11.3 Positive Pressure Ventilation, MR. SOPA & Advanced Resuscitation
Key Takeaways
- Positive pressure ventilation must begin within 60 seconds of birth when the infant is apneic, gasping, or has a heart rate below 100 bpm.
- PPV is delivered at 40 to 60 breaths per minute with an initial peak inspiratory pressure of 20 to 25 cm H2O and PEEP of 5 cm H2O.
- Resuscitation of infants at 35 weeks or later begins with 21 percent oxygen, and preterm infants below 35 weeks with 21 to 30 percent.
- The pulse oximeter probe goes on the right hand or wrist because pre-ductal blood reflects what is perfusing the brain and heart.
- Target pre-ductal saturation is only 60 to 65 percent at 1 minute, rising to 85 to 95 percent by 10 minutes.
The "Golden Minute" & Positive Pressure Ventilation (PPV)
At 30 seconds of life, assess respirations and heart rate. Evaluate the heart rate by auscultating the precordium with a stethoscope for 6 seconds and multiplying by 10 (or using a 3-lead ECG monitor).
[!CRITICAL] The Golden Minute Rule: If the neonate is apneic, gasping, OR has a heart rate <100 bpm after the initial steps, the clinician MUST initiate Positive Pressure Ventilation (PPV) within 60 seconds of birth ("the Golden Minute"). Effective ventilation is the single most critical and effective intervention in neonatal resuscitation.
Technical Standards for Positive Pressure Ventilation
- Ventilation Rate: 40 to 60 breaths per minute. Use the rhythmic verbal cadence: "Breathe, two, three, breathe, two, three..." (squeeze on "Breathe", release on "two, three").
- Inspiratory Pressures: Initial Peak Inspiratory Pressure (PIP) of 20 to 25 cm H2O; Positive End-Expiratory Pressure (PEEP) of 5 cm H2O (delivered via a T-piece resuscitator or flow-inflating bag; self-inflating bags require an attached PEEP valve).
- Initial Oxygen Concentration (FiO2):
- Term and late-preterm infants (≥35 weeks): Begin resuscitation with 21% oxygen (room air). Initiating resuscitation with 100% oxygen in term neonates increases mortality, prolongs time to spontaneous respiration, and generates toxic reactive oxygen species causing reperfusion injury to the brain and myocardium.
- Preterm infants (<35 weeks): Begin resuscitation with 21% to 30% oxygen.
- Pulse Oximetry Monitoring: Place a pulse oximeter sensor on the right hand or right wrist (pre-ductal site) before connecting the cable to the monitor. Pre-ductal blood reflects the exact oxygen concentration perfusing the cerebral circulation and heart via the carotid and coronary arteries (upstream of the ductus arteriosus).
Target Pre-Ductal SpO2 Milestones
Healthy neonates do not achieve adult oxygen saturation levels immediately. The NRP target pre-ductal SpO2 milestones are:
Titrate the blender oxygen concentration (FiO2) up or down to keep the infant's pre-ductal SpO2 within these physiological windows, avoiding both hypoxemia and hyperoxia.
Ventilation Corrective Steps: The MR. SOPA Mnemonic
Assess heart rate and chest movement 15 seconds after initiating PPV:
- If the heart rate is increasing: Continue PPV. Reassess heart rate at 30 seconds.
- If the heart rate is NOT increasing but the chest IS moving: Continue PPV for another 15 seconds (total 30 seconds) and reassess.
- If the heart rate is NOT increasing and the chest is NOT moving: Effective ventilation has NOT been established. Immediately interrupt ventilation to perform the MR. SOPA corrective steps in pairs:
MR. SOPA Ventilation Corrective Ladder
├── 1. M & R ──> Mask Adjustment (reseal) + Reposition Head (sniffing) ──> Test 5 breaths
├── 2. S & O ──> Suction Mouth/Nose + Open Mouth (jaw thrust) ──> Test 5 breaths
├── 3. P ──> Pressure Increase (+5 cm H2O increments to max 40) ──> Test 5 breaths
└── 4. A ──> Alternative Airway (Endotracheal Tube or Laryngeal Mask)
- M & R (Mask and Reposition):
- M - Mask Adjustment: Re-apply the mask with gentle downward pressure to establish an airtight seal against the infant's face. Use the "C-and-E" hand grip.
- R - Reposition Head: Re-position the head and neck into the neutral "sniffing" position.
- Check: Deliver 5 breaths; observe for chest rise.
- S & O (Suction and Open):
- S - Suction Mouth and Nose: Clear the pharynx and nares of thick secretions or mucus using a bulb syringe or suction catheter.
- O - Open Mouth: Lift the jaw forward and open the infant's mouth slightly.
- Check: Deliver 5 breaths; observe for chest rise.
- P (Pressure Increase):
- P - Pressure Increase: Incrementally increase the peak inspiratory pressure by 5 cm H2O increments, assessing chest rise after each change, up to a maximum PIP of 30 to 40 cm H2O for term infants.
- Check: Deliver 5 breaths; observe for chest rise.
- A (Alternative Airway):
- A - Alternative Airway: Insert an endotracheal tube (ETT) or a laryngeal mask airway (LMA). Secure the airway, verify bilateral breath sounds, confirm exhaled CO2 with a colorimetric detector, and deliver 30 seconds of effective PPV that moves the chest.
Advanced Resuscitation: Chest Compressions & Emergency Pharmacotherapy
Indication for Chest Compressions
Chest compressions are indicated ONLY when the heart rate remains <60 beats per minute despite at least 30 seconds of effective PPV that moves the chest (almost always following placement of an endotracheal tube or laryngeal mask).
Compressions Technique & Parameters
- FiO2 Escalation: Increase the delivered oxygen concentration to 100% FiO2 whenever chest compressions are initiated.
- Technique: The 2-thumb encircling-hands technique is strongly preferred over the 2-finger technique because it generates superior peak systolic pressures, higher coronary perfusion gradients, and causes less rescuer fatigue. Place both thumbs side-by-side or overlapping on the lower third of the sternum, directly between the nipples, avoiding the xiphoid process. Encircle the infant's torso with fingers supporting the spine.
- Compression Depth & Recoil: Depress the sternum approximately one-third of the anterior-posterior (AP) diameter of the chest (approximately 1.5 inches in a term infant). Ensure complete chest wall recoil between compressions without allowing the thumbs to lose contact with the sternum.
- Ratio and Cadence: Deliver compressions and ventilations in a 3:1 ratio (3 compressions to 1 ventilation). Coordinate 90 compressions and 30 ventilations per minute, totaling 120 events per minute. Use the rhythmic cadence: "One-and-two-and-three-and-breathe-and..."
- Continuous Resuscitation: Continue coordinated compressions and ventilations for at least 60 seconds before pausing briefly to reassess the heart rate. A 3-lead ECG monitor should be utilized to minimize interruptions in chest compressions.
Emergency Pharmacotherapy: Epinephrine & Volume Expansion
If the neonatal heart rate remains <60 bpm despite at least 60 seconds of chest compressions coordinated with effective 100% PPV via an alternative airway, emergency pharmacotherapy is urgently indicated.
| Medication / Fluid | Concentration & Preparation | Route & Dosage | Administration Protocol & Clinical Rationale |
|---|---|---|---|
| Epinephrine (Adrenaline) | 0.1 mg/mL (formerly labeled 1:10,000 solution) | Intravenous (IV) or Intraosseous (IO): 0.02 mg/kg (= 0.2 mL/kg of 0.1 mg/mL formulation) | Preferred route. Administer as a rapid IV push via an emergency umbilical venous catheter (UVC) inserted 2–4 cm into the umbilical vein. Follow immediately with a 3 mL normal saline flush to propel the drug into the central venous circulation. Repeat every 3 to 5 minutes if HR <60 bpm. |
| Epinephrine (Endotracheal) | 0.1 mg/mL (1:10,000) | Endotracheal (ETT): 0.1 mg/kg (= 1.0 mL/kg of 0.1 mg/mL formulation) | Temporary measure only while vascular access is being established. Dilute or follow with positive-pressure breaths to disperse into the distal tracheobronchial tree. Note: ETT dosing is 5 times higher due to erratic alveolar absorption. |
| Volume Expander | 0.9% Normal Saline (0.9% NaCl) or uncrossmatched Type O Rh-negative PRBCs | IV or IO: 10 mL/kg | Indicated for documented or suspected acute hypovolemia/blood loss (e.g., placental abruption, vasa previa, fetomaternal hemorrhage, cord avulsion) AND poor response to resuscitation (pale, weak pulses, persistent bradycardia). Infuse steadily over 5 to 10 minutes. Avoid rapid boluses in preterm infants to prevent intraventricular hemorrhage. |
[!CAUTION] Medications No Longer Recommended: Sodium bicarbonate, atropine, and calcium gluconate are NOT recommended during acute neonatal resuscitation. Sodium bicarbonate produces hypercarbia and worsens intracellular acidosis; atropine is ineffective against hypoxemic bradycardia; and routine calcium administration is associated with myocardial injury.
A term infant has received 15 seconds of positive pressure ventilation (PPV) with a well-fitted mask. The certified nurse-midwife evaluates the infant: the heart rate is 72 bpm and not increasing, and the chest is not moving with ventilations. The midwife begins the MR. SOPA ventilation corrective steps. After adjusting the mask (M) and repositioning the head into the sniffing position (R), five test breaths still result in no chest rise. What is the next immediate pair of corrective steps according to the NRP algorithm?
A term female infant is delivered following a precipitous labor complicated by a placental abruption. At delivery, the infant is limp, ashen, and apneic. Initial steps are completed, and PPV is initiated at 45 seconds of life. At 1 minute, the heart rate is 50 bpm. An endotracheal tube is placed with confirmed bilateral breath sounds and chest movement, and PPV with 100% oxygen is continued. Despite 30 seconds of effective PPV with visible chest rise, the heart rate remains 48 bpm. Chest compressions are initiated using the 2-thumb encircling-hands technique at a 3:1 ratio. After 60 seconds of coordinated compressions and ventilation, the ECG monitor shows a heart rate of 44 bpm. Intravenous access is established via an emergency umbilical venous catheter. What is the recommended pharmacologic intervention?