FAQ’s

FAQs are submitted to the NRP Education Subcommittee by NRP Instructors, the CPS or NRP Steering Committee members.

FAQs are reviewed by the Education Subcommittee, and modified or withdrawn based on new information or redundancy. The FAQ is then circulated to the NRP Executive, followed by the Steering Committee for input and approval before being posted.

The FAQs reflect a consensus of opinion of clinicians, educators and administrators from multiple Canadian jurisdictions. Scientific answers are interpretation of the literature by the group. FAQs are normally written in response to issues requiring clarification rather than policy statements, prescriptive guidelines or evidence based scientific recommendations.

Please provide feedback or new questions if you feel either are required.

Physicians: NRP is approved for Mainpro-C credits (College of Family Physicians of Canada) and Maintenance of Certification Section 2 credits (Royal College of Physicians and Surgeons of Canada). NRP course participants can claim credits for every educational hour. These credits apply to all NRP training, including Provider courses and Instructor training/updates.

Nurses: In Canada, nurses can log their course time as part of their provincial regulatory body’s continuing competency requirements.

Midwives: In Canada, midwives can log their course time as part of their provincial regulatory body’s continuing competency requirements.

RRTs: The individual regulatory bodies determine what qualifies for credits according to their program. The Canadian Society of Respiratory Therapists allocates 1 credit per educational hour.

The NRP course and online exam is approved for continuing professional education and development credits.

The national Canadian NRP Instructor database is managed by the Canadian Paediatric Society. 

NRP Instructors and Instructor Trainers (IT) listed in the database:

1. Receive NRP Instructor or Instructor Trainer cards.
2. Receive credit for leading or assisting courses.
3. Have access to a secure, online system for updating their information and reviewing their status.  
4. Are able to register Provider and Instructor courses, and submit participant rosters online.
5. Receive pre-printed provider cards to distribute to course attendees.  
6. Receive regular updates on Canadian guidelines and Canadian NRP FAQs 
7. Receive 6-month and 3-month reminders to renew their Instructor status.  
8. Receive notice of NRP resources available on the website

When included on an Instructor's roster, NRP Providers:

• Receive an NRP Provider card as proof of their status.
• Are able to verify their status from the national office.
• Can replace a lost NRP Provider card (10$ replacement fee, see replacement form for more detail)

Confidentiality: All information in the database is confidential; however the CPS will share NRP data with provincial and national NRP organizations to enable them to monitor the availability of Instructor Trainers and Instructors as well as the provision and number of courses within their area.

Yes, through course rosters and the distribution of Provider cards. Instructor and Provider data will be supplied to provincial organizations to help monitor and improve NRP activity within each province.

Yes. Please contact the CPS at nrp@cps.ca to obtain a Login ID and Password.

Please see our becoming a registered NRP Instructor page for details.

Yes. Currently, Instructors pay a registration fee of $85.00 every two years. The fee covers the cost of maintaining the database and supports the issuing of Instructor and Provider cards. The CPS does not charge Providers directly.

Effective in January 2013 the registration fee will be $115 plus applicable taxes every three years. (see table below)

Yes. Organizations may do so by completing an Instructor Registration Form for each Instructor and then forwarding all the forms, along with payment for each Instructor.

An Instructor must teach two courses every two years and pay the registration fee to remain current. The CPS database will keep an electronic record of rosters, confirming which Instructors have taught courses.

Six months prior to their status expiring, Instructors will be sent an email reminder, which will include the official expiration date of their Instructor registration, as well as the number of courses the CPS has on file for them. Three months later, Instructors will be sent a hard-copy letter (to their preferred mailing address), which they must fill out and return to the CPS office, along with the appropriate fee. This fee is payable by cheque (to the CPS), Visa or MasterCard. Once all of the necessary documentation has been received, the renewal will be processed and a new Instructor card will be issued.

New Instructor candidates are required to ‘team teach' a Provider course with an Instructor Trainer or Delegate before they can submit their registration form and be entered into the database. This ‘team teach' course does not count as one of the courses needed to stay current.
Current Instructors should participate in an Instructor Update workshop when there is a significant change in NRP guidelines.

