when learning neonatal resuscitation there are the essentials and advanced but here we're going beyond advanced i have this recurring nightmare i'm out of delivery and i can't ventilate the baby the airway seems obstructed so i asked my team to hand me the meconium aspirator they reply meconium aspirator what's that after finding it myself and showing the team they say i wondered what that thingy was for every industry seems to have its thingy gadget doodad thingamabob doohickey or whatchamacallit for neonatology our thingy has to be the meconium aspirator but how and when should we use it let's start with the how if you suspect that meconium is plugging your airway and preventing you from ventilating the baby then you need to suction that stuff out first the baby should be intubated with an appropriate size endotracheal tube make sure the meconium aspirator thingy is connected to your suction source set at 80 to 100 millimeters of mercury then attach the meconium aspirator to the endotracheal tube now you occlude the suction control port on the side with your finger which diverts the suction from that port to the tip of the endotracheal tube this turns your endotracheal tube into a large bore suction catheter now withdraw the endotracheal tube slowly over three to five seconds while holding suction your endotracheal tube is now out of the airway so be prepared to resume face mask ventilation or reintubate with a clean tube if your baby is not breathing now how about the when starting in the seventh edition of nrp we went away from routinely suctioning babies born through meconium our obstetric colleagues are on board the american college of obstetrics and gynecology even has a committee opinion paper number 689 if you need to know stating quote resuscitation should follow the same principles for infants with meconium stain fluid as for those with clear fluid the data since this change supports that this was overall a good change there are fewer or no difference in the number of babies born with meconium aspiration syndrome and slightly more or a lot less nicu admissions depending on which paper's data you look at so we are doing less and basically getting similar or slightly better outcomes this brings up the larger issue of when to suction at all the nrp algorithm clearly states to suction only if needed that's because no one needs it routinely not crying babies not haptic babies ethnic babies need ppv not quietly breathing babies not noisy breathing babies noisy breathing babies might be transitioning just fine not pink babies and not blue babies blue babies need pulse oximetry monitoring to guide their oxygen supplementation no one needs suctioning routinely routine bulb or catheter suction of babies has been shown in randomized trials to have no benefit and to cause reduced oxygen saturations and lower 5-minute apgar scores one trial showed that just wiping the mouth and nose at birth with the towel was as good as clearing the airways and no baby harm was found so the baby that needs suctioning is that baby that is not transitioning well due to an obstruction in their ability to breathe so when do we need to get the thingy to do the suctioning let's look at mr sopa at this point you are trying to give ppv and are not getting effective ventilation you have checked the mast seal and repositioned the airway now you are suctioning the open mouth but don't get the thingy yet suctioning here is the bulb or catheter suction even if the baby was born with meconium stained amniotic fluid you continue to troubleshoot your ppv with an increased pressure but no improvement so you place your alternative airway the endotracheal tube now you might think that you should aspirate the trachea at this point i mean who wants to blow the meconium in the airway down further into the lungs and that makes some sense but we also do not want to delay starting effective ventilation so nrp is pretty clear that they want you to start ppv and only then if you are unable to move the chest and improve the heart rate would you consider using the meconium aspirator to suction the airway for meconium by the way this thing is no one trick pony this handy dandy doohickey can be used to suction any thick secretions whether it is meconium or cellular debris or vermix or blood or the booger from hell or a toy truck hey how'd that get in there the meconium aspirator turns your endotracheal tube into a large bore suction catheter to get any type of thick secretion that is obstructing the airway let's recap how and when we use the meconium aspirator how one you attach the meconium aspirator to your suction source set at 80 to 100 millimeters of mercury two you attach the meconium aspirator to the endotracheal tube that is already in the baby's trachea three you include the suction port while withdrawing the endotracheal tube slowly over three to five seconds when do you use it you use the meconium aspirator after you've gone through all the steps of mr sopa and you are unable to achieve effective ventilation and are still concerned that the airway is obstructed by any type of thick secretion i hope you've enjoyed this video like and share below and follow me here on youtube or on twitter leave a comment below if you have another idea for a topic i can cover that goes beyond advanced in neonatal resuscitation