Minute ventilation at different compression to ventilation ratios, different ventilation rates, and continuous chest compressions with asynchronous ventilation in a newborn manikin

Abstract

Background
In newborn resuscitation the recommended rate of chest compressions should be 90 per minute and 30 ventilations should be delivered each minute, aiming at achieving a total of 120 events per minute. However, this recommendation is based on physiological plausibility and consensus rather than scientific evidence. With focus on minute ventilation (Mv), we aimed to compare today’s standard to alternative chest compression to ventilation (C:V) ratios and different ventilation rates, as well as to continuous chest compressions with asynchronous ventilation.

Methods
Two investigators performed cardiopulmonary resuscitation on a newborn manikin with a T-piece resuscitator and manual chest compressions. The C:V ratios 3:1, 9:3 and 15:2, as well as continuous chest compressions with asynchronous ventilation (120 compressions and 40 ventilations per minute) were performed in a randomised fashion in series of 10 × 2 minutes. In addition, ventilation only was performed at three different rates (40, 60 and 120 ventilations per minute, respectively). A respiratory function monitor measured inspiration time, tidal volume and ventilation rate. Mv was calculated for the different interventions and the Mann–Whitney test was used for comparisons between groups.

Results
Median Mv per kg in ml (interquartile range) was significantly lower at the C:V ratios of 9:3 (140 (134–144)) and 15:2 (77 (74–83)) as compared to 3:1 (191(183–199)). With ventilation only, there was a correlation between ventilation rate and Mv despite a negative correlation between ventilation rate and tidal volumes. Continuous chest compressions with asynchronous ventilation gave higher Mv as compared to coordinated compressions and ventilations at a C:V ratio of 3:1.

Conclusions
In this study, higher C:V ratios than 3:1 compromised ventilation dynamics in a newborn manikin. However, higher ventilation rates, as well as continuous chest compressions with asynchronous ventilation gave higher Mv than coordinated compressions and ventilations with 90 compressions and 30 ventilations per minute.

Full text

O R I G I N A L R E S E A R C H Open Access
Minute ventilation at different compression to
ventilation ratios, different ventilation rates, and
continuous chest compressions with
asynchronous ventilation in a newborn manikin
Anne L Solevåg
1,2*
, Jorunn Marie Madland
1,2
, Espen Gjærum
1,2
and Britt Nakstad
1,2
Abstract
Background: In newborn resuscitation the recommended rate of chest compressions should be 90 per minute and
30 ventilations should be delivered each minute, aiming at achieving a total of 120 events per minute. However,
this recommendation is based on physiological plausibility and consensus rather than scientific evidence. With
focus on minute ventilation (Mv), we aimed to compare today’s standard to alternative chest compression to
ventilation (C:V) ratios and different ventilation rates, as well as to continuous chest compressions with
asynchronous ventilation.
Methods: Two investigators performed cardiopulmonary resuscitation on a newborn manikin with a T-piece
resuscitator and manual chest compressions. The C:V ratios 3:1, 9:3 and 15:2, as well as continuous chest
compressions with asynchronous ventilation (120 compressions and 40 ventilations per minute) were performed in
a randomised fashion in series of 10 × 2 minutes. In addition, ventilation only was performed at three different
rates (40, 60 and 120 ventilations per minute, respectively). A respiratory function monitor measured inspiration
time, tidal volume and ventilation rate. Mv was calculated for the different interventions and the Mann–Whitney
test was used for comparisons between groups.
Results: Median Mv per kg in ml (interquartile range) was significantly lower at the C:V ratios of 9:3 (140 (134–144))
and 15:2 (77 (74–83)) as compared to 3:1 (191(183–199)). With ventilation only, there was a correlation between
ventilation rate and Mv despite a negative correlation between ventilation rate and tidal volumes. Continuous
chest compressions with asynchronous ventilation gave higher Mv as compared to coordinated compressions and
ventilations at a C:V ratio of 3:1.
Conclusions: In this study, higher C:V ratios than 3:1 compromised ventilation dynamics in a newborn manikin.
