5.3 Rate, PIP, and PEEP

Why Numbers Matter During the First Minutes

Once you know that PPV is indicated and which device is in your hands, you must deliver breaths with the right rate and pressure. Too slow and you under-ventilate a hypoxic myocardium. Too fast and you stack breaths, impair venous return, and lose the rhythm the team can follow. Too little pressure and the lungs never open. Too much pressure and you risk pneumothorax, air leak, and long-term lung injury—especially in preterm infants.

NRP gives you practical starting numbers, then demands titration to response. The Online Learning Assessment loves these values; skills stations watch whether your cadence and pressure discipline match them.

Ventilation Rate: 30 to 60 Breaths per Minute

The recommended assisted-ventilation rate for newborns is 30–60 breaths per minute.

9th Edition change: the 8th Edition taught 40–60 breaths per minute; the 9th Edition widened the target to 30–60 breaths per minute. If an older pocket card or practice bank still says 40–60, it reflects 8th Edition teaching.

Cadence that works under stress

A widely taught counting rhythm is:

“Breathe, two, three; breathe, two, three…”

Each “breathe” is an inspiration; “two, three” fills the time for expiration before the next breath. That pattern lands comfortably inside the 30–60 range for most providers. Alternatives exist, but whatever phrase you use, rehearse it until your hands and voice stay calm when the room is loud.

What rate is not

• Not 100–120/min (that range is related to coordinated compression–ventilation events later, not standalone PPV rate)
• Not the adult bagging rate you might use in other codes
• Not “as fast as I can squeeze”

When chest compressions begin (later chapter), the ratio becomes 3 compressions : 1 ventilation, totaling about 120 events per minute—but that is a different phase. For pure PPV before compressions, stay at 30–60/min.

Inspiratory time

Deliver a brief, controlled inspiration—enough to move the chest—then allow expiration. Extremely prolonged squeezes at high rate reduce the time for gas to leave the lung and can cause stacking. The goal is visible, gentle chest rise, not a prolonged plateau on every breath unless a specific strategy is taught for a particular device and scenario.

Peak Inspiratory Pressure (PIP)

PIP is the highest pressure applied during the inspiratory phase. It is what inflates the fluid-filled newborn lung enough to establish gas exchange.

Starting guidance (9th Edition–aligned teaching)

• The suggested initial PIP is 25 cm H₂O. The 9th Edition simplified starting pressure to this single number for all newborns needing assisted ventilation.
• Acceptable initial range by gestational age: ≥32 weeks → 25–30 cm H₂O; <32 weeks → 20–25 cm H₂O.
• The 8th Edition told everyone to “start with a PIP of 20 to 25 cm H₂O”; material that still says that is out of date.
• Some term infants with fluid-filled, stiff lungs may need higher PIP briefly to achieve the first effective inflations—then reduce once the lungs open.

There is no virtue in a permanently high number. The governing rule is:

Use the lowest PIP that achieves a rising heart rate and adequate (gentle) chest movement.

How to adjust

1. Start at the recommended initial setting for gestational age/device.
2. Look for chest movement and rising HR within a short reassessment window.
3. If no movement and HR not rising—and seal/airway have been optimized—increase PIP in increments (commonly taught in ~5–10 cm H₂O steps during corrective “Pressure” adjustments) rather than slamming to the device maximum.
4. If the chest is bouncing dramatically or HR is recovering well, wean pressure toward the minimum effective level.

On a T-piece, turn the PIP control deliberately; on a bag, watch the manometer if available. “Feel alone” is how barotrauma happens.

Pop-off valves and intentional override

Self-inflating bags may vent through a pop-off near a manufacturer limit. Occasionally a very stiff lung needs pressure above pop-off for initial inflation—only with training, monitoring, and immediate reassessment. This is advanced technique awareness, not a license to disable safety for every breath.

