Use of Respiratory Function Monitors during Simulated Neonatal Resuscitation

Transcription

1 Review 261 Use of Respiratory Function Monitors during Simulated Neonatal Resuscitation Atemfunktionsmonitor w ä hrend neonatalen Simulationstrainings Authors G. M. Schm ö lzer 1, 2, 3, C. C. Roehr 4 Affiliations 1 Neonatal Services, Royal Women s Hospital, Melbourne, Australia 2 The Ritchie Centre, Monash Institute for Medical Research, Monash University, Melbourne, Australia 3 Division of Neonatology, Department of Paediatrics, Medical University, Graz, Austria 4 Department of Neonatology, Charit é University Medical Center, Berlin, Germany Key words positive pressure ventilation respiratory function monitor neonatal resuscitation tidal volume face mask leak simulation-based manikin training Schl ü sselw ö rter positive Druckbeatmung Atemfunktionsmonitor neonatale Reanimation Tidalvolumen Beatmungsmaske Le ck Simulationstraining Bibliography DOI /s Published online: May 31, 211 Klin Padiatr 211; 223: Georg Thieme Verlag KG Stuttgart New York ISSN Correspondence Georg M. Schm ö lzer, MD, PhD The Royal Women s Hospital Department of Newborn Research 2 Flemington Road Parkville 352 Victoria Australia Tel.: 61 / ()3 / Fax: 61 / ()3 / georg.schmoelzer@me.com Abstract We describe how a Respiratory Function Monitor (RFM) can aid during simulation-based manikin training. We demonstrate how a RFM can provide quantitative and qualitative assessment of the trainee s resuscitation technique. A RFM can assist i) to identify correct mask hold and positioning techniques; ii) to assess the delivered airway pressures and adjust the inflating pressures to deliver the appropriate tidal volume. Abbreviations PPV RFM NLS RFM V T PEEP PIP RR MVe SI-bag t I t E Positive Pressure Ventilation Respiratory Function Monitor Neonatal Life Support Courses Respiratory Function Monitor Positive End Expiratory Pressure Peak Inflation Pressure Respiratory Rate Expiratory Inspiratory Expiratory Minute Ventilation Self-inflating bag Inspiration Time Expiration Time Introduction Approximately 3 5 % of neonates require active resuscitation at birth [49]. There is general agreement that the key to successful neonatal resuscitation is adequate positive pressure ventilation (PPV), provided by manual inflation devices and a face mask [14, 32, 38, 61]. However, the provision Zusammenfassung Anhand von Beispielen demonstrieren wir, wie ein Atmungsfunktionsmonitor (RFM) w ährend des Trainings zur quantitativen und qualitativen Beurteilung des Auszubildenden verwendet werden kann. Ein RFM kann die optimale Maskenposition identifizieren und Rückkopplung über das vorhandene Maskenleck geben. Weiterhin kann der Beatmungsdruck gemessen und ggf. adaptiert werden, um ein ad ä quates Atemzugsvolumen zu verabreichen. of adequate PPV relies on appropriate mask hold and seal [44, 59], and the delivery of defined pressures [1] and tidal volumes [34, 4, 44]. An international consensus statement as well as regional and na tional guidelines provide advice regarding techniques and equipment used for neonatal resuscitation [14, 32, 38, 61]. According to these guidelines, the need for ventilation and the evaluation of its effectiveness should be done by clinical assessment of an increase in an infants heart rate at regular 3 s intervals [14, 32, 38, 61]. Adequacy of effective ventilation should be judged by assessment of chest wall rise in order to gauge ventilatory support [14, 32, 38, 61]. However, recent studies have shown that assessment of face mask seal [59], tidal volume delivery and chest wall rise is limited and subjective [11, 44]. In addition, various studies have shown that patient assessment in the delivery room based merely on clinical impression is inaccurate [12, 13, 19, 27, 28]. Recently, experts suggested to apply technologies used in the intensive care units to the delivery room to more objectively monitor resuscitation efforts [11, 15, 3, 37, 43, 5, 56]. The clinical skills of manual PPV provision are being taught at neonatal life support courses (NLS) [22]. These courses are universally offered Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223:

