Detailed description of NRP

1. DR. LOKANATH REDDY
JUNIOR RESIDENT
DEPT. OF PAEDIATRICS
KASTURBA MEDICAL COLLEGE
MANIPAL

2.  History
 Overview and Principles of Resuscitation
 Initial steps of resuscitation
 Positive – Pressure ventilation
 Chest compressions
 Endotracheal tube intubation and LMA insertion
 Medications
 Special considerations
 Resuscitation of Preterm babies
 Ethics and Care at the end of life

3.  For the past 40 yrs Fetal anoxia was one of
the most investigated conditions affecting
the newborn.
 Better understanding of the effect of certain
conditions on fetus like placental disease
and hemorrhage.
 It was then realized that obstruction to the
airway immediately following birth should be
the first concern in newborn resuscitation.

4.  18th Century Scottish Obstetrician Blundell first
used mechanical device for tracheal intubation
in living newborn
 In 1920 Joseph B. DeLee introduced simple
rubber catheter and glass trap to clear upper
airways and stomach.
 In 1953 Apgar Score was given byVarginia
Apgar. She is also the first to catheterise UA in
newborn

5.  1966 national guidelines for resuscitation of
adults was recommended by National Academy
of Sciences.
 In 2000 the consensus document on advanced
life support of the newborn converted the
previously published advisory statements into a
set of guidelines.
 In 2010 revised guidelines was published.

6. Professor of Pediatrics and Director of the
Neonatology Department at Saint Louis
University in St. Louis, Missouri.

7. Preterm
27%
Sepsis &
pneumonia
26%
Asphyxia
23%
Congenital
7%
Tetanus
7%
Diarrhoea
3%
Others
7%
4 million neonatal deaths:When? Where? Why? Lancet 2005; 365: 891–900

8. WHYTO LEARN NEWBORN RESUSCITATION ?
 Birth asphyxia accounts for about 1/4th of the
4 million neonatal deaths that occur each year
worldwide.
 For many newborns resuscitation is not
available
 Outcomes of these newborns can be improved
with timely and effective resuscitation.

9.  Approximately 90% of newborns make
smooth transition from intrauterine to
extrauterine life requiring little or no
assistance
 10% of newborns need some assistance
 Only 1% require extensive resuscitation
 We must always be prepared to resuscitate,
as even some of those with no risk factors
will require resuscitation.

10. ADULT vs. NEONATAL RESUSCITATION
 The sequence of resuscitation in adults is C-A-B
 But in newborns the sequence remains
A-B-C as the etiology of neonatal compromise is
nearly always a breathing difficulty
 AIRWAY(position and clear)
 BREATHING (stimulate to breathe)
 CIRCULATION (assess HR and oxygenation)

11. Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with positive
pressure
Intubate the trachea
Provide chest
compressions
Medications
Always needed
Needed less
frequently
Rarely needed

13. BEFORE BIRTH
 Oxygen supply by placental
membranes
 No role of lungs. Fluid filled
alveoli and constricted arterioles
due to low Po2 in fetal blood.

14.  Low Po2 
constricted arterioles
 increased
pulmonary vascular
resistance 
shunting of blood
from Pulmonary
Artery  Ductus
Arteriosus  Aorta.

15. AFTER BIRTH
 Baby cries  takes first breath  air enters alveoli
 alveolar fluid gets absorbed  increased Po2 
relaxes pulmonary arterioles  decreased PVR

16.  Umbilical arteries constrict +
clamp cord  closure of
Umbilical Arteries and
UmbilicalVein  increased
SVR
 Decreased PVR + Increased
SVR  functional closure
of Ductus Arteriosus 
increased blood flow into
lungs  oxygenation 
supply to body through
aorta.

17. WHAT CAN GOWRONG ?
 Compromise of uterine or placental blood flow 
deceleration of FHR (1st clinical sign)
 Weak cry  inadequate ventilation to push the alveolar
fluid
 In utero hypoxia  Meconium passage may block the
airways
 Fetal blood loss (abruption)  Systemic Hypotension
 Fetal Hypoxia/ischemia  poor cardiac contractility &
fetal bradycardia  Systemic Hypotension
 Pulmonary arterioles remain constricted  PPHN

18.  Low muscle tone
 Respiratory depression
(apnoea / gasping)
 Tachypnea
 Bradycardia
 Hypotension
 Cyanosis

19. Rapid
breathing
Irregular
Gasping
If the baby does not begin breathing immediately after being
stimulated, he or she is likely In secondary apnea and will require
PPV

20. Primary Apnea
Stimulation
Secondary Apnea
Effective Positive pressure ventilation
Myocardium is depressed
Chest compressions, medications
Changes due to oxygen deprivation

21. Suction Catheter
Oral mucus sucker
Radiant warmer

24. TRANSPORT
INCUBATOR

26. Term / Preterm ?
 Term: smooth transition
 Preterm : stiff, under-developed lungs,
insufficient muscle strength, can’t maintain
temperature
Breathing/Crying ?
 Watch baby’s chest
 Gasping is a series of deep, single or stacked
inspirations that occur presence of
hypoxia/ischemia.Treated as apnea.