All NRP Instructors should also:

• Maintain currency in neonatal resuscitation practices and education.
• Know their own limitations, and seek resources and assistance when required.
• Complete and submit course rosters to CPS, ensuring that successful course participants receive their Provider cards.
• Maintain communication with their Provincial/Regional NRP Program.

“Team teaching” (also known in some provinces as the “return demonstration”) is an important last step in the process of becoming an NRP Instructor. Team teaching should occur soon after participation in an NRP Instructor course - and no longer than 6 months after the course.

The learning environment for teaching should be an NRP Provider course – the NRP Instructor course may include facilitated skill stations, however, these do not fulfill the team teaching requirement. Team teaching is a learning experience for the Instructor candidate during which a preceptor observes, debriefs and provides constructive feedback to the Instructor candidate.  Occasionally, Instructor candidates will need more than one team teaching experience – successful completion of a team teach is at the discretion of the preceptor.

The preceptor should be an NRP Instructor-Trainer (IT) or an experienced NRP Instructor (Delegate), designated by an IT. The role of the preceptor is to support and guide the new Instructor.

The team teaching course is not counted as one of the two courses an Instructor needs to teach every two years.

No, the “Team Teach” is not considered one of the courses required to remain current.

No. In exceptional circumstances, institutions may extend Instructor status for a fixed period (no more than three months) to allow them to teach a course and meet the requirements (see similar question regarding Providers).

While this extension is at the discretion of the institution, the date of renewal will remain unchanged.

You will need to take an Instructor course. Contact your local NRP Instructor Trainer, provincial or regional representative for details.

Visit Running NRP Courses. Instructors must be registered to submit rosters or to be credited as an assisting Instructor.

A NRP Provider course needs to include the following components:

i. Pre-reading of the  6th ed. NRP textbook (and/or viewing the DVD) followed by successful completion of the online exam within 30 days prior to the scheduled course.

ii. Successful completion of a face-to-face NRP workshop that includes:

• Performance skills stations,
• Integrated skills stations (practice scenarios including a Megacode assessment for each participant), and
• Participation in a Simulation based learning and debriefing exercise.

Individual courses will vary in both length and specific content according to the particular participants’ learning needs.  For example, participants who are members of a regional transport team may identify the need to practice intubation and umbilical vein insertion. They would need to successfully complete skills stations, integrated skills stations, Megacodes, and simulation and debriefing exercises relevant to these learning needs. Depending on numbers, this course, may take 3-4 hours.

Courses for new learners or those who have identified more content for performance skills stations (i.e. checking the equipment, initial steps, medication administration, effective positive pressure ventilation, etc.) may take longer but still include the requisite components: performance skills stations, integrated skills stations and simulation and debriefing. This course may take 6-8 hours.

Tailoring each NRP course to meet the learning needs of the participants is a relatively new concept in NRP and may take time to figure out the logistics and timing of each course – it will however, lead to more efficient and relevant courses.  Briefing course content with your fellow course Instructors before a course, and debriefing after will improve participants’ experience and facilitate planning future courses.

No. In order for learners to have completed recognised NRP training, they are required to complete all components of the course, these being successful completion of the online test ahead of face-to-face course attendance.

NRP courses comprise practical skills stations focusing on the acquisition of individual taskwork skills, completion of an objective evaluation (Megacode) and a simulation and debriefing exercise which focus on teamwork skills. Simulation based learning is just one aspect of the NRP course and in order to have successfully completed NRP training, learners must complete all components.

Given the registration requirements of the National Steering Committee and the Canadian Paediatric Society [CPS], it is suggested that Instructors or institutions keep the following documents on file for a period of 3 years:

1. A completed course roster (either one completed by the participants in class or a copy of the roster submitted electronically to CPS)
2. A copy of each participant’s ‘Online Examination Verification’
*It is also suggested that a signed copy of the ‘Confidentiality Agreement’ from each participant be kept for a period of one year. 

If you have applied for continuing education credits for a course, the granting body may have specific requirements – please check with them for details.

In addition, individual institutions may have guidelines for managing personnel records so Instructors are encouraged to consult their manager or risk management/quality assurance department.

No. The participant is expected to print the page that indicates they have passed/failed and bring that to the Instructor. The printout does not indicate which questions the participant got wrong. Future versions of the software may address this issue.

