Two hands are better than one: Positive pressure ventilation in a preterm neonatal manikin model

Approximately 10% of newborn infants require some assistance to establish regular breathing at birth.1, 2 The need to progress resuscitation beyond ventilation and commence cardiac compressions and epinephrine administration is rare (<1%) and may signal poor ventilation technique in as many as 50% of such situations.2 Respiratory support is typically delivered to newborn infants via positive pressure ventilation (PPV) using an appropriately sized facemask (Figure 1). Previous studies investigating mask leak in modified newborn manikin models have shown high levels of leak (up to 65%), even in participants with many years of experience.3, 4 Few studies have examined the optimum mask hold to achieve the lowest possible leak during PPV. Our primary aim was to compare a two-handed (TH) hold of the facemask when delivering PPV during neonatal resuscitation with a one-handed (OH) hold. A secondary aim was to investigate if the level of clinical experience influenced PPV provision. Medical and nursing staff within the neonatal and paediatric departments of Cork University Maternity Hospital and Cork University Hospital, respectively, were invited to participate. Staff holding a valid certificate in either Neonatal Resuscitation Program seventh edition or Advanced Paediatric Life Support sixth edition were eligible. All participants reviewed the study information leaflet and signed a consent form before participating. This was a randomised crossover trial. The Neopuff T-piece Infant Resuscitator (Fisher median (IQR) 4.16 mL/inflation (3.65–7.11) in the OH group, and 3.87 mL/inflation (3.70–4.71) in the TH group (p = 0.270). There was no difference between years of experience and OH (rs = −0.24, p = 0.128) or TH leak values (rs = −0.10, p = 0.551) or professional group and OH (p = 0.381) or TH (p = 0.774) leak values. In this simulated study, we found the median leak was significantly lower using the TH technique compared to the OH technique (Hodges–Lehmann median difference between OH and TH 95% CI: 8.0% 0.2%–27.7%). These findings are similar to Tracy et al,4 although they reported mean values. However, this is a much lower median leak than previous studies, where reported mask leak varies from 30% to 60%.3 This low leak may be due to the artificial nature of the scenario. The analysis of the second minute only may have also contributed to the lower levels of leak, along with the fact that we used a preterm manikin, which may have made it easier to form a good seal. We feel this adds strength to the finding of lower leak with TH technique, as it is more likely to be an accurate representation of the best inflations each participant can deliver with each technique. The limitations of this study are shared by similar studies on manikins. A manikin, while an effective learning tool, can never provide the same cues in relation to clinical deterioration and improvement as a neonate. When using positive pressure ventilation in a neonatal manikin model, TH technique is superior to OH technique in reducing mask leak. Further clinical trials of OH versus TH hold are warranted in the delivery suite. Anne Murray: Writing – original draft; formal analysis; conceptualization; methodology; investigation; project administration; data curation. Tom Beechinor: Investigation; writing – original draft; conceptualization; project administration; methodology; data curation. Vicki Livingstone: Formal analysis; writing – review and editing; supervision; methodology; validation. Eugene Dempsey: Conceptualization; writing – review and editing; supervision; methodology; investigation; formal analysis; project administration. Open access funding provided by IReL. This study was performed within the principles of the Declaration of Helsinki. Approval was granted by the Cork Research Ethics Committee (ECM 3 (II) 11/05/2021 and ECM (g) 12/11/2019). Written informed consent was obtained from all participants in relation to participating in this study.