27. Good tone ?
 Term: flexed extremities
 Preterm/sick: flaccid/limp,
extended extremities

28.  Provide warmth :
Radiant warmer, don’t
cover with towels.
 Position head and
clear airway as
necessary
 Dry and stimulate
the baby to breathe,
reposition

30.  Suction mouth first, then
nose
 “M” before “N”
 To prevent aspiration of
mouth contents

31. Vigorous if
1. Good tone
2. Good Cry/
Breathing
3. HR> 100/min

32. Insert Laryngoscope
Clear Mouth and posterior
pharynx using 12F/14F catheter
Insert ET tube
Attach ET tube to meconium
aspirator and suction source
Apply suction and remove
slowly
Count 1-1000,2-1000,3-1000,
withdraw
Repeat if HR is < 100

33. Stimulate :
Flicking the soles/
drying & rubbing
the back

34.  Respirations
 Heart rate: Best is
auscultation, alternatively
pulsations at base of cord is
felt. Count for 6s and “x”10
 Oxygenation by oximeter

35. If Apneic or HR < 100 bpm:
 Provide positive-pressure
ventilation,spo2 monitoring.
 If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
 If respiratory distress is
persistent , consider CPAP and
connect oximeter

36.  Free flow oxygen
 Oxygen mask
 Flow inflating bag
 T- piece resuscitator
 Oxygen tubing held
close to baby’s nose
 CPAP provided with
 Flow inflating bag
 T-piece resuscitator
 Start with room air and
increase to maintain
target SpO2
Time Target Spo2
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%

38. MASK
Flow Inflating Bag
T-Piece Resuscitator

39.  Ventilation of the lungs is the
single most and most effective
step in newborn resuscitation
Indications:
 Gasping/apnea
 HR < 100/min
 SpO2 remains below target
values despite free flow
supplemental oxygen increased
to 100%.

40.  Peak inspiratory pressure (PIP) : Pressure
delivered with each breath, such as the
pressure at the end of a squeeze of
resuscitation bag or at the end of breath with
aT – piece resuscitator
 Positive end – expiratory pressure (PEEP) :
The gas pressure which remains in the system
between breaths, such as during relaxation
and before the next squeeze

41.  Continuous positive airway pressure(CPAP) :
Same as PEEP, but used when the baby is
breathing spontaneously and not receiving PPV.
It is pressure in the system at the end of
spontaneous breath when a mask is held tightly
on baby’s face but the bag is not being
squeezed.
 Rate: The number of assisted breaths given per
minute

42. Self Inflating bag
Flow Inflating Bag
T-Piece Resuscitator
DEVICES USED

43. Self inflating bag Flow inflating bag T- Piece resuscitator
Does not require
Compressed Gas
source for inflation of
Bag
Requires Compressed Gas
Source for inflating the bag
Requires Compressed
Gas Source for
inflating the bag
Functions even
without a proper seal
Does not work without
proper seal
Does not work
without proper seal
PIP/Ti How hard & Long the
bag in squeezed
Flow of incoming gas and
how hard & long the bag is
squeezed
Can be set exactly
manually
PEEP Only if additional valve
is attached
Given by adjusting flow
control valve
Can be set exactly
manually
CPAP/Fre
e flow O2
Cannot be delivered Given by adjusting flow
control valve
Can be set exactly
manually
Safety
Features
Pop-OffValve
Pressure gauge
Pressure gauge Maximum Pressure
relief valve
Pressure gauge

44. Appropriate
Sizes
 Mask should
Rest on Chin
Cover Mouth
& Nose

45. Suction & Position
Cup the chin in
the mask and
then cover the
nose
Light Pressure on
mask to create a
seal
Anterior pressure
on posterior rim
of mandible

46. 40 to 60 breaths per minute
Start With 21% ( higher in preterm's) oxygen and
increase according to target Saturation
Initial Pressure at 20mmH2O

47.  Most Important sign is the rising of HR
 Improvement in Oxygen Saturation
 Equal and adequate breath sounds B/L
 Good Chest rise