If the Instructor’s institution has set up an Express site with HealthStream, the Instructor will be able to generate reports related to participants’ activity (number of attempts and results).

Provider status is to be renewed every 2 years and is done by successfully completing the online exam and participating in a Provider workshop.

With the introduction of the 6th edition guidelines, there no longer exists a ‘Provider Renewal’ course per se; rather, current Providers attend a course in which the content is tailored to meet their particular needs and offers opportunities to practice relevant Performance and Integrated Skills Stations and successfully complete the relevant Megacode.

In exceptional circumstances, institutions and/or regions have permitted an extension or a "grace" period, extending NRP Provider registration for periods of several weeks to allow for scheduling of courses or academic calendars. This grace period should not exceed three months however the length of the extension is at the discretion of the institution.  Please note that the Provider’s original renewal date will remain unchanged. Extension of Provider status should be the exception rather than the rule, reserved for unexpected or unavoidable circumstances. Please see Maintaining Current Provider Status for more information.

Once a course roster has been submitted, CPS staff forward Provider cards to the course Instructor for signature and distribution to course participants. We encourage Instructors to ask course participants to provide a self-addressed, postage paid envelope for the Instructor to use to forward Provider cards. The cost of Provider cards is included in the Instructor registration fee.

Once you have been issued a CPS NRP Instructor or Provider card, you can contact CPS staff for a replacement at nrp@cps.ca. There is no charge for your original card; however there is a $10 charge for replacement cards, see replacement form for more details. Please include the following information with your request:

• The date of your most recent NRP Provider or Instructor course.
• The name of your NRP Instructor. 

The CPS does not routinely register NRP Providers outside Canada. Exceptions have been made by prior arrangement with the Canadian NRP Steering Committee to assist jurisdictions that use Canadian materials and do not yet have the capacity to maintain their own NRP infrastructure.

NRP Instructors with current registration with the CPS who deliver Instructor or Provider courses outside of Canada can apply to have the course included in the CPS database. The course can be accepted by the CPS if:

• It is supported by a Canadian educational institution,
• Uses Canadian NRP Instructors as faculty, and
• The Canadian version of NRP is taught.

The Canadian Instructors can then register themselves as having delivered that course for the purpose of maintaining their Instructor status.

The CPS does not have any jurisdiction over health care providers outside Canada. Canadian NRP Instructors who teach outside Canada should make themselves aware of local organizations that might oversee neonatal resuscitation education. When teaching NRP, it should be made clear that the NRP is an educational program. Successful completion of the program does not imply certification or clinical competence.

Both Instructor and Provider status is portable across Canada.

However, given the provincial and territorial differences in process, Instructors and Instructor Trainers should contact the local provincial or regional NRP administration as eligibility criteria may differ across jurisdictions.  Some jurisdictions require incoming Instructors to team teach before delivering courses in their institutions. Instructors who are relocating to the United States will need to contact local or state representatives as the requirements and mandatory resources are different.

Lesson 8 is most suited to Providers who are likely to care for preterm babies; however it is important to note that a preterm baby may be born in any facility. All Providers are encouraged to read the entire NRP text.

No. There are currently 2 options to reach course completion. Practitioners who are required to perform or assist in all levels of resuscitation will complete all lessons. For those practitioners whose skill set or scope of practice does not include the full extent of resuscitation, lessons 1 to 4 and 9 and the Basic Megacode are completed for course registration. Practitioners are encouraged to complete Lesson 8 as well.

The Provider card, issued by the Canadian Paediatric Society will indicate the Lessons and Megacode completed. All Providers are encouraged to read the entire NRP text.

Yes. Even though Lesson 9 has a focus on the application of ethical and communication principles as they may arise in the clinical labour and delivery area, the fundamental principles are applicable to resuscitation in any setting. Health care professionals such as paramedics and emergency room personnel may encounter situations involving unexpected preterm labour and birth.

To support parents and deliver care in these stressful situations, it is helpful to understand ethical and communication principles and apply them using an informed, compassionate and family-centred manner. The NRP course can provide discussion opportunities that can assist in applying the content of Lesson 9 to your particular environment.

