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Chest Compressions and Ventilation in
Delivery Room Resuscitation
Anne Lee Soleva
˚g, MD,
PhD,*
†‡
Po-Yin Cheung,
MBBS, PhD,*
†
Georg
M. Schmo¨lzer, MD, PhD*
†x
Author Disclosure
Drs Soleva
˚g, Cheung,
and Schmo¨lzer have
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion of
an unapproved/
investigative use of
a commercial product/
device.
Educational Gap
The optimal ratio of chest compressions to ventilation for neonatal resuscitation would
benefit from further research studies.
Abstract
The purpose of chest compressions(CCs)istogeneratebloodflow to vital organs in
a state in which the myocardium is unable to produce forward blood flow by internal
pump mechanisms. In newborn infants requiring CCs in the delivery room, the most
frequent cause of myocardial compromise is energy depletion due to hypoxia. Hypoxemia
and the accompanying hypercarbia and metabolic acidosis (ie, asphyxia) causes systemic
vasodilation, further compromising perfusion pressure. Hence, in neonatal cardiopulmo-
nary resuscitation (CPR), the focus is on both reversing hypoxia and enhancing coronary
and systemic perfusion pressure. There are limited clinical data to support a recommen-
dation for how CC and ventilation should be optimized for this purpose in the newborn.
However, studies in animal models and manikins suggest that using a compression-to-
ventilation ratio (C:V) of 3:1 and delivering compressions during a pause in ventilation
results in improved ventilation and reversal of hypoxia. Use of the 3:1 ratio, compared
with higher C:V ratios, also results in more effective CC during prolonged CPR. A C:V
ratio of 3:1 is perceived as more exhausting to perform than higher ratios, and a high CC
rate,whichmaybebeneficial, cannot be achieved with pauses in CCs for the delivery of
ventilation. Continuous CCs and asynchronous ventilation have been shown to have im-
proved outcomes in adults and older children after cardiac arrest, and current evidence
suggests that it is as good as a 3:1 C:V ratio in neonatal resuscitation. Further studies are
needed and should focus on the optimal resuscitative approach in neonatal CPR.
Objectives After completing this article readers should be able to:
1. Explain the etiology of cardiac arrest in the newborn.
2. Understand the mechanisms responsible for forward blood flow during
cardiopulmonary resuscitation.
3. Describe the advantages of using a 3:1 chest compression-to-ventilation ratio.
4. Recognize opportunities for further optimizing cardiopulmonary resuscitation in the
newborn.
Introduction
The majority of newborn infants successfully make the transi-
tion from fetal to neonatal life without any help. (1) However,
in approximately 10% of deliveries, some form of respiratory
support is required. Infrequently, cardiopulmonary resuscitation
(CPR) (w0.08%–0.1% for near-term and term deliveries) with
chest compressions (CCs) and, in a few cases, epinephrine
administration (2)(3) is needed. Asphyxia, a condition of im-
paired gas exchange with simultaneous hypoxia and hypercapnia
Abbreviations
CPR: cardiopulmonary resuscitation
CCs: chest compressions
DBP: diastolic blood pressure
CCaV: chest compressions and asynchronous ventilations
C:V: compression-to-ventilation ratio
ROSC: return of spontaneous circulation
*Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
†
Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
‡
Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway.
x
Department of Pediatrics, Medical University Graz, Graz, Austria.
