Doctor reviews: 13 Questions and Answers on Neonatal Resuscitation!!

Hi, I'm Dr. Tala, a board certified neonatologist, and today we are going to cover some multiple choice questions on NRP. Our members specifically asked us for these questions, so if you're interested in having that sort of power, then please join our membership. All these questions are based on the ninth edition of NRP, which as you all know, is the most recent edition. So let's get started. Question one, per NRP, when you are delivering chest compressions with assisted ventilation breaths, how many total events should you be giving in a minute? A, 60, 30 chest compressions plus 30 PPV. B, 90, 60 chest compressions plus 30 PPV. C, 120, 90 chest compressions plus 30 PPV. Or D, 150, 120 chest compressions plus 30 PPV. And the answer is C. We always give 90 chest compressions and 30 assisted breaths. Note I keep saying assisted breaths. In the NRP ninth edition, they wanted us to use assisted ventilation more than the positive pressure ventilation, even though we can still use those interchangeably, just so that it's more consistent with other resuscitation guidelines. But you know what I'm saying. 90 chest compressions and 30 assisted ventilation breaths. So remember that the ratio in a minute is one and two and three and breathe. One and two and three and breathe. Often people go much faster than this. So make sure that you're saying this out loud and you get used to that combination. Question two, when performing chest compressions, how deep should you be pushing the lower part of the sternum? A, a quarter the anterior posterior diameter of the chest. B, a third the AP diameter of the chest. C, half the AP diameter of the chest. Or D, the chest should not be depressed at all, just the sternum. B, the NRP recommends pressing down to one third the AP diameter of the chest. At this sort of pressure, it is the best amount of pressure that you can do for the baby to help with cardiac output as well as blood flow to the coronaries. It should be the lower third of the sternum. You definitely don't want to do it over the xiphoid process, which could end up with actually damage to the liver. And you don't want to do it over the ribs, which could end up with a rib fracture. Question three, according to NRP, if a baby is stable, the newborn can stay with a mother after delivery. The current NRP algorithm recommends the baby satisfies three characteristics to stay with mother. What are they? A, infant must be term, have good tone, and a heart rate above 100. B, infant must be breathing, have a heart rate above 100, and be pink. C, infant must have good tone, be term, and be pink. Or D, the infant must be breathing, must be term, and must have good tone. And the answer is D. After a delivery, a baby can stay with a mother on the mother's chest if the baby is term, so has a gestational age above 37 weeks, or what you assume to be above 37 weeks, if the baby is breathing, and if the baby has good tone. A heart rate above 100 is not a stipulation for the baby staying with the mother because you're not necessarily checking the heart rate, but you would assume that if the baby is breathing or crying, then the heart rate is above 100. A good mnemonic for this is it is better if the baby stays with mother. So if the baby is breathing, little e, baby has good tone, and baby is term, then the baby can stay with the mother. Question four. According to NRP 9th edition, what PIP, peak inspiratory pressure for ventilation, could we start on all babies no matter their gestational age? A, 20 centimeters of water. B, 25 centimeters of water. C, 30 centimeters of water. D, there is no PIP appropriate for all gestational ages. Well, according to the 9th edition of NRP, they've basically divided the babies into two groups, above 32 weeks and less than 32 weeks. Above 32 weeks, it's recommended that the initial PIP should be between 25 and 30, and below 32 weeks, the initial PIP should be between 20 and 25. So basically, if you used an initial PIP of 25, then it would work on all gestational ages. Question number five. When you give chest compressions to a neonate, the FIO2 at which you deliver PPV should be at A, 21 percent. B, 30 percent. C, 10 percent higher than the previous FIO2. Or D, 100 percent. And the answer is D. During chest compressions, you want to give 100 percent FIO2. Basically, you have no idea what your perfusion is like, and you have to assume that not a lot of oxygen is getting to the cells. So if you're giving chest compressions, immediately dial the FIO2 up to 100 percent. Then remember that hopefully by that point, you've definitely got a pulse ox on the baby, that once you do start getting a saturation, titrate that back down again, once you've got hopefully the heart rate and everything going again. Question six. A CO2 detector device, or a PD cap, was placed at the end of an endotracheal tube after intubation. The color remained purple, meaning no carbon dioxide was detected. Which of the following could explain this? A, the infant is not intubated correctly, e.g. the ET tube may be in the esophagus. B, there's ineffective ventilation. C, poor circulation. Or D, all of the above. The answer is D. First of all, I cannot emphasize this enough. Whenever you have an all of the above answer, and you're not sure exactly what it is, then definitely put all of the above or none of the above. In this situation, it is all of the above. There are lots of reasons why you might not end up with a yellow color change on your PD cap, where it's not detecting the CO2. The first one is that obviously you could be intubated in the wrong place. The endotracheal tube, normally the wrong place is down the esophagus. That's the first thing that you should make sure is not going on. Sometimes if the endotracheal tube is too deep, so it's going all the way into the right main stem bronchi, again, then you're not going to see that color change because there's like ineffective ventilation. The PD cap is not seeing enough CO2 coming out. You could also have a blockage somewhere. You could have a blockage within the endotracheal tube, or that you're literally not ventilating enough to get the CO2 out from the alveoli up out of the lungs. So inadequate ventilation can definitely also cause lack of color change in the PD cap. Also, if there's no perfusion, so even if there is a lot of CO2 in the blood cells all around the body, if the blood isn't being pumped around the body to the alveoli and then diffusing into the lungs, then that CO2 is not going to get out of the lungs. So just having hypoperfusion in itself can also result in no color change. So if you are sure that you are in and that you are sure you are in the right place, sometimes you have to be very patient to wait for that PD cap to actually change color. Question number seven. In what situation should you use a meconium aspirator to perform neonatal tracheal suction? A. In all babies born through meconium-stayed amniotic fluid, MSAF. B. In non-vigorous babies born through MSAF. C. In non-vigorous babies born through MSAF who don't respond to warming and drying. Or D. In non-vigorous babies born through MSAF who don't respond to effective PPV. And the answer is D. Basically, we're only giving, we're only doing tracheal suctioning in babies after they've been through all the initial steps of the NRP and the babies aren't improving at all. This is one of those points that's changed a lot compared to previous editions. 20 years ago, any baby that was born through meconium-stained amniotic fluid, we would intubate immediately and suction. And then a lot of studies came out and showed that that didn't really make a difference. Now it's like we've swung completely the other way. That unless a baby is literally not responding to like the MR SOPR and even if we're intubated and stuff, then at that point you can consider actually, you know, doing the tracheal suction once you've intubated. There is still quite a lot of conversation about this and I think the way that I interpret this is just have a lower threshold to do the tracheal suctioning if you are going through the steps and nothing's really making a difference. This isn't a baby that I would go through steps and then intubate and then just carry on, you know, continuing trying to ventilate this baby for a couple of minutes before it occurring to me that maybe this baby might benefit from actually doing the meconium suctioning and pulling that tube out and then re-intubating again. Question eight. Which of the following is not one of the steps of MR SOPR when needing to improve oxygenation or ventilation in the delivery room? A. Suction the mouth and nose. B. Open the mouth. C. Increase the pressure. And D. Suction below the cords. And the answer is D if you listen to the previous one. Suctioning below the cords, which basically you'd have to do after you intubated the baby with an endotracheal tube is not part of the MR SOPR guidelines. So this is when you're not getting effective ventilation and so you are trying to improve the effective ventilation normally with a bag mask ventilation. So you can do the mask readjustment, reposition the face, so put the baby's face in kind of like a neutral position, maybe a little bit extended or what we call the sniffing position. S is when you suction the mouth and nose. O is when you make sure that the mouth is open and they're actually getting the pressures. P is when you increase the pressure that you're giving through the bag mask ventilation. And then A is the alternate airway. So you're doing a, you're actually intubating with an endotracheal tube or you're inserting an LMA. So obviously, like we said, the suctioning below the cords is not part of MR SOPR. What's interesting is that in the ninth edition for NRP, they stipulated that MR SOPR does not have to be in the same order any longer. You don't have to go through them in the sequence. So if you're getting ineffective ventilation and the baby's mouth is shut, then just go straight to opening the baby's mouth. Or you've got loads of secretions, then suction out the secretions before going through the mask readjustment and whatever else. So in the ninth edition, they're like, it doesn't have to be done in the order. Do whatever you think is right for the baby first. Question nine. According to the current edition of NRP, after initial steps of resuscitation, you need to start PPV or assisted ventilation for all of the following situations except A. Infant is apneic, B. Infant is gasping, C. Infant is cyanotic or D. The heart rate is less than 100 beats per minute. And the answer is C. If the baby is cyanotic, then we're not going to start PPV or any assisted ventilation. So per the NRP, after the initial steps where you're warming and drying and stimulating and everything, then there are some scenarios where you actually have to start PPV. So if the baby has apnea, so baby's not breathing at all, or the baby is gasping, so so having very ineffective ventilation, or the baby's heart rate is less than 100, those three reasons, then you do