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Background: Intrapartum-related hypoxia accounts for 30% of neonatal deaths in Tanzania. This has led to the introduction and scaling-up of the Helping Babies Breathe (HBB) programme, which is a simulation-based learning programme in newborn resuscitation skills. Studies have documented ineffective ventilation of non-breathing newborns and the inability to follow the HBB algorithm among providers. Objective: This study aimed at exploring barriers and facilitators to effective bag mask ventilation, an essential component of the HBB algorithm, during actual newborn resuscitation in rural Tanzania. Methods: Eight midwives, each with more than one year's working experience in the labour ward, were interviewed individually at Haydom Lutheran Hospital, Tanzania. The audio recordings were transcribed and translated into English and analysed using qualitative content analysis. Results: Midwives reported the ability to monitor labour properly, preparing resuscitation equipment before delivery, teamwork and frequent ventilation training as the most effective factors in improving actual ventilation practices and promoting the survival of newborns. They thought that their anxiety and fear due to stress of ventilating a non-breathing baby often led to poor resuscitation performance. Additionally, they experienced difficulties assessing the baby's condition and providing appropriate clinical responses to initial interventions at birth; hence, further necessary actions and timely initiation of ventilation were delayed. Conclusions: Efforts should be focused on improving labour monitoring, birth preparedness and accurate assessment immediately after birth, to decrease intrapartum-related hypoxia. Midwives should be well prepared to treat a non-breathing baby through high-quality and frequent simulation training with an emphasis on teamwork training.

Airway management is a key objective in adapted electroconvulsive therapy (ECT) protocols during the COVID-19 pandemic to prevent infection. The objective of this study was to describe the effectiveness of a modified ventilation procedure designed to reduce aerosol-generating bag-mask ventilation (BMV) and isolate possible droplets while maintaining adequate respiratory gas values in ECT sessions. This prospective study analyzed the results of the modified protocol applied over a month. Adaptations entailed preoxygenation and extension of the voluntary hyperventilation (VHV) time for two minutes before anesthesia induction, asking patients to hyperventilate with oxygen therapy via nasal cannula and while wearing a face mask. Thereafter, vigorous hyperventilation was avoided, and patients were only assisted with tightly sealed BMV until emergence from anesthesia, isolating the ventilation by using a single-use plastic device. Oxygen saturation (SpO ) and transcutaneous partial pressure of carbon dioxide (TcPCO ) were recorded throughout the session. The study included 74 sessions of bilateral ECT with the modified ventilation protocol in 15 subjects. After VHV, the mean SpO increase was 2.12±2.14%, and the mean TcPCO decrease was 4.05±2.98 mmHg. TcPCO values at the moment of stimulus administration were 2.22±3.07 mmHg below pre-ECT values. The mean EEG seizure was 38.70±17.03 s, and postictal suppression was 68.31± 34.58% and 2.13±0.75 on a 0-3 scale. Brief desaturation (SpO <90) of 4-5 seconds duration was observed in 4 sessions. This modified ventilation protocol was effective during COVID-19, and it did not elicit significant side effects. In addition to avoiding vigorous BMV, it induced moderate hypocapnia, which has been tied to seizure optimization and less hypercapnia during the apnea period.

AimA controlled bench test was undertaken to determine the performance variability among a range of neonatal self-inflating bags (SIB) compliant with current International Standards Organisation (ISO).IntroductionUse of SIB to provide positive pressure ventilation during newborn resuscitation is a common emergency procedure. The United Nations programmes advocate increasing availability of SIB in low-income and middle-income nations and recommend devices compliant with ISO. No systematic study has evaluated variance in different models of neonatal SIB.Methods20 models of SIB were incrementally compressed by an automated robotic device simulating the geometry and force of a human hand across a range of precise distances in a newborn lung model. Significance was calculated using analysis of variance repeated measures to determine the relationship between distance of SIB compression and delivered ventilation. A pass/fail was derived from a composite score comprising: minimum tidal volume; coefficient of variation (across all compression distances); peak pressures generated and functional compression distance.ResultsTen out of the 20 models of SIB failed our testing methodology. Two models could not provide safe minimum tidal volumes (2.5–5 mL); six models exceeded safety inflation pressure limit >45 cm H2O, representing 6% of their inflations; five models had excessive coefficient of variation (>30% averaged across compression distances) and three models did not deliver inflation volumes >2.5 mL until approximately 50% of maximum bag compression distance was reached. The study also found significant intrabatch variability and forward leakage.ConclusionCompliance of SIBs with ISO standards may not guarantee acceptable or safe performance to resuscitate newborn infants.