Suggested solutions for a participant who repeatedly requires re-evaluation of the ISS and Megacode include:

• debriefing with the participant, and troubleshooting to discover where the problem(s) arose;
• a period of retraining to address the problems;
• re-testing with a different Instructor;
• Additional supervised practice.

Readiness for clinical practice and certification of competence are determined by healthcare employers and regulatory bodies, and not through participation in an NRP course, which is an educational tool. In addition, the Megacode does not test competence - it tests the ability to perform in a simulation based learning activity.

With the wider acceptance of air as the preferable gas for initiating resuscitation for most babies, there are no longer separate algorithms for the USA and Canada.  Currently, the major difference in clinical practice relates to the recommended dose of epinephrine. In Canada, we continue to use the simplified doses recommended in 2006.

There are other minor differences in interpretation of the 6th edition in the Canadian context.  Students who take courses in Canada should read the Canadian Addendum  for a summary of Canadian treatment recommendations.

The changes in the algorithm include:

• 3 (vs. 4) rapid assessment questions
• a change in the timeline (left margin) to reflect a need for re-evaluation every 30 seconds for the first 90 seconds only; after 90 seconds and once compressions have been initiated re-evaluate every 45-60 seconds 
• clearing the airway “as necessary”
• the use of pulse oximetry when positive pressure ventilation (PPV) is initiated or supplemental oxygen is provided
• use of CPAP for infants with laboured respirations or persistent cyanosis

NOTE: Although the rapid assessment questions no longer specifically ask ‘Fluid Clear?’ the care of the non-vigorous infant born through meconium-stained amniotic fluid (MSAF) has not changed. These infants should be intubated and suctioned below the cords prior to stimulation or positive pressure ventilation.

According to the International Liaison Committee of Resuscitation [ILCOR] "(T)he use of simulation as an adjunct to traditional education methodologies may enhance performance of healthcare professionals in actual clinical settings and simulated resuscitations."  (2010, p.E1330 ). Simulation based training provides an opportunity to learn both task work and teamwork skills within a safe learning environment.

The creation of simulated scenarios provides a standardised learning experience and enables the Instructor to focus on key predetermined learning objectives specific to the learners’ needs. These learning objectives will  integrate cognitive, technical and behavioural aspects of resuscitation and facilitate development of team skills. Well-developed scenarios enable the learner to become immersed in the scenario and behave as they would in real life. Participation in these scenarios followed by reflection and discussion enables rich learning which can be transferred to the clinical setting.

Simulation based training not only provides opportunities for standardised training but also enables learners to gain experience from otherwise potentially infrequent but high risk clinical scenarios.  The use of interprofessional teams (eg. RN, MD, RRT, RM (midwives), etc) is highly recommended to best mimic the real-life environment.

No. Increasing technical fidelity of a simulation does not always increase the learning experience for course participants. 

The integral component of a well-developed simulation is its realism and thereby the ability of the learner to ”suspend disbelief” and act as they would in a real-life setting. The technical fidelity of the equipment may vary according to the learning objectives of a given scenario. The creation of a realistic context or learning environment is more important than the use of high technology equipment. Simple accessories such as a gown and gloves can markedly increase the “contextual fidelity” of a simulation and thereby facilitate learner engagement.

Video recording of simulated scenarios with subsequent review and reflective discussion provides further opportunities for learning.

According to the International Liaison Committee of Resuscitation [ILCOR] "(i)t is reasonable to recommend the use of debriefings during learning activities while caring for simulated patients and during clinical activities." (2010, p.E1330) 

Debriefing provides learners with an opportunity to reflect on the previous scenario and discuss important cognitive, technical and behavioural aspects of resuscitation. Debriefing should focus on predetermined learning objectives but may incorporate other discussion points which arise during the scenario.

The use of video recording to facilitate debriefing of simulated scenarios allows learning points to be identified by both the facilitator and the learners. Facilitator-led group discussion enables learners to reflect on their performance of important task work and teamwork skills. Rather than providing direct feedback, the facilitator encourages the group reflection and learning through open questioning. This process of promoting and stimulating the learners’ own critical thinking and reflection on their performance is a powerful learning tool.

