDezavantaje:Necesit surs de gaz sub presiune de la surs Necesit un contact etan ntre masc i fa pentru a rmne umflatNecesit surs de gaz pentru a se umfla. Dac este gol, arat ca un balon dezumflatDe obicei nu are supap de siguranUtilizeaz o valv de control al fluxului pentru a regla presiunea/inflaiap. 78

Balonul de anestezieAvantaje:Livreaz oxigen cu concentraii de 21% pn la 100% depinznd de sursUor de evaluat etaneitatea mtii pe faa copiluluiPoate fi folosit pentru administrarea de oxigen n flux liber pe masc

p. 78

Balon destins de flux (de anestezie : Reglarea Fluxului de Oxigen i PresiuniiFacei click pe imagine pentru videop. 78

Resuscitatorul cu pies nTAvantaje:

Administrare constant a presiuniiControl sigur al presiunilor (PIP, PEEP) Livrare sigur a oxigenului 100% Nu apare oboseala ca la ventilaia cu balonp. 79

Resuscitatorul cu pies nTDezavantaje:Necesit surs de gaz sub presiuneTrebuie s aib contact etan ntre masc i fa pentru a destinde plmniiCompliana pulmonar nu poate fi simitNecesit reglarea presiunii nainte de folosireSchimbarea presiunilor n timpul utilizrii este mai dificilp. 79

Dispozitive de resuscitare: Oxigen n flux liberOxigenul n flux liberNu poate fi administrat n siguran prin balon autogonflabil i mascPoate fi administrat n siguran prin masc i balon de anestezie sau resuscitator cu pies n Tp. 87

Luai n considerare asigurarea unui balon autogonflabil ca rezerv de fiecare dat cnd ar putea fi nevoie de reanimare, pentru situaia n care sursa de gaz sub presiune sau dispozitivul cu pies n T nu funcioneaz. Rezerva de urgen: Balonul autogonflabilp. 89

Plasarea Mtii3-23Ap. 91

Caracteristici de Siguran: Balonul de AnestezieFacei click pe imagine pentru videop. 122

Caracteristici de Siguran: Resuscitatorul cu Pies n TFacei click pe imagine pentru videop. 128

Anexe: Descrierea Dispozitivelor de ReanimareBaloane autogonflabileBaloane de anestezieResuscitatoare cu pies n TTrecei n revist dispozitivele folosite n spitalul vostrup. 117-130

Anexa B: Baloane de reanimare de anestezie Facei click pe imagine pentru videop. 122

Balon de anestezie: Probleme PotenialeBalonul nu se va expansiona dacMasca nu este bine etaneizat pe gura i nasul nou-nscutuluiExist o sprtur n balonValva de control a fluxului este deschis prea multManometrul lipsete sau portul nu este nchisp. 123

Anexa C: Resuscitatorul cu Pies n TFacei click pe imagine pentru videop. 128

Pregtirea Resuscitatorului cu Pies n T pentru FolosireFacei click pe imagine pentru videop. 129

Resuscitatorul cu pies n T: TroubleshootingFacei click pe imagine pentru videop. 130

Etaneizarea mtii pe fa

Contactul etan necesar pentru destinderea balonului de anestezieContactul etan necesar pentru destinderea plmnilor cnd este comprimat balonul autogonflabilContactul etan necesar pentru destinderea plmnilor cnd valva de PEEP este acoperit la folosirea resuscitatorului cu piesa n TUn contact etan pentru este esenial pentru realizarea VPP eficientep. 88

*In Lesson 3 you will learnWhen to give positive-pressure ventilationThe similarities and differences among flow-inflating bags, self-inflating bags, and T-piece resuscitatorsThe operation of each device to provide positive-pressure ventilationThe correct placement of the masks on the newborns faceHow to test and troubleshoot devices used to provide positive-pressure ventilationHow to evaluate the success of positive-pressure ventilation

*If, after the initial steps, the baby is not breathing or is gasping, the heart rate is less than 100 bpm, or the color remains cyanotic despite 100% free-flow oxygen, the next step is to provide positive-pressure ventilation. This is a critically important skill and the single most important step in the resuscitation of the compromised newborn. The success of resuscitation may be dependent on the effectiveness of this procedure.

*If, after the initial steps, the baby is not breathing or is gasping, the heart rate is less than 100 bpm, or the color remains cyanotic despite 100% free-flow oxygen, the next step is to provide positive-pressure ventilation. This is a critically important skill and the single most important step in the resuscitation of the compromised newborn. The success of resuscitation may be dependent on the effectiveness of this procedure.

