Comparison of methods of bag and mask ventilation for neonatal resuscitation

Background: There are a variety of manual bagging devices used for neonatal resuscitation. To our knowledge, there has been no comparison of the abili ty of different operators to utilize such devices for the delivery of prede termined inspiratory and end-expiratory pressures. In addition, the use of prolonged inflation may be of benefit for infants who require bag and mask ventilation, and there has been no evaluation of the ability of a variety o f operators to reliably deliver such breaths using currently available equi pment. Methods: We utilized a neonatal manikin (Laerdal Armonk, NY) with a functional larynx and lungs, and a clear cushioned mask (Owens-BriGam, Morg anton, NC). We studied a latex-free disposable anesthesia type bag (Model 5 126 Vital Signs, Totawa, NJ), a Jackson-Rees (JR) type anesthesia bag (Mode l E191 Anesthesia Associates, San Marcos, CA) fitted with a Norman elbow an d a flow-control tail-piece (Dupaco, Oceanside, CA), and the Neopuff (Fishe r and Paykel, Auckland, New Zealand), an FDA approved mechanical device tha t is flow-controlled and pressure-limited, specifically designed to facilit ate neonatal resuscitation. The ventilating pressures were continuously rec orded throughout the process. We evaluated neonatal nurses, neonatal nurse practitioners, neonatal staff and fellows, pediatric residents and neonatal respiratory therapists. Results: The peak inspiratory pressure (PIP) was s ignificantly different between operators using either anesthesia bag, P < 0 .001. Similar results were found for positive end-expiratory pressure (PEEP ) with a significant difference among the operator groups, P < 0.001. All t he differences in post hoc analysis were between the therapists and the oth er groups, P < 0.05. Therapists produced significantly higher pressures tha n the other groups for both PIP and PEEP (P < 0.001). The PIP was similar f or all groups using the Neopuff device. The PIP and PEEP delivered by the N eopuff differed from the other two devices independent of the operators (P < 0.05). On post hoc analysis, there was a significant difference between t he disposable anesthesia bag and Neopuff for both PIP and PEEP for the ther apists, whereas among the non-therapists, there was a difference in PIP wit h the JR device producing a greater PIP (26.6 +/- 3.8 cmH(2)O) compared wit h the Neopuff and disposable anesthesia bag (24.8 +/- 1.1 cmH(2)O, 24.8 +/- 4.3 cmH(2)O). The level of PEEP was significantly different among all thre e devices for the non-therapists (1.3 +/- 1.6 cmH(2)O, Disposable; 2.9 +/- 1.2 cmH(2)O, JR; 4.7 +/- 0.5 cmH(2)O, Neopuff; P < 0.05). Only the therapis ts were able to consistently deliver PEEP with the anesthesia bags, whereas all operators could generate the target PEEP with the Neopuff (P < 0.05). We compared the pressure delivered during the first second to the pressure delivered during the fifth second during prolonged 5-s inflations. The abso lute differences between the first and fifth second for the Neopuff versus the anesthesia bags were significantly different with a median of 7.1 cmH(2 )O for the anesthesia bags compared with 0.2 cmH(2)O for the Neopuff, P < 0 .001, reflecting the difficulty in obtaining and maintaining the target inf lation pressures. Conclusions: Our experience suggests that the Neopuff, a purpose-built neonatal resuscitator ventilator, facilitates the delivery of the desired airway pressures while maximizing the operators ability to obt ain and maintain a patent airway, and facilitates the delivery of prolonged inflations. Further research is required to determine the clinical benefit of end-expir atory pressure and prolonged inflations in neonatal resuscitation. (C) 2001 Elsevier Science Ireland Ltd, All rights reserved.