Article critical care
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leading to a mixed metabolic and respiratory acidosis, is
the most common reason newborns fail to make success-
ful transition. (4) Asphyxia could result from either failure
of placental gas exchange before delivery (eg, abruption,
chorioamnionitis) or deficient pulmonary gas exchange
immediately after birth (eg, apnea, airway obstruction,
respiratory distress syndrome). (4) Asphyxia depresses
myocardial function, leading to cardiogenic shock, and
promotes maximal vasodilation, resulting in low diastolic
blood pressures (DBP). CCs serve to mechanically pump
the blood through the body until the myocardium be-
comes sufficiently oxygenated to improve function. (4)
Blood expulsion from the ventricles during CPR is thought
to occur by either direct compression of the heart between
the sternum and vertebral column (cardiac pump theory)
or phasic increases in intrathoracic pressure (thoracic pump
theory). The “cardiac pump theory”postulates that CCs
directly eject blood from the heart into the circulation with
each compression. (5) In comparison, the “thoracic pump
theory”states that a phasic increase in intrathoracic pres-
sure produced by compression of the chest creates a
pressure gradient between the arterial and venous compart-
ment. (6)(7)(8)(9)(10)(11) This pressure gradient then
serves as the driving force for antegrade blood flow. Opti-
mized CC has been demonstrated to generate 30% of nor-
mal organ perfusion, with preferential (>50%) perfusion to
the heart and brain. (6)(12)(13)(14) During CC, coronary
blood flow occurs during diastole with coronary perfusion
pressure determined by the difference of aortic blood pres-
sure and right atrial pressure. (15) In adult animals and hu-
mans, uninterrupted CC and systemic vasoconstrictors
such as epinephrine enhance DBP during CPR. Studies us-
ing sudden cardiac collapse models in 2- to 3-month-old
asphyxiated pigs (16) as well as randomized trials during
adult cardiac arrest (17) have demonstrated that continu-
ous CCs without rescue breaths significantly reduces time
to return of spontaneous circulation (ROSC) and increases
survival because of improved hemodynamics. These studies
led to a change in adult life-support guidelines recom-
mending that bystander CPR be performed without res-
cue breaths and that in lone-rescuer advanced CPR,
CCs should be uninterrupted for the first few minutes.
(18) In both adult and pediatric advanced life support,
continuous CCs with asynchronous ventilations (CCaV)
are recommended after a secure airway has been estab-
lished. (18)(19)
In contrast, current neonatal resuscitation guidelines
recommend using a coordinated 3:1 compression-to-
ventilation (C:V) ratio if CCs are needed. This approach
is composed of 90 CCs and 30 inflations per minute, with
a pause after every third CC to deliver one effective
inflation. However, the most effective C:V ratio in new-
borns remains controversial. (20) This article discusses
the justification for using a 3:1 C:V ratio during neonatal
CPR and reviews the emerging reports of alternative ap-
proaches including different C:V ratios and CCaV.
Rationale for the Current Recommendation of
a 3:1 C:V Ratio
The recommendation of a ratio of 3:1 CCs and inflations
is based on expert opinion and consensus rather than strong
scientific evidence. (20) Rationales for using a 3:1 C:V ratio
include the higher physiological heart rate of 120 to 160
per minute and breathing rates of 40 to 60 per minute
in newborns compared with adults. Furthermore, profound
bradycardia or cardiac arrest in newborns is usually caused
by hypoxia rather than primary cardiac compromise. There-
fore, providing ventilation is more likely to be beneficial in
neonatal CPR compared with adult CPR. (1) Babbs and
Nadkarni used a mathematical model based on body weight
to estimate ideal C:V ratios. Their model suggested that
C:V ratios currently recommended for adults would lead
to underventilation in infants and that a 3:1 C:V ratio
would be appropriate in terms of optimal oxygen delivery
and blood flow during neonatal CPR. (19) Animal studies
using cardiac arrest induced by asphyxia in newborn piglets
demonstrated that combining CCs with ventilations im-
proves ROSC and neurologic outcome at 24 hours com-
pared with ventilations or CCs alone. (16)(21)
Solevag et al performed a study investigating alternat-
ing 9 CCs and 3 ventilations in asphyxiated piglets with
cardiac arrest with the hypothesis that 9 CCs would gen-
erate higher DBP during CPR than only 3 CCs in a series.
