Advanced life support

If mask ventilation fails to produce an adequate heart rate check again for evidence of upper airway obstruction and aspirate the nasal passages and nasopharynx. Meconium present in the trachea should have been aspirated under direct vision using a laryngoscope before ventilation, but this may need repeating. If clearing of the airway and reventilation fails to produce a normal heart rate, endotra-cheal intubation is required. This technique is not difficult but requires practice and carries a considerable danger in inexperienced hands: the endotracheal tube will enter the oesophagus easily and significantly inhibit ventilation. If an infant does not rapidly improve after attempted endotracheal intubation, there is presumptive evidence of the tube being in the oesophagus. It should be removed and intubation repeated. If there is doubt it may be safer to concentrate on bag and mask ventilation while awaiting skilled assistance.

Once the endotracheal tube is placed, auscultate the chest over both lungs to ascertain that breath sounds are equal. Inequality implies that the tube has been inserted too far and entered one lung, but could also suggest major problems such as pneumothorax or congenital diaphragmatic hernia.

Endotracheal intubation secures access for mechanical ventilation. Initial ventilation should include an inspira-tory time of approximately 1sto distend collapsed alveoli, and peak pressures sufficient to visibly move the chest. Once the alveoli are expanded less pressure is required. Thus the first breaths may require peak pressures of 30 cm of water or more in term babies, whereas after this it is usually possible to ventilate the lungs with pressures of approximately half this, and a respiratory time of 0.5 s at a rate of 40 breaths/min. If there is evidence or presumption of surfactant deficiency, exogenous surfactant should be administered early.

Effective ventilation is enough to resuscitate most infants and only rarely is cardiac massage or the administration of blood because of bleeding required. On very rare occasions, endotracheal adrenaline may need to be administered for persistent bradycardia and if this fails intravenous adrenaline may be given. It is no longer good practice to administer sodium bicarbonate intravenously to infants unless blood gases are measured or circulatory failure is very prolonged.

Most low-risk infants who require resuscitation can be extubated within a few minutes and can usually be nursed by their mothers as long as (1) there is no specific problem such as meconium aspiration, prematurity or a history of infection and (2) adequate observation can be maintained. Infants who cannot be extubated successfully in this time or who continue to have respiratory problems require admission to a neonatal unit.

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