2 262 Review and in many regions a compulsory element of neonatal training. They emphasise the importance of bag and mask ventilation, however, the evaluation of how well the train ee applies the mask and ventilates the manikin again remains subjective. This could be overcome by the routine use of objective monitoring devices, like a respiratory function monitor (RFM). Respiratory function monitors have been used for training purposes to i) help identifying correct mask hold and optimize mask positioning techniques to reduce gas leak between the mask and face; ii) continuously measure and display the peak inflation pressure and positive end expiratory pressure, iii) enable the operator to adjust the pressure to deliver an appropriate tidal volume; [17, 43, 44]. However, up to now there is only scare evidence about the use of a RFM during neonatal training. The object of this review is to describe the use of a RFM during simulated neonatal resuscitation. We describe its current capabilities and limitations during simulation-based manikin training. Respiratory Function Monitor Respiratory function monitors measure and display respiratory parameters including airway pressure, gas flow and tidal volume (V T ). A number of devices are available, for instance the Florian (Acutronic Medical Systems AG, Zug, Switzerland) monitor or CO 2 SMO (Novametrix Inc., Wellingford, CT) which can be used to assist during mask ventilation [15, 4, 43]. Regularly used ventilation devices include self-inflating bags (SI-bag), flow-inflating bags, T-piece resuscitation devices, or ventilators [1, 18, 25, 26, 39, 46, 55]. Commonly, a flow sensor is placed between the mask and the ventilation device. An airway pressure line needs to be connected to measure the peak inflating pressure (PIP) and positive end expiratory pressure (PEEP) [29]. The inspiratory and expiratory tidal volumes (, VTe ) passing through the sensor are automatically calculated by integrating the flow signal [41]. A RFM continuously displays the airway pressure, gas flow and V T waves and numerical values for PIP, PEEP,, VTe, respiratory rate (RR), expiratory minute ventilation (MV e ), inflation and expiration time (t I, t E ) ( Fig. 1a, b ). To assess the percentage of leak between mask and face is commonly calculated and displayed with the following equation: [( ) VTi ] 1 (see Figure 2) [29]. However, different definitions of leak are currently being used [41]. The figures in this article were obtained during PPV of a modified, leak free Laerdal neonatal manikin (Laerdal Medical AS; Stavanger; Norway). The PPV was performed using a round silicone face mask (Laerdal Medical AS; Stavanger; Norway) and a Neopuff Infant T-Piece Resuscitator (Fisher & Paykel Healthcare; Auckland; New Zealand), a continuous flow, pressure limited, T-piece device with a built in manometer and a PEEP valve or a self-inflating bag (Laerdal Medical AS; Stavanger; Norway) with no PEEP valve attached. A laptop computer or computer and monitor can be used to display, store and analyze the data from the RFM. The RFM used was the Florian (Acutronic Medical Systems AG, Zug, Switzerland) monitor. [23, 24, 42, 44, 59]. Previous studies have suggested that soft lipped, rounded face masks were superior to anatomically shaped masks [31], although a more recent comparisons between round and even rimmed face masks found no significant difference [59]. A RFM can be used for evaluating mask leak ( Fig. 2a, b ). Once mask leak is observed the trainee is able to adjust their mask position to achieve leak free ventilation ( Fig. 3a, b ). A RFM can be used for teaching the optimal mask positioning and mask holding technique ( Fig. 1a, b ). Recently, a RFM was used to evaluate bag and mask ventilation performance during simulated manikin resuscitation [23, 58, 59, 6]. While applying PPV, participants had large and unrecognised mask leak [59]. However, when a RFM was used participants recognised mask leak, re-adjusted the mask position and consequently