(22) However, increasing the number of CCs in a row
should not be at the expense of ventilation; hence, the ra-
tio of CCs and ventilation was maintained at 3:1. The time
to ROSC was similar between the two approaches (150
and 148 seconds for 3:1 and 9:3, respectively). In addition,
there were no differences in DBP during CC and interleukin-
1bas a marker of inflammation in bronchoalveolar lavage
fluid (148 versus 129 pg/mL) or cerebrospinal fluid
(14.7 versus 6.0 pg/mL). (22) Similarly, C:V ratios of 3:1
and 15:2 were compared using the same model. (23) Al-
though the 15:2 C:V ratio provided higher mean CCs per
minute (75 versus 58 for 3:1), time to ROSC was similar
between groups (median time of 195 and 150 seconds for
15:2 and 3:1, respectively). (23) These studies confirmed
that during neonatal CPR, higher C:V ratios did not im-
prove outcomes, suggesting that a 3:1 C:V ratio should
continue to be used in newborns. This is further supported
by manikin studies showing higher ventilation rates in 3:1
critical care delivery room resuscitation
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C:V during CPR compared with higher C:V ratios. (24)
(25)(26) A similar manikin study reported higher minute
ventilation and CCs per minute with a 5:1 C:V ratio (2.2 L
and 88 CCs per minute) compared with 10:2 (2.0 L and
79 CCs per minute) or 15:2 (1.4 L and 84 CCs per min-
ute) C:V ratios during pediatric CPR with two rescuers.
(27) Similar benefits have been reported for CC depth us-
ing C:V ratios of 3:1, 5:1, and 15:2 during two-minute
simulated CPR. (26) Participants had higher and more
consistent CC depth during 3:1 C:V CPR; however, the
CC rate was lower in CPR with C:V ratio of 3:1 compared
with 15:2. In addition, the depth decay during CC was
significantly higher during 5:1 C:V and 15:2 C:V ratios
compared with 3:1 C:V. (26) Interestingly, this contrasts
with a study by Srikantan et al (25) who reported no differ-
ences in effective CCs per minute among the C:V ratios of
3:1, 5:1, 10:2, and 15:2 during simulated one-rescuer
CPR. Similarly to other studies, Sirkantan et al reported
that rescuers achieved a higher mean ventilation rate using
a 3:1 C:V ratio compared with using C:V ratios of 5:1,
10:2, and 15:2. (25) A more recent neonatal manikin
study examined respiratory parameters during neonatal
CPR and reported that a 3:1 C:V ratio delivered signifi-
cantly higher minute ventilation of 191 mL/kg compared
with the minute ventilation at 9:3 and 15:2 C:V ratios
(140 and 77 mL/kg, respectively). (28) Further aspects
of neonatal resuscitation including the optimal depth of
CCs and superiority of the two-thumb method have also
been studied in the period since the publication of the first
neonatal guidelines in 1999, and changes have been imple-
mented on the basis of these data.
Future Directions
Outcome studies of delivery-room resuscitation have
shown high rates of mortality and neurodevelopmental
impairment in those infants receiving CCs or epinephrine.
(29)(30) The poor prognosis associated with receiving
CCs alone or with medications in the delivery room raises
questions as to whether improved CPR methods specifi-
cally tailored to the newborn could improve outcomes.
(4) Several experimental studies reported that participants
perceived the 3:1 C:V ratio as being more physically tiring
compared with other ratios. (24)(25)(31) Sirkantan et al
reported that rescuers preferred the 10:2 and 15:2 C:V ra-
tios over a 3:1 C:V ratio. (25) In a baby manikin study
Whyte et al reported that participants did not manage
to deliver the intended number of ventilations during
CPR at the 3:1 C:V ratio. (24) Foglia et al confirmed that
compliance with the current algorithm is poor in simulated
neonatal CPR with providers, irrespective of experience,
performing CCs at a significantly higher rate than the
recommended 90 CCs per minute. (31) This is further
supported by a recent clinical observation that even expe-
rienced resuscitators do not always comply with the
current algorithm of neonatal CPR. (32) A recent math-
ematical study suggests that higher CC rates than the cur-
rently recommended 90 CCs per minute could optimize
systemic perfusion. (33) This model further suggests that
the most effective CC frequency depends on body size and
weight, which would translate to 180 CCs per minute for
term infants and even higher rates for preterm infants. (33)
However, CC rates of 180 CCs per minute or greater are
impossible to achieve using either a 3:1 C:V ratio or
CCaV. A manikin study compared 3:1 C:V with CCaV
and reported similar tidal volumes of 6.4 and 5.6 mL/kg,
respectively. However, minute ventilation was signifi-
cantly higher in the CCaV group compared with the
3:1 group (221 versus 191 mL/kg/min, respectively).
