2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines

The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily to neonates undergoing transition from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. The terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth.Approximately 10% of newborns require some assistance to begin breathing at birth. Approximately 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large number of births, a sizable number will require some degree of resuscitation.Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 4 characteristics: If the answer to all 4 of these questions is “yes,” the infant does not need resuscitation and should not be separated from the mother. The infant can be dried, placed directly on the mother's chest, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.If the answer to any of these assessment questions is “no,” there is general agreement that the infant should receive 1 or more of the following 4 categories of action in sequence: The decision to progress from one category to the next is determined by the simultaneous assessment of 3 vital signs: respirations, heart rate, and color. Approximately 30 seconds is allotted to complete each step, reevaluate, and decide whether to progress to the next step (see Fig 1).Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.1With careful consideration of risk factors, the majority of newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. If a preterm delivery (<37 weeks of gestation) is expected, special preparations will be required. Preterm infants have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm infants also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock caused by small blood volume.The initial steps of resuscitation are to provide warmth by placing the infant under a radiant heat source, position the head in a “sniffing” position to open the airway, clear the airway with a bulb syringe or suction catheter, and dry the infant and stimulate breathing. Recent studies have examined several aspects of these initial steps. These studies are summarized below.Very low birth weight (<1500 g) preterm infants are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss (level of evidence [LOE] 5).2For this reason it is recommended that additional warming techniques be used, such as covering the infant in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat (Class IIa; LOE 23,4; LOE 45,6; LOE 57). Temperature must be monitored closely because of the slight but described (LOE 2)4risk of hyperthermia with this technique. Other techniques to maintain temperature during stabilization of the infant in the delivery room (eg, drying and swaddling, warming pads, increased environmental temperature, placing the infant skin-to-skin with the mother and covering both with a blanket) have been used (LOE 8),8,9but they have not been evaluated in controlled trials nor compared with the plastic-wrap technique for premature infants. All resuscitation procedures, including endotracheal intubation, chest compression, and insertion of lines, can be performed with these temperature-controlling interventions in place.Infants born to febrile mothers have been reported (LOE 4)10–12to have a higher incidence of perinatal respiratory depression, neonatal seizures, and cerebral palsy and increased risk of mortality. Animal studies (LOE 6)13,14indicate that hyperthermia during or after ischemia is associated with progression of cerebral injury. Hyperthermia should be avoided (Class IIb). The goal is to achieve normothermia and avoid iatrogenic hyperthermia.Aspiration of meconium before delivery, during birth, or during resuscitation can cause severe aspiration pneumonia. One obstetrical technique to try to decrease aspiration has been to suction meconium from the infant's airway after delivery of the head but before delivery of the shoulders (intrapartum suctioning). Although some studies (LOE 315–17) suggested that intrapartum suctioning might be effective for decreasing the risk of aspiration syndrome, subsequent evidence from a large multicenter randomized trial (LOE 1)18did not show such an effect. Therefore, current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid (Class I).Traditional teaching (LOE 5)19–21recommended that meconium-stained infants have endotracheal intubation immediately following birth and that suction be applied to the endotracheal tube as it is withdrawn. Randomized, controlled trials (LOE 1)15,22have shown that this practice offers no benefit if the infant is vigorous (Class I). A vigorous infant is defined as one who has strong respiratory efforts, good muscle tone, and a heart rate >100 beats per minute (bpm). Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth (Class Indeterminate).After the immediate postbirth assessment and administration of initial steps, further resuscitative efforts should be guided by simultaneous assessment of respirations, heart rate, and color. After initial respiratory efforts the newly born infant should be able to establish regular respirations that are sufficient to improve color and maintain a heart rate >100 bpm. Gasping and apnea indicate the need for assisted ventilation.23Increasing or decreasing heart rate can also provide evidence of improvement or deterioration.A newly born infant who is uncompromised will achieve and maintain pink mucous membranes without administration of supplementary oxygen. Evidence obtained with continuous oximetry, however, has shown that neonatal transition is a gradual process. Healthy infants born at term may take >10 minutes to achieve a preductal oxygen saturation >95% and nearly 1 hour to achieve postductal saturation >95% (LOE 5).24–26Central cyanosis is determined by examining the face, trunk, and mucous membranes. Acrocyanosis (blue color of hands and feet alone) is usually a normal finding at birth and is not a reliable indicator of hypoxemia but may indicate other conditions, such as cold stress. Pallor or mottling may be a sign of decreased cardiac output, severe anemia, hypovolemia, hypothermia, or acidosis.There are concerns about the potential adverse effects of 100% oxygen on respiratory physiology and cerebral circulation and the potential tissue damage from oxygen free radicals. Conversely there are also concerns about tissue damage from oxygen deprivation during and after asphyxia. Studies (LOE 6)27–31examining blood pressure, cerebral perfusion, and various biochemical measures of cell damage in asphyxiated animals resuscitated with 100% oxygen versus 21% oxygen (room air) have shown conflicting results. One (LOE 2)32study of preterm infants (<33 weeks of gestation) exposed to 80% oxygen found lower cerebral blood flow when compared with those stabilized using 21% oxygen. Some animal data (LOE 6)27indicated the opposite effect, that is, reduced blood pressure and cerebral perfusion with 21% oxygen (room air) versus 100% oxygen. Meta-analysis of 4 human studies (LOE 1)33,34showed a reduction in mortality rate and no evidence of harm in infants resuscitated with room air versus those resuscitated with 100% oxygen, although these results should be viewed with caution because of significant methodologic concerns.Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis (Class Indeterminate). The standard approach to resuscitation is to use 100% oxygen. Some clinicians may begin resuscitation with an oxygen concentration of less than 100%, and some may start with no supplementary oxygen (ie, room air). There is evidence that employing either of these practices during resuscitation of neonates is reasonable. If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air (Class Indeterminate).Administration of a variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly. Concerns about potential oxidant injury should caution the clinician about the use of excessive oxygen, especially in the premature infant.If the infant remains apneic or gasping, if the heart rate remains <100 bpm 30 seconds after administering the initial steps, or if the infant continues to have persistent central cyanosis despite administration of supplementary oxygen, start positive-pressure ventilation.In term infants, initial inflations—either spontaneous or assisted—create a functional residual capacity (LOE 5).35–41The optimum pressure, inflation time, and flow rate required to establish an effective functional residual capacity have not been determined. Average initial peak inflating pressures of 30 to 40 cm H2O (inflation time undefined) usually successfully ventilate unresponsive term infants (LOE 5).36,38,40–43Assisted ventilation rates of 40 to 60 breaths per minute are commonly used, but the relative efficacy of various rates has not been investigated.The primary measure of adequate initial ventilation is prompt improvement in heart rate. Chest wall movement should be assessed if heart rate does not improve. The initial peak inflating pressures needed are variable and unpredictable and should be individualized to achieve an increase in heart rate and/or movement of the chest with each breath. If inflation pressure is being monitored, an initial inflation pressure of 20 cm H2O may be effective, but ≥30 to 40 cm H2O may be required in some term infants without spontaneous ventilation (Class IIb). If pressure is not monitored, the minimum inflation required to achieve an increase in heart rate should be used. There is insufficient evidence to recommend an optimum inflation time. In summary, assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute (Class Indeterminate; LOE 8) to promptly achieve or maintain a heart rate >100 bpm.Effective ventilation can be achieved with a flow-inflating bag, a self-inflating bag, or with a T-piece (LOE 444,45; LOE 546). A T-piece is a valved mechanical device designed to control flow and limit pressure. The pop-off valves of self-inflating bags are flow-dependent, and pressures generated may exceed the value specified by the manufacturer (LOE 6).47Target inflation pressures and long inspiratory times are more consistently achieved in mechanical models when T-piece devices are used rather than bags (LOE 6),48although