Background Almost two-thirds of the adults in Europe are overweight or obese. Obese patients are at higher risk of complications, especially during intubation. Therefore, the management of general anesthesia is crucial. Regarding intubation, there is no consensus among anesthesiologists between the two strategies: standard sequence intubation (i.e., with bag-mask ventilation between induction and intubation) vs. rapid sequence intubation (i.e., without bag-mask ventilation between induction and intubation) assuming that these patients are at high risk of inhalation and desaturation during apnea. This study aims to compare the incidence of intubation-related complications between these two strategies in severely obese patients undergoing elective surgery. Methods The VENT OR NOT study is a prospective, multicenter, open-label, randomized trial including obese patients with a body mass index ≥ 35 kg/m 2 requiring tracheal intubation before scheduled surgery. We will assess the superiority of the standard sequence intubation (“VENT strategy”) compared with the rapid sequence intubation (“NO VENT strategy”) to prevent intubation-related complications in 702 obese patients. Enrolment started in September 2023 in 13 French academic and nonacademic hospitals and is expected to finish in September 2025. The primary outcome is a composite criterion of complications occurring from the induction of general anesthesia up to 10 min after intubation including: oxygen desaturation < 95%, intubation failure on the first attempt, aspiration or regurgitation, and severe hypotension defined as a systolic blood pressure < 80 mmHg. The VENT OR NOT trial began after ethics committee approval has been obtained and is carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. Discussion The VENT OR NOT trial is the first randomized controlled trial designed to investigate whether the “VENT strategy” reduces the risk of intubation-related complications compared with the “NO VENT strategy” for elective surgery. Trial registration ClinicalTrials.gov NCT05930678. Registered on June 1, 2023

There is a substantial gap in our understanding of resuscitation practices following Helping Babies Breathe (HBB) training. We sought to address this gap through an analysis of observed resuscitations following HBB 2nd edition training in the Democratic Republic of the Congo. This is a secondary analysis of a clinical trial evaluating the effect of resuscitation training and electronic heart rate monitoring on stillbirths. We included in-born, liveborn neonates ≥28 weeks gestation whose resuscitation care was directly observed and documented. For the 2592 births observed, providers dried/stimulated before suctioning in 97% of cases and suctioned before ventilating in 100%. Only 19.7% of newborns not breathing well by 60 s (s) after birth ever received ventilation. Providers initiated ventilation at a median 347 s (>five minutes) after birth; no cases were initiated within the Golden Minute. During 81 resuscitations involving ventilation, stimulation and suction both delayed and interrupted ventilation with a median 132 s spent drying/stimulating and 98 s suctioning. This study demonstrates that HBB-trained providers followed the correct order of resuscitation steps. Providers frequently failed to initiate ventilation. When ventilation was initiated, it was delayed and interrupted by stimulation and suctioning. Innovative strategies targeting early and continuous ventilation are needed to maximize the impact of HBB.

Background Bag-Mask Ventilation (BMV) is a crucial skill in managing emergency airway situations and induction of general anesthesia. Ensuring proficient BMV execution is imperative for healthcare providers. Various techniques exist for performing BMV. This study aims to compare the quality of ventilation achieved using the E/C technique, Thenar Eminence (T/E) technique and a novel approach referred to as the hook technique. The goal is to identify the most effective single-person BMV method. Method We conduct a pilot study on manikins involving 63 medical staff members who used the hook technique for ventilation. Subsequently, we obtained ethical approval and patient guardian consent to perform the study on 492 emergency department (ED) patients. These patients were randomly divided into three groups, with each group subjected to one three ventilation techniques. The study focused on patients requiring reliable airway management for rapid sequence intubation (RSI). Ventilation was administrated using bag-mask device connected to the capnograph. End-tidal CO2 (ETCO2) levels were recorded. Demographic data were collected and analyzed by SPSS software version 22. Success rates were reported as frequency (percentage) as well as mean ± standard deviation. Result Comparing partial pressure of CO2 (PCO2) results obtained via capnography between T/E, E/C and hook techniques, we found that the successful ventilation rate was 87.2% for T/E, 89.6% for E/C, and 93.3% for the hook methods. The hook method demonstrated significantly higher success rate compared to the other two techniques (P-value = 0.038). Furthermore, we observed statistically significant trends in PCO2 changes between measurements both within and between groups (P-value < 0/001). Conclusion Our study indicates that the hook method achieved notably higher success rate in ventilation compared to the T/E and E/C methods. This suggests that the hook method, which involves a chin lift maneuver while securely fitting the mask, could serve as a novel BMV technique, particularly for resuscitation with small hands for a prolonged use without fatigue and finger discomfort. Our finding contributes to the development of a new BMV method referred to as the hook technique. Trial registration IRCT registration number: IRCT20121010011067N5. URL of trial registry record: https://www.irct.ir/trial/57420 .