(28) Schmölzer et al compared 3:1 C:V CPR with CCaV
in a piglet model of neonatal asphyxia and reported sim-
ilar median tidal volumes (14.7 versus 11.0 mL/kg) and
minute ventilation (387 versus 275 mL/kg). In addition,
both groups had similar median time to ROSC (143 and
114 seconds for 3:1 and CCaV, respectively), survival (3/8
and 6/8 with mean survival time of 197 and 217 minutes,
respectively) and hemodynamic recovery. (34) An argu-
ment of synchronized CPR is the potential interference
of asynchronized CCs with tidal volume delivery, hence
impairment of oxygen delivery. However, we observed
29% and 25% of manual inflations were similarly affected
by CC during CCaV and 3:1 C:V CPR, respectively, in
a porcine model of asphyxia. (34) These studies suggest
that a similar oxygen delivery can be achieved with coor-
dinated CC and ventilation at a ratio of 3:1 or CCaV.
Reoxygenation and adequate blood flow are the cor-
nerstones of neonatal CPR. Any effective resuscitative
maneuver should increase blood flow and optimize oxy-
gen delivery. In addition to standard CPR, maneuvers
that raise intrathoracic pressure can significantly increase
carotid blood flow during CPR. (7)(35) Chandra et al
provided ventilation at high airway pressure while simul-
taneously performing CCs in an animal model and dem-
onstrated increased carotid flow without compromising
oxygenation. (7) Furthermore, studies in preterm lambs
have demonstrated that a sustained inflation also in-
creases intrathoracic pressure without impeding blood
flow. (11) An experimental study using a ventricular fi-
brillation model of adult cardiac arrest demonstrated that
emphasis on CC over ventilation increases neurologically
intact survival in pigs. (36) In the resuscitation of asphyx-
iated newborn piglets, Schmölzer et al recently reported
critical care delivery room resuscitation
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that passive ventilation during CC, achieved by superim-
posing CCs with a sustained inflation, significantly im-
proved hemodynamics, minute ventilation, and time to
ROSC compared with the current approach of 3:1 C:V
ratio (mean arterial pressure: 51 versus 31 mm Hg; pulmo-
nary arterial pressure: 41 versus 31 mm Hg; mean minute
ventilation: 936 versus 623 mL/kg; median time to ROSC:
38 versus 143 seconds, respectively). (37) Superimposing
CCs with sustained inflation(s) could be a novel resuscita-
tive approach in neonatal CPR and requires further
study to confirm its therapeutic potential in neonatal
asphyxia. In fact, a randomized controlled trial is cur-
rently being performed studying the effect of a sustained
inflation during CC in the delivery room. (38)
Limitations
CCs are needed in approximately 1 in 1,000 newborn in-
fants, (3) which makes large randomized clinical trials ad-
dressing various issues of neonatal CPR difficult. (39)
The evidence presented in this article is mainly derived
from animal and manikin studies. Studies in newborn in-
fants are limited to case reports and case series. A further
disadvantage is the use of animal models with completed
perinatal transition (eg, 2- to 3-day-old piglets); these
studies do not fully reflect delivery-room situations with
the unique transitional physiology of the newborn. Fur-
thermore, despite the recommended guideline to use air
at the start of neonatal resuscitation, the possible effects
of supplemental oxygen on outcomes during neonatal
CPR have not been taken into account in this review.