However, higher ventilation rates, as well as continuous chest compressions with asynchronous ventilation gave
higher Mv than coordinated compressions and ventilations with 90 compressions and 30 ventilations per minute.
Keywords: Newborn, Resuscitation, Positive-pressure respiration, Heart massage, Pulmonary ventilation, Manikin
Background
Five to ten percent of newborns need assistance to estab-
lish breathing at birth [1-5]. Even though scientific studies
have not addressed the optimal ventilation rate when
positive pressure ventilation (PPV) is required in the de-
livery room, The International Liaison Committee on
Resuscitation (ILCOR) guidelines state that 40 to 60 ven-
tilations per minute might be appropriate [6]. A com-
monly used tidal volume (V
T
) in assisted ventilation of
newborns is 4–8 ml/kg [7]. There is insufficient evidence
to recommend an optimal inflation time.
If 30 seconds of effective PPV do not lead to a rise in
heart rate above 60 beats per minute, chest compres-
sions should be initiated with a compression:ventilation
(C:V) ratio of 3:1. The rate of chest compression should
* Correspondence: a.l.solevag@medisin.uio.no
1
The Department of Children and Adolescents, Akershus University Hospital,
1478 Lørenskog, Norway
2
University of Oslo, 0316 Oslo, Norway
© 2012 Solevåg et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Solevåg et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:73
http://www.sjtrem.com/content/20/1/73

be 90 per minute and 30 inflations should be delivered
each minute during cardiopulmonary resuscitation
(CPR), aiming at achieving a total of 120 events per mi-
nute [8]. However, this recommendation is based on
physiological plausibility and consensus, rather than sci-
entific evidence.
We aimed to investigate different C:V ratios, ventila-
tion rates, as well as continuous chest compressions with
asynchronous ventilation with regards to delivered V
T
and minute ventilation (Mv) by using a newborn mani-
kin, a T-piece resuscitator and a respiratory function
monitor.
Our research question was whether alternative C:V
ratios, ventilation rates or continuous chest compres-
sions with asynchronous ventilation would compromise
ventilation as measured by reduced Mv in a newborn
manikin.
Methods
Technical equipment
We used the SimNewB
TM
(Lærdal Medical AS, Stavan-
ger, Norway), simulating a 3.5 kg newborn baby. The
SimNewB
TM
is an advanced simulator with a range of
options with regards to airway characteristics, including
three settings for airway restriction and airway compli-
ance. We used the simulator with the default settings
from the manufacturer with fully open airways and no
noticeable restrictions during ventilation. In order to
deliver PPV, the Neopuff
TM
T-piece resuscitator (Fisher
& Paykel Healthcare, Auckland, New Zealand) was
used; medical air being used to generate a flow of 8 l/
min. In a pilot experiment we found that a positive
end-expiratory pressure (PEEP) of 8 cm H
2
O and a
peak inspiratory pressure (PIP) of 30 cm H
2
O were ap-
propriate in order to obtain tidal volumes of 4–8 ml/kg
in this model. The Laerdal Silicone Infant Mask No 0/1
was the facemask in use. A SensorMedics Vmax 26
(Eco Medics AG, Switzerland) was used to measure V
T
,
ventilation rates, inspiration times (T
I
) and expiration
times (T
E
). In order to be able to deliver chest com-
pressions and ventilations at the assigned rate, we used
a web-based metronome (webmetronome.com).
The SensorMedics Vmax 26 has a dead volume of less
than 2 ml in the standard setup for infant flow monitor-
ing. We added a connector between the Neopuff
TM
and
this device, adding less than 0,5 ml of dead space vol-
ume. The Vmax was set up for standard infant flow
measurements (i.e. default settings) as indicated by the
manufacturer, except from a volume deviation of 100%.
