Tidal volume delivery during chest compression with either an endotracheal tube or supraglottic airway in a porcine animal model

Tidal volume delivery during chest compression with either an endotracheal tube or supraglottic airway in a porcine animal model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tidal volume delivery during chest compression with either an endotracheal tube or supraglottic airway in a porcine animal model Brandon Kowal, Megan O'Reilly, Raza Hyderi, Marwa Ramsie, Tze-Fun Lee, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6735597/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jul, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: The 2023 Consensus of Science and Treatment Recommendations states that a supraglottic airway (SGA) device can be used to deliver positive pressure ventilation. However, it is unclear if a SGA can effectively be used during chest compressions. We aimed to compare tidal volume (V T ) delivery during either chest compressions with sustained inflations (CC+SI) or 3:1 compression-to-ventilation (3:1 C:V) technique with SGA and endotracheal tube (ETT) using various ventilation devices: T-piece, self-inflating bag (SIB), flow-inflating bag (FIB), NextStep TM resuscitator. Methods: Randomized crossover animal trial using seven mixed-breed piglets (1-3 days old; 1.8-2.4 kg). Piglets were euthanized to eliminate any potential interference with gasping or spontaneous breathing, and randomized to a sequence of resuscitation techniques: 1) CC+SI with T-piece, 2) CC+SI with FIB, 3) CC+SI with SIB, 4) CC+SI with NextStep TM , 5) 3:1 C:V with T-piece, 6) 3:1 C:V with FIB, and 7) 3:1 C:V with SIB. Resuscitation was performed for 1 min per technique via the SGA and then ETT. Respiratory parameters were recorded. Results: Resuscitation using an ETT and CC+SI resulted in a gain in V T , irrespective of ventilation device. In contrast, resuscitation with an ETT or SGA and 3:1 C:V resulted in a loss in V T across all ventilation devices. There was substantial leak with the SGA, regardless of the ventilation device or compression technique. Conclusions: Using the CC+SI technique for resuscitation paired with an ETT resulted in V T gain, regardless of ventilation device. Substantial leak during chest compressions with a SGA may hinder effective V T delivery. Infants Newborn Neonatal Resuscitation Chest compressionS Asphyxia endotraCHEAL tube supraglottic airway Figures Figure 1 Figure 2 Figure 3 What is known A supraglottic airway device can be used as an alternative airway during neonatal resuscitation, but ventilation efficacy during chest compressions remains unknown. What is new Chest compressions result in substantial leak via the supraglottic airway, hindering effective tidal volume delivery during neonatal resuscitation. Neonatal resuscitation using the 3:1 compression-to-ventilation technique leads to tidal volume loss, regardless of ventilation device, but the alternative technique of continuous chest compressions with sustained inflations results in improved tidal volume delivery. Introduction Asphyxia affects 1-9/1,000 newborns, is the main cause of cardiac arrest in newborns, and the third leading cause of neonatal death [1, 2] . It occurs due to impaired gas exchange, leading to simultaneous hypoxia and hypercapnia [3–5] . Neonatal cardiopulmonary resuscitation combines i) effective chest compressions (CC) to temporarily generate blood flow to sustain perfusion until the myocardium receives sufficient oxygen to restore independent cardiac output [6–12] and ii) effective ventilation to deliver adequate tidal volume (V T ) to facilitate gas exchange and reverse hypoxia and hypercapnia[13, 14]. The International Liaison Committee of Resuscitation (ILCOR) Consensus of Science and Treatment Recommendations (CoSTR) describe three ventilation devices for respiratory support including the flow-inflating bag (FIB), the self-inflating bag (SIB), and the T-piece resuscitator (T-piece)[15, 16]. While the T-piece most consistently provides pre-set positive end expiratory pressure (PEEP) and peak inflation pressure (PIP), the PEEP and PIP is rather variable with a FIB and SIB[17–21]. Once CC are started, the American Heart Association guidelines recommend an alternative airway, either an endotracheal tube (ETT) or a supraglottic airway (SGA) device, while the European guidelines do not specify which airway device should be used during CC[13, 22]. More recently, the 2023 ILCOR CoSTR stated that a SGA device can be used as an alternative to mask ventilation where resources and training permits[16, 23, 24]. While animal and human studies reported that the mask leak is highly variable with a SGA[19, 25, 26], time to return of spontaneous circulation was not difference in animal trials[27, 28] , however ventilation efficacy with a SGA during CC remains unclear. While the current CoSTR recommends a 3:1 Compression:Ventilation (3:1 C:V) ratio, the most effective CC approach remains unknown. A potential alternative technique is continuous CC during sustained inflation (CC+SI), which significantly reduced time to return of spontaneous circulation and mortality in animal studies, with a similar trend in human studies[29–33]. Therefore, we aimed to compare V T delivery during CC with either 3:1 C:V or CC+SI with either a SGA or ETT airway using various ventilatory devices. We hypothesized that the CC+SI technique would provide more effective V T delivery compared to 3:1 C:V with either an ETT or an LMA. Materials and methods This was a randomized crossover animal trial, including seven term neonatal mixed breed piglets obtained on the day of experimentation from the University Swine Research Technology Centre, Edmonton, Alberta, Canada. There were no exclusion criteria. All experiments were conducted in accordance with the guidelines and approval of the Animal Care and Use Committee (Health Sciences), University of Alberta [AUP00004212], conducted and presented according to the ARRIVE 2.0 guidelines[34], conducted according to the Canadian Council of Animal Care guidelines, and registered at preclinicaltrials.eu (PCTE0000583). The experiments conducted in this study were performed after completion in the same piglets from our previously published study by Gibbs et al [19]. At the end of the experiments of Gibbs et al[19] , which examined positive pressure ventilation (PPV) during compliance changes with a SGA, the piglets were euthanized to eliminate any possible interference with potential gasping or spontaneous breathing. Randomization The sequence of resuscitation using a T-piece, FIB, SIB, and NextStep TM resuscitator device during CC+SI and 3:1 C:V was randomized in all piglets. Allocation was block randomized with variable sized blocks using a computer-generated randomization program (http://www.randomizer.org). Sequentially numbered, sealed, brown envelopes containing the sequence allocation were opened during the experiment. Blinding It was not possible to blind the team to the allocation due to the nature of the intervention. However, the statistical analysis was blinded to group allocation. Animal preparation Piglets were instrumented as previously described with modifications [29, 35] As we wanted to avoid spontaneous breathing, which could confound the V T measurements, piglets were euthanized with an intravenous overdose of sodium pentobarbital (120 mg/kg). A size 1.5 SGA was placed (Ambu ® AuraStraight, Balleruo, Denmark). Placement of the SGA was confirmed in each piglet using a bronchoscope (Ambu ® , Balleruo, Denmark). Afterwards, piglets were tracheotomized and an ETT was tightly secured in the trachea. Chest compression were commenced two minutes after the overdose of sodium pentobarbital was given. Respiratory parameters A respiratory function monitor (NM3, Respironics, Philips, Andover, MA) was used to continuously measure V T , airway pressures, and gas flow. The NM3 flow sensor has a fixed orifice pneumotach, which uses the pressure difference to calculate the gas flow passing