Limited information is available to date on how oxygen
supplementation affects hypoxia-reoxygenation injury,
hemodynamic recovery, and short- and long-term out-
comes in newborn infants requiring CPR. Some data ex-
ist indicating that supplementary oxygen does not reduce
time to ROSC compared with air in asphyxiated newborn
pigs. (40)(41) Nonetheless, the role of oxygen in CPR
should be a focus of further studies. Finally, the evidence
reviewed in this article is based on term and near term
infants, and different considerations may be applicable
in preterm infants.
Conclusions
If a newborn infant requires CC, the current evidence sup-
ports the use of coordinated 3:1 compressions to ventila-
tions to allow enough time to deliver adequate ventilation.
However, alternative approaches in animal models show
promising results. Some evidence even suggest that CCaV
is comparable to 3:1 C:V. Further studies including ran-
domized trials are needed to address these issues.
References
1. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal
resuscitation: 2010 American Heart Association Guidelines for Car-
diopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122(18, suppl 3):S909–S919
2. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus
intravenous epinephrine during neonatal cardiopulmonary resuscita-
tion in the delivery room. Pediatrics. 2006;118(3):1028–1034
3. Perlman JM, Risser R. Cardiopulmonary resuscitation in the
delivery room. Associated clinical events. Arch Pediatr Adolesc Med.
1995;149(1):20–25
4. Kapadia V, Wyckoff MH. Chest compressions for bradycardia or
asystole in neonates. Clin Perinatol. 2012;39(4):833–842
5. Higano ST, Oh JK, Ewy GA, Seward JB. The mechanism of
blood flow during closed chest cardiac massage in humans: trans-
esophageal echocardiographic observations. Mayo Clin Proc. 1990;
65(11):1432–1440
6. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic
effects of interrupting chest compressions for rescue breathing during
cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest.
Circulation. 2001;104(20):2465–2470
7. Chandra N, Weisfeldt ML, Tsitlik J, et al. Augmentation of
carotid flow during cardiopulmonary resuscitation by ventilation at
high airway pressure simultaneous with chest compression. Am J
Cardiol. 1981;48(6):1053–1063
8. Halperin HR, Tsitlik JE, Guerci AD, et al. Determinants of
blood flow to vital organs during cardiopulmonary resuscitation in
dogs. Circulation. 1986;73(3):539–550
9. Rudikoff MT, Maughan WL, Effron M, et al. Mechanisms of
blood flow during cardiopulmonary resuscitation. Circulation.1980;
61(2):345–352
10. Criley JM. The thoracic pump provides a mechanism for coronary
perfusion. Arch Intern Med. 1995;155(11):1236
11. Sobotka KS, Hooper SB, Allison BJ, et al. An initial sustained
inflation improves the respiratory and cardiovascular transition at
birth in preterm lambs. Pediatr Res. 2011;70(1):56–60
12. Delguercio LR, Coomaraswamy RP, State D, et al. Cardiac
output and other hemodynamic variables during external cardiac
massage in man. N Engl J Med. 1963;269:1398–1404
13. Voorhees WB, Babbs CF, Tacker WA Jr. Regional blood flow
during cardiopulmonary resuscitation in dogs. Crit Care Med.
1980;8:3
14. Berkowitz ID, Gervais H, Schleien CL, et al. Epinephrine
dosage effects on cerebral and myocardial blood flow in an infant
swine model of cardiopulmonary resuscitation. Anesthesiology.1991;
75(6):1041–1050
15. Kern KB, Hilwig R, Ewy GA. Retrograde coronary blood flow
during cardiopulmonary resuscitation in swine: intracoronary Dopp-
ler evaluation. Am Heart J. 1994;128(3):490–499
American Board of Pediatrics Neonatal–Perinatal
Content Specification
• Know the indications for,
techniques, and potential
complications of chest compression
in the delivery room.
critical care delivery room resuscitation
NeoReviews Vol.15 No.9 September 2014 e399
by guest on July 21, 2017http://neoreviews.aappublications.org/Downloaded from
16. Berg RA, Hilwig RW, Kern KB, Ewy GA. “Bystander”chest
compressions and assisted ventilation independently improve out-
come from piglet asphyxial pulseless “cardiac arrest”.Circulation.