Analogue signals in the Vmax are being digitised and
analysed using the Spiroware
W
recording software with
the tidal breathing flow volume loop (TBFVL)-INF pro-
gram. Filter size 1 with dead space reducer (Eco Medics,
DSR Set 1 (small)) was used. With this instrument, in-
spiratory volume (V
TI
) and expiratory volume (V
TE
) are
automatically calculated by integrating the flow signals
and V
T
is calculated as the mean of V
TI
and V
TE
. The
software continuously displays gas flow and V
T
waves.
In addition, it measures and displays numerical values
for V
TI
,V
TE
,T
I
,T
E
and respiratory rate.
Optimizing ventilation and chest compressions
The main study was preceded by a pilot study where we
tested different ways of delivering PPV to the SimNewB
TM
in order to minimize face/mask leak.
1) Nasal and oral endotracheal tube
a) Self-inflating bag
b) Neopuff
TM
2) Bag-mask ventilation directly on the manikin’s face,
covering the nose and mouth with the mask.
With the mask being placed over the nose and the
mouth of the manikin, there was a significant leak be-
tween the rubber ”skin”of the manikin and the face. To
overcome this problem, the ”skin”was removed, and the
mask was placed directly onto the face of the manikin.
The investigators practised ventilation of this model
until they managed to ventilate the manikin without a
significant mask leak (as measured by V
TI
≈V
TE
). The
mask was attached to the flow sensor of the SensorMedics
Vmax 26, and further onto the Neopuff
TM
.
Chest compressions were performed using the two-
thumb-encircling hands technique. In the pilot study,
the investigators practised their technique for perform-
ing chest compressions with correct finger placement on
the manikin chest and depth of compressions being
approximately one third of the anterior-posterior diam-
eter of the chest.
Experimental protocol
In this study, we chose to investigate the ratio of 9:3
chest compressions to ventilations because in theory it
will, in the clinical setting, produce a higher coronary
perfusion pressure due to more compressions in a series,
and at the same time maintain ventilation as compared
to 3:1. A C:V ratio of 15:2 was chosen because this is the
currently recommended ratio in all patients when
advanced CPR is performed, except in newborns.
Two investigators, JMM and EG performed CPR on
the SimNewB
TM
with the C:V ratios 3:1, 9:3 and 15:2, as
well as continuous chest compressions with asynchron-
ous ventilation (120 compressions and 40 ventilations
per minute). JMM and EG were undergraduate medical
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Table 1 Ventilation characteristics at different compression:ventilation ratios, continuous chest compressions with asynchronous ventilation; and ventilation
rates
Intervention Number of
ventilations/min
p-value* V
T
(ml)
Absolute
p-value* V
T
(ml)
Per kg
p-value* Mv (ml) p-value* Mv (ml)
Per kg
p-value* T
I
(s) p-value*
Continuous chest compressions
with asynchronous ventilation
39 (39–39) <0.001 19.7 (18.8-21.1) 0.002 5.6 (5.4-6.0) 0.002 777 (735–836) <0.001 221 (210–239) <0.001 0.52 (0.49-0.58) 0.427
C:V = 3:1 120 events per minute 30 (29–30) 22.3 (21.9-23.8) 6.4 (6.3-6.8) 668 (642–697) 191 (183–199) 0.50 (0.48-0.55)
C:V 9:3 120 events per minute 28 (28–30) 0.057 17.1 (16.5-17.1) <0.001 4.9 (4.8-5.1) <0.001 490 (468–506) <0.001 140 (134–144) 0.002 0.33 (0.33-0.34) <0.001
C:V 15:2 120 events per minute 14 (13–15) <0.001 19.1 (19.0-19.9) <0.001 5.5 (5.4-5.7) <0.001 268 (261–289) <0.001 77 (74–83) <0.001 0.33 (0.32-0.34) 0.001
Ventilations only 40 per minute 40 (40–40) <0.001 19.5 (18.8-19.9) <0.001 5.6 (5.4-5.7) <0.001 760 (734–775) <0.001 217 (210–221) <0.001 0.59 (0.57-0.71) 0.003
Ventilations only 60 per minute 58 (58–59) <0.001 17.4 (16.8-17.8) <0.001 5.0(4.8-5.1) <0.001 1013 (973–1028) <0.001 289 (278–294) <0.001 0.56 (0.53-0.60) 0.049
Ventilations only 120 per minute 118 (117–118) <0.001 13.1 (13.1-13.6) <0.001 3.8 (3.7-3.9) <0.001 1544 (1525–1595) <0.001 441 (436–456) <0.001 0.24 (0.24-0.25) <0.001
Values are shown as median (IQR) *compared to a chest compression to ventilation ratio of 3:1.