through the sensor, which is then translated into the inspiratory and expiratory V T . The sensor was placed between the ETT or the SGA and the ventilation device. V T was calculated by integrating the flow signal[36]. The accuracy for gas flow is ±0.125 L/min[37]. Ventilation devices Neopuff T-piece (Fisher & Paykel, Auckland, New Zealand) with default setting of PIP of 24 cmH 2 O, PEEP of 5 cmH 2 O. Flow-inflating bag (FIB) (Mapleson Anesthesia Breathing Circuit, Mercury Medical, Clearwater, FL). Self-inflating bag (SIB) (Preterm model, Laerdal Silicone Resuscitator, Laerdal Medical, Stavanger, Norway) with no PEEP valve or manometer attached. NextStep TM Neonatal Resuscitator (KM Medical, Auckland, New Zealand) with default settings of maximum pressure (Pmax) of 40 cmH 2 O, PEEP of 5 cmH 2 O, rate of 50/min, set V T of 5mL/kg, and inspiration: expiration ratio of 1:3. The NextStep TM delivers V T with an accuracy of 0.1–0.3mL (according to the manufacturer); it also controls ventilation rate and monitors airway pressure[18, 19, 38, 39]. None of the devices were connected to heated/humidified gas. Experimental protocol Piglets were randomized to receive a sequence of seven resuscitation techniques: 1) CC+SI with T-piece, 2) CC+SI with FIB, 3) CC+SI with SIB, 4) CC+SI with NextStep TM resuscitator, 5) 3:1 C:V with T-piece, 6) 3:1 C:V with FIB, and 7) 3:1 C:V with SIB. After euthanization, a sequentially numbered, sealed brown envelope containing the sequence randomization was opened. Each resuscitation technique was performed for a duration of 1 min via the SGA. Thereafter, the SGA was removed, and piglets underwent a tracheostomy for placement of the ETT. Each resuscitation technique was then performed via the ETT for a duration of 1 min per technique. During CC+SI, ventilations (sustained inflations) were provided for 30 sec each. There was a 1 sec pause between successive inflations. Compressions were continuously delivered at a rate of 120/min [29–33] . During 3:1 C:V, 90 compressions were synchronized with 30 ventilations (inflations) per minute at a ratio of 3:1. Ventilations were delivered using the ventilation device as per the randomized sequence[13, 14]. The NextStep TM resuscitator device provides continuous ventilation and cannot be programmed to pause for compressions. As such, it could not be used with 3:1 C:V resuscitation and was only used with continuous CC. Data collection and analysis For the SIB, FIB, and T-piece interventions, airway pressures, gas flow, and V T were measured and analyzed using Flow Tool Physiologic Waveform Viewer (Philips Healthcare, Wallingford, CT, USA). The NextStep TM ventilator screen was captured by a video camera during the experiment (iPhone 14 Pro Max, Apple, CA). BK reviewed the video recordings frame-by-frame and stopped the recording after each inflation to record respiratory parameters. BK was not involved in statistical analysis. The data was tested for normality (Shapiro-Wilk and Kolmogorov-Smirnov test) and compared using ANOVA for repeated measures using Bonferroni post-test. The data are presented as mean (standard deviation-SD) for normally distributed variables and median (interquartile range-IQR) for skewed variables. P-values are 2-sided and p<0.05 was considered statistically significant. Statistical analyses were performed with Stata version 17 (StataCorp LLC, College Station, TX). Results Seven term neonatal mixed breed piglets (1-3 days of age, weighing 1.8-2.4 kg) were obtained on the day of the experimentation. Respiratory Parameters Respiratory parameters are presented in Table 1 for ETT and in Table 2 for SGA. The difference in and total inspired and expired V T during resuscitation with ETT are presented in Figure 1 A&B and with SGA in Figure 2 A&B. During resuscitation using the ETT with CC+SI technique, a greater inspiratory than expiratory V T was observed, regardless of which ventilation device was used. The resulting gain in V T is indicative of lung recruitment (Figure 1A&B). Contrary to this, during resuscitation using the ETT with 3:1 C:V technique, there was a loss in V T in all ventilation devices, indicating lung derecruitment (greater expiratory than inspiratory V T resulting in a negative difference; Figure 1). All ventilation devices used during 3:1 C:V with ETT resulted in significant V T loss compared to CC+SI with ETT (p<0.05; Figure 1). During resuscitation using the SGA with CC+SI technique, all ventilation devices led to a slight loss in V T, albeit not as substantial as the loss in V T during resuscitation using the SGA with 3:1 C:V technique (Figure 2). During CC+SI, the T-Piece (*p=0.022), SIB (*p=0.026), and Next Step TM (*p=0.005) had significant less V T loss compared to FIB with 3:1 C:V (Figure 2A&B), all other comparisons were not significant (Figure 2A&B). There was substantial leak associated with the SGA, regardless of the ventilatory device or compression technique (Figure 3). Discussion In the current study, we investigated various ventilatory devices during CC with either a SGA or ETT in place. The results of our study can be summarized as follows: 1) resuscitation with CC+SI and ETT resulted in a gain in V T , regardless of the ventilation device, 2) resuscitation with the 3:1 C:V technique with both SGA and ETT resulted in a loss in V T , regardless of the ventilation device, and 3) SGA resulted in substantial leak, regardless of ventilation device or CC technique. As the purpose of ventilation (inflations) during resuscitation is to deliver an adequate V T to facilitate gas exchange, the use of a SGA to deliver an adequate V T during CC remains to be investigated because of substantial leak. It is vital that inflations during resuscitation deliver an adequate V T to facilitate gas exchange. We have previously demonstrated that during CC using a T-piece device and an ETT, the 3:1 C:V technique results in significant V T loss, whereas the CC+SI technique leads to a gain in V T[40] . During 3:1 C:V, a cumulated loss of V T of 4.5 mL/kg occurred for each 3:1 C:V cycle, whereas during CC+SI, a constant lung recruitment and establishment of functional residual capacity was observed (a gain of 2.3 mL/kg per CC+SI cycle) [40] . In the current study, we also demonstrated that more air was forced out of the chest during the 3:1 C:V technique during resuscitation with either the ETT or SGA, compared to using the CC+SI technique. The passive chest recoil during 3:1 C:V leads to loss of V T and contributes to dead space ventilation and lung derecruitment. In our study, the ventilation device used to deliver the inflations did not appear to have an effect on lung recruitment. In contrast, the CC+SI technique demonstrates that ventilation is passively achieved during chest compressions, by enabling a greater inspiratory than expiratory V T leading to a gain in V T and recruitment of the lung. This CC+SI associated passive lung ventilation/aeration was observed across all ventilation devices with ETT. By improving lung aeration and increasing oxygenated blood flow returning from the lung, cardiac function can be restored and lead to better tissue oxygen delivery during resuscitation. Studies have identified increased leak when chest compressions are initiated during neonatal resuscitation[41–44]. During resuscitation of a premature infant in the delivery room, Li et al reported that mask leak significantly increased during chest compressions[41]. In a newborn piglet model, Mendler et al observed a significant increase in ETT leak (average increase of 11.4%) when chest compressions were added to respiratory support using a T-piece, SIB, and a ventilator[42]. In the current study, we report high percentages of leak when using a SGA (approximately 40-70%) during CC, irrespective of ventilation device used. In our previous study by Gibbs et al[19] , we reported very low leak when using the SGA to deliver only PPV (highest median leak of 12% with SIB). However, slight movements of the SGA can increase leak, and in any case when CC are started greater