2000;101(14):1743–1748
17. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmo-
nary resuscitation by chest compression alone or with mouth-to-
mouth ventilation. N Engl J Med. 2000;342(21):1546–1553
18. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced
cardiovascular life support: 2010 American Heart Association Guide-
lines for Cardiopulmonary Resuscitation and Emergency Cardiovascu-
lar Care. Circulation. 2010;122(18, suppl 3):S729–S767
19. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14:
pediatric advanced life support: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Car-
diovascular Care. Circulation. 2010;122(18, suppl 3):S876–S908
20. Perlman JM, Wyllie J, Kattwinkel J, et al; Neonatal Resuscita-
tion Chapter Collaborators. Part 11: Neonatal resuscitation: 2010
International Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science With Treatment Recom-
mendations. Circulation. 2010;122(16, suppl 2):S516–S538
21. Berg RA, Hilwig RW, Kern KB, et al. Simulated mouth-to-
mouth ventilation and chest compressions (bystander cardiopulmonary
resuscitation) improves outcome in a swine model of prehospital
pediatric asphyxial cardiac arrest. Crit Care Med. 1999;27(9):
1893–1899
22. Solevåg AL, Dannevig I, Wyckoff M, et al. Extended series of
cardiac compressions during CPR in a swine model of perinatal
asphyxia. Resuscitation. 2010;81(11):1571–1576
23. Solevåg AL, Dannevig I, Wyckoff M, et al. Return of sponta-
neous circulation with a compression:ventilation ratio of 15:2 versus
3:1 in newborn pigs with cardiac arrest due to asphyxia. Arch Dis
Child Fetal Neonatal Ed. 2011;96(6):F417–F421
24. Whyte SD, Sinha AK, Wyllie JP. Neonatal resuscitation—
a practical assessment. Resuscitation. 1999;40(1):21–25
25. Srikantan SK, Berg RA, Cox T, et al. Effect of one-rescuer
compression/ventilation ratios on cardiopulmonary resuscitation in
infant, pediatric, and adult manikins. Pediatr Crit Care Med. 2005;
6(3):293–297
26. Hemway RJ, Christman C, Perlman J. The 3:1 is superior to
a 15:2 ratio in a newborn manikin model in terms of quality of chest
compressions and number of ventilations. Arch Dis Child Fetal
Neonatal Ed. 2013;98(1):F42–45
27. Kinney SB, Tibballs J. An analysis of the efficacy of bag-valve-
mask ventilation and chest compression during different compression-
ventilation ratios in manikin-simulated paediatric resuscitation.
Resuscitation. 2000;43(2):115–120
28. Solevåg AL, Madland JM, Gjærum E, Nakstad B. Minute
ventilation at different compression to ventilation ratios, different
ventilation rates, and continuous chest compressions with asynchronous
ventilation in a newborn manikin. Scand J Trauma Resusc Emerg Med.