have to start assisted ventilation. Remember that babies can take up to five to 10 minutes before they start looking pink. And you remember all the like different saturation levels for every minute of the baby's lives. And so you expect the baby to be cyanotic at one to two minutes of life. And even if the baby is still cyanotic at 10 minutes and looks blue and the sats are low, if the baby's breathing and has a good heart rate, then you just need to provide oxygen. You don't need to do any assisted ventilation. Question 10. The P in MR-SOPA of NRP is A. Position the airway. B. Pulmonary toilet, so where you're kind of suctioning the lungs or TPT or whatever. C. Pulse, ensure that it's 100 beats per minute. Or D. Pressure, where you increase the pit. And the answer is D. Like we've already discussed, the P in the MR-SOPA is to increase pressure. So as you're going through the different MR-SOPA steps to try to improve and make the ventilation effective, there are obviously different things that you consider. Like we keep saying in the ninth edition, they don't have to go in the order of the MR-SOPA. Like we said, you can pretty much start on a PIP of 25 in all babies of all gestational ages. In above 32 weeks, we're starting PIPs of 25 to 30. And less than 32 weeks, we're starting PIPs of 20 to 25. So according to the MR-SOPA, if you're not having effective ventilation, then go up on your PIP. In term babies, you can go up to a PIP all the way to 40 if you need it. And in preemie babies, they recommend that you don't take the PIP up above 30. So yes, the P is going up on pressures up to 40 in a term baby, up to 30 in a preterm baby. Question 11. At what rate should PPV or assisted ventilation be delivered during neonatal resuscitation? A, 20 to 30 breaths per minute. B, 30 to 60 breaths per minute. C, 60 to 80 breaths per minute. Or D, 100 to 120 breaths per minute. And the answer is B, 30 to 60 breaths per minute. So this is also something that changed in the NRP ninth edition versus the eighth edition, where in the eighth edition, the respiratory rate recommended was between 40 to 60. And here it's 30 to 60. Studies have showed that you can get adequate ventilation with a rate of 30 breaths per minute. So that's why it kind of was lowered a little bit. Not just that, but if you think about it, when we're doing combined chest compressions and the assisted ventilation, then we're actually doing the positive pressure breaths at 30 times a minute. So it's just kind of keeping consistent with that as well. So we can do 30 to 60 times a minute when we're just giving the positive pressure breaths and 30 times a minute when they are being coordinated with the chest compressions. If you go a lot faster than that, then you're not giving enough time for exhalation. And if you go a lot slower than that, then you're not going to get adequate tidal volume and adequate ventilation. Question number 12. Regarding intubation, which of the following ET tube sizes is appropriately matched for AGA infant? A, 2.5 endotracheal tube, 26 weeks. B, 2.5 endotracheal tube, 35 weeks. C, 3.0 endotracheal tube, 23 weeks. D, 3.0 endotracheal tube, 41 weeks. And the answer is A, a 2.5 endotracheal tube for a 26-week baby. I couldn't remember the gestational age of the baby. So this has also changed a little bit in the last NRP guideline as well. And basically we used to be like we're giving a 2.5 endotracheal tube up to about one kilo in baby's weight. This most recent NRP guideline recommends that we continue using the 2.5 endotracheal tube up to babies being about 1.2 kilos. So really that's about up to about kind of 29 weeks that we're using the 2.5 endotracheal tube. And then we're using the 3.0 endotracheal tube until about 34, 35 weeks. And then we're using the 3.5 endotracheal tube. For the tiny babies, you might need a 2.0 endotracheal tube. So like the 22, 23 weekers. So a good way to remember this is 2.5, 25 weeks, 3.0, 30 weeks, 3.5, 35 weeks. And that stays pretty consistent with the most recent NRP guidelines as well. Just remember the only thing that slightly changed is that we use the 2.5 endotracheal tube up to 1.2 kilos. And question 13, you are about to attend a delivery and you are setting up the oxygen. Which is the correct FIO2 according to the ninth edition for the gestational ages of the baby? A, 25 week baby, you put at 21 percent. B, 28 week baby, you put at 21 percent. C, 28 week baby at 30 percent. And D, 40 week baby at 30 percent. And the answer is C, a 28 week baby, you want to use 30 percent. This has also changed in the last edition of the NRP. And basically, what's really being emphasized is that by five minutes of life, we want a baby's saturation to be at 80 percent. And so it kind of ended up with giving slightly higher FIO2s in the delivery room to really try to make sure that we can get that saturation to 80 percent by five minutes of life. So in this new edition, what they recommend is that in all babies less than 32 weeks, we start the initial FIO2 at 30 percent. If babies are above 35 weeks, we can still start at 21 percent. And if they're between 32 and 35 weeks, then we can use anywhere between 21 and 30 percent. Again though, whatever your gestational age of the baby, make sure that your pulse box is on and you're titrating that FIO2 up or down to try to make sure that those saturations are staying within the recommended guidelines per the NRP. Okay, we've reached the end of our questions on NRP. I hope that was helpful for you. 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