leaks can occur[43, 44]. Use of a SGA when CC are needed may not be the optimal approach to ensure adequate V T delivery, especially when the resuscitation technique is 3:1 C:V. Limitations In keeping with our commitment to the three Rs of animal research, we reduced the number of animals required to obtain results by using animals that were initially used for a different study[19] . Nevertheless, all animals received similar prior interventions and we believe it did not influence the outcome of this study. An Ambu ® AuraStraight, size 1.5 SGA was used as we were unable to obtain suitable placement with the i-gel ® SGA. The NextStep TM uses a digital flow sensor while the NM3 uses a fixed orifice flow sensor[37], which may have resulted in slight differences in V T measurements. However, the accuracy of the used flow sensors are within clinically acceptable deviations in V T measurements[45]. The current data are from a piglet study and the impact of these findings to infants remains unknown. Conclusion Using the CC+SI technique for resuscitation paired with an ETT resulted in a gain in V T , regardless of which ventilation device was used. It is important to highlight the substantial leak that occurred during chest compressions with a SGA, which may hinder effective V T delivery. Using the 3:1 C:V technique for resuscitation leads to lung derecruitment, especially when paired with an SGA. Further studies to determine if SGA can effectively be used during chest compressions are warranted. Abbreviations CC - Chest compressions CPR - Cardiopulmonary resuscitation CC+SI - Chest compressions with sustained inflation C:V - Compression-to-ventilation ratio ETT - Endotracheal tube FIB - Flow-inflating bag PEEP - Positive end expiratory pressure PIP - Positive inspiratory pressure PPV - Positive pressure ventilation SGA - Supraglottic airway SIB - Self-inflating bag V T - Tidal volume Declarations Author Contribution Conception and design: GMS, PYC, MOR, TFLCollection and assembly of data: GMS, PYC, MOR, TFL, MR, BK, RHAnalysis and interpretation of the data: GMS, PYC, MOR, TFL, MR, BK, RH Drafting of the article: GMS, PYC, MOR, TFL, MR, BK, RH Critical revision of the article for important intellectual content: GMS, PYC, MOR, TFL, MR, BK, RHFinal approval of the article: GMS, PYC, MOR, TFL, MR, BK, RH Conflict of Interest: None Funding: None Data availability: No AI has been used in the writing of this article References Perin J, Mulick A, Yeung D, et al (2022) Global, regional, and national causes of under-5 mortality in 2000–19: an updated systematic analysis with implications for the Sustainable Development Goals. 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Archives of Disease in Childhood-Fetal … 99:F120-3. https://doi.org/10.1136/archdischild-2013-304311 Huynh T, Huynh T, Hemway RJ, Perlman JM (2015) Assessment of effective face mask ventilation is compromised during synchronised chest compressions. Archives of disease in childhood Fetal and neonatal edition 100:F39–F42. https://doi.org/10.1136/archdischild-2014-306309 Verbeek C, Zanten HA van, Vonderen JJ van, et al (2016) Accuracy of currently available neonatal respiratory function monitors for neonatal resuscitation. Eur J Pediatr 175:1065–1070. https://doi.org/10.1007/s00431-016-2739-1 Tables Table 1. Respiratory parameters during 1 minute of resuscitation with ETT. Respiratory parameters CC+SI 3:1 C:V T-piece FIB SIB NextStep FIB SIB T-piece PIP (cmH 2 O) 39.36 (6.02) 38.57 (5.63) 37.87 (13.26) 48.30 (17.48) 46.04 (10.94) 37.29 (4.44) 16.15 (10.04) PEEP (cmH 2 O) 3.74 (3.07) 0 2.14 (1.68) PIF (mL/min) 5.05 (1.61) 9.67 (2.71) 4.67 (0.96) 5.38 (2.19) 13.16 (2.60) 14.07 (2.85) 3.61 (2.32) PEF (mL/min) -10.68 (3.76) -14.52 (3.29) -7.91 (2.16) -8.12 (4.63) -13.10 (2.76) -13.86 (2.18) -4.38 (3.37) Inspired V T (mL/kg) # 11.74 (8.32-15.23) 17.71 (11.82-22.18) 7.85 (5.87-8.51) 7.43 (5.35-11.83) 23.56 (20.67-24.68) 16.33 (12.86-24.05) 6.90 (3.54-10.50) Expired V T (mL/kg) # 7.99 (5.13-10.45) 12.95 (7.89-16.94) 5.21 (4.39-7.22) 5.32 (3.90-7.65) 35.65 (28.92-38.43) 22.00 (17.19-30.66) 15.81 (11.66-21.12) Data are presented as mean (SD), unless otherwise indicated # median (IQR). PIP, Peak Inflation Pressure; PEEP, Positive End Expiratory Pressure; PIF, Peak Inspiratory Flow; PEF, Peak Expiratory Flow; V T , Tidal Volume. With CC+SI PIP=PEEP. Table 2. Respiratory parameters during 1 minute of resuscitation with SGA. Respiratory parameters CC+SI 3:1 C:V T-piece FIB SIB NextStep FIB SIB T-piece PIP (cmH 2 O) 37.31 (3.69) 32.48 (9.56) 29.60 (11.22) 32.81 (13.81) 40.32 (6.89) 31.82 (2.71) 23.46 (3.83) PEEP (cmH 2 O) 3.65 (3.46) 0 3.59 (0.58) PIF (mL/min) 5.87 (2.02) 11.92 (4.20) 5.99 (1.98) 5.39 (2.08) 16.37 (2.20) 15.16 (2.12) 5.56 (0.96) PEF (mL/min) -7.73 (2.78) -11.15 (5.83) -4.31 (2.81) -5.20 (2.24) -13.80 (3.41) -15.91 (3.01) -7.59 (1.60) Inspired V T (mL/kg) # 10.64 (6.50-12.14) 18.65 (11.45-28.95) 14.87 (5.32-15.88) 4.83 (3.27-12.55) 22.98 (19.83-28.88) 28.49 (26.09-30.92) 9.62 (6.83-12.78) Expired V T (mL/kg) # 5.39 (5.11-6.63) 8.53 (4.97-11.86) 3.93 (2.88-4.89) 5.10 (3.41-8.18) 21.37 (19.79-35.48) 22.14 (19.79-32.25) 13.82 (12.29-16.57) Data are presented as mean (SD), unless otherwise indicated # median (IQR). PIP, Peak Inflation Pressure; PEEP, Positive End Expiratory Pressure; PIF, Peak Inspiratory Flow; PEF, Peak Expiratory Flow, V T , Tidal Volume. With CC+SI PIP=PEEP. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Jul, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 11 Jun, 2025 Reviews received at journal 05 Jun, 2025 Reviewers agreed at journal 01 Jun, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 30 May, 2025 Editor assigned by journal 25 May, 2025 Submission checks completed at journal 25 May, 2025 First submitted to journal 23 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6735597","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464766301,"identity":"cace1565-2768-4c4c-af5f-67a6327fe557","order_by":0,"name":"Brandon Kowal","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Brandon","middleName":"","lastName":"Kowal","suffix":""},{"id":464766302,"identity":"087d58e6-8e47-43cb-a1eb-31a4a42587be","order_by":1,"name":"Megan O'Reilly","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"O'Reilly","suffix":""},{"id":464766303,"identity":"8f6b9538-8660-4f6a-97ba-edfbd15e1095","order_by":2,"name":"Raza Hyderi","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Raza","middleName":"","lastName":"Hyderi","suffix":""},{"id":464766304,"identity":"5e92b93e-4a4c-4ce3-b58c-512bb5fe986f","order_by":3,"name":"Marwa Ramsie","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Marwa","middleName":"","lastName":"Ramsie","suffix":""},{"id":464766305,"identity":"4888c954-a333-4cc4-867a-7d539e63167f","order_by":4,"name":"Tze-Fun Lee","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Tze-Fun","middleName":"","lastName":"Lee","suffix":""},{"id":464766306,"identity":"e7efe1f8-846a-41e0-81d9-3ed01b0a5b22","order_by":5,"name":"Georg M. Schmölzer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIie2PsWrDMBCGT2g1ZCsqDegVzhgSCqFrX+NAoMmQ1ZMJBJolD1Dw0FfIFOgmI/DkOYsWZ8/gQgcNgTbuGLBCtg764G44/o+fA4hE/jM4rO4yk/sUuszj6m4FzY2kfF03X99QyvmDrTs6L5bZwRrwxX5USdtGVVOw6WelFVKin/dOE9u2blx5zzMuwBC6fCZIWJy5HDl7Cygfp0EpB2XuCX8wq5Z9UJEiyVgP/K8FiAziUw5BBROtOKBNd04rQUahcBrr0C9yYy3zRSnRqbrvzy84qdSx80WgxQDwBK+uZjQ/tKwAmA8lIpFIJPIL5/RVOvua/vAAAAAASUVORK5CYII=","orcid":"","institution":"University of Alberta","correspondingAuthor":true,"prefix":"","firstName":"Georg","middleName":"M.","lastName":"Schmölzer","suffix":""}],"badges":[],"createdAt":"2025-05-23 20:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6735597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6735597/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-025-06312-4","type":"published","date":"2025-07-08T15:57:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83843243,"identity":"5b49a041-7f5c-4223-adff-d5ed4f653099","added_by":"auto","created_at":"2025-06-03 14:37:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96873,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTidal volume during resuscitation with ETT. \u003c/strong\u003eDifference in (A) and total (B) inspired and expired tidal volume (V\u003csub\u003eT\u003c/sub\u003e, mL/kg) during 1 minute of chest compressions (CC) using the CC+SI technique or the 3:1 C:V technique. Data are presented as median (solid bar), IQR (box margin). The first four ventilation devices (T-piece, FIB, SIB, NextStep\u003csup\u003eTM\u003c/sup\u003e) are from the CC+SI technique and the final three ventilation devices (FIB, SIB, T-piece) are from the 3:1 C:V technique. P\u0026lt;0.05 represents significant difference between CC+SI technique groups versus 3:1 C:V technique groups.