mask leak was more than halved [58]. As a further advantage, the trainee receives constant visual feedback of the magnitude of leak and can re-position the face mask in order to minimise leak ( Fig. 3a, b ) [43]. Assessment of PIP and PEEP According to ILCOR 21, spontaneously breathing preterm infants with respiratory distress can be supported with continuous positive airway pressure [14, 32, 38, 61]. Recent animal studies have shown that adequate PEEP is essential to assist the formation of the functional residual capacity and improves oxygenation [35, 36, 48]. It is noteworthy that different devices for manual ventila tion produce PEEP differently. Self-inflating bags do not provide PEEP, by attaching a PEEP-valve, PEEP can be delivered, however this is often low and inconsistent [16, 21]. An RFM allows the equipment to be checked for adequate provision of PIP or PEEP prior to its clinical use [16]. The need for PIP administration in the newborn infant with respiratory failure is recognized in international guidelines [14, 32, 38, 61]. The purpose of applying PIP is to open the lungs and to deliver an appropriate tidal volume and hence gas exchange. Self-inflating and flow-inflating bags were the most popular devices for delivering PIP [18, 25, 46]. In general, the pressures delivered by bags are unknown and uncontrolled unless they are measured and displayed using a manometer. Several studies have shown that self- or flow inflating bags can deliver excessively high PIPs, irrespective of operator experience in neonatal resuscitation [1, 24, 4, 44]. The delivered pressure with a T-piece device is displayed on a manometer dial. Operators can observe the rise of the delivered pressure. However, the rapid pressure rises and falls are still difficult to follow by the operator. In addition, studies have shown that the use of manometers did not affect the pressures used, V T delivered, or the degree of mask leak during PPV [24, 54]. During manikin training with a RFM a trainee can easily assess the whole pressure wave and the numerical values of PIP and PEEP (see Fig. 1 ). In addition, the positive effect of training (PIP provision) with use of a RFM has been shown to sustain, even 3 weeks after initial training [17]. Mask hold and positioning techniques Face masks are used as interfaces between the ventilation devices and the mannequin. Optimal mask seal is difficult to obtain and mask leak during PPV is a common and a mostly unrecognised problem which can lead to failure of ventilation Adjusting PIP to achieve appropriate tidal volumes During PPV the delivered tidal volume (V T ) is usually not measured. Animal studies and human observational studies have suggested an optimal V T within a range of 4 to 8 ml /kg [2, 8, 52, 53, 57]. Insufficient V T can lead to inadequate gas ex- Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223:

3 Review 263 change, whereas excessive V T can lead to volutrauma [2, 4, 8, 33, 47]. The purpose of applying PIP during PPV is to deliver an adequate V T thereby inflate the lung and facilitate gas exchange. ILCOR recommends that a set PIP of 2 cm H 2 O can deliver appropriate tidal volumes in preterm infants [14, 32, 38, 61]. However, recent studies have shown that the delivered V T varies greatly within the first minutes after birth [34, 44]. Furthermore, as the lung continues to aerate, the delivered V T will change, depending on the compliance and resistance of the lung and the infants own breathing effort [51], and rapid adaptation of the delivered PIP may become necessary [44]. Additionally, recent studies have shown that operators are unable to deliver appropriate V T while providing PPV during neonatal training or during neonatal resuscitation [15, 44]. However, when the participants could see the delivered V T displayed by a RFM they were able to adjust the PIP and achieve the desired volume more accurately [15]. Once the trainee confidently provides leak free mask ventilation, the next focus should be on learning to assess the delivered V T by adjusting the PIP. When using a self- or