Background Early Neonatal mortality (ENM) (< 7 days) remains a significant problem in low resource settings. Birth asphyxia (BA), prematurity and presumed infection contribute significantly to ENM. The study objectives were to determine: first, the overall ENM rate as well as yearly ENM rate (ENMR) from 2015 to 2019; second, the influence of decreasing GA (< 37 weeks) and BW (< 2500 g) on ENM; third, the contribution of intrapartum and delivery room factors and in particular fetal heart rate abnormalities (FHRT) to ENM; and fourth, the Fresh Still Birth Rates (FSB) rates over the same time period. Methods Retrospective cohort study undertaken in a zonal referral teaching hospital located in Northern Tanzania. Labor and delivery room data were obtained from 2015 to 2019 and included BW, GA, fetal heart rate (FHRT) abnormalities, bag mask ventilation (BMV) during resuscitation, initial temperature, and antenatal steroids use. Abnormal outcome was ENM < 7 days. Analysis included t tests, odds ratios (OR), and multivariate regression analysis. Results The overall early neonatal mortality rate (ENMR) was 18/1000 livebirths over the 5 years and did not change significantly comparing 2015 to 2019. Comparing year 2018 to 2019, the overall ENMR decreased significantly (OR 0.62; 95% confidence interval (CI) 0.45–0.85) as well as infants ≥37 weeks (OR 0.45) (CI 0.23–0.87) and infants < 37 weeks (OR 0.57) (CI 0.39–0.84). ENMR was significantly higher for newborns < 37 versus ≥37 weeks, OR 10.5 ( p  < 0.0001) and BW < 2500 versus ≥2500 g OR 9.9. For infants < 1000 g / < 28 weeks, the ENMR was ~ 588/1000 livebirths. Variables associated with ENM included BW - odds of death decreased by 0.55 for every 500 g increase in weight, by 0.89 for every week increase in GA, ENMR increased 6.8-fold with BMV, 2.6-fold with abnormal FHRT, 2.2-fold with no antenatal steroids (ANS), 2.6-fold with moderate hypothermia (all < 0.0001). The overall FSB rate was 14.7/1000 births and decreased significantly in 2019 when compared to 2015 i.e., 11.3 versus 17.3/1000 live births respectively ( p  = 0.02). Conclusion ENM rates were predominantly modulated by decreasing BW and GA, with smaller/ less mature newborns 10-fold more likely to die. ENM in term newborns was strongly associated with FHRT abnormalities and when coupled with respiratory depression and BMV suggests BA. In smaller newborns, lack of ACS exposure and moderate hypothermia were additional associated factors. A composite perinatal approach is essential to achieve a sustained reduction in ENMR.

All providers who attend deliveries independently should be well versed in the performance of effective ventilation, assessment of the quality of ventilation/interventions supplied and able to troubleshoot in situations where these may be ineffective. A novel manikin serves as a unique ventilation-focused training tool to practice these clinical skills and decision-making. The data generated by the manikin, with the aid of a facilitator, may be used for formative and summative feedback on an individual level or curricular development on a larger level. This communication describes the importance of focused ventilation training for front-line providers and illustrates how this manikin can be incorporated into an individualized ventilation training program.

(1) Objective: This study aimed to assess the evolution of the quality of ventilations of a group of rescuers after two training sessions by taking into account inspiration times. (2) Materials and Methods: A pilot simulation study was carried out with a sample of 10 lifeguard students. Two training sessions were held three weeks apart, in which CPR skills were trained by means of feedback tools. Participants performed three tests in pairs on a ResusciAnne QCPR® manikin connected to SkillReporter QCPR software, namely one pre-training test and one test after each training session. CPR was performed in pairs for two minutes and began with five rescue breaths. (3) Results: One training session was enough to improve chest compression quality (T0: 48%; IQR 17–77/T1: 83%; IQR 59–88; p = 0.022/T2: 79%; IQR 64–92; p = 0.002). The quality of the ventilations increased progressively in each training session without reaching high-quality results (T0: 0%; IQR 0–0/T2: 15%; IQR 8–27; p = 0.011). (4) Conclusion: A two-session training program focused on inspiratory times achieved significant improvements in the quality of bag-mask ventilations performed by lifeguard students. Training focused on the insufflation time of ventilations and not only on the volume seems to be an important factor in improving the quality of ventilations.

Airway management is a vital life‐saving skill for the ICU provider. The human airway consists of two openings: the nose, which leads to the nasopharynx, and the mouth, which leads to the oropharynx. Innervation of the upper airway is from the cranial nerves. Complete airway assessment includes taking a history and a physical examination, noting any findings indicative of possible difficulty with mask ventilation, endotracheal intubation, or both. Essential equipment for airway management includes oxygen source (wall or tank), suction, bag‐mask ventilation circuit, direct and/or video laryngoscopes, endotracheal tubes of several sizes, supraglottic airway device, blood pressure/ECG/pulse oximetry, and CO 2 detection device. Proper patient positioning is of utmost importance and should be achieved prior to any airway intervention, particularly if direct laryngoscopy is to be attempted. During airway management, adequate preoxygenation should be provided in all but the most emergent situations.