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6735597/v1/82dcb270f725e3f73ed62a4a.png"},{"id":83843241,"identity":"fee25b94-29e1-4076-bd9b-3ad399223929","added_by":"auto","created_at":"2025-06-03 14:37:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95848,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTidal volume during resuscitation with SGA. \u003c/strong\u003eDifference in (A) and total (B) and total inspired and expired tidal volume (V\u003csub\u003eT\u003c/sub\u003e, mL/kg) during 1 minute of chest compressions (CC) using the CC+SI technique or the 3:1 C:V technique. Data are presented as median (solid bar), IQR (box margin). The first four ventilation devices (T-piece, FIB, SIB, NextStep\u003csup\u003eTM\u003c/sup\u003e) are from the CC+SI technique and the final three ventilation devices (FIB, SIB, T-piece) are from the 3:1 C:V technique. P\u0026lt;0.05 represents significant difference between CC+SI technique groups versus 3:1 C:V technique groups. During CC+SI with T-Piece (*p=0.022), SIB (*p=0.026), and Next Step\u003csup\u003eTM\u003c/sup\u003e (*p=0.005) had significant less V\u003csub\u003eT\u003c/sub\u003e loss, compared to FIB with 3:1 C:V\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6735597/v1/2d38bfeacd4e10ce9031a966.png"},{"id":83843242,"identity":"4334f89e-d611-486e-98a8-e8d9555e77c1","added_by":"auto","created_at":"2025-06-03 14:37:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":129348,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLeak during resuscitation with SGA. \u003c/strong\u003ePercentage of leak during 1 minute of chest compressions (CC) using the CC+SI technique or the 3:1 C:V technique with the SGA. Data are presented as median (solid bar), IQR (box margin). Boxplots represent the percentage of leak for each ventilation device. The first four ventilation devices (T-piece, FIB, SIB, NextStep\u003csup\u003eTM\u003c/sup\u003e) are from the CC+SI technique and the final three ventilation devices (FIB, SIB, T-piece) are from the 3:1 C:V technique. The was no significant difference in leak between all groups.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6735597/v1/0e678569070d96d641f7ca54.png"},{"id":86699256,"identity":"4ea7b709-560f-4345-a771-8a48b14bde96","added_by":"auto","created_at":"2025-07-14 16:06:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6735597/v1/b54603a0-ef4b-42e0-a45a-5b66b3566496.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tidal volume delivery during chest compression with either an endotracheal tube or supraglottic airway in a porcine animal model","fulltext":[{"header":"What is known ","content":"\u003cul\u003e\n \u003cli\u003eA supraglottic airway device can be used as an alternative airway during neonatal resuscitation, but ventilation efficacy during chest compressions remains unknown.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is new\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eChest compressions result in substantial leak via the supraglottic airway, hindering effective tidal volume delivery during neonatal resuscitation.\u003c/li\u003e\n \u003cli\u003eNeonatal resuscitation using the 3:1 compression-to-ventilation technique leads to tidal volume loss, regardless of ventilation device, but the alternative technique of continuous chest compressions with sustained inflations results in improved tidal volume delivery.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eAsphyxia affects 1-9/1,000 newborns,\u0026nbsp;is the main cause of cardiac arrest in newborns,\u0026nbsp;and the third leading cause of neonatal death\u003cstrong\u003e[1, 2]\u003c/strong\u003e. It occurs due to impaired gas exchange, leading to simultaneous hypoxia and hypercapnia\u003cstrong\u003e[3\u0026ndash;5]\u003c/strong\u003e.\u0026nbsp;Neonatal cardiopulmonary resuscitation combines i) effective chest\u0026nbsp;compressions (CC) to temporarily generate blood flow to sustain perfusion until the myocardium receives sufficient oxygen to restore independent cardiac output\u003cstrong\u003e[6\u0026ndash;12]\u003c/strong\u003e and ii) effective ventilation to\u0026nbsp;deliver adequate tidal volume (V\u003csub\u003eT\u003c/sub\u003e) to facilitate gas exchange and reverse hypoxia and hypercapnia[13, 14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe International Liaison Committee of Resuscitation (ILCOR) Consensus of Science and Treatment Recommendations (CoSTR) describe three ventilation devices for respiratory support including the flow-inflating bag (FIB), the self-inflating bag (SIB), and the T-piece resuscitator (T-piece)[15, 16]. While the T-piece most consistently provides pre-set positive end expiratory pressure (PEEP) and peak inflation pressure (PIP), the PEEP and PIP is rather variable with a FIB and SIB[17\u0026ndash;21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnce CC are started, the American Heart Association guidelines recommend an alternative airway, either an endotracheal tube (ETT) or a supraglottic airway (SGA) device, while the European guidelines do not specify which airway device should be used during CC[13, 22]. More recently, the 2023 ILCOR CoSTR stated that a SGA device can be used as an alternative to mask ventilation where resources and training permits[16, 23, 24]. While animal and human studies reported that the mask leak is highly variable with a SGA[19, 25, 26], time to return of spontaneous circulation was not difference in animal trials[27, 28] , however ventilation efficacy with a SGA during CC remains unclear. While the current CoSTR recommends a 3:1 Compression:Ventilation (3:1 C:V) ratio, the most effective CC approach remains unknown.\u003c/p\u003e\n\u003cp\u003eA potential alternative technique is continuous CC during sustained inflation (CC+SI), which significantly reduced time to return of spontaneous circulation and mortality in animal studies, with a similar trend in human studies[29\u0026ndash;33]. Therefore, we aimed to compare V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003edelivery during CC with either 3:1 C:V or CC+SI with either a SGA or ETT airway using various ventilatory devices. We hypothesized that the CC+SI technique would provide more effective V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003edelivery compared to 3:1 C:V with either an ETT or an LMA. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis was a randomized crossover animal trial, including seven term neonatal mixed breed piglets obtained on the day of experimentation from the University Swine Research Technology Centre, Edmonton, Alberta, Canada. There were no exclusion criteria. All experiments were conducted in accordance with the guidelines and approval of the Animal Care and Use Committee (Health Sciences), University of Alberta [AUP00004212], conducted and presented according to the ARRIVE 2.0 guidelines[34], conducted according to the Canadian Council of Animal Care guidelines, and registered at preclinicaltrials.eu (PCTE0000583). The experiments conducted in this study were performed after completion in the same piglets from our previously published study by Gibbs \u003cem\u003eet al\u003c/em\u003e[19]. At the end of the experiments of Gibbs \u003cem\u003eet al[19]\u003c/em\u003e , which\u003cem\u003e\u0026nbsp;\u003c/em\u003eexamined positive pressure ventilation (PPV) during compliance changes with a SGA, the piglets were euthanized to eliminate any possible interference with potential gasping or spontaneous breathing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRandomization\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe sequence of resuscitation using a T-piece, FIB, SIB, and NextStep\u003csup\u003eTM\u003c/sup\u003e resuscitator device during CC+SI and 3:1 C:V was randomized in all piglets. Allocation was block randomized with variable sized blocks using a computer-generated randomization program (http://www.randomizer.org). Sequentially numbered, sealed, brown envelopes containing the sequence allocation were opened during the experiment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBlinding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt was not possible to blind the team to the allocation due to the nature of the intervention. However, the statistical analysis was blinded to group allocation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnimal preparation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePiglets were instrumented as previously described with modifications\u003cspan lang=\"EN-US\"\u003e[29, 35]\u003c/span\u003e As we wanted to avoid spontaneous breathing, which could confound the V\u003csub\u003eT\u003c/sub\u003e measurements, piglets were euthanized with an intravenous overdose of sodium pentobarbital (120 mg/kg). A size 1.5 SGA was placed (Ambu\u003csup\u003e\u0026reg;\u003c/sup\u003e AuraStraight, Balleruo, Denmark). Placement of the SGA was confirmed in each piglet using a bronchoscope (Ambu\u003csup\u003e\u0026reg;\u003c/sup\u003e, Balleruo, Denmark). Afterwards, piglets were tracheotomized and an ETT was tightly secured in the trachea. Chest compression were commenced two minutes after the overdose of sodium pentobarbital was given.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespiratory parameters\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA respiratory function monitor (NM3, Respironics, Philips, Andover, MA) was used to continuously measure V\u003csub\u003eT\u003c/sub\u003e, airway pressures, and gas flow.\u0026nbsp;The NM3 flow sensor has a fixed orifice pneumotach, which uses the pressure difference to calculate the gas flow passing through the sensor, which is then translated into the inspiratory and expiratory V\u003csub\u003eT\u003c/sub\u003e. The sensor was placed between the ETT or the SGA and the ventilation device. V\u003csub\u003eT\u003c/sub\u003e was calculated by integrating the flow signal[36]. The accuracy for gas flow is \u0026plusmn;0.125 L/min[37].\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVentilation devices\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNeopuff T-piece (Fisher \u0026amp; Paykel, Auckland, New Zealand) with default setting of PIP of 24 cmH\u003csub\u003e2\u003c/sub\u003eO, PEEP of 5 cmH\u003csub\u003e2\u003c/sub\u003eO. Flow-inflating bag (FIB) (Mapleson Anesthesia Breathing Circuit, Mercury Medical, Clearwater, FL). Self-inflating bag (SIB) (Preterm model, Laerdal Silicone Resuscitator, Laerdal Medical, Stavanger, Norway) with no PEEP valve or manometer attached. NextStep\u003csup\u003eTM\u003c/sup\u003e Neonatal Resuscitator (KM Medical, Auckland, New Zealand) with default settings of maximum pressure (Pmax) of 40 cmH\u003csub\u003e2\u003c/sub\u003eO, PEEP of 5 cmH\u003csub\u003e2\u003c/sub\u003eO, rate of 50/min, set V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003eof 5mL/kg, and inspiration: expiration ratio of 1:3. The NextStep\u003csup\u003eTM\u003c/sup\u003e delivers V\u003csub\u003eT\u003c/sub\u003e with an accuracy of 0.1\u0026ndash;0.3mL (according to the manufacturer); it also controls ventilation rate and monitors airway pressure[18, 19, 38, 39]. None of the devices were connected to heated/humidified gas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExperimental protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePiglets were randomized to receive a sequence of seven resuscitation techniques: 1) CC+SI with T-piece, 2) CC+SI with FIB, 3) CC+SI with SIB, 4) CC+SI with NextStep\u003csup\u003eTM\u003c/sup\u003e resuscitator, 5) 3:1 C:V with T-piece, 6) 3:1 C:V with FIB, and 7) 3:1 C:V with SIB. After euthanization, a sequentially numbered, sealed brown envelope containing the sequence randomization was opened. Each resuscitation technique was performed for a duration of 1 min via the SGA. Thereafter, the SGA was removed, and piglets underwent a tracheostomy for placement of the ETT. Each resuscitation technique was then performed via the ETT for a duration of 1 min per technique.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring CC+SI, ventilations (sustained inflations) were provided for 30 sec each. There was a 1 sec pause between successive inflations. Compressions were continuously delivered at a rate of 120/min\u003cspan lang=\"EN-US\"\u003e[29\u0026ndash;33]\u003c/span\u003e. During 3:1 C:V, 90 compressions were synchronized with 30 ventilations (inflations) per minute at a ratio of 3:1. Ventilations were delivered using the ventilation device as per the randomized sequence[13, 14]. The NextStep\u003csup\u003eTM\u003c/sup\u003e resuscitator device provides continuous ventilation and cannot be programmed to pause for compressions. As such, it could not be used with 3:1 C:V resuscitation and was only used with continuous CC. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor the SIB, FIB, and T-piece interventions, airway pressures, gas flow, and V\u003csub\u003eT\u003c/sub\u003e were measured and analyzed using Flow Tool Physiologic Waveform Viewer (Philips Healthcare, Wallingford, CT, USA). The NextStep\u003csup\u003eTM\u003c/sup\u003e ventilator screen was captured by a video camera during the experiment (iPhone 14 Pro Max, Apple, CA). BK reviewed the video recordings frame-by-frame and stopped the recording after each inflation to record respiratory parameters. BK was not involved in statistical analysis. The data was tested for normality (Shapiro-Wilk and Kolmogorov-Smirnov test) and compared using ANOVA for repeated measures using Bonferroni post-test. The data are presented as mean (standard deviation-SD) for normally distributed variables and median (interquartile range-IQR) for skewed variables. P-values are 2-sided and p\u0026lt;0.05 was considered statistically significant. Statistical analyses were performed with Stata version 17 (StataCorp LLC, College Station, TX).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSeven term neonatal mixed breed piglets (1-3 days of age, weighing 1.8-2.4 kg) were obtained on the day of the experimentation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespiratory Parameters\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRespiratory parameters are presented in Table 1 for ETT and in Table 2 for SGA. The difference in and total inspired and expired V\u003csub\u003eT\u003c/sub\u003e during resuscitation with ETT are presented in Figure 1 A\u0026amp;B and with SGA in Figure 2 A\u0026amp;B. During resuscitation using the ETT with CC+SI technique, a greater inspiratory than expiratory V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003ewas observed, regardless of which ventilation device was used. The resulting gain in V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003eis indicative of lung recruitment (Figure 1A\u0026amp;B). Contrary to this, during resuscitation using the ETT with 3:1 C:V technique, there was a loss in V\u003csub\u003eT\u003c/sub\u003e in all ventilation devices, indicating lung derecruitment (greater expiratory than inspiratory V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003eresulting in a negative difference; Figure 1). All ventilation devices used during 3:1 C:V with ETT resulted in significant V\u003csub\u003eT\u003c/sub\u003e loss compared to CC+SI with ETT (p\u0026lt;0.05; Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring resuscitation using the SGA with CC+SI technique, all ventilation devices led to a slight loss in V\u003csub\u003eT,\u003c/sub\u003e albeit not as substantial as the loss in V\u003csub\u003eT\u003c/sub\u003e during resuscitation using the SGA with 3:1 C:V technique (Figure 2). During CC+SI, the T-Piece (*p=0.022), SIB (*p=0.026), and Next Step\u003csup\u003eTM\u003c/sup\u003e (*p=0.005) had significant less V\u003csub\u003eT\u003c/sub\u003e loss compared to FIB with 3:1 C:V (Figure 2A\u0026amp;B), all other comparisons were not significant (Figure 2A\u0026amp;B).