flow inflating bag the trainee can experience how rapid and hard he / she needs to squeeze the bag to produce a certain pressure. The RFM will simultaneously display the measurements of the applied V T. Using a bag or T-piece devices the trainee will be able to adjust the PIP to deliver an adequate V T. Obviously, manikins differ significantly from human infants. In particular, the changes in lung compliance after birth and for instance physician-patient interactions remain a challenge to simulate. However, the principles of PIP and V T administration can be practiced and consequently be applied to real-life resuscitation [6, 7, 62]. Possible pitfalls during use of a Respiration Function Monitor Lack of experience and knowledge concerning the interpretation of the displayed waveforms may lead to misinterpretation of the signals. Therefore, anyone using a RFM should be trained to correctly interpret the pressure, flow and V T signals. Furthermore, the attention of any operator may be diverted from the manikin a b PIP of 3 cm H 2 O Flow away from the manikin PEEP of 5 cm H 2 O Flow towards the manikin VTe 5 PIP of ~28 cm H 2 O t I t I t E t E Fig. 1 a PPV with a face mask and no leak (T-Piece): PPV with a set PIP of 3 cm H 2 O and a PEEP of 5 cm H 2 O. The gas flow returns to the baseline after each inflation and expiration. This indicates a sufficiently long inflation and expiration time. The areas underneath the inflation and expiration flow curves reflect an equal amount of gas entering and leaving the lungs. The displayed and show an equal volume of gas entering and leaving the lungs. The curve returns to zero, indicating leak free PPV. b PPV with a face mask and no leak (Self-inflating bag): PPV with a slight variation of delivered PIP 28 cmh 2. No PEEP is being delivered as PPV was performed by a SI-bag without an attached PEEP valve. The gas flow returns to the baseline after each inflation and expiration. This indicates a long enough inflation and expiration time. The areas underneath the inflation and expiration flow curves reflect an equal amount of gas entering and leaving the lungs. The displayed and show an equal volume of gas entering and leaving the lungs. The curve returns to zero, indicating no leak free PPV Flow away from the manikin Flow towards the manikin Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223:

4 264 Review a 5 Fig. 2a b Airway leak during PPV: There is a larger area underneath the inflation flow curve compared to the expiratory flow curves. This is also reflected in the tidal volume curve, where a larger compared to is displayed and a straight line in the tidal volume curve indicates the mask leak Leak Leak End of inflation and start of expiration Leak b Leak Leak Leak End of inflation and start of expiration to the monitor, which would be counterproductive in the real life setting. Further, previous studies have shown that even minor distractions during simulated resuscitation alters the clinical performance ( [2]. It should be noted that the use of a flow sensor increases dead-space by approx. 1 ml. Lastly, this additional device placed between the face mask and the resuscitation device may make holding of the ventilation device and mask awkward and, however briefly, be unfamiliar for trainees [43]. Limitations of using a Respiration Function Monitor It needs to be considered with any of the available RFMs that for example the numerical value for mask leak is an averaged value from a certain time interval and therefore should not be used for evaluating or altering individual inflations. In addition, RFMs display the numerical data and graphical curves which can aid the resuscitator, but they do not provide any interpretation of the signals [43]. Clinical applicability of Respiratory Function Monitoring at birth: implementing available knowledge While in a recent paper Schm ö lzer et al. reviewed the usefulness of a RFM during resuscitations in the DR [43], the Cochrane review concludes there is still insufficient evidence to determine the efficacy and safety of a RFM during PPV [45]. Obviously, there