According to the International Liaison Committee of Resuscitation [ILCOR] “(d)elay in umbilical cord clamping for at least 1 minute is recommended for newborn infants not requiring resuscitation.” (2010, p. S524).

There is evidence that delaying cord clamping improves short and long term neonatal outcomes. Both ILCOR and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend that clinicians implement this practice in certain populations of newborns.

The timing of cord clamping in well babies who do not require resuscitation will depend on your institutional policy and maternal wishes.  As with any clinical practice, delayed cord clamping has both indications and contraindications.  Obstetric and neonatal teams should be prepared and coordinated, with clear expectations for evaluation, resuscitation and observation of the baby if signs of compromise present.

“There is insufficient evidence to support or refute a recommendation to delay cord clamping in babies requiring resuscitation” (ILCOR, 2010, p. S524).

Most studies on delayed cord clamping excluded infants that needed resuscitation and there are limited numbers of studies of the feasibility of resuscitation with the cord attached.

The timing of clamping of the umbilical cord after birth in a baby in whom resuscitation is indicated should take into account the following:

• The key principles of neonatal resuscitation still apply. These include inflation and ventilation of the lungs, and maintenance of a stable thermal environment.
• Mask ventilation, the most important intervention of neonatal resuscitation, is a challenging skill, even in controlled circumstances.
• The benefits of delayed cord clamping during prolonged apnea or bradycardia have not been studied.
• NRP was developed in the era of early cord clamping, so most existing interventions have been evaluated in this context.

It is suggested that a continued position of equipoise be taken regarding neonatal resuscitation with the cord attached.  Until further evidence is available, a reasonable approach is to perform an initial evaluation with the cord attached. If clinical signs indicate a need for resuscitation (ineffective respiratory effort or bradycardia despite gentle stimulation), the cord should be clamped and respiratory support initiated as per NRP guidelines.  Alternatively, resuscitation with the cord intact may be considered as part of a clinical trial, or if institutional policy, staff training and birth set-up support this practice.

Observational data suggest that raised body temperature at birth may be detrimental to the neonatal brain in infants who have sustained hypoxic ischaemic injury. There is, however, little or no evidence to suggest that compromised babies should be cooled in the first minutes after birth (i.e. during or immediately following resuscitation). It is important to establish the underlying cause (and severity) of compromise before initiating therapeutic cooling. However in term and near term infants, once the indications are established, cooling should be instituted without delay, preferably within 6 hours of birth and in consultation with your tertiary referral centre.

Until more information is available, the recommendations regarding temperature management found in the current NRP guidelines should prevail:

• During and after resuscitation, the NRP textbook (2011) recommends that '(b)abies temperatures should be maintained in the normal range.' (p. 252).
• Decisions regarding ongoing temperature management of potential candidates for induced hypothermia or targeting borderline low temperatures should be discussed with your tertiary centre.

Meconium-stained amniotic fluid (MSAF) continues to be a risk factor for neonatal resuscitation and should be communicated to the resuscitating practitioner along with other risk factors (such as abnormal fetal heart rate tracing) prior to delivery.

The purpose of the rapid assessment questions, however, is to help determine if a baby needs resuscitation or can remain with its mother and receive skin-to-skin care while being observed.  The presence or absence of meconium in the amniotic fluid does not affect this decision and vigorous, term babies born through MSAF should remain with their mothers.

Until further research determines otherwise, current practice prevails and non-vigorous babies born through MSAF should be intubated for tracheal suction.

Yes. NRP recommends that laryngeal mask airways be readily accessible so that staff skilled in their use may utilize them when necessary. As with intubation, the clinical use of laryngeal mask airway requires additional training and supervision, as well as site-specific and professional scope of practice considerations.

Pulse oximetry should be considered during neonatal resuscitation when Positive Pressure Ventilation (PPV) is initiated or supplemental oxygen is provided.  Babies who are persistently cyanosed, or who have laboured breathing are also candidates for pulse oximetry.  The goals of pulse oximetry are to avoid both high and low oxygen levels during resuscitation.

The following are therefore suggested:

• Develop a strategy to ensure the immediate availability of pulse oximetry during neonatal resuscitation.
• Reinforce saturation targets during resuscitation by placing a chart of target ranges in the neonatal resuscitation area.
• Train staff to apply the pulse oximeter sensor to the right arm (wrist or hand) and then plug it into the monitor shortly after instituting mask ventilation and before increasing inspired oxygen concentration.

Pulse oximetry will help to guide both the administration and titration of oxygen therapy, as will the knowledge of target newborn saturations during transition in the first 10 minutes of age. The table below outlines preductal saturations that are acceptable in term infants during transition.

TARGETED (SP02) PREDUCTAL AFTER BIRTH

There is limited evidence to indicate how fast to titrate inspired oxygen, and at what increments.  Observational data would support increasing or decreasing inspired oxygen concentrations by 10 to 15% every 30 seconds to achieve target saturations.  Further research is required to clarify best practice.

Another difficult clinical question is the definition of “persistent cyanosis” in a spontaneously breathing newborn.  The difficulty arises from the inability of observers to agree on when natural, central cyanosis is no longer present.  Observational studies suggest that the average age at which central cyanosis is no longer detected in a healthy baby is approximately 5 minutes, however the range is very wide.  Unfortunately the appreciation of cyanosis correlates poorly with oximetry, reinforcing the need to apply a saturation monitor when supplemental oxygen is considered.

The optimal resuscitation gas for preterm infants is not known.  It is generally accepted that, in babies born at 33 weeks gestational age or more, resuscitation may be initiated in air (21% oxygen) and subsequent oxygen therapy be guided by pulse oximetry.  In this situation, arterial oxygen saturation targets are based on the normal rise that occurs in healthy term infants over the first few minutes of age.

The evidence is less clear in babies born <33 weeks gestational age.  If one were to target the normal rise in arterial oxygen saturation that occurs in healthy term infants, many well preterm babies will require supplemental oxygen.  For this reason, many experts recommend initiating resuscitation with 30% oxygen below a certain gestational age cut-off (somewhere between 28 and 32 weeks). 

As most of these babies are born in tertiary and advanced secondary level perinatal centres, it is recommended that one follows the well-established protocols in your local high-risk centre.

A blender should be used to titrate oxygen. The NRP textbook states that it is possible to provide approximately 40% oxygen by removing the reservoir from the self-inflating bag when attached to an oxygen source. Recent literature suggests that this may not be the case and different self-inflating resuscitation bags may, in fact, deliver a higher concentration of oxygen than described above. Therefore, it is important that users are familiar with the function and capability of their particular resuscitation bag.

Ideally, NRP instructors should be familiar with all three recommended devices for providing positive pressure ventilation during resuscitation (flow-inflating bags, self-inflating bags, and T-piece resuscitators). Providers only need to be trained to use the device(s) available in their institutions. The type of device is an institutional decision, and not an NRP recommendation at this time.

There is limited evidence to make a strong recommendation on initial peak inspiratory pressures for neonatal resuscitation. It is suggested that initial peak inspiratory pressures should be 20-25 cm H2O. Peak inspiratory pressures may be increased if ineffective ventilation cannot be resolved by adjusting the mask, repositioning the baby's head, suctioning the oropharynx and opening the mouth. If pressures greater than 30 cm H2O are required, an alternative airway should be considered. Further research is required to clarify this question.

Studies suggest that during neonatal resuscitation, inflation of the lungs is normally followed, within seconds, with a rise in heart rate. Consequently, a rising heart rate is the primary indicator of adequate inflation or ventilation of the lungs. One should, however, observe chest movement, and auscultate for bilateral air entry as confirmatory signs, particularly if providing ventilation via an endotracheal tube.
If an increase in heart rate does not occur following initiation of positive pressure ventilation, implement the corrective steps outlined in the NRP textbook , which include: 

• Mask adjustment   
• Reposition the airway
• Suction mouth and nose 
• Open the mouth
• Pressure increase
• Alternate airway

The acronym MR SOPA may help you remember these corrective  steps.

Positive end expiratory pressure (PEEP) is generally the term used when a patient is receiving positive pressure ventilation, either by manual ventilation (‘bagging’) or by mechanical ventilator with imposed mechanical breaths. Animal studies have suggested that the use of PEEP is beneficial in preserving surfactant function and maintaining lung volumes. Continuous positive airway pressure (CPAP) is the term used most often when the patient is receiving positive pressure support while breathing spontaneously with no imposed mechanical breaths.