*There are 3 types of devices to give positive-pressure ventilation to newborns.The self-inflating bag inflates without a compressed gas source after it is squeezed. It remains inflated at all times.The flow-inflating bag is collapsed when not in use, and it looks like a deflated balloon. It inflates only when gas flows into the bag and the opening is sealed, as when the mask is placed tightly on a newborns face.The T-piece resuscitator works only when gas flows into it. The gas is directed to the environment or to the baby by occluding or releasing the opening on a T-shaped tube with your finger or thumb.

*The self-inflating bag, as its name implies, inflates automatically without a compressed gas source. It remains inflated at all times unless being squeezed. Peak inspiratory pressure (or peak inflation pressure) is controlled by how hard the bag is squeezed. The self-inflating bag has a pressure-release (pop-off) valve that opens if peak inspiratory pressures greater than 30 to 40 cm H2O are generated. This is a safety feature that makes over-inflation less likely. *The self-inflating bag, as its name implies, inflates automatically without a compressed gas source. It remains inflated at all times unless being squeezed. Peak inspiratory pressure (or peak inflation pressure) is controlled by how hard the bag is squeezed. The self-inflating bag has a pressure-release (pop-off) valve that opens if peak inspiratory pressures greater than 30 to 40 cm H2O are generated. This is a safety feature that makes over-inflation less likely. *A variety of mask sizes, appropriate for newborns of different weights, should be available at every delivery. Cushioned, anatomically shaped masks are preferred.

Term newborns who require positive-pressure ventilation at birth should be initially ventilated with a high concentration of oxygen (90%-100%). Bags used for newborns should have a volume of 200 to 750 mL. Term newborns require only 15 to 25 mL with each ventilation (5-8 mL/kg).

To minimize complications resulting from high ventilation pressures, resuscitation devices should have certain safety features to prevent unwanted high pressures.*Self-inflating bags should have a pressure-release (pop-off) valve, which is generally set to 30 to 40 cm H2O. If pressures greater than 30 to 40 cm H2O are generated, the valve opens, limiting the pressure being transmitted to the baby.

In some self-inflating bags, the pressure-release valve can be temporarily occluded or bypassed to allow high pressure to be administered. This is usually not necessary, but can be done to ventilate a newborns non-aerated lungs when the usual pressures are not effective, especially with the first few breaths. Many self-inflating bags also are equipped with a port to attach to a pressure gauge.*The best indications that the mask is sealed and the lungs are being adequately inflated are improvements in heart rate, color, and muscle tone. If these signs are not improving, you should look for the presence of chest movement with each positive-pressure breath and have an assistant listen to both sides of the lateral areas of the chest with a stethoscope to assess breath sounds. Abdominal movement due to air entering the stomach may be mistaken for effective ventilation.

The lungs of a fetus are filled with fluid, while the lungs of a newborn must be filled with air. To establish a gaseous volume (functional residual capacity) in a newly born baby, the first breaths often require higher pressures and longer inflation times than with subsequent breaths. It is helpful to monitor pressure with a pressure gauge to avoid high lung volumes and airway pressures. You should ventilate the lungs with the lowest pressure required to improve heart rate, color, and muscle tone.*Newborns who require resuscitation with assisted ventilation at birth may require a high concentration of oxygen (90% to 100%).

Air drawn into a self-inflating bag through the air inlet dilutes the concentration of oxygen in the bag. As a result, the concentration of oxygen actually received by the patient is greatly reduced to about 40%.

*There are several different types of oxygen reservoirs, but they all perform the same function. Some have open ends, and others have a valve that allows some air to enter the reservoir.*For the mask to be the correct size, as pictured in this slide, the rim will cover the tip of the chin, the mouth, and the nose, but not the eyes.

If the mask is too large, it may cause eye damage.

If the mask is too small, it will not cover the mouth and nose and may occlude the nose.*Before beginning positive-pressure ventilation, check the following:The mask should cover the mouth, nose, and the tip of the chin, but not the eyes.Suction the mouth and nose to be certain there is no obstruction.The newborns neck should be extended slightly to maintain an open airway. One way to accomplish this is to place a small roll under the shoulders.Position yourself at the side or head of the newborn to use the resuscitation device effectively. This position allows you to hold the mask on the newborns face comfortably. The mask may be swiveled on the bag or T-piece resuscitator for optimal fit to the face and to your position. If using a bag, it must be positioned so that it does not block your view of the newborns chest since you need to be able to observe movement of the newborns chest during ventilation.*Care should be taken in holding the mask on the newborns face. Observe the following precautions.*The amount of pressure delivered by a self-inflating bag is not dependent on the flow of oxygen entering the bag. When you seal the mask on the newborns face (or connect the bag to an endotracheal tube), there will be no color of a in the inflation of the self-inflating bag.*The amount of pressure delivered by a self-inflating bag is not dependent on the flow of oxygen entering the bag. When you seal the mask on the newborns face (or connect the bag to an endotracheal tube), there will be no change in the inflation of the self-inflating bag.*If the baby appears to be receiving very deep breaths from positive-pressure ventilation, the lungs are being overinflated. Too much pressure is being used and there is danger of producing a pneumothorax. Remember that the volume of a newborn breath is much smaller than the amount of gas in the resuscitation bag.One tenth of a 240-mL self-inflating bagOne thirtieth of a 750-mL flow-inflating bag

Abdominal movement may be due to air entering the stomach and should not be mistaken for effective ventilation.*If the heart rate, muscle tone, and color do not improve, check to see if the chest is moving with each positive-pressure breath. If the chest is not expanding adequately and there are poor breath sounds, it may be due to one of the following reasons:

Seal is inadequate. You may hear or feel air escaping from around the mask. Reapply the mask to the face and try to form a better seal while using a little more pressure on the rim of the mask.Airway is blocked. Check the newborns position and extend the neck a bit farther. Check the mouth or oropharynx and nose for secretions and suction if necessary. Try ventilating with the newborns mouth slightly open.Not enough pressure given. If you are not providing enough pressure to move the lungs, increase the pressure. If using a resuscitation device with a pressure gauge, the pressure limit may have to be increased. If using a bag with a pressure-release valve, increase the pressure until the valve actuates.Malfunctioning equipment, including a torn bag, a faulty flow-control valve, or an improper connection, also may be the cause of inadequate chest expansion.

*This chart is a summary of steps to follow if the baby does not improve and adequate chest expansion is not observed. Also make sure the equipment is functioning correctly. Replace the resuscitation bag, if necessary. If you still are unable to obtain physiologic improvement and adequate chest movement after going through this sequence, endotracheal intubation and positive-pressure ventilation through the endotracheal tube are usually required.*During the initial stages of resuscitation, breaths should be delivered at a rate of 40 to 60 breaths per minute or slightly less than once a second. If you squeeze the bag or occlude the PEEP cap of the T-piece resuscitator on Breathe and release while you say Two, Three, you probably are ventilating at a proper rate.

Check the 4 signs for improvement (rising heart rate, improving color, spontaneous breathing, and improving tone) after 30 seconds of administering positive-pressure ventilation. As the heart rate increases toward normal, ventilation should be continued at a rate of between 40 and 60 breaths per minute. With improvement, the newborn should become pink and muscle tone should improve.

When the heart rate stabilizes above 100 bpm, reduce the rate and pressure of assisted ventilation until you see effective spontaneous respiration. When color improves, supplemental oxygen can also be weaned as tolerated. If the heart rate remains below 60 bpm, you need to proceed to the next step of chest compressions, as described in the next lesson.*Positive-pressure ventilation with a mask generally is not as effective as positive-pressure ventilation through an endotracheal tube. A mask does not seal on the face as tightly as an endotracheal tube seals in the larynx. If you have checked all of the factors listed on the preceding slide and chest movement is still unsatisfactory, or if you dont hear good breath sounds bilaterally, usually it will be necessary to insert an endotracheal tube. Also, additional complications, such as pneumothorax, may have occurred. If the newborns condition continues to deteriorate or fails to improve, and the heart rate is less than 60 beats per minute despite 30 seconds of adequate positive-pressure ventilation, the next step is to begin chest compressions.*Positive-pressure ventilation with a mask generally is not as effective as positive-pressure ventilation through an endotracheal tube. A mask does not seal on the face as tightly as an endotracheal tube seals in the larynx. If you have checked all of the factors listed on the preceding slide and chest movement is still unsatisfactory, or if you dont hear good breath sounds bilaterally, usually it will be necessary to insert an endotracheal tube. Also, additional complications, such as pneumothorax, may have occurred. If the newborns condition continues to deteriorate or fails to improve, and the heart rate is less than 60 beats per minute despite 30 seconds of adequate positive-pressure ventilation, the next step is to begin chest compressions.*Positive-pressure ventilation with a mask generally is not as effective as positive-pressure ventilation through an endotracheal tube. A mask does not seal on the face as tightly as an endotracheal tube seals in the larynx. If you have checked all of the factors listed on the preceding slide and chest movement is still unsatisfactory, or if you dont hear good breath sounds bilaterally, usually it will be necessary to insert an endotracheal tube. Also, additional complications, such as pneumothorax, may have occurred. If the newborns condition continues to deteriorate or fails to improve, and the heart rate is less than 60 beats per minute despite 30 seconds of adequate positive-pressure ventilation, the next step is to begin chest compressions.*Newborns requiring positive-pressure ventilation with a mask for longer than several minutes should have an orogastric tube inserted and left in place. During positive-pressure ventilation, gas is forced into the oropharynx, where it is free to enter the trachea and the esophagus. Some gas will be forced into the stomach. Gas forced into the stomach will interfere with ventilation by preventing full expansion of the lungs and may cause regurgitation and aspiration of contents. This problem may be relieved by the insertion of an orogastric tube.*Always measure the length of the tube needed for insertion. The length of the inserted tube should be equal to the distance from the bridge of the nose to the earlobe, and earlobe to a point halfway between the xyphoid process (the lower tip of the sternum) and the umbilicus. Note the centimeter mark at this place on the tube.*The tube will not interfere with the face-mask seal if an 8F feeding tube is used and the tube exits from the side of the mask over the soft area of the newborns cheek. A larger tube may make it difficult to obtain a seal, particularly in premature infants. A smaller tube can easily be occluded by secretions. Ventilation can be continued once the tube is inserted and before aspiration with the syringe.*Check for adequacy of chest expansion, and use a stethoscope to listen for bilateral breath sounds.

Is the face-mask seal tight? Is the airway blocked?Is the resuscitation equipment working properly?Is adequate pressure being used?Is adequate oxygen being administered?Is oxygen tubing attached to the device and to an oxygen source? If using the self-inflating bag, is the oxygen reservoir attached? If using a tank (rather than wall oxygen), is there oxygen in the tank? Is gas flowing through the flowmeter?

**The best indications that the mask is sealed and the lungs are being adequately inflated are improvements in heart rate, color, and muscle tone. If these signs are not improving, you should look for the presence of chest movement with each positive-pressure breath and have an assistant listen to both sides of the lateral areas of the chest with a stethoscope to assess breath sounds. Abdominal movement due to air entering the stomach may be mistaken for effective ventilation.

The lungs of a fetus are filled with fluid, while the lungs of a newborn must be filled with air. To establish a gaseous volume (functional residual capacity) in a newly born baby, the first breaths often require higher pressures and longer inflation times than with subsequent breaths. It is helpful to monitor pressure with a pressure gauge to avoid high lung volumes and airway pressures. You should ventilate the lungs with the lowest pressure required to improve heart rate, color, and muscle tone.****To check the operation of a self-inflating bag, block the mask or patient outlet with the palm of your hand and squeeze the bag. A manometer is not necessary.Do you feel pressure against your hand?Can you force the pressure-release valve open?Does the pressure gauge (if present) register 30 to 40 cm H2O pressure when the pressure-release valve opens? If not, check for a crack or leak in bag. Check to see if the pressure gauge is missing, if the pressure-release valve is missing or stuck closed, and whether the patient outlet is sufficiently blocked.**The flow-inflating bag is collapsed like a deflated balloon when not in use. It inflates only when a gas source is forced into the bag and the opening of the bag is sealed, as when a mask is placed tightly on a babys face. Peak inspiratory pressure is controlled by the flow rate of incoming gas, adjustment of the flow control valve, and how hard the bag is squeezed. Positive end-expiratory pressure (PEEP) or CPAP is controlled by an adjustable flow-control valve. A pressure manometer should be used to avoid excessive inflation pressure. *Flow-inflating bags deliver 100% oxygen directly to the patient and can be used to deliver free-flow oxygen through the mask. The bag will not inflate unless there is a tight seal against the babys face, making it easy to assess the quality of the seal.*When using a flow-inflating bag, inflate the bag with compressed gas (oxygen, air, or blended). Once the gas enters the bag, it is not diluted and the concentration of oxygen you put in the bag is the same concentration given to the patient. Once you seal the mask on the newborns face, all of the oxygen coming from the wall or tank will be directed to the bag and out the flow-control valve. This will cause the bag to inflate. Pressure in the bag can be adjusted by adjusting the flowmeter to regulate how much gas enters the bag (usually at least 5 L/min) or by adjusting the flow-control valve, regulating how much gas escapes from the bag.*The T-piece resuscitator is an old device that has been recently reintroduced into the delivery room. The T-piece resuscitator provides flow-controlled and pressure-limited ventilation or CPAP. Think of this device as a manually cycled mechanical ventilator.