is a lack of human data and more clinical trials are needed. We believe that a RFM can aid to training and neonatal resuscitations by adding objectivity to the patient assessment. Kelm et al. have recently shown the positive effect of manual ventilation training by using a RFM in order to reduce the frequency of excessive PIP and V T by previously untrained medical personnel [17]. Recent studies have shown that a RFM has the potential to improve mask ventilation in the delivery room. In addition, it has been shown that mannequin teaching with the addition of a RFM improves individual staff competency during neonatal resuscitation. For the purposes of quality assurance this technique should be available in both primary care facilities and training Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223:

5 Review 265 a b 5 * Leak (ml) * * Correction of mask position Interval of repositioning the mask position Fig. 3 a Correction of face mask position with a T-Piece. During PPV the set PIP is not achieved and the flow curve indicates gas flow towards the face mask. However, there is much less expiratory flow indicating mask leak. The tidal volume curve reflects the flow curve and displays a leak of around 9 to 1 %. Almost no gas enters or leaves the lungs. After repositioning the mask, a significant reduction in mask leak is observed and the gas flow entering and leaving the lungs is equal and the set PIP is being delivered. b Correction of face mask position with a selfinflating bag. During PPV a PIP between 17 and 22 cm H 2 O is being delivered. The flow curve indicates a greater amount of gas flow towards the face mask, much less expiratory flow indicating mask leak. The tidal volume curve reflects the flow curve and displays a leak of around 9 1 %. Only a very small amount of gas is entering or leaving the lungs. After the face mask is repositioned, mask leak is diminished to %, gas is entering and leaving the lungs and an adequate tidal volume is being delivered. (ml/sec * Leak 3 * * centers [3, 5, 9]. However, further studies are needed to investigate whether the use of a RFM during simulation can improve short and long term outcomes of neonatal resuscitations. Summary Use of a respiratory function monitor can aid simulation-based manikin training by providing quantitative and qualitative assessment of the trainee s resuscitation technique. During simulated bag and mask ventilation a RFM can assist to identify correct mask hold and positioning techniques, to assess the provided PIP and PEEP, to adjust the PIP in order to deliver the appropriate V T, and to provide an objective and reproducible assessment of the trainee s performance. Furthermore, it demonstrates the within-subject variations of PIP and delivered V T using different resuscitation devices. Conflict of interest : The authors have no conflict of interest to disclose. References 1 Bennett S, Finer NN, Rich W et al. A comparison of three neonatal resuscitation devices. Resuscitation 25 ; 67 : Bjorklund LJ, Ingimarsson J, Curstedt T et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 1997 ; 42 : Boehler T, Schaeff B, Hornberg I et al. How nationally concordated measures for quality assurance in clinical care of term and preterm infants are put into practice in Baden-Württemberg. Klin Padiatr 29 ; 221 : Clark RH, Gerstmann DR, Jobe AH et al. Lung injury in neonates: causes, strategies for prevention, and long-term consequences. J Pediatr 21 ; 139 : Gortner L. Structure of perinatal and neonatal care impact for outcome data? Klin Padiatr 29 ; 221 : Halamek LP. Teaching versus learning and the role of simulation-based training in pediatrics. J Pediatr 27 ; 151 : Halamek LP. The simulated delivery-room environment as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation. Semin Fetal Neonatal Med 28 ; 13 : Hillman NH, Moss TJ, Kallapur SG et al. Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med ; 176 : Hoehn T, Hoppenz M. Neonatal and childhood mortality rates in Myanmar. Klin Padiatr 29 ; 221 : Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223:

6 266 Review 1 Iriondo M, Thio M, Buron E et al. A survey of neonatal resuscitation in Spain: gaps between guidelines and practice. Acta Paediatr 29 ; 98 : Johnston ED, Stenson BJ. Am I getting chest wall movement? Arch Dis Child Fetal Neonatal Ed 21 ; 95 : F391 F Kamlin CO, Dawson JA, O Donnell CP et al. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr 28 ; 152 : Kamlin CO, O Donnell CP, Everest NJ et al. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation 26 ; 71 : Kattwinkel J, Perlman JM, Aziz K et al. Special Report Neonatal Resuscitation: 21 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics Kattwinkel J, Stewart C, Walsh B et al. Responding to compliance changes in a lung model during manual ventilation: perhaps volume, rather than pressure, should be displayed. Pediatrics 29r ; 123 : e465 e47 16 Kelm M, Proquitte H, Schmalisch G et al. Reliability of two common PEEP-generating devices used in neonatal resuscitation. Klin Padiatr 29 ; 221 : Kelm M, Roehr CC, Schmalisch G et al. Schulung und praktisches Vorgehen am k ü nstlichen Lungenmodell des Neugeborenen beeinflu ßt die H ö he des applizierten Spitzendruckes und des Tidalvolumens. Z Geburtshilfe Neonatol 27 ; 211 (Suppl 1) : Leone TA, Rich W, Finer NN. A survey of delivery room resuscitation practices in the United States. Pediatrics 26 ; 117 : e164 e Manley BJ, Dawson JA, Kamlin CO et al. Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival. Pediatrics 21 ; 125 : e559 e564 2 McHale S, Thomas M, Hayden E et al. Variation in inspiratory time and tidal volume with T-piece neonatal resuscitator: association with operator experience and distraction. Resuscitation 28 ; 79 : Morley CJ, Dawson JA, Stewart MJ et al. The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag. J Paediatr Child Health 21 ; 46 : Newborn Life Support Subcommittee. Newborn Life Support Resuscitation at Birth (2 nd edition) O Donnell CP, Davis PG, Lau R et al. Neonatal resuscitation 2: an evaluation of manual ventilation devices and face masks. Arch Dis Child Fetal Neonatal Ed 25 ; 9 : F392 F O Donnell CP, Davis PG, Lau R et al. Neonatal resuscitation 3: manometer use in a model of face mask ventilation. Arch Dis Child Fetal Neonatal Ed 25 ; 9 : F397 F4 25 O Donnell CP, Davis PG, Morley CJ. Positive pressure ventilation at neonatal resuscitation: review of equipment and international survey of practice. Acta Paediatr 24 ; 93 : O Donnell CP, Davis PG, Morley CJ. Use of supplementary equipment for resuscitation of newborn infants at tertiary perinatal centres in Australia and New Zealand. Acta Paediatr 25 ; 94 : O Donnell CP, Kamlin CO, Davis PG et al. Clinical assessment of infant colour at delivery. Arch Dis Child Fetal Neonatal Ed 27 ; 92 : F465 F O Donnell CP, Kamlin CO, Davis PG et al. Interobserver variability of the 5-min Apgar score. J Pediatr 26 ; 149 : O Donnell CP, Kamlin CO, Davis PG et al. Neonatal resuscitation 1: a model to measure inspired and expired tidal volumes and assess leakage at the face mask. Arch Dis Child Fetal Neonatal Ed 25 ; 9 : F388 F391 3 O Donnell CP, Stenson BJ. Respiratory strategies for preterm infants at birth. Semin Fetal Neonatal Med 28 ; 13 : Palme C, Nystrom B, Tunell R. An evaluation of the efficiency of face masks in the resuscitation of newborn infants. Lancet 1985 ; 1 : Perlman JM, Wyllie J, Kattwinkel J et al. Special Report Neonatal Resuscitation: 21 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics Polglase GR, Hillman NH, Pillow JJ et al. Positive end-expiratory pressure and tidal volume during initial ventilation of preterm lambs. Pediatr Res 28 ; 64 : Poulton DA, Schmölzer GM, Morley CJ et al. Assessment of chest rise during mask ventilation of preterm infants in the delivery room. Resuscitation 21 ; 82 : Probyn ME, Hooper SB, Dargaville PA et al. Effects of tidal volume and positive end-expiratory pressure during resuscitation of very premature lambs. Acta Paediatr 25 ; 94 : Probyn ME, Hooper SB, Dargaville PA et al. Positive end expiratory pressure during resuscitation of premature lambs rapidly improves blood