Positive End-Expiratory Pressure (PEEP)

PEEP is the pressure remaining in the airway at the end of expiration. It helps establish and maintain functional residual capacity (FRC) so alveoli do not fully collapse between breaths.

Typical value

When using a PEEP-capable device (T-piece, flow-inflating bag managed for PEEP, or self-inflating bag with a PEEP valve), NRP-oriented teaching commonly uses about 5 cm H₂O PEEP during neonatal PPV.

Why PEEP helps

• Recruits lung volume after fluid-filled collapse
• Stabilizes preterm lungs that lack surfactant
• May improve oxygenation at a given FiO₂
• Supports the physiology of transition by keeping air in the lung between inflations

When PEEP is missing

If your only device is a self-inflating bag without a PEEP valve, you still provide intermittent PIP breaths—do not withhold life-saving PPV because ideal PEEP is unavailable—but recognize the limitation and prefer PEEP-capable equipment when resuscitation is anticipated.

CPAP for the spontaneously breathing infant with labored respirations is related conceptually (continuous distending pressure) but is not the same as intermittent PPV rate settings; know both pathways exist.

Oxygen Concentration vs Pressure (Do Not Confuse Them)

PIP/PEEP are pressure settings. FiO₂ is oxygen fraction, titrated to preductal SpO₂ targets with a blender. Starting free air or low supplemental oxygen for term infants, and careful blending for preterm infants, is covered in oxygen-targeting content. Raising FiO₂ is not a substitute for fixing an inadequate PIP or a bad seal. Conversely, 100% oxygen does not justify crushing the chest with 40 cm H₂O on every breath when 25 cm H₂O already moves the chest and HR is rising.

During chest compressions (later), oxygen is increased to 100%—again a different phase from initial PPV pressure selection.

Avoiding Excessive Pressure

Complications of excessive PIP/tidal volume include:

• Pneumothorax and other air leaks
• Pulmonary interstitial emphysema
• Worsening bradycardia if high intrathoracic pressure impairs venous return
• Long-term lung injury pathways in preterm infants

Warning signs that should make you reassess pressure and symmetry: sudden deterioration after “good” ventilation, unequal breath sounds, shifted heart sounds, or progressive difficulty achieving chest rise after initial success. Pneumothorax management is a special-consideration topic; prevention starts with disciplined PIP.

Putting Rate, PIP, and PEEP Together

A practical initial package many teams verbalize:

• Rate 30–60/min
• PIP ~25 cm H₂O for many ≥32-week newborns (lower start often preferred if very preterm; adjust to response)
• PEEP ~5 cm H₂O if device allows
• FiO₂ per algorithm/gestational strategy with SpO₂ titration
• Reassess HR and chest movement early and often

Realistic scenarios

Scenario A. Term apneic infant. T-piece set PIP 25, PEEP 5, rate paced at “breathe, two, three.” Chest rises gently; HR climbs from 70 to 120 in short order. → Maintain, then wean support as spontaneous effort returns.

Scenario B. 28-week infant; team starts PIP 40 “to be sure.” Chest heaves; later unilateral breath sounds. → Excessive pressure was the wrong first move; start lower and titrate.

Scenario C. Bag without manometer; provider bags at nearly 100/min. Team cannot assess HR and the infant does not improve. → Slow to 30–60, improve seal, measure pressure if possible.

Scenario D. HR not rising, no chest movement at PIP 25 after seal checks. → Incrementally increase PIP as part of corrective steps; prepare alternative airway—not immediate epinephrine.

Exam Checklist

• Rate 30–60; know the breathe, two, three mnemonic
• Suggested initial PIP 25 cm H₂O (acceptable range 25–30 if ≥32 weeks, 20–25 if <32 weeks); lowest effective always
• PEEP typically 5 when available
• Titrate to rising HR + chest movement
• Avoid maximum pressure as a default

Master these numbers so that when simulation noise rises, your hands still deliver calm, effective, lung-protective ventilation.