Technically, PEEP and CPAP describe the same phenomenon: positive pressure being maintained in the patient's airways and alveoli during expiration. The purpose of both PEEP and CPAP is to prevent airway and alveolar collapse on expiration and maintain functional lung volume.

The NRP 2011 guidelines have introduced the use of CPAP for the infant who when breathing spontaneously displays respiratory distress and/or remains persistently cyanotic. If the patient is breathing spontaneously and does not require manual breaths, CPAP can be provided using a flow-inflating bag or a T-piece resuscitator. It must be noted that CPAP CANNOT be provided with a self-inflating bag, even if a PEEP valve is used.

A pressure manometer should be used to monitor either PEEP or CPAP, usually delivered at 3 to 6 cm water. In the absence of lung disease, excessive PEEP or CPAP (especially over 6 cm water) may be harmful, increasing the work of breathing, causing overdistenstion of the lung, and impairing cardiac output. Preterm babies who require respiratory support with CPAP may be candidates for surfactant therapy, particularly if their oxygen requirements are rising.

During your pre-resuscitation equipment check you may use these practical tips for providing PEEP or CPAP during and after resuscitation.

• Flow-inflating bag: Using approximately 8 L/min of gas flow (starting with 21% oxygen), occlude the patient outlet (or mask) and adjust the flow control valve to provide a baseline PEEP/CPAP to 5 to 6 cm water. On these settings one can easily provide peak pressures of 20 cm water or more.
• Self-inflating bag: This device cannot provide CPAP, but can provide PEEP during manual ventilation if an external PEEP valve is attached. With the PEEP valve attached to the self-inflating device, turn the PEEP valve screw to the 5 cm water mark. One may test the effectiveness of this setting using a manometer and bagging with the patient outlet (mask) occluded.
• T-piece resuscitator: During the set-up of the T-piece resuscitator, occlude the patient outlet (or mask) and adjust the PEEP valve so that the manometer reads 5 cm water. The manufacturer may recommend the use of an artificial lung bag during setup.

It is becoming increasingly common practice to utilize nasal CPAP (by prongs or mask) after the resuscitation of preterm babies, while evaluating the need for surfactant therapy, and considering endotracheal intubation. If you do not provide CPAP routinely you should consider how you might provide this type of support before the occasion arises – your regional outreach education program may assist you in this respect.

It is not clear from the evidence what initial positive end expiratory pressure (PEEP) should be chosen when providing ongoing mechanical ventilation. A consensus of the Canadian NRP Committee is that an initial default may be 5 cm water (range 3 to 6 cm water). Further research is required to clarify this question.

Post-resuscitation care is subject to clinical judgment and stabilization protocols. These are clinical decisions influenced by institutional practice.

The Canadian NRP Committee recommends that the initial dose of epinephrine may be given endotracheally during cardiopulmonary resuscitation while umbilical venous access is being initiated.

As the endotracheal dose (1 mL/kg of 1:10,000 epinephrine to a maximum of 3 mL) is 10 times the intravenous dose (0.1 mL/kg of 1:10,000 epinephrine), it would make sense to draw the endotracheal dose up in a 3 mL syringe and the intravenous dose in a 1 mL syringe. The routine practice of drawing epinephrine up in 2 different sized syringes (3 mL for ETT administration and 1 mL for IV administration) may reduce the chances of a medication error.

Naloxone is a post-resuscitation drug, and should only be considered after the baby has been resuscitated and is receiving appropriate respiratory support. Consequently, the use and availability of naloxone in the delivery area is an institutional preference.

Ideally, a practitioner with the skills and scope of practice to make a decision to discontinue resuscitation should make this decision.

Completing all the steps of resuscitation, including volume expansion, is likely to take 10 minutes or more.  Once all the steps have been completed, including volume expansion, and the heart beat remains absent, a designated practitioner should initiate a discussion with the team and parents regarding the benefit or futility of continuing resuscitative measures. There is always the option to consult with a specialist or referring centre while resuscitation is ongoing.