Elsevier

Resuscitation

Volume 82, Issue 2, February 2011, Pages 175-179
Resuscitation

Clinical paper
Assessment of chest rise during mask ventilation of preterm infants in the delivery room

https://doi.org/10.1016/j.resuscitation.2010.10.012Get rights and content

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 (VTe) were measured during neonatal resuscitation using a respiratory function monitor. After 60 s 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 VTe. These estimates were compared with VTe measurements taken during the previous 30 s.

Result

We studied 20 infants who received a mean (SD) of 23 (4) inflations during the 30 s. 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 3.5 mL and 3.3 mL respectively. Agreement between clinical assessment and measured VTe was generally poor.

Conclusion

During mask ventilation, resuscitators were unable to accurately assess chest wall movement visually from either head or side view.

Introduction

If preterm infants fail to initiate spontaneous breathing immediately after birth positive pressure ventilation (PPV) should be given.1 The purpose of PPV is to establish and maintain a functional residual capacity, deliver an appropriate tidal volume (VT) and facilitate gas exchange.2, 3 Adequacy of gas exchange is judged by an increase in heart rate.1, 4 However, if the heart rate does not increase, chest wall movements should be assessed.1

The current neonatal resuscitation guidelines do not describe how chest wall movement during PPV should be assessed.1 We recently reported that resuscitators standing at the infant's head were unable to accurately assess chest wall movements during PPV.5

Assessing chest wall movement during PPV while standing at the infant's head might be difficult. The ventilation device partly obstructs the resuscitators view and the resuscitator is focused on ventilation. Assessment by an observer standing on the side of the infant and not providing assisted ventilation may overcome these difficulties.

We hypothesised that a resuscitator positioned at the side of the infant would assess chest wall movements more accurately compared to resuscitator positioned at the infants head. The aim of this study was to compare observers’ clinical estimates of tidal volume with the tidal volume measured using a flow sensor during PPV of newborns in the delivery room.

Section snippets

Patients and methods

This study was carried out at The Royal Women's Hospital, Melbourne, a tertiary perinatal centre admitting more than 100 infants with a birth weight of < 1000 g to the neonatal nursery annually. Infants were enrolled between September 2009 and February 2010 when a member of the research team was available to attend the delivery. The study was approved by the Royal Women's Hospital Research and Ethics Committees. Written consent was obtained before birth if the mother was not in established labor

Results

One hundred and five infants < 32 weeks gestation were born between September 2009 and January 2010. The research team was not notified of impending delivery of 66 infants a further 19 did not receive PPV in the delivery room. We recorded 20 infants who received PPV. Infant demographics are presented in Table 1. None of the infants received chest compressions or adrenaline.

A total of 433 inflations were analysed; a mean (SD) of 23 (4) inflations per infant during the 30 s baseline. PPV was

Discussion

Neonatal resuscitation can be stressful, which may contribute to the imprecision and inaccuracy of assessment of colour and heart rate in the delivery room.8, 9 We recently reported that junior doctors standing at the infants’ head were unable to simultaneously assess chest wall movements while performing mask ventilation.5 Some could argue that the resuscitator's limited experience of neonatal resuscitation might have contributed to this result. In our delivery room junior medical staff

Conclusion

Resuscitators were unable to accurately assess chest wall movements from either head or side view. Using a respiratory function monitor in the delivery room to continuously measure and display the delivered tidal volume might improve the effectiveness of neonatal resuscitation.

Conflict of interest statement

None.

Acknowledgements

GMS is a past recipient of a RWH Postgraduate Scholarship. GMS is supported in part by a Monash University International Postgraduate Research Scholarship. PGD is supported in part by an Australian National Health and Medical Research Council Practitioner Fellowship. PGD and CJM hold an Australian National Health and Medical Research Council Program Grant No. 384100.

The authors would like to acknowledge Brett Manley for reading the manuscript.

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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.10.012.

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