C:V = chest compressions to ventilations, V
T
= tidal volume, Mv = minute ventilation, T
I
= inspiratory time.
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students and had no practical experience in neonatal
resuscitation. As previously mentioned, they practiced
ventilation and chest compressions in this model to an
extent that made them capable of delivering consistent
CPR without signs of fatigue as measured by stable
ventilation parameters during the 2-minute series of
CPR.
A commonly used duration of CPR cycles in this type
of research is 90 seconds or 2 minutes [9,10]. We chose
to perform each intervention in series of 10 × 2 minutes.
The different interventions were randomized and a
metronome was used to guide CPR at a rate of 120
events per minute as recommended by international
guidelines for newborn resuscitation [6].
In addition, ventilation only was performed at three
different rates (40, 60 and 120 ventilations per minute,
respectively).
The alternative interventions were compared to the
currently recommended ratio of 3:1 chest compressions
to ventilations with a total rate of 120 events per minute
The different interventions are presented in Table 1.
Statistical calculations
Statistical analyses were performed using SPSS 15.0 for
Windows (SPSS Inc., Chicago, Ill., USA).
Based on the pilot experiment the study was powered
to detect a difference in 0.25 ml V
T
(per kg) between the
groups with a type I error rate of 5% and a power of
80%. The calculated number of experiments (series)
needed for each intervention was then 6. Because per-
forming more experiments did not pose ethical chal-
lenges as in clinical studies, we decided on repeating
each intervention 10 times.
As ventilatory parameters were not normally distribu-
ted, we report descriptive statistics as median and inter-
quartile range (IQR). The Mann–Whitney test was used
for comparisons between groups.
Results
General
As the experiments were metronome-guided, we mana-
ged to achieve a number of ventilations at the different
rates and ratios close to target (Table 1). At the C:V ratio
of 3:1 and a total of 120 events per minute, median
number of ventilations per min was 30, whereas at the
ratio of 9:3, we achieved a median of 28 ventilations per
minute. Likewise, in the case of ventilations only, the
number of ventilations achieved approximated the target
(Table 1). In addition, V
T
was within the recommended
range of 4–8 ml/kg in all interventions except ventila-
tions only at a rate of 120 per minute (Table 1). There
was a highly significant correlation between T
I
and V
T
in all groups (p<0.001).
Different compression to ventilation ratios
The C:V ratio of 3:1 gave both higher T
I
and V
T
than
the ratio of 9:3, giving a significantly higher minute vol-
ume (Mv) in ml per kg with 3:1 compressions to ventila-
tions: 191(183–199) (median (IQR)) than in the 9:3
group: 140 (134–144) (p<0.001). The ventilation rate
(median (IQR)) at a C:V ratio of 15:2 (14 (13–15) per
minute) was significantly lower than at a ratio of 3:1 (30
(29–30) per minute) giving a significantly lower Mv in
ml per kg with 15:2 compressions to ventilations
(77 (74–83)) (p<0.001) (Table 1).
Ventilation only at different rates
Even though T
I
and V
T
were inversely correlated to the
ventilation rate, the higher rates (i.e. 60 and 120 per
minutes) gave higher Mv per kg than a ventilation rate
of 40 per minute (Table 1), demonstrating a correlation
between Mv and ventilation rate.
Continuous chest compressions with asynchronous
ventilation
Continuous chest compressions with asynchronous ven-
tilation gave lower V
T
than coordinated compressions
and ventilations at a ratio of 3:1 (p=0.002). However, due
to a higher number of ventilations per minute, a higher
Mv per kg than with the currently recommended C:V
ratio of 3:1was achieved (p<0.001) (Table 1).
Discussion
In this study we demonstrated that Mv was signifi-
cantly reduced at alternative C:V ratios such as 9:3
and 15:2 compared to the standard ratio of 3:1. At the
9:3 ratio this was caused by a shorter T
I
leading to
lower V
T
; whereas at the 15:2 ratio, reduced Mv was
mainly caused by a lower ventilation rate. With venti-
lation only, ventilation rate was correlated to Mv.
Interestingly, continuous chest compressions with asyn-
chronous ventilation gave higher Mv than the currently
recommended C:V ratio of 3:1 due to a higher rate of
ventilations.
C:V ratios
In a recent manikin study by Hemway et al., the C:V ratio
of 3:1 was found to generate more ventilations per 2-
minute CPR cycle than the C:V ratios of 5:1 and 15:2.
However, that study did not evaluate the effectiveness of
ventilations at the different ratios [10]. Assuming that ven-
tilation is crucial in newborn resuscitation, the 3:1 C:V
ratio seems to be the most favourable based on both the
present study and the study by Hemway et al.
Ventilation rates
Important clinical studies investigating different assisted
ventilation rates in the newborn were performed in the
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1980’s [11,12]. Field et al. showed that mechanical venti-
lation at a rate of 100 per minute resulted in better oxy-
genation than lower rates [11]. However, as the authors
proposed that the advantageous effect of increasing the
ventilator rate was due to a suppression of spontaneous
breathing, these results cannot be readily transferred to
resuscitation in the delivery room.
Continuous chest compressions with asynchronous
ventilation
In children (except for the newly born) and adults, con-
tinuous chest compressions with asynchronous ventila-
tion are recommended once an advanced airway is in
place [13,14]. With regards to newborns, two studies of
infant pigs have compared uncoordinated compressions
and ventilations to coordinated chest compressions and
ventilations at a ratio of 5:1 [15,16]. Berkowitz et al. con-
cluded that the uncoordinated approach might be advan-
tageous for myocardial blood flow during brief periods of
cardiac arrest [16]. However, methodological concerns
related to these studies, as well as a lack of human data
make guideline development difficult, especially with
regards to the question of the safety and effectiveness of
continuous chest compressions with asynchronous venti-
lation in the newborn.
Hence, continuous chest compressions with asyn-
chronous ventilation have to be studied in different
models before change in practice can be recommended.
Resuscitator preferences and exhaustion at the different
ratios and rates, as well as at continuous compressions
with asynchronous ventilation can influence outcome in
the clinical setting. However, our results do indicate that
continuous compressions with asynchronous ventilation
may be safe with regards to ventilation also in the
newborn.
The manikin model
Manikins have been used extensively in the study of
mechanical aspects of CPR [17,18]. Various technical
features of the manikins, as well as the structure and
size of the manikins make different studies more or
less comparable. In neonatal CPR a commonly used
manikin is the Laerdal Heart Code BLS that is suitable
for recording chest compression dynamics [10,19].
However, as the Heart Code BLS manikin equals a 6
kg infant, we found it more appropriate to use the
SimNewB
TM
that according to Laerdal is more similar
to a 3.5 kg infant in terms of size, compliance of the
chest and airways, as well as the relationship between
the airways and the thoracic wall. However, as the
Laerdal manikins are primarily developed for educa-
tional purposes (the SimNewB
TM
does not record
chest compression mechanics precise enough for this
type of research), the results of scientific studies per-
formed with these models should be interpreted with
a certain degree of caution.
Still, we argue that manikin studies can provide
knowledge about ventilation dynamics at alternative
C:V ratios, ventilation rates and continuous chest
compressions with asynchronous ventilation. In this
study we measured the effect of different C:V ratios and
ventilation rates on ventilation volumes, demonstrating
plausible effects: Increasing ventilation rates makes
each ventilation shorter which in turn reduces V
T
;
and increasing the number of ventilations increases Mv.