gases without adversely affecting arterial pressure. Pediatr Res 24 ; 56 : Rich WD, Leone T, Finer NN. Delivery room intervention: improving the outcome. Clin Perinatol 21 ; 37 : Richmond S, Wyllie J. European Resuscitation Council Guidelines for Resuscitation 21 Section 7. Resuscitation of babies at birth. Resuscitation 21 ; 81 : Roehr CC, Grobe S, Rudiger M et al. Delivery room management of very low birth weight infants in Germany, Austria and Switzerland a comparison of protocols. Eur J Med Res 21 ; 15 : Roehr CC, Kelm M, Fischer HS et al. Manual ventilation devices in neonatal resuscitation: tidal volume and positive pressure-provision. Resuscitation 21 ; 81 : Schmalisch G, Fischer H, Roehr CC et al. Comparison of different techniques to measure air leaks during CPAP treatment in neonates. Med Eng Phys 29 ; 31 : Schmölzer GM, Dawson JA, Kamlin COF et al. Airway obstruction and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed Schmölzer GM, Kamlin OC, Dawson JA et al. Respiratory monitoring of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 21 ; 95 : F295 F33 44 Schmölzer GM, Kamlin OC, O Donnell CP et al. Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 21 ; 95 : F393 F Schmölzer GM, Morley CJ, Davis PG. Respiratory function monitoring to reduce mortality and morbidity in newborn infants receiving resuscitation. Cochrane Database Syst Rev 21 ; CD Schmölzer GM, Olischar M, Raith W et al. Review of equipment and survey of practice in Austria. Monatsschr Kinderheilkd 21 ; 158 : Schm ö lzer GM, Te Pas AB, Davis PG et al. Reducing lung injury during neonatal resuscitation of preterm infants. J Pediatr 28 ; 153 : Siew ML, Te Pas AB, Wallace MJ et al. Positive end-expiratory pressure enhances development of a functional residual capacity in preterm rabbits ventilated from birth. J Appl Physiol 29 ; 16 : Singhal N, McMillan DD, Yee WH et al. Evaluation of the effectiveness of the standardized neonatal resuscitation program. J Perinatol 21 ; 21 : Stenson BJ, Boyle DW, Szyld EG. Initial ventilation strategies during newborn resuscitation. Clin Perinatol 26 ; 33 : 65 vii 51 Te Pas AB, Davis PG, Hooper SB et al. From liquid to air: breathing after birth. J Pediatr 28 ; 152 : Te Pas AB, Davis PG, Kamlin CO et al. Spontaneous breathing patterns of very preterm infants treated with continuous positive airway pressure at birth. Pediatr Res 28 ; 64 : Te Pas AB, Wong C, Kamlin CO et al. Breathing patterns in preterm and term infants immediately after birth. Pediatr Res 29 ; 65 : Tracy MB, Klimek J, Shingde V et al. Neopuff T-piece mask resuscitator: is mask leak related to watching the pressure dial? Acta Paediatr 21 ; 99 : Trevisanuto D, Doglioni N, Ferrarese P et al. Neonatal resuscitation of extremely low birthweight infants: a survey of practice in Italy. Arch Dis Child Fetal Neonatal Ed 26 ; 91 : F123 F Vento M, Aguar M, Leone TA et al. Using intensive care technology in the delivery room: a new concept for the resuscitation of extremely preterm neonates. Pediatrics 28 ; 122 : Vilstrup CT, Bjorklund LJ, Werner O et al. Lung volumes and pressurevolume relations of the respiratory system in small ventilated neonates with severe respiratory distress syndrome. Pediatr Res 1996 ; 39 : Wood FE, Morley CJ, Dawson JA et al. A respiratory function monitor improves mask ventilation. Arch Dis Child Fetal Neonatal Ed 28 ; 93 : F38 F Wood FE, Morley CJ, Dawson JA et al. Assessing the effectiveness of two round neonatal resuscitation masks: study 1. Arch Dis Child Fetal Neonatal Ed 28 ; 93 : F235 F237 6 Wood FE, Morley CJ, Dawson JA et al. Improved techniques reduce face mask leak during simulated neonatal resuscitation: study 2. Arch Dis Child Fetal Neonatal Ed 28 ; 93 : F23 F Wyllie J, Perlman JM, Kattwinkel J et al. Part 11: Neonatal resuscitation: 21 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 21 ; 81 (Suppl 1) : e26 e Yaeger KA, Halamek LP, Coyle M et al. High-fidelity simulation-based training in neonatal nursing. Adv Neonatal Care 24 ; 4 : Schmölzer GM, Roehr CC. RFM use in resuscitation training Klin Padiatr 211; 223: