Neonatal Resuscitation Program Versus Pediatric Advanced Life Support: An Examination of Rescue Breaths With Changing Pulmonary Mechanics Using a Simulator.

Abstract

Background: The Neonatal Resuscitation Program (NRP) and Pediatric Advanced Life Support (PALS) differ considerably, and the transition from one to the other has not been well studied. Pulmonary mechanics change markedly with growth, increasing compliance, decreasing airway resistance, and prolonging the time constant. Differences in lung mechanics may warrant different rescue breath strategies. Design/Methods: Using published predictive equations and Centers for Disease Control and Prevention growth nomograms, gender-agnostic pulmonary compliance (Cstat) and resistance (Rrs) were computed for infants at birth and at regular intervals starting at 2 weeks of age. An IngMar ASL 5000 high-fidelity breathing simulator was used to model these infants. A Maquet Servo-i ventilator provided positive pressure peak inspiratory pressure set at 20 and PEEP set at 5 cm H₂O. Inspiratory time was set to 0.5 s for NRP and 1 s for PALS. For NRP, the rate was set to 40, 50, and 60 breaths/min. For PALS it was set to 12, 20, and 30 breaths/min. Inspired tidal volume (V_Ti), PEEP measured at the airway (PEEP_aw) and total PEEP (PEEP_tot) values were extracted. Minute ventilation (V̇_E) was calculated and corrected to the model's weight. Data were analyzed by linear regression. Results: At a set ventilator pressure differential, NRP rescue breaths were associated with a greater decline in corrected V_Ti and V̇_E for age. PALS consistently delivered larger corrected V_Ti regardless of rate than NRP. Increasing the rate from 20 to 30 in PALS led to an expected increase in corrected V̇_E that approached those seen in NRP. Providing breaths at 50 and 60 breaths/min in NRP was associated with significant inadvertent development of PEEP_tot. Providing PALS at 30 and NRP at 40 breaths/min provided comparable PEEP_tot. Conclusions: PALS at 30 breaths/min provides similar corrected V̇_E and PEEP_tot to NRP at 40 breaths/min. Higher rates that can be employed in NRP can lead to a concerning buildup of PEEP_tot in older patients.