Peak inspiratory pressure and positive end-expiratory pressure (PEEP), or CPAP if desired, are manually set with adjustable controls. Intermittent inflating pressure is delivered when the operator alternately occludes and releases the opening on the device. This device can reliably deliver varying concentrations of oxygen up to 100% free-flow oxygen.*The T-piece resuscitator will not work unless connected to a compressed gas source. This device requires a tight face-mask seal to deliver a breath. The device also requires some preparation time to assemble, turn on gas flow, and adjust the pressure limits appropriately. Because the pressures are set manually by the operator, changing inflation pressure during resuscitation is more difficult than with the other devices.*Free-flow oxygen cannot be given reliably with a self-inflating bag-and-mask device. The oxygen flow entering a self-inflating bag will normally be diverted to the air inlet, through its attached oxygen reservoir, and then evacuated out the end of the oxygen reservoir or out a valve that is attached to the reservoir.

A flow-inflating bag and mask or T-piece resuscitator can be used to deliver free-flow oxygen. The mask should be loosely placed on the face, allowing some gas to escape around the edges. When using a flow-inflating bag, it should not inflate when used for this purpose. *The self-inflating bag can be used in any setting and without a gas source, making it immediately available for initiating neonatal resuscitation, even outside the obstetric/neonatal patient care area. Consider stocking a self-inflating bag and different size masks in your portable emergency resuscitation supplies to ensure that a neonatal positive-pressure device is available no matter where in the hospital you may be called upon to initiate newborn resuscitation.**Flow-inflating bags have a flow-control valve that can be adjusted to deliver the desired peak pressure and positive end-expiratory pressure (PEEP). A pressure manometer attached to the bag will allow proper adjustment of the valve.*The T-piece resuscitator has 2 controls to adjust the inspiratory pressure. The inspiratory pressure control sets the amount of pressure desired during a normal assisted breath. The maximum pressure relief control is a safety feature that prevents the pressure from exceeding a preset value (usually 40 cm H2O, but adjustable). Excessive pressure can also be avoided by watching the circuit pressure gauge.*This next section reviews the device(s) used for the administration of positive-pressure ventilation to newborns. You will be responsible to know how to operate, test, and troubleshoot devices used for resuscitation of newborns in your hospital.*The flow-inflating bag has 4 parts.Flow-control valve: provides an adjustable leak that allows pressure to be regulated in the bag.Oxygen inlet: oxygen from a compressed source enters the bag.Pressure manometer attachment site: allows for attachment of manometer to indicate the amount of pressure being used to ventilate the newborn.Patient outlet: oxygen exits from the bag to the patient.

The pressure manometer alerts you to the amount of pressure being used to ventilate the newborn. If the flow-inflating bag has a connecting site for a pressure manometer, a manometer must be attached to the site, or the attachment site will be a source of leak and the bag will not inflate properly.*The inflation of a flow-inflating bag depends on a sealed system. If the bag does not inflate, check for potential problems, such as those mentioned here.*There are 6 parts to a flow-controlled, pressure-limited T-piece resuscitator.Oxygen (gas) inlet: where gas from a compressed source enters the resuscitator.Patient (gas) outlet: where gas exits the resuscitator to the patient T-piece where the mask or endotracheal tube attaches.Inspiratory pressure control: used to set desired peak inspiratory pressure.Patient T-piece with positive end-expiratory pressure (PEEP) cap: the mask or endotracheal tube attaches to the T-piece and the PEEP cap is used to set the positive end-expiratory pressure, if needed.Circuit pressure gauge: used to set and monitor peak inspiratory pressure, positive end-expiratory pressure, and maximum circuit pressure.Maximum pressure relief control: controls desired maximum pressure by occluding the PEEP cap and turning the maximum pressure relief control to the maximal pressure limit.*Assemble the parts of the T-piece resuscitator as instructed by the manufacturer.

Attach a test lung to the patient outlet (provided by manufacturer).

Connect the device to the gas source (this will be tubing either from 100% oxygen source or a blender that permits adjustment of oxygen concentration).

*If the baby doesnt improve or the desired peak pressure is not reached,The mask may not be properly sealed on the babys face.The gas supply may not be connected or of sufficient flow.The maximum circuit pressure, peak inspiratory pressure, or positive end-expiratory pressure may be incorrectly set.

Free-flow oxygen can be given reliably with the T-piece resuscitator if you occlude the PEEP cap and hold the mask loosely over the babys face.*An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs.

Also, a flow-inflating bag will not stay inflated without a good face-mask seal, and, therefore, you will not be able to squeeze the bag to create the desired pressure.

With a self-inflating bag or a T-piece resuscitator, you will not be able to deliver positive pressure unless there is a good face-mask seal. This can be determined by watching for chest movement with each inspiration.