1. Positive Pressure Ventilation

2. Birth • Term Gestation? • Clear of Meconium? • Breathing or crying? • Good Muscle Tone? • Routine Care • Provide warmth • Clear Airway if needed • Dry • Assess color Yes No 30 seconds • Provide warmth • Position clear airway • (as necessary) • Dry, stimulate, reposition Evaluate Resp, HR and Color Breathing, HR>100, Pink Breathing, HR>100, Cyanotic Pink HR < 100 Apnea Persistent cyanosis Observational Care Give Supplementary Oxygen • Provide positive pressure ventilation   Endotraheal intubation may be considered at several steps

3. Use of Bag and Mask In this lesson we will learn • When to give Positive-pressure ventilation • The similarities and difference between flow-inflating, self-inflating bags and T-piece resuscitator • The operation of each device to provide PPV • The correct placement of mask on newborn’s face • Testing and trouble shooting of bag • Evaluating success of bag and mask ventilation

4. Indications of Bag & Mask Ventilation After 30 seconds of Initial steps if • Baby is not breathing or is gasping • Heart rate is less than 100 bpm and /or • Is Cyanotic despite supplemental oxygen

5. Flow inflating bags Fills only when oxygen from a compressed source flows in to it Self inflating bags Fills spontaneously after it is squeezed, pulling oxygen or air in to the bag Different Types of Resuscitation Devices T-piece resuscitator Also works when gas from compressed source flows into it. The gas is directed into the baby by occluding the opening on T-piece

6. Flow Inflating Bags Flow-control valve Oxygen

7. Self Inflating Bags Oxygen

8. PEEP Adjustment Circuit Pressure Inspiratory Pressure Control Maximum Pressure Relief Gas Outlet Gas Inlet T-piece Resuscitator

9. T-piece Resuscitator

10. Flow Inflated Bags Advantages • Delivers 21-100% oxygen depending on source • Easy to determine when there is a seal on the patient’s face • Can deliver free flow oxygen • Can deliver PEEP or CPAP

11. Flow Inflated Bags Disadvantages • Requires a gas source to inflate • Requires a tight seal between the mask and the patient to remain inflated • Usually does not have a safety pop off valve

12. Self Inflating Bag Advantages • Will always refill after being squeezed even with no compressed gas source • Pressure-release valve makes over-inflation less likely

13. Self Inflating Bag Disadvantages • Will Inflate even if there is no tight seal • Requires a reservoir to deliver 100% O2 • Cannot be used to deliver free-flow oxygen reliably • Cannot deliver CPAP and can deliver PEEP only when special valve is connected

14. T-piece resuscitator Advantages • Consistent pressure • Reliable control of PIP & PEEP • Reliable delivery of oxygen • No Fatigue from bagging

15. T-piece resuscitator Disadvantages • Requires gas supply • Compliance of lung can’t be felt • Requires pressures to be set prior to use • Changing inflation pressure during resuscitation

16. General Characteristics • Size of bag – 240 to 750 ml • Oxygen capacity -- capable of delivering 90-100% oxygen • Safety features – capable of avoiding excessive pressures • Size of mask – appropriate sized mask

17. Capacity of the Bag

18. 2. Oxygen inlet 7.Pressure manometer site 3. Patient outlet Self Inflating Resuscitation Bag

19. Self Inflating Bag Without Oxygen Reservoir

20. Self Inflating Bag with Oxygen Reservoir

21. Different types of OxygenReservoirs

22. Safety Features • Pop – off valve set at 30 – 40 cm H20 • Port to attach a manometer Pop off Valve

23. Face Mask • Cushioned rims – less traumatic, better fit • Shape – round or anatomical • Size – appropriate fit

24. Face Mask Shapes

25. Correct Incorrect Incorrect Face mask positions

26. Face mask positions Correct

27. Preparing the Equipment • Attach oxygen tubing and oxygen reservoir • Adjust flow to 5 – 10 l/min • Block patient outlet or the mask by the palm of the hand and squeeze the bag * Feel pressure against the hand ? * Pressure valve is opened?

28. Checking Equipment

29. Prerequisites for PPV • Select the appropriate-sized mask • Be sure there is a clear airway • Position the baby’s head • Position yourself at the bedside

30. Position yourself at bedside Incorrect Correct Correct

31. Correctly Positioning the Mask

32. Signs of Effective Positive-pressure Ventilation • Rapid rise in heart rate • Improvement in color and tone • Audible breath sound • Chest movement

33. How much to squeeze the bag • Initial breath after delivery >30 cm H2O • Normal lungs 15-20 cm • Immature or diseased lungs 20-40 cm

34. Squeeze Squeeze Release ------------------- Frequency of BM Ventilation 40 – 60 breaths per day Breath ----- two -----three ----- Breath

35. Frequency of PPV

36. When to stop PPV • Increasing heart rate : HR > 100 • Improving color • Spontaneous breathing • Improving muscle tone

37. Baby not improving on PPV • The seal is inadequate • The airway is blocked * Position * Secretions * Small nares in premature • Not Enough Pressure

38. What else if baby requires prolonged IPPR

39. Inserting Orogastric Tube • Needing PPV longer than several minutes • Measure the length to be inserted • Insert the tube through the mouth • Gently aspirate stomach contents • Leave the end of the tube open • Tape the tube to the cheek of the baby

40. Inserting Orogastric Tube Equipment Required • 8 F feeding tube • 20 - syringe

41. Measuring the length of tube 10 cm 12 cm 9 cm

42. Inserting Orogastric tube Insertion

43. Inserting Orogastric tube Aspiration

44. Inserting Orogastric tube Remove syringe and leave end open

45. Inserting Orogastric tube Tape the tube

46. If the Baby Is Not Improving • Is the chest movement adequate • Is the face-mask seal tight • Is the airway blocked: Improper position or Secretions • Is he equipment working • Is air in stomach interfering with chest expansion

47. If the Baby Is Not Improving • Is adequate oxygen being used • Is oxygen tube attached to ventilation device and to oxygen source • Is gas flowing through the flow meter • Self-inflating bag, is the oxygen reservoir attached • If using cylinder (rather than wall oxygen), is there oxygen in the cylinder

48. Next Step • If after 30 seconds of effective PPV with supplemental oxygen the baby is not improving: Evaluate • Not breathing: Perform ET intubation and continue PPV • Breathing but HR < 100 continue PPV • Breathing, HR > 100, central cyanosis + continue PPV • Heart rate < 60 Initiate Chest compressions