The Neonatal Resuscitation Algorithm remains unchanged from 2015 and is the organizing framework for major concepts that reflect the needs of the baby, the family, and the surrounding team of perinatal caregivers. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. Uncrossmatched type O, Rh-negative blood (or crossmatched, if immediately available) is preferred when blood loss is substantial.4,5 An initial volume of 10 mL/kg over 5 to 10 minutes may be reasonable and may be repeated if there is inadequate response. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Intravenous epinephrine is preferred because plasma epinephrine levels increase much faster than with endotracheal administration. The 7th edition of the Textbook of Neonatal Resuscitation recommends 0.5-mL to 1-mL flush following IV epinephrine (0.01 to 0.03 mg/kg dose) via a low-lying UVC [6]. There were only minor changes to the NRP algorithm and recommended practices. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. Median time to ROSC and cumulative epinephrine dose required were not different. If the infant's heart rate is less than 100 bpm, PPV via face mask (not mask continuous positive airway pressure) is initiated at a rate of 40 to 60 breaths per minute to achieve and maintain a heart rate of more than 100 bpm.1,2,57 PPV can be administered via flow-inflating bag, self-inflating bag, or T-piece device.1,6 There is no major advantage of using one ventilatory device over another.23 Thus, each institution should standardize its equipment and train the neonatal resuscitation team appropriately. Numerous nonrandomized quality improvement (very low to low certainty) studies support the use of warming adjunct bundles.. Both hands encircling chest Thumbs side by side or overlapping on lower half of . Circulation. . Animal studies in newborn mammals show that heart rate decreases during asphyxia. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . PEEP has been shown to maintain lung volume during PPV in animal studies, thus improving lung function and oxygenation.16 PEEP may be beneficial during neonatal resuscitation, but the evidence from human studies is limited. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. All Rights Reserved. If the infant's heart rate is less than 100 beats per minute and/or the infant has apnea or gasping respiration, positive pressure ventilation via face mask should be initiated with 21 percent oxygen (room air) or blended oxygen using a self-inflating bag, flow-inflating bag, or T-piece device while monitoring the inflation pressure. Consider pneumothorax. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. In observational studies in both preterm (less than 37 weeks) and low-birth-weight babies (less than 2500 g), the presence and degree of hypothermia after birth is strongly associated with increased neonatal mortality and morbidity. Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. For participants who have been trained in neonatal resuscitation, individual or team booster training should occur more frequently than every 2 yr at a frequency that supports retention of knowledge, skills, and behaviors. Table 1. Internal validity might be better addressed by clearly defined primary outcomes, appropriate sample sizes, relevant and timed interventions and controls, and time series analyses in implementation studies. The very limited observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; however, most babies received at least 1 intravenous dose before ROSC. Copyright 2023 American Academy of Family Physicians. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an intravenous access. Post-resuscitation care. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. When possible, healthy term babies should be managed skin-to-skin with their mothers. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. Wait 60 seconds and check the heart rate. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. Supplemental oxygen: 100 vs. 21 percent (room air). However, free radicals are generated when successful resuscitation results in reperfusion and restoration of oxygen delivery to organs.44 Use of 100 percent oxygen may increase the load of oxygen free radicals, which can potentially lead to end-organ damage. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. After an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. There should be ongoing evaluation of the baby for normal respiratory transition. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate-to-severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (odds ratio 0.75; 95% CI, 0.680.83). Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. (if you are using the 0.1 mg/kg dose.) If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. Initiate effective PPV for 30 seconds and reassess the heart rate. It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,13 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births 6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and risk of bradycardia. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. Rescuer 2 verbalizes the need for chest compressions. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. Compresses correctly: Rate is correct. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. If the heart rate has not increased to 60/ min or more after optimizing ventilation and chest compressions, it may be reasonable to administer intravascular* epinephrine (0.01 to 0.03 mg/kg). Two observational studies found an association between hyperthermia and increased morbidity and mortality in very preterm (moderate quality) and very low-birth-weight neonates (very low quality). 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. After 30 seconds, Rescuer 2 evaluates heart rate. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. Neonatal resuscitation science has advanced significantly over the past 3 decades, with contributions by many researchers in laboratories, in the delivery room, and in other clinical settings. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Placing healthy newborn infants who do not require resuscitation skin-to-skin after birth can be effective in improving breastfeeding, temperature control and blood glucose stability. If the baby is apneic or has a heart rate less than 100 bpm Begin the initial steps Warm, dry and stimulate for 30 seconds However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. This guideline affirms the previous recommendations. The following knowledge gaps require further research: For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. 5 As soon as the infant is delivered, a timer or clock is started. It may be reasonable to use higher concentrations of oxygen during chest compressions. NRP courses are moving from the HealthStream platform to RQI. While this research has led to substantial improvements in the Neonatal Resuscitation Algorithm, it has also highlighted that we still have more to learn to optimize resuscitation for both preterm and term infants. Newly born infants born at 36 wk or more estimated gestational age with evolving moderate-to-severe HIE should be offered therapeutic hypothermia under clearly defined protocols. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience. If the heart rate is less than 60 bpm, begin chest compressions. Infants with unintentional hypothermia (temperature less than 36C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). Chest compressions are a rare event in full-term newborns (approximately 0.1%) but are provided more frequently to preterm newborns.11When providing chest compressions to a newborn, it may be reasonable to deliver 3 compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute). CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. National Center Tell your doctor if you have ever had: heart disease or high blood pressure; asthma; Parkinson's disease; depression or mental illness; a thyroid disorder; or. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. Author disclosure: No relevant financial affiliations. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5, Term and late preterm newborns have lower shortterm mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3, In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. There are long-standing worldwide recommendations for routine temperature management for the newborn. minutes, and 80% at 5 minutes of life. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. In this review, we provide the current recommendations for use of epinephrine during neonatal . Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. See permissionsforcopyrightquestions and/or permission requests. During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. If a birth is at the lower limit of viability or involves a condition likely to result in early death or severe morbidity, noninitiation or limitation of neonatal resuscitation is reasonable after expert consultation and parental involvement in decision-making. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. A meta-analysis (very low quality) of 8 animal studies (n=323 animals) that compared air with 100% oxygen during chest compressions showed equivocal results. Epinephrine can cause increase in heart rate and blood pressure. When epinephrine is required, multiple doses are commonly needed. If there is a heart rate response: Continue uninterrupted ventilation until the infant begins to breathe adequately and the heart rate is above 100 min-1. Flush the UVC with normal saline. To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. Table 1 lists evidence and recommendations for interventions during neonatal resuscitation.1,2,57,2043, Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.1,2,5,6, Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6, Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5, A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.1,6, Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.6, Initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.5, Ventilation rates of 40 to 60 breaths per minute are recommended.5,6, Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,6, Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.5,6, No evidence exists to support or refute the use of mask CPAP in term infants.2,5, PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.5, Delivery rooms should have a pulse oximeter readily available.57, A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.57, Supplemental oxygen should be administered using an air/oxygen blender.57. When attempts at endotracheal intubation are unsuccessful, laryngeal mask airway (size 1) is an alternative for providing PPV in infants weighing more than 2 kg or in infants greater than 34 weeks' gestation.5,6,26, Neonatal resuscitation aims to restore tissue oxygen delivery before irreversible damage occurs. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. When the heart rate increases to more than 100 bpm, PPV may be discontinued if there is effective respiratory effort.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure 1).5, If there is no heartbeat after 10 minutes of adequate resuscitative efforts, the team can cease further resuscitation.1,5,6 A member of the team should keep the family informed during the resuscitation process. If the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate PPV, epinephrine should be administered, ideally via the intravenous route. High-quality observational studies of large populations may also add to the evidence. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. The dosage interval for epinephrine is every 3 to 5 minutes if the heart rate remains less than 60/min, although an intravenous dose may be given as soon as umbilical access is obtained if response to endotracheal epinephrine has been inadequate. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. Reviews in 2021 and later will address choice of devices and aids, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart rate monitoring, near infrared spectroscopy), feedback, and documentation. Admission temperature should be routinely recorded. HR below 60/min? Administer epinephrine, preferably intravenously, if response to chest compressions is poor. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. Reduce the inflation pressure if the chest is moving well. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. June 2021 The NRP 8th Edition introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. On the basis of animal research, the progression from primary apnea to secondary apnea in newborns results in the cessation of respiratory activity before the onset of cardiac failure.4 This cycle of events differs from that of asphyxiated adults, who experience concurrent respiratory and cardiac failure. When intravenous access is not feasible, the intraosseous route may be considered. 1. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. If the heart rate is less than 100 bpm and/or the infant has apnea or gasping respiration, positive pressure ventilation (PPV) via face mask is initiated with 21 percent oxygen (room air) or blended oxygen, and the pulse oximeter probe is applied to the right hand/wrist to monitor heart rate and oxygen saturation.5,6 The heart rate is reassessed after 30 seconds, and if it is less than 100 bpm, PPV is optimized to ensure adequate ventilation, and heart rate is checked again in 30 seconds.57 If the heart rate is less than 60 bpm after 30 seconds of effective PPV, chest compressions are started with continued PPV with 100 percent oxygen (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute) for 45 to 60 seconds.57 If the heart rate continues to be less than 60 bpm despite adequate ventilation and chest compressions, epinephrine is administered via umbilical venous catheter (or less optimally via endotracheal tube).57, Depending on the skill of the resuscitator, the infant can be intubated and PPV delivered via endotracheal tube if chest compressions are needed or if bag and mask ventilation is prolonged or ineffective (with no chest rise).5 Heart rate, respiratory effort, and color are reassessed and verbalized every 30 seconds as PPV and chest compressions are performed. RCTs and observational studies of warming adjuncts, alone and in combination, demonstrate reduced rates of hypothermia in very preterm and very low-birth-weight babies. NRP Advanced is suited for health care professionals who serve as members of the resuscitation team in the delivery room or in other settings where complex neonatal resuscitation is required. Studies of newly born animals showed that PEEP facilitates lung aeration and accumulation of functional residual capacity, prevents distal airway collapse, increases lung surface area and compliance, decreases expiratory resistance, conserves surfactant, and reduces hyaline membrane formation, alveolar collapse, and the expression of proinflammatory mediators.
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