the clinical implications are not clear. To provide the desired pressure, health care providers need more training in the use of flow-inflating bags than with self-inflating bags (LOE 6).49A self-inflating bag, a flow-inflating bag, or a T-piece can be used to ventilate a newborn (Class IIb).Laryngeal mask airways (LMAs) that fit over the laryngeal inlet have been shown to be effective for ventilating newly born near-term and full-term infants (LOE 250and LOE 551). There are limited (LOE 5)52,53data on the use of these devices in small preterm infants. Data from 3 case series (LOE 5)51,54,55show that the use of the LMA can provide effective ventilation in a time frame consistent with current resuscitation guidelines, although the infants being studied were not being resuscitated. A randomized, controlled trial (LOE 2)50found no clinically significant difference between the use of the LMA and endotracheal intubation when bag-mask ventilation was unsuccessful. It is unclear whether this study can be generalized because the LMA was inserted by experienced providers. Case reports (LOE 5)56–58suggest that when bag-mask ventilation has been unsuccessful and endotracheal intubation is not feasible or is unsuccessful, the LMA may provide effective ventilation. There is insufficient evidence to support the routine use of the LMA as the primary airway device during neonatal resuscitation, in the setting of meconium-stained amniotic fluid, when chest compressions are required, in very low birth weight infants, or for delivery of emergency intratracheal medications (Class Indeterminate).Evidence from animal studies (LOE 6)59indicates that preterm lungs are easily injured by large-volume inflations immediately after birth. Additional animal studies (LOE 6)60,61indicate that when positive-pressure ventilation is applied immediately after birth, the inclusion of positive end-expiratory pressure protects against lung injury and improves lung compliance and gas exchange (LOE 6).60,61Evidence from case series in human infants indicates that most apneic preterm infants can be ventilated with an initial inflation pressure of 20 to 25 cm H2O, although some infants who do not respond require a higher pressure (LOE 5).62,63When ventilating preterm infants after birth, excessive chest wall movement may indicate large-volume lung inflations, which should be avoided. Monitoring of pressure may help to provide consistent inflations and avoid unnecessary high pressures (Class IIb). If positive-pressure ventilation is required, an initial inflation pressure of 20 to 25 cm H2O is adequate for most preterm infants (Class Indeterminate). If prompt improvement in heart rate or chest movement is not obtained, higher pressures may be needed. If it is necessary to continue positive-pressure ventilation, application of positive end-expiratory pressure may be beneficial (Class Indeterminate). Continuous positive airway pressure in spontaneously breathing preterm infants after resuscitation may also be beneficial63(Class Indeterminate).Endotracheal intubation may be indicated at several points during neonatal resuscitation: The timing of endotracheal intubation may also depend on the skill and experience of the available providers.After endotracheal intubation and administration of intermittent positive pressure, a prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation (LOE 5).64Exhaled CO2 detection is effective for confirmation of endotracheal tube placement in infants, including very low birth weight infants (LOE 5).65–68A positive test result (detection of exhaled CO2) in patients with adequate cardiac output confirms placement of the endotracheal tube within the trachea, whereas a negative test result (ie, no CO2 detected) strongly suggests esophageal intubation (LOE 5).65,67Poor or absent pulmonary blood flow may give false-negative results (ie, no CO2 detected despite tube placement in the trachea), but endotracheal tube placement is correctly identified in nearly all patients who are not in cardiac arrest (LOE 7).69A false-negative result may also lead to unnecessary extubation in critically ill infants with poor cardiac output.Other clinical indicators of correct endotracheal tube placement are evaluation of condensed humidified gas during exhalation and the presence or absence of chest movement, but these have not been systematically evaluated in neonates. Endotracheal tube placement must be assessed visually during intubation and by confirmatory methods after intubation if the heart rate remains low and is not rising. Except for intubation to remove meconium, exhaled CO2 detection is the recommended method of confirmation (Class IIa).Chest compressions are indicated for a heart rate that is <60 bpm despite adequate ventilation with supplementary oxygen for 30 seconds. ventilation is the most effective action in neonatal resuscitation and because chest compressions are likely to with effective ventilation, should that assisted ventilation is being delivered before chest should be delivered on the lower of the a of one of the of the