456 APPENDIXES Appendix B Box B-1. Mask Ventilation Procedural Steps1 1. Gather and check equipment: resuscitation device (flow-inflating or self-inflating bag, or T-piece resuscitator), various sizes of masks, oxygen source with blender and flow meter, suction, appropriately sized orogastric tubes, electrocardio- graphic leads, pulse oximeter probe, stethoscope. 2. Select appropriate mask (size and shape). 3. Optimize the infant’s head and body position (eg, sniffing position consider the use of a shoulder roll). 4. Apply universal precautions: wash hands, and put on gloves. 5. Perform a time-out. 6. Apply the mask to the baby’s face (the upper pole of the mask is placed over the nasal bridge, and the lower part rests between the lips and chin it is not extending below the chin). 7. With the hand on the mask in the “C” position, maintain a seal and avoid placing your fingers onto the soft tissues of the baby’s neck. 8. Administer the correct ventilation rate (40–60 breaths/min). 9. Administer the appropriate peak inspiratory pressure. 10. Maintain appropriate positive end-expiratory pressure. 11. Assess MV effectiveness within the NRP-recommended time frame (eg, adequate chest movement, HR change). 12. If ineffective ventilation, incorporate appropriate corrective steps (“MR SOPA”). 13. Appropriately manage postevent respiratory support (eg, CPAP). Abbreviations: CPAP, continuous positive airway pressure HR, heart rate MR SOPA, mask readjustment, repositioning the airway, suctioning the mouth then nose, opening the mouth, pressure increase, and alternative airway NRP, Neonatal Resuscitation Program MV, mask ventilation. Box B-2. Endotracheal Intubation Procedural Steps2 1. Gather and check equipment: laryngoscope handle, laryngoscope blades (sizes 00, 0, 1), ETTs (sizes 2.5F, 3.0F, 3.5F), stylet (optional), CO2 detector, Magill forceps (for nasal intubation), suction, tape, resuscitation device (flow-inflating or self-inflating bag, or T-piece resuscitator), oxygen and air source, blender and flow meter, electrocardiographic leads, pulse oximeter probe, stethoscope. 2. Select appropriate size of ETT (and insert stylet [optional] and ensure that the stylet tip does not protrude beyond the end of the ETT). 3. Order appropriate sedation and/or premedication (including possible use of paralytics and atropine), as appropriate. 4. Apply universal precautions: wash hands, and put on gloves. 5. Perform a time-out. 6. Perform preoxygenation, as appropriate. 7. Position the patient into sniffing position, with their head toward the operator (shoulder roll optional). 8. By holding the laryngoscope in the left hand, insert the blade smoothly into the baby’s mouth. 9. Lift the handle forward (do not pivot the handle, and use a smooth movement). 10. Visualize the vocal cords (understand how to manipulate the blade request other maneuvers, as needed [eg, applying cricoid pressure] to aid in visualizing the vocal cords). 11. Suction the airway (if needed). 12. Insert the ETT into the oropharynx, from the corner of the mouth, and through the vocal cords by using one smooth motion. 13. Insert the ETT to an appropriate depth (check the position at the level of the lips). 14. Remove the laryngoscope blade from the mouth. 15. Holding the ETT firmly in the nondominant hand, remove the stylet by using the dominant hand. 16. Attach the CO2 detector between the ETT and the resuscitation device and begin providing PPV. 17. Confirm ETT placement by assessing chest rise, auscultation of breath sounds, exhaled CO2 detection, increase in HR, and increase in saturation levels. 18. Secure the ETT with tape: one piece is placed onto the upper lip, and then a tight loop is made around the apparatus and fixed. This process is repeated with the lower lip. Abbreviations: CO2, carbon dioxide ETT, endotracheal tube HR, heart rate PPV, positive pressure ventilation. NeoSim.indb 456 2/21/21 12:13 PM
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