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PEDIATRIC RESUSCITATION UPDATE
Table 1 Expected respiratory rates, according to age [4] Age, y
Breaths, per min
!1 1–3 4–5 6–12 13–18þ
30–60 24–40 22–34 18–30 12–16
With regard to increased respiratory effort, a child may exhibit nasal flaring, retractions or accessory muscle use, or irregular respirations. Further factors to assess are adequate and equal chest wall excursion, and the auscultation of air movement. Abnormal lung sounds include stridor, grunting, gurgling, wheezing, and crackles. Management Once an advanced airway is in place, respirations should be administered simultaneously with chest compressions, at a rate of 8 to 10 per minute. Note that this rate is markedly lower than previous recommendations. Hyperventilation is not recommended, as it can actually be harmful. Increased respiratory rates cause an increased intrathoracic pressure, thereby decreasing venous return and coronary perfusion pressure. This has been shown to decrease survival rates [13]. Neonates In the situation of neonates, it is often necessary to provide positive-pressure ventilation. This can be achieved with the use of a self-inflating bag, a flow-initiating bag, or a T-piece device. The T-piece is a valved device in which regulated pressure and limits flow [14]. The best indicator of successful ventilation is in an increase in the heart rate. Whenever positive pressure is indicated for resuscitation, supplemental oxygen is recommended. For those babies who are breathing but have central cyanosis, free-flow oxygen is indicated. The standard is to use 100% FiO2; however, it is reasonable to begin with an oxygen concentration less than 100% or room air. If there is no improvement after 90 seconds, oxygen should be administered. This updated recommendation reflects the possible adverse effects that high-concentration oxygen has on the respiratory physiology and cerebral circulation of newborns [15]. On the same token, oxygen deprivation and asphyxia cause further tissue damage. Therefore, the goal is to provide adequate oxygenation, which is a balance between oxygen delivery and tissue demand. In a vigorous infant, it is no longer recommended to perform oropharyngeal and nasopharyngeal suctioning of meconium-stained amniotic fluid at