- Initiating Positive-Pressure Ventilation
- Assessing PPV Effectiveness and Corrective Steps
Initiating Positive-Pressure Ventilation
Positive-pressure ventