Recent discussions
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Colin Morley
- Mask PPV skills are difficult to acquire because their assessment the is subjective.
- Acquiring and retaining skills takes hours of practice. It is naïve to think after a session skills will be retained for months without a lot of practice. Organising training frequently is very difficult. However, with a RFM, a leak free manikin, data storage, a video, individuals or units can test their own skills, improve them and compare progress. They could do that on any day individually or in a group .
- Objective training to eliminating mask leaks and deliver appropriate tidal volumes must be assessed subjectively.
- Cost compared with other NICU costs would be probably less than £1000 each. A NICU should need one for training and one for DR monitoring The cost of training is already part of the cost of courses.
- It is important to recognise that modern neonatal ventilators measure and display similar signals to a RFM and so training for modern ventilation should overlap with RFM and vice versa.
- The studies of using RFMs have “no harms were demonstrated”.
- We now have sensors and electronics. Measuring and analysing resuscitations is easy so we should not be using and teaching outdated subjective, often very inaccurate, assessments to guide neonatal resuscitations.
- Neonatal studies have several difficulties: the numbers able to be enrolled are small. They will have variable gestations and pathologies. Staff will have variable abilities. It is very easy to criticise studies without putting them in context because they don’t fulfil the criteria used for other studies. Anyone reading comments of RFM reviews may be put off studying or using an RFM. The analyses do not consider the difficulties of doing the studies.
- A clinical study (Kuypers 2023 63) reported high satisfaction with a RFM. A manikin study (Dalley AM, et al. Resusc Plus. 2023 Dec 30;17:100535) reported high levels of satisfaction for both term and preterm manikins and similar for inexperienced and more experienced staff: median (IQR) 83 (77-93) v 81 (71.5-95) respectively.
- A RFM may distract the resuscitator from looking at the baby. However, 1) resuscitations without an RFM, resuscitations are often not well done, 2) an RFM shows mask leak and tidal volumes not seen by looking at the baby.
- As mask ventilation is reported as unsatisfactory anything that improves mask ventilation will useful.
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MARIA REGO
Nothing to add to the methodology of the scoping review.
I wish to express the relevance of making systematic or scoping reviews available for "public comment" for guideline updates. This process can enhance commitment to the development of science and the implementation of sound clinical practices, particularly in middle-income countries.
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Andrea Lube
In our service, we are unable to perform respiratory function monitoring.
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Andrea Lube
In our service in Brazil, we use a manual T-piece ventilator or a self-inflating bag for neonate ventilation in the operating room, following the recommendations of our neonate resuscitation program. We do not have the means to monitor exhaled CO2 or inspiratory time. We do not perform sustained ventilation.
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Patricia Laranjeira
The Task Force judged that RFM use in training has moderate-certainty evidence for improving immediate performance at course completion (reduced mask leak and improved tidal volume delivery) and low–moderate certainty evidence for improved knowledge. However, evidence is inconclusive for skill retention and transfer to settings without RFM, and there is no evidence linking RFM training to clinical resuscitation practice or infant outcomes. Given uncertain cost-effectiveness and affordability—especially across diverse resource settings—a conditional recommendation is appropriate. Future studies should evaluate potential adverse effects (eg, cognitive overload), optimal display/interface, the role of instructor feedback, and the costs and cost-effectiveness of routine RFM use.
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Patricia Laranjeira
As a neonatal resuscitation instructor in Brazil, and based on the studies cited, I recognize that important uncertainties remain regarding the optimal delivery of positive pressure ventilation (PPV) at birth, particularly in preterm and extremely preterm infants. The limited reliability of clinical signs such as chest expansion, the delayed heart rate response after initiating or adjusting PPV, and the poor correlation between PIP and delivered tidal volume highlight the challenges we face in bedside decision-making. These findings reinforce that current recommendations, largely based on low-certainty evidence, may not fully address the complexity of the transitional physiology. In practice, this underscores the need for more robust trials and objective monitoring tools to better individualize PPV strategies across different resource settings.
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Ari Moskowitz
Thank you for this perspective. We agree that medication administration is not the primary intervention during cardiac arrest. High-quality chest compressions, early defibrillation when indicated, and minimizing interruptions in perfusion remain the foundation of resuscitation. Medications serve as adjuncts within established algorithms rather than substitutes for effective circulation. In particular, thrombolytics have not demonstrated consistent improvement in survival or neurologic outcomes when administered during undifferentiated cardiac arrest.
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Ari Moskowitz
Thank you for your comment. The role of thrombolytics during cardiac arrest remains uncertain and is not supported for routine use in undifferentiated arrest. High-quality CPR, rapid defibrillation when indicated, and timely access to definitive post-arrest care, including coronary angiography when appropriate, remain the cornerstones of management.
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Ari Moskowitz
Thank you for this comment. A growing body of evidence suggests that video laryngoscopy is associated with higher first-pass success compared with direct laryngoscopy in many emergency and cardiac arrest settings. However, improvements in first-pass success have not consistently translated into clear differences in short- or long-term patient-centered outcomes, such as survival or neurologic recovery. Airway management during cardiac arrest is highly dependent on provider experience, team dynamics, and minimizing interruptions in chest compressions.
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Ari Moskowitz
Thank you for this important observation. We agree that ventilation and oxygenation are only effective when there is adequate circulation to deliver oxygen to tissues. During cardiac arrest, systemic oxygen delivery is profoundly flow-limited, which is why high-quality chest compressions and early defibrillation remain the foundation of resuscitation. Oxygenation and ventilation support this goal but cannot substitute for effective perfusion.