But, despite the predictability of the results, these
hypotheses have never been tested in scientific studies
prior to this.
Even though our manikin was not intubated, con-
tinuous chest compressions with asynchronous ventila-
tion did not interfere with ventilation as measured by
a higher Mv with this approach as compared to today’s
standard of 3:1 chest compressions to ventilations.
However, as our experiments were optimised to
achieve standardised ventilations with minimal face/
mask leak, the situation is not entirely comparable to
CPR in the delivery room where the amount of mask
leak might be different at different ventilation/com-
pression interventions.
As the results of the different interventions were strik-
ingly consistent with low variability (narrow IQRs) for
Mv within each intervention (Table 1), we find that our
model is robust and reliable. Also, as we almost uni-
formly achieved V
T
within the recommended range of
4–8 ml/kg, this adds to the notion that the model we
used is suitable for investigating ventilatory dynamics in
the newborn. However, as opposed to a newborn under-
going pulmonary transition with changes in the amounts
of liquid in the alveoli during resuscitation, lung compli-
ance was high (no airway resistance) and fixed in our
manikin model.
However, as the aim of the study was to measure dif-
ferences between alternative measures, we believe that
our results add to the knowledge about how ventilation
is influenced by different C:V ratios and ventilation
rates.
Higher ventilation rates improved Mv in this study.
However, it is not known how easily these rates can be
achieved in a real life setting and how this may influence
clinical outcome.
Importantly, this study only investigated one aspect
of CPR, delivery of Vt and Mv. In the clinical setting,
cardiac output is influenced by chest compression. As
oxygenation depends both on ventilation and cardiac
output, the entire truth about the influence of differ-
ent C:V ratios cannot be found through manikin
research.
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The investigators
As opposed to the participants in the study by Hemway
et al. who mostly were health care workers in neonatology
[10], the subjects performing CPR in this study were prob-
ably not biased toward any intervention.
These manikin studies are valuable since the ques-
tions being addressed are difficult to examine in clin-
ical studies, as significant ethical issues concerning
resuscitation research in the newborn would have to
be taken into account. However, further studies investi-
gating the optimal C:V ratio and ventilation rates; as
well as continuous chest compressions with asynchron-
ous ventilation in newborn resuscitation should be
undertaken.
Conclusions
In a neonatal manikin, higher C:V ratios than the cur-
rently recommended 3:1 did compromise ventilation dy-
namics as measured by reduced Mv. However, continuous
chest compressions with asynchronous ventilation
increased Mv, which may be desirable in asphyxiated
infants.
Alternatives to today’s CPR standards may be easier
to perform in real life and this can affect outcome in
the clinical setting. Also, the quality of chest compres-
sions at different C:V ratios is thought to influence
outcome in newborn CPR. We did not measure chest
compression characteristics in this study. However,
this together with rescuer preferences and pedagogical
concerns should be investigated further as they may
possibly influence guideline development.
Abbreviations
PPV: Positive pressure ventilation; ILCOR: The International Liaison Committee
on Resuscitation; V
T
: Tidal volume; C:V: Compression:ventilation;
CPR: Cardiopulmonary resuscitation; Mv: Minute ventilation; PEEP: Positive
end-expiratory pressure; PIP: Peak inspiratory pressure; T
I
: Inspiratory time;
T
E
: Expiratory time; V
TI
: Inspiratory volume; V
TE
: Expiratory volume.
Competing interests
The authors declare that they have no competing interests. The study was
not funded by external sources.
Authors’contributions
ALS and BN conceived of the idea for the study and drafted the research
protocol. JMM and EG refined the protocol and carried out the experiments
in close collaboration with ALS and BN. ALS performed the statistical analysis
and drafted the manuscript. All authors read and approved the final
manuscript.
Acknowledgements
The authors wish to thank Sissel Aalde Bendiksen in the Outpatient Clinic in
the Department of Children and Adolescents for technical assistance with
the SensorMedics Vmax 26.
Received: 10 September 2012 Accepted: 12 October 2012
Published: 17 October 2012
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