2012;20:73
29. Haddad B, Mercer BM, Livingston JC, et al. Outcome after
successful resuscitation of babies born with Apgar scores of
0atboth1and5minutes.Am J Obstet Gynecol. 2000;182(5):
1210–1214
30. Jain L, Ferre C, Vidyasagar D, et al. Cardiopulmonary re-
suscitation of apparently stillborn infants: survival and long-term
outcome. J Pediatr. 1991;118(5):778–782
31. Foglia E, Patel J, Niles D, et al. Provider adherence to neonatal
resuscitation program recommendations for coordinated neonatal
chest compressions and ventilations. Analg Resusc. 2013;Suppl 1
32. Li ES, Cheung PY, Pichler G, et al. Respiratory function and
near infrared spectroscopy recording during cardiopulmonary re-
suscitation in an extremely preterm newborn. Neonatology. 2014;
105(3):200–204
33. Babbs CF, Meyer A, Nadkarni V. Neonatal CPR: room at the
top—a mathematical study of optimal chest compression frequency
versus body size. Resuscitation. 2009;80(11):1280–1284
34. Schmölzer GM, O’Reilly M, Labossiere J, et al. 3:1 compres-
sion to ventilation ratio versus continuous chest compression with
asynchronous ventilation in a porcine model of neonatal resuscita-
tion. Resuscitation. 2014;85(2):270–275
35. Chandra N, Rudikoff M, Weisfeldt ML. Simultaneous chest
compression and ventilation at high airway pressure during cardio-
pulmonary resuscitation. Lancet. 1980;1(8161):175–178
36. Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous
chest compressions during cardiopulmonary resuscitation: improved
outcome during a simulated single lay-rescuer scenario. Circulation.
2002;105(5):645–649
37. Schmölzer GM, O’Reilly M, Labossiere J, et al. Cardiopulmo-
nary resuscitation with chest compressions during sustained in-
flations: a new technique of neonatal resuscitation that improves
recovery and survival in a neonatal porcine model. Circulation.
2013;128(23):2495–2503
38. Schmölzer GM. Chest Compression and Sustained In-
flation for Asystole or Bradycardia in Newborn Infants. Avail-
abl e at: www.ClinicalTrials.gov. Identifier: NCT02083705. Accessed
June 24, 2014
39. Wyckoff MH, Berg RA. Optimizing chest compressions during
delivery-room resuscitation. Semin Fetal Neonatal Med. 2008;13
(6):410–415
40. Linner R, Werner O, Perez-de-Sa V, Cunha-Goncalves D.
Circulatory recovery is as fast with air ventilation as with 100%
oxygen after asphyxia-induced cardiac arrest in piglets. Pediatr Res.
2009;66(4):391–394
41. Solevåg AL, Dannevig I, Nakstad B, Saugstad OD. Resuscita-
tion of severely asphyctic newborn pigs with cardiac arrest by using
21% or 100% oxygen. Neonatology. 2010;98(1):64–72
critical care delivery room resuscitation
e400 NeoReviews Vol.15 No.9 September 2014
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1. A newborn 38-week gestational age male infant is born after emergency cesarean delivery for absent fetal
heart tones. The baby has no respiratory effort, even after positive pressure ventilation is administered for more
than 45 seconds. The team begins chest compressions. Which of the following is true regarding chest
compressions for this infant?
A. If chest compressions are optimally performed, there will be preferential perfusion (>50%) to the brain
and minimal perfusion to the heart, lung, and kidneys.
B. The majority of coronary blood flow occurs during diastole when chest compressions are being
administered.
C. Because of recent studies emphasizing the importance of compressions, current neonatal resuscitation
guidelines recommend that compressions and ventilation be administered at a ratio of 4:1 or 5:1.
D. Although previous guidelines emphasized the need for coordination of compressions to ventilation, the
most recent editions (2012) of national and international guidelines state that this coordination may be
harmful and that there should be no pause for ventilation during neonatal CPR.
E. If performed effectively with optimal techniques, neonatal chest compressions should be able to generate
upward of 80% of normal organ perfusion.
2. Studies and guidelines for adult and pediatric CPR have changed in recent years. Although these changes
should not necessarily translate into guidelines for neonatal resuscitation, it may be beneficial to be aware of
the guidelines for these older patients. Which of the following is true regarding CPR for non-neonatal
patients?
A. The recognition that ventilation is paramount for resuscitation in neonates has influenced adult CPR
guidelines to also emphasize adequate ventilation over chest compressions, with the first minute of
resuscitation focusing solely on airway and breathing in adults and older children.
B. In adult CPR, recent studies have demonstrated that chest compressions without rescue breath can
significantly reduce the time to return of spontaneous circulation and can increase survival.
C. In adult CPR, epinephrine is contraindicated in all circumstances because of its myocardial depressive
effect.
D. In both adult and pediatric CPR, chest compressions should be paused every 15 seconds for ventilations
after a secure airway has been established.
E. The most recent guidelines for adult and pediatric advanced life support have recommended that the ratio
of compressions to ventilation be coordinated at 3:1 compressions to ventilation.
3. While waiting for the delivery of an infant, the resuscitation team members review the neonatal resuscitation
guidelines. One of the team members reminds you of the 3:1 compressions to ventilation ratio. Which of the
following statements is correct?
A. For neonates, this ratio is based on strong scientific evidence; namely, a multicenter randomized controlled
trial sponsored by the Neonatal Research Network found that a 3:1 versus 5:1 ratio led to improved
survival and long-term neurodevelopment by 50% to 75% for both term and very low birthweight infants.
B. Although some number of chest compressions and efforts at ventilation are both recommended, there is
actually no specific ratio recommended by any national resuscitation guideline group.
C. One rationale for this ratio is the higher physiological heart rate of 120 to 160 per minute and breathing
rates of 40 to 60 in newborns.
D. Animal studies have not shown any benefit of combining chest compressions with ventilation over chest
compressions or ventilation alone.
E. Because profound bradycardia in a newborn infant is likely due to primary cardiac compromise, the first
step before chest compressions should be application of an automated defibrillating device.
critical care delivery room resuscitation
NeoReviews Vol.15 No.9 September 2014 e401
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4. You are performing chest compressions on a newborn infant who has birth asphyxia. Which of the following
statements regarding studies on the effectiveness of chest compressions is true?
A. The chest compression depth may be higher and more consistent with a 15:2 compression:ventilation ratio
compared with ratios of 5:1 and 3:1.
B. When considering decay of effort in terms of depth of compression, the highest decay occurs during 3:1
compression:ventilation ratio compared with 5:1 or 15:2 ratios.
C. In manikin studies, chest compression rates are highest overall with a compression:ventilation ratio of 3:1
compared with a ratio of 15:2.
D. Higher mean ventilation rates are observed using a compression:ventilation ratio of 3:1 compared with 5:1
or 15:2.
E. Chest compressions should start slowly for birth asphyxia, at a rate of 40 to 60 per minute, to reduce
reperfusion injury.
5. A 30-week gestational age female infant received chest compressions and epinephrine soon after birth in the
delivery room because of persistent bradycardia. Which of the following statements regarding delivery-room
resuscitation is correct?
A. Outcome studies have shown that infants who receive cardiopulmonary resuscitation in the delivery room
have improved outcomes compared with those who do not.
B. The main reason that a 3:1 ratio for compressions to ventilation is used is that it appears to be easier and
less tiring than other ratios for health-care providers.
C. A key advantage of a 3:1 ratio for compressions to ventilation is that it can ultimately achieve high rates of
chest compressions, up to 240 per minute if done correctly.
D. According to the current guidelines, chest compressions should be provided in approximately 1 of 100
newborn infants because that is the prevalence of bradycardia in the first minute after delivery.
E. A maneuver that may increase carotid blood flow without compromising oxygenation is providing
ventilation at high airway pressure during CPR.
critical care delivery room resuscitation
e402 NeoReviews Vol.15 No.9 September 2014
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DOI: 10.1542/neo.15-9-e396
2014;15;e396NeoReviews
Anne Lee Solevåg, Po-Yin Cheung and Georg M. Schmölzer
Chest Compressions and Ventilation in Delivery Room Resuscitation
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Anne Lee Solevåg, Po-Yin Cheung and Georg M. Schmölzer
Chest Compressions and Ventilation in Delivery Room Resuscitation
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