Special Situations and NICU Resuscitation
Situations that rewrite the algorithm
Meconium-stained fluid: no routine intubation or tracheal suctioning - begin with the standard algorithm, suction the mouth and nose only if obstructing.
Preterm (<35 weeks): start blended oxygen at 21–30%, use a T-piece for consistent PIP/PEEP, and protect temperature with a plastic wrap, hat, thermal mattress, and warm room.
Congenital diaphragmatic hernia: avoid mask ventilation (it distends bowel and worsens lung compression) - intubate early and place a nasogastric tube for decompression.
Suspected pneumothorax: sudden deterioration or asymmetric chest with poor response to PPV - consider transillumination and needle aspiration in the second intercostal space.
Airway anomalies, hydrops, neuromuscular disease, opioid exposure: anticipate difficulty; opioid-induced respiratory depression is treated with ventilation, not naloxone.
NICU/transport: infants may need sedation for agitation on a ventilator, careful fluid and pressor management, and continuation of cooling during transfer.
Traps
Suctioning every meconium infant; bag-masking a suspected CDH; delaying intubation for a known airway anomaly until the infant is bradycardic; forgetting the nasogastric tube; using naloxone in the delivery room.
Rule of thumb
Know the anomaly before the delivery, and change only what the anomaly demands. Worked example: antenatally diagnosed left CDH at 38 weeks - intubate at birth, avoid mask ventilation, decompress the stomach, and ventilate gently to avoid injuring the hypoplastic lung.