\u003c/p\u003e\n\u003cp\u003eThere was substantial leak associated with the SGA, regardless of the ventilatory device or compression technique (Figure 3).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the current study, we investigated various ventilatory devices during CC with either a SGA or ETT in place. The results of our study can be summarized as follows: 1) resuscitation with CC+SI and ETT resulted in a gain in V\u003csub\u003eT\u003c/sub\u003e, regardless of the ventilation device, 2) resuscitation with the 3:1 C:V technique with both SGA and ETT resulted in a loss in V\u003csub\u003eT\u003c/sub\u003e, regardless of the ventilation device, and 3) SGA resulted in substantial leak, regardless of ventilation device or CC technique. As the purpose of ventilation (inflations) during resuscitation is to deliver an adequate V\u003csub\u003eT \u003c/sub\u003eto facilitate gas exchange, the use of a SGA to deliver an adequate V\u003csub\u003eT\u003c/sub\u003e during CC remains to be investigated because of substantial leak. \u003csub\u003e \u003c/sub\u003e \u003c/p\u003e\n\n\u003cp\u003eIt is vital that inflations during resuscitation deliver an adequate V\u003csub\u003eT\u003c/sub\u003e to facilitate gas exchange. We have previously demonstrated that during CC using a T-piece device and an ETT, the 3:1 C:V technique results in significant V\u003csub\u003eT\u003c/sub\u003e loss, whereas the CC+SI technique leads to a gain in V\u003csub\u003eT[40]\u003c/sub\u003e . During 3:1 C:V, a cumulated loss of V\u003csub\u003eT \u003c/sub\u003eof 4.5 mL/kg occurred for each 3:1 C:V cycle, whereas during CC+SI, a constant lung recruitment and establishment of functional residual capacity was observed (a gain of 2.3 mL/kg per CC+SI cycle)\u003csub\u003e[40]\u003c/sub\u003e. In the current study, we also demonstrated that more air was forced out of the chest during the 3:1 C:V technique during resuscitation with either the ETT or SGA, compared to using the CC+SI technique. The passive chest recoil during 3:1 C:V leads to loss of V\u003csub\u003eT\u003c/sub\u003e and contributes to dead space ventilation and lung derecruitment. In our study, the ventilation device used to deliver the inflations did not appear to have an effect on lung recruitment. In contrast, the CC+SI technique demonstrates that ventilation is passively achieved during chest compressions, by enabling a greater inspiratory than expiratory V\u003csub\u003eT\u003c/sub\u003e leading to a gain in V\u003csub\u003eT\u003c/sub\u003e and recruitment of the lung. This CC+SI associated passive lung ventilation/aeration was observed across all ventilation devices with ETT. By improving lung aeration and increasing oxygenated blood flow returning from the lung, cardiac function can be restored and lead to better tissue oxygen delivery during resuscitation.\u003c/p\u003e\n\n\u003cp\u003eStudies have identified increased leak when chest compressions are initiated during neonatal resuscitation[41\u0026ndash;44]. During resuscitation of a premature infant in the delivery room, Li \u003cem\u003eet al \u003c/em\u003ereported that mask leak significantly increased during chest compressions[41]. In a newborn piglet model, Mendler \u003cem\u003eet al \u003c/em\u003eobserved a significant increase in ETT leak (average increase of 11.4%) when chest compressions were added to respiratory support using a T-piece, SIB, and a ventilator[42]. In the current study, we report high percentages of leak when using a SGA (approximately 40-70%) during CC, irrespective of ventilation device used. In our previous study by Gibbs \u003cem\u003eet al[19]\u003c/em\u003e, we reported very low leak when using the SGA to deliver only PPV (highest median leak of 12% with SIB). However, slight movements of the SGA can increase leak, and in any case when CC are started greater leaks can occur[43, 44]. Use of a SGA when CC are needed may not be the optimal approach to ensure adequate V\u003csub\u003eT\u003c/sub\u003e delivery, especially when the resuscitation technique is 3:1 C:V. \u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn keeping with our commitment to the three Rs of animal research, we reduced the number of animals required to obtain results by using animals that were initially used for a different study[19] . Nevertheless, all animals received similar prior interventions and we believe it did not influence the outcome of this study. An Ambu\u003csup\u003e\u0026reg;\u003c/sup\u003e AuraStraight, size 1.5 SGA was used as we were unable to obtain suitable placement with the i-gel\u003csup\u003e\u0026reg;\u003c/sup\u003e SGA. The NextStep\u003csup\u003eTM\u003c/sup\u003e uses a digital flow sensor while the NM3 uses a fixed orifice flow sensor[37], which may have resulted in slight differences in V\u003csub\u003eT \u003c/sub\u003emeasurements. However, the accuracy of the used flow sensors are within clinically acceptable deviations in V\u003csub\u003eT \u003c/sub\u003emeasurements[45]. The current data are from a piglet study and the impact of these findings to infants remains unknown.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUsing the CC+SI technique for resuscitation paired with an ETT resulted in a gain in V\u003csub\u003eT\u003c/sub\u003e, regardless of which ventilation device was used. It is important to highlight the substantial leak that occurred during chest compressions with a SGA, which may hinder effective V\u003csub\u003eT\u0026nbsp;\u003c/sub\u003edelivery. Using the 3:1 C:V technique for resuscitation leads to lung derecruitment, especially when paired with an SGA. Further studies to determine if SGA can effectively be used during chest compressions are warranted.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCC - Chest compressions \u003c/p\u003e\n\u003cp\u003eCPR - Cardiopulmonary resuscitation\u003c/p\u003e\n\u003cp\u003eCC+SI - Chest compressions with sustained inflation\u003c/p\u003e\n\u003cp\u003eC:V - Compression-to-ventilation ratio\u003c/p\u003e\n\u003cp\u003eETT - Endotracheal tube\u003c/p\u003e\n\u003cp\u003eFIB - Flow-inflating bag\u003c/p\u003e\n\u003cp\u003ePEEP - Positive end expiratory pressure\u003c/p\u003e\n\u003cp\u003ePIP - Positive inspiratory pressure\u003c/p\u003e\n\u003cp\u003ePPV - Positive pressure ventilation\u003c/p\u003e\n\u003cp\u003eSGA - Supraglottic airway\u003c/p\u003e\n\u003cp\u003eSIB - Self-inflating bag\u003c/p\u003e\n\u003cp\u003eV\u003csub\u003eT\u003c/sub\u003e - Tidal volume\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConception and design: GMS, PYC, MOR, TFLCollection and assembly of data: GMS, PYC, MOR, TFL, MR, BK, RHAnalysis and interpretation of the data: GMS, PYC, MOR, TFL, MR, BK, RH Drafting of the article: GMS, PYC, MOR, TFL, MR, BK, RH Critical revision of the article for important intellectual content: GMS, PYC, MOR, TFL, MR, BK, RHFinal approval of the article: GMS, PYC, MOR, TFL, MR, BK, RH\u003c/p\u003e\n\u003ch2\u003eConflict of Interest:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData availability:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNo AI has been used in the writing of this article\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePerin J, Mulick A, Yeung D, et al (2022) Global, regional, and national causes of under-5 mortality in 2000\u0026ndash;19: an updated systematic analysis with implications for the Sustainable Development Goals. 