techniques have been with with the chest and the hands or with with a the the hands technique may higher peak and perfusion pressure than the technique (LOE LOE the hands technique is recommended for chest compressions in newly born infants. the technique may be when to the is required during insertion of an with a than offers for blood flow in the very compressions and should be to avoid simultaneous delivery (LOE chest should be to during but the should not the There should be a of compressions to with 90 compressions and 30 breaths to achieve per minute to ventilation at an rate (Class Indeterminate). each will be allotted with exhalation during the first after each heart rate, and color should be about every 30 and chest compressions and should continue the spontaneous heart rate is bpm (Class IIa; LOE are indicated in resuscitation of the newly born in the newborn infant is usually the result of lung inflation or and adequate ventilation is the most step to correct if the heart rate remains <60 bpm despite adequate ventilation with 100% oxygen and chest administration of or or may be a or may be after guidelines recommended that initial of be an endotracheal tube because the can be administered more than when an must be animal studies (LOE a positive of endotracheal used higher than are and the 1 animal study (LOE used recommended no effect. the of data on endotracheal the should be used as as is recommended is to per are not recommended (Class because animal (LOE (LOE show decreased and after administration of in the of If the endotracheal is used, of or will likely be Therefore, administration of to per is the (Class is being obtained, administration of a higher to the endotracheal tube may be (Class but the and efficacy of this practice have not been The concentration of for either should be when blood loss is or the infant to be in shock poor perfusion, and has not to other resuscitative measures. rather than is the of for in the delivery room (Class LOE recommended is which may need to be resuscitating premature infants, care should be to avoid because rapid of large have been associated with of is not recommended as of initial resuscitative efforts in the delivery room for newborns with respiratory If administration of is heart rate and color must first be by ventilation. The is or the of clinical data in endotracheal administration of is not recommended (Class Indeterminate). The recommended is but no studies have examined the efficacy of this in In 1 case to an infant born to an mother was associated with (LOE should be avoided in infants whose mothers are of to (Class Indeterminate). may have a than the the neonate should be monitored closely for apnea or and subsequent of may be who require resuscitation are at risk for after vital have to adequate ventilation and circulation have been the infant should be in or to an in which and care can be blood has been associated with adverse in a neonatal animal of and resuscitation (LOE animals (LOE were at the time of an or of cerebral or decreased or when compared with One clinical study (LOE an between and poor after perinatal clinical neonatal studies have the between and although in (LOE is associated with The of blood concentration associated with the least brain injury after and resuscitation be defined on available who require significant resuscitation should be monitored and to maintain in the normal (Class a multicenter trial (LOE newborns with by need for resuscitation at birth, and head was associated with a reduction in the number of with severe at months but a significant benefit in the with with severe and not benefit from with (LOE large multicenter trial (LOE asphyxiated newborns by need for resuscitation at birth or presence of with to following to severe was associated with a significant decrease in or at small controlled study (LOE asphyxiated infants with found and at is associated with and blood pressure that do not usually require but a rapid increase in temperature may cause (LOE to a temperature may cause and but studies have not reported these in infants with (eg, (LOE is insufficient data to recommend routine use of or cerebral after resuscitation of infants with (Class Indeterminate). clinical trials are needed to which infants benefit most and which method of is most of hyperthermia is in infants who may have a and mortality for newborns to and of (LOE that a in to resuscitation and continue support of neonatal providers the and of in such newborns (LOE is possible to associated with high mortality and poor in which resuscitative efforts may be when there has been the for agreement (LOE consistent and approach to by the and neonatal and the is an of resuscitation and of during or after resuscitation are and clinicians should not to support when functional is The following guidelines must be to current without of heart and no respiratory after minutes of resuscitation show either a high mortality or severe (LOE minutes of continuous and adequate resuscitative efforts, of resuscitation may be if there are no of (Class of to the of to this