What are the indications for positive-pressure ventilation (PPV), intubation, and chest compression in a newborn with respiratory distress and bradycardia?

Indications for Positive-Pressure Ventilation, Intubation, and Chest Compressions in Neonatal Resuscitation

Positive-Pressure Ventilation (PPV) Indications

Initiate PPV immediately if the infant remains apneic, gasping, or has a heart rate <100 bpm after completing initial steps (warming, positioning, clearing secretions if needed, drying, and stimulation). 1, 2

Specific Clinical Scenarios:

• Apnea or gasping respirations after initial stabilization steps 1, 3
• Heart rate <100 bpm despite adequate initial steps 1, 2
• Persistent respiratory distress with inadequate spontaneous breathing effort 2

Technical Parameters for PPV:

• Start with room air (21% oxygen) for term infants or 21-30% oxygen for preterm infants 1, 2, 3
• Use a ventilation rate of 40-60 breaths per minute 1, 3
• Apply initial inflation pressure of 20 cm H₂O (though 30-40 cm H₂O may be required in some term infants) 1, 3
• Maintain PEEP of approximately 5 cm H₂O when using equipment capable of delivering it 1, 2, 4
• The primary indicator of effective ventilation is a rising heart rate, not chest rise 3

Critical Timing Consideration:

Assessment and decision to initiate PPV should occur within 60 seconds after birth 3. Reassess heart rate after 30 seconds of adequate ventilation before escalating to chest compressions 3, 4.

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Endotracheal Intubation Indications

Intubation is indicated when bag-mask ventilation is ineffective, when chest compressions are performed, or in special circumstances requiring definitive airway control. 1

Specific Indications:

• Ineffective bag-mask ventilation despite corrective steps (MR SOPA algorithm) 1, 3
• When chest compressions are performed (heart rate <60 bpm despite adequate PPV) 1, 3
• Prolonged ventilation is anticipated or required 3, 4
• Special resuscitation circumstances:
  • Suspected congenital diaphragmatic hernia 1
  • Initial endotracheal suctioning of non-vigorous meconium-stained newborns (though routine suctioning is no longer recommended) 1, 3

Alternative Airway Option:

• Laryngeal mask airway should be considered for infants ≥34 weeks gestation or ≥2000g when facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible 1, 3, 4
• Laryngeal mask has not been evaluated during chest compressions or for emergency medication administration 1

Confirmation of Tube Placement:

• Use exhaled CO₂ detection as the primary confirmation method for endotracheal tube placement 1, 3
• Note that poor cardiac output may give false-negative results (no CO₂ detected despite correct tracheal placement) 1

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Chest Compression Indications

Begin chest compressions at a 3:1 compression-to-ventilation ratio if heart rate remains <60 bpm despite 30 seconds of adequate PPV with supplemental oxygen. 2, 3, 4

Prerequisites Before Starting Compressions:

• Full 30 seconds of effective ventilation with visible chest rise must be achieved first 3
• Oxygen concentration increased to 100% if heart rate remains <60 bpm after 90 seconds of PPV with lower oxygen concentration 1, 4
• Ventilation is the cornerstone of neonatal resuscitation because bradycardia results from inadequate lung inflation or profound hypoxemia, not primary cardiac pathology 2, 3

Technical Parameters:

• Use two-thumb encircling technique 3
• Maintain 3:1 compression-to-ventilation ratio (90 compressions and 30 ventilations per minute) 3, 5
• Do not delay ventilation to establish IV access or prepare for intubation 3

Critical Pitfall to Avoid:

The vast majority of bradycardic newborns will respond to effective ventilation alone 3. Starting chest compressions before ensuring 30 seconds of adequate ventilation is a common error that should be avoided 3. Research shows that in bradycardic infants, heart rate typically does not increase until after 20 seconds of adequate PPV 6, 7.

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Escalation Algorithm Summary

1. Initial assessment (within 30 seconds): breathing effort, heart rate, tone 2
2. If apneic, gasping, or HR <100 bpm: Start PPV with 21% oxygen (term) or 21-30% oxygen (preterm) 1, 2
3. After 30 seconds of adequate PPV: Reassess heart rate 3
4. If HR remains <60 bpm after 90 seconds: Increase oxygen to 100% 1, 4
5. If HR remains <60 bpm after 30 seconds of adequate PPV with 100% oxygen: Begin chest compressions at 3:1 ratio and consider intubation 1, 3, 4