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JACC: Basic to Translational Science 4:116\u0026ndash;121. https://doi.org/10.1016/j.jacbts.2018.12.004\u003c/li\u003e\n\u003cli\u003eKoo J, Cheung P-Y, Pichler G, et al (2024) Chest compressions superimposed with sustained inflation during neonatal cardiopulmonary resuscitation: are we ready for a clinical trial? Arch Dis Child - Fetal Neonatal Ed fetalneonatal-2023-326769. https://doi.org/10.1136/archdischild-2023-326769\u003c/li\u003e\n\u003cli\u003eSchm\u0026ouml;lzer GM, Reilly MO, Fray C, et al (2018) Chest compression during sustained inflation versus 3:1 chest compression:ventilation ratio during neonatal cardiopulmonary resuscitation: a randomised feasibility trial. Arch Dis Child Fetal neonatal Ed 103:F455\u0026ndash;F460. https://doi.org/10.1136/archdischild-2017-313037\u003c/li\u003e\n\u003cli\u003eSchm\u0026ouml;lzer GM, Pichler G, Solev\u0026aring;g AL, et al (2024) Sustained inflation and chest compression versus 3:1 chest compression to ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborns (SURV1VE): A cluster randomised controlled trial. Arch Dis Child - Fetal Neonatal Ed fetalneonatal-2023-326383. https://doi.org/10.1136/archdischild-2023-326383\u003c/li\u003e\n\u003cli\u003eSert NP du, Hurst V, Ahluwalia A, et al (2020) The ARRIVE guidelines 2.0: Updated guidelines for reporting animal research. Exp Physiol 105:1459\u0026ndash;1466. https://doi.org/10.1113/ep088870\u003c/li\u003e\n\u003cli\u003eCheung P-Y, Gill RS, Bigam DL (2011) A swine model of neonatal asphyxia. 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Journal of Maternal-Fetal and Neonatal Medicine 30:595\u0026ndash;599. https://doi.org/10.1080/14767058.2016.1180360\u003c/li\u003e\n\u003cli\u003eLi ES, Cheung P-Y, O\u0026rsquo;Reilly M, Schm\u0026ouml;lzer GM (2015) Change in tidal volume during cardiopulmonary resuscitation in newborn piglets. Arch Dis Child - Fetal Neonatal Ed 100:F530\u0026ndash;F533. https://doi.org/10.1136/archdischild-2015-308363\u003c/li\u003e\n\u003cli\u003eLi ES, Cheung P-Y, Pichler G, et al (2014) Respiratory function and near infrared spectroscopy recording during cardiopulmonary resuscitation in an extremely preterm newborn. Neonatology 105:200\u0026ndash;204. https://doi.org/10.1159/000357609\u003c/li\u003e\n\u003cli\u003eMendler MR, Weber C, Hassan MA, et al (2016) Tidal Volume Delivery and Endotracheal Tube Leak during Cardiopulmonary Resuscitation in Intubated Newborn Piglets with Hypoxic Cardiac Arrest Exposed to Different Modes of Ventilatory Support. Neonatology 111:100\u0026ndash;106. https://doi.org/10.1159/000447663\u003c/li\u003e\n\u003cli\u003eBinder-Heschl C, Schm\u0026ouml;lzer GM, O\u0026rsquo;Reilly M, et al (2014) Human or monitor feedback to improve mask ventilation during simulated neonatal cardiopulmonary resuscitation. Archives of Disease in Childhood-Fetal \u0026hellip; 99:F120-3. https://doi.org/10.1136/archdischild-2013-304311\u003c/li\u003e\n\u003cli\u003eHuynh T, Huynh T, Hemway RJ, Perlman JM (2015) Assessment of effective face mask ventilation is compromised during synchronised chest compressions. Archives of disease in childhood Fetal and neonatal edition 100:F39\u0026ndash;F42. https://doi.org/10.1136/archdischild-2014-306309\u003c/li\u003e\n\u003cli\u003eVerbeek C, Zanten HA van, Vonderen JJ van, et al (2016) Accuracy of currently available neonatal respiratory function monitors for neonatal resuscitation. Eur J Pediatr 175:1065\u0026ndash;1070. https://doi.org/10.1007/s00431-016-2739-1\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Respiratory parameters during 1 minute of resuscitation with ETT.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"917\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRespiratory parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 36.9984%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC+SI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 25.2828%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3:1 C:V\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003eT-piece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003eFIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003eSIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003eNextStep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003eFIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003eSIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003eT-piece\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003ePIP (cmH\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e39.36 (6.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e38.57 (5.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e37.87 (13.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e48.30 (17.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e46.04 (10.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e37.29 (4.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e16.15 (10.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003ePEEP (cmH\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e3.74 (3.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e2.14 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003ePIF (mL/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e5.05 (1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e9.67 (2.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e4.67 (0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e5.38 (2.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e13.16 (2.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e14.07 (2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e3.61 (2.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003ePEF (mL/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e-10.68 (3.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e-14.52 (3.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e-7.91 (2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e-8.12 (4.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e-13.10 (2.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e-13.86 (2.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e-4.38 (3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003eInspired V\u003csub\u003eT\u003c/sub\u003e (mL/kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e11.74 (8.32-15.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e17.71 (11.82-22.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e7.85 (5.87-8.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e7.43 (5.35-11.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e23.56 (20.67-24.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e16.33 (12.86-24.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e6.90 (3.54-10.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.3033%;\"\u003e\n \u003cp\u003eExpired V\u003csub\u003eT\u003c/sub\u003e (mL/kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e7.99 (5.13-10.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5594%;\"\u003e\n \u003cp\u003e12.95 (7.89-16.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2939%;\"\u003e\n \u003cp\u003e5.21 (4.39-7.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2054%;\"\u003e\n \u003cp\u003e5.32 (3.90-7.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1263%;\"\u003e\n \u003cp\u003e35.65 (28.92-38.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.1168%;\"\u003e\n \u003cp\u003e22.00 (17.19-30.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.8249%;\"\u003e\n \u003cp\u003e15.81 (11.66-21.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean (SD), unless otherwise indicated\u003csup\u003e#\u003c/sup\u003e median (IQR). PIP, Peak Inflation Pressure; PEEP, Positive End Expiratory Pressure; PIF, Peak Inspiratory Flow; PEF, Peak Expiratory Flow; V\u003csub\u003eT\u003c/sub\u003e, Tidal Volume. With CC+SI PIP=PEEP.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Respiratory parameters during 1 minute of resuscitation with SGA.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"941\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRespiratory parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1147%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 40.5381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC+SI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 20.9865%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3:1 C:V\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003eT-piece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003eFIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003eSIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003eNextStep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003eFIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003eSIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003eT-piece\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003ePIP (cmH\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e37.31 (3.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e32.48 (9.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e29.60 (11.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e32.81 (13.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e40.32 (6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e31.82 (2.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e23.46 (3.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003ePEEP (cmH\u003csub\u003e2\u003c/sub\u003eO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e3.65 (3.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e3.59 (0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003ePIF (mL/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e5.87 (2.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e11.92 (4.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e5.99 (1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e5.39 (2.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e16.37 (2.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e15.16 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e5.56 (0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003ePEF (mL/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e-7.73 (2.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e-11.15 (5.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e-4.31 (2.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e-5.20 (2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e-13.80 (3.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e-15.91 (3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e-7.59 (1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003eInspired V\u003csub\u003eT\u003c/sub\u003e (mL/kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e10.64 (6.50-12.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e18.65 (11.45-28.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e14.87 (5.32-15.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e4.83 (3.27-12.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e22.98 (19.83-28.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e28.49 (26.09-30.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e9.62 (6.83-12.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.7354%;\"\u003e\n \u003cp\u003eExpired V\u003csub\u003eT\u003c/sub\u003e (mL/kg)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6996%;\"\u003e\n \u003cp\u003e5.39 (5.11-6.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4901%;\"\u003e\n \u003cp\u003e8.53 (4.97-11.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.4305%;\"\u003e\n \u003cp\u003e3.93 (2.88-4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.2377%;\"\u003e\n \u003cp\u003e5.10 (3.41-8.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7758%;\"\u003e\n \u003cp\u003e21.37 (19.79-35.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2242%;\"\u003e\n \u003cp\u003e22.14 (19.79-32.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6726%;\"\u003e\n \u003cp\u003e13.82 (12.29-16.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean (SD), unless otherwise indicated\u003csup\u003e#\u003c/sup\u003e median (IQR). PIP, Peak Inflation Pressure; PEEP, Positive End Expiratory Pressure; PIF, Peak Inspiratory Flow; PEF, Peak Expiratory Flow, V\u003csub\u003eT\u003c/sub\u003e, Tidal Volume. With CC+SI PIP=PEEP.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Infants, Newborn, Neonatal Resuscitation, Chest compressionS, Asphyxia, endotraCHEAL tube, supraglottic airway","lastPublishedDoi":"10.21203/rs.3.rs-6735597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6735597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThe 2023 Consensus of Science and Treatment Recommendations states that a supraglottic airway (SGA) device can be used to deliver positive pressure ventilation. However, it is unclear if a SGA can effectively be used during chest compressions. We aimed to compare tidal volume (V\u003csub\u003eT\u003c/sub\u003e) delivery during either chest compressions with sustained inflations (CC+SI) or 3:1 compression-to-ventilation (3:1 C:V) technique with SGA and endotracheal tube (ETT) using various ventilation devices: T-piece, self-inflating bag (SIB), flow-inflating bag (FIB), NextStep\u003csup\u003eTM \u003c/sup\u003eresuscitator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Randomized crossover animal trial using seven mixed-breed piglets (1-3 days old; 1.8-2.4 kg). Piglets were euthanized to eliminate any potential interference with gasping or spontaneous breathing, and randomized to a sequence of resuscitation techniques: 1) CC+SI with T-piece, 2) CC+SI with FIB, 3) CC+SI with SIB, 4) CC+SI with NextStep\u003csup\u003eTM\u003c/sup\u003e, 5) 3:1 C:V with T-piece, 6) 3:1 C:V with FIB, and 7) 3:1 C:V with SIB. Resuscitation was performed for 1 min per technique via the SGA and then ETT. Respiratory parameters were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eResuscitation using an ETT and CC+SI resulted in a gain in V\u003csub\u003eT\u003c/sub\u003e, irrespective of ventilation device. In contrast, resuscitation with an ETT or SGA and 3:1 C:V resulted in a loss in V\u003csub\u003eT\u003c/sub\u003e across all ventilation devices. There was substantial leak with the SGA, regardless of the ventilation device or compression technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Using the CC+SI technique for resuscitation paired with an ETT resulted in V\u003csub\u003eT\u003c/sub\u003e gain, regardless of ventilation device. Substantial leak during chest compressions with a SGA may hinder effective V\u003csub\u003eT \u003c/sub\u003edelivery.\u003c/p\u003e","manuscriptTitle":"Tidal volume delivery during chest compression with either an endotracheal tube or supraglottic airway in a porcine animal model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 14:37:38","doi":"10.21203/rs.3.rs-6735597/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-11T10:59:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T06:07:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133520820440114482709864035069845568414","date":"2025-06-01T11:07:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306476956329084213763588023432064156928","date":"2025-05-30T08:47:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68873952200711921013824020492749366960","date":"2025-05-30T08:26:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T07:37:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-25T23:58:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-25T23:54:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2025-05-23T20:49:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2945a419-05a5-404f-8cf4-d671f5fe4dcb","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T15:59:12+00:00","versionOfRecord":{"articleIdentity":"rs-6735597","link":"https://doi.org/10.1007/s00431-025-06312-4","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2025-07-08 15:57:01","publishedOnDateReadable":"July 8th, 2025"},"versionCreatedAt":"2025-06-03 14:37:38","video":"","vorDoi":"10.1007/s00431-025-06312-4","vorDoiUrl":"https://doi.org/10.1007/s00431-025-06312-4","workflowStages":[]},"version":"v1","identity":"rs-6735597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6735597","identity":"rs-6735597","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}