48.  Heart rate
 Oxygenation by
oximeter
If heart rate <100 bpm

49. Corrective steps Action
M Mask Adjustment Ensure Good seal of mask
on face
R Reposition airway Sniffing Position
S Suction Mouth and nose If secretions present
O Open mouth Ventilate with baby mouth
slightly open and lift the
jaw forward
P Pressure increase Gradually increase the
pressure every few breaths
A Airway alternative Consider ET or Laryngeal
mask airway

50.  Place an OG tube, Suction gastric contents
and leave the end open.

51. If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,

52. Indications :
 HR <60/min
despite at least
30 sec of
effective PPV
Strongly consider Endotracheal intubation at this point
as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions

53. Rationale:
 HR<60/min despite PPV indicates
very low O2 levels and significant acidosis 
depressed myocardium  no blood in lungs
to get oxygenated(supplied by PPV)
 Chest compressions + effective ventilation
(ET/PPV)  oxygenation of blood 
recovery of myocardium to function
spontaneously  HR increases  O2 supply
to brain increases

54. Principle:
 Rhythmic compressions of
sternum that
 Compress the heart against the
spine
 Increases intrathoracic pressure
 Circulate blood to vital organs
 Chest compressions 
compresses heart & increased
Intrathoracic pressure  blood
pumped into arteries
 Pressure released  blood enters
heart from veins

55. Positions :
 Chest compressions are of
little value unless the lungs
are effectively ventilated
 2 persons are required
 1 – chest compressions
provider should have access to
the chest with his hands
positioned correctly
 2 –Ventilation provider should
be at head end to maintain
effective mask-face seal or to
stabilize ET tube

56. Technique:
 Thumb technique: 2
thumbs depress the
sternum, hands encircle the
torso and the fingers
support the spine.
Preferred technique
 2 – Finger technique: Tips
of middle & index/ring
finger of one hand
compresses sternum, other
hand supports the back.

57.  Thumb technique is
preferred as
 Better control of depth of
compression
 Can provide pressure
consistently
 Superior in generating
peak systolic and coronary
arterial perfusion
pressure.

58. For small chests with
thumbs overlapped

60. 2- finger technique

62.  Depth : 1/3rd of the
anter0posterior
diameter of chest.
 Duration of
downward stroke
should be shorter
than the duration
of release
 Do not lift the
fingers off the
chest

63. Complications:
 Laceration of liver
 Breakage of ribs

64. Coordination of chest compressions and
ventilation:
 Avoid giving compression and ventilation
simultaneously
 1 breathe after every 3 compressions
 Ratio is 1 : 3 or 30: 90 per minute
 One cycle: 2 sec, 3Compresssions + 1 ventilation
 1 minute : 30 cycles or 120 events (90 compressions +
30 breaths)

65. When to stop chest compressions?
 Reassess after 45-60 sec, if HR > 60/min stop
chest compressions and increase breaths to
40-60 per minute.
If HR is not improving…
 Insert an umbilical catheter and give IV
epinephrine

67.  WHENTO CONSIDER INTUBATION ?
Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea
 HR < 100/min inspite of PPV
 HR < 60/min
 No adequate chest rise and no clinical
improvement
 If chest compressions are needed, intubation
provides better coordination and efficacy of PPV
 To administer drugs

68.  WHENTO CONSIDER INTUBATION ?
 Special conditions
 Meconium aspiration if baby is depressed in
which it is the first step to be done
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia

69.  Laryngoscope with extra
blades and bulbs
 Straight blades
 Term – 1
 Preterm – 0
 Extremely preterm - 00

70. Weight GA(weeks) Tube size(mm)
(internal diameter)
Below 1 kg 28 2.5
1-2 kg 28-34 3.0
2-3 kg 34-38 3.5
>3kg >38 3.5- 4.00

77. CRICOID
PRESSURE
SUCTIONING

81.  Add 6 to baby’s wt.
Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm

82.  Watching the tube passing between cords
 Watching for chest movements
 Listening for breath sounds ( Axilla and stomach)
 Colourimeter/Capnography ( Can also be used for PPV
with mask or LMA
 Improvement in HR and Spo2
 Vapour Condensing inside tube

83. LMA

84. Mechanism of action :
 Increases systemic vascular resistance
 Increases coronary artery perfusion pressure
 Improves blood flow to myocardium and
restores depleted ATP
Indications :
 If HR remains < 60/min even after 30 sec of
effective ventilation preferably after intubation
and atleast another 45-60 sec of coordinated
chest compressions and effective ventilation

85. Administration :
 Intravenous (recommended)
 Endotracheal
Preparation and dosage:
 Adrenaline vial 1ml = 1mg (1:1000 solution)
 Dilute with NS to make 1:10,000 solution (1ml =
100 mcg)
 IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
 ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
 Give rapidly – as quickly as possible
 Can repeat every 3-5 minutes

86. Indications:
 Bradycardia not improving with adrenaline
 Placenta previa/Abruption
Volume Expanders:
 Normal saline (recommended)
 Ringer lactate
 Dosage: 10 ml/kg
 Route : Umbilical vein
 Rate: over 5-10 min , rapid infusion may
cause IVH in <30 weeks babies

87.  Additional resources , additional personnel,
additional thermoregulation strategy
▪ Portable warming pad
▪ Polyethylene Plastic wrap (< 29wk)
▪ Prewarmed transport incubator
 Use of Oxymeter, blender to target Spo2
85%- 95%
 Use Lower PIP 20-25 cm of H2O during PPV
 Consider giving CPAP
 Consider Surfactant

88.  Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and E/O
Acute perinatal HIE
 Monitor for Apnea, bradycardia, BP, SPo2
&Urine output.
 Monitor B. Sugars, electrolytes , Hematocrit ,
Platelets,ABG
 Maintain adequate oxygenation & support
ventilation as needed

89.  Delay feeds, Start IV fluids, consider
parenteral nutrition
 Consider inotropes , fluid bolus
 Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)

90.  Choanal atresia – oral Airway
 Pierre Robin : place prone , 12F Et through
nose with tip in post pharynx
 Laryngeal web, cystic hygroma, Cong. Goiter-
ET/tracheostomy
 Pneumothorax : Percutaneous needle
aspiration
 Pleural effusion : Percutaneous needle
aspiration
 Congenital Diaphragmatic hernia

91.  Meeting and discussing with parents and
documenting the conversation.
 Where GA ( < 23wks ), B.wt ( < 400g) and / or
Cong. Anomalies are associated with certainly
early death and unacceptably high morbidity
among rare survivors resuscitation is not
indicated
 After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no
signs of life (no heart beat and no respiratory
effort).

93. Resuscitation
step
Recommendatio
ns (2005)
Recommendations
(2010)
Comments/LOE
Assessment Four questions
• Amniotic fluid-
clear or not?
Three questions
• Gestation-term or not?
•Tone- Good?
• Breathing /Crying?
However, tracheal
suction of nonvigorous
babies with
(MSAF)
still to be continued
Assessment
(after
initial steps )
Look for 3 signs
• Hear rate
• Color
• Respiration
Look for 2 signs
• Heart rate
• Respiration( Labored,
unlabored, apnea,
gasping)
HR Palpation of
umbilical cord
pulsation
Auscultation of heart at
the
precordium is the most
accurate
LOE4

94. Resuscitation
step
Recommendatio
ns (2005)
Recommendations (2010) Comments/LOE
Oxygenation Pulse oximetry
recommended
for only
preterm <
32weeks with
need for PPV
pulse oximetry
for both term and preterm
Target
saturation
(pre-ductal)
Not defined Target SpO2 ranges provided as
a part of algorithm

95. Initial oxygen
concentration for
resuscitation in
case
of PPV
Term babies(≥ 37 weeks)
• Start with 100% O2 during
PPV
• In case non availability of
O2- start room air
resuscitation
Preterm babies(<32weeks)
Start with oxygen
concentration
between 21-100%
Term babies (≥ 37 weeks) LOE-2
• Start with room air (21%)
•use higher
concentration by graded
increase up to 100% to
attain target saturations
Preterm(<32weeks)
• Initiate resuscitation using
O2 concentration between
30-90%
Initial breath
strategy
Positive
pressure
ventilation
(PPV)
No specific PIP
recommendation
• No specific
recommendation for PEEP
• Guiding of PPV looking at
chest rise and improvement
in heart rate
PIP- for initial breaths 20-25 cm H2O
for preterm and 30-40 cm H2O for
some term babies
• PEEP for preterm infants, if provided
with T-piece or flow inflating bags
(LOE 5)

96. CPAP in delivery
room
Suggested for preterm
babies
( < 32 weeks) with
respiratory
distress
Spontaneously breathing
preterm infants with respiratory
distress may be supported with
CPAP
Therapeutic
Hypothermia
No sufficient evidence recommended for infants ≥
36weeks with moderate to
severe HIE

97.  Doing the simple things better is probably the
most cost-effective policy.
 Resuscitation can come as complete surprise
So be prepared for resuscitation.
 It may take several hours to learn but it
should be implemented over seconds.
 Practice makes one perfect.

98.  Neonatal resuscitationTextbook 6th ed.
 4 million neonatal deaths:When?Where?
Why? Lancet 2005; 365: 891–900
 Park’sTextbook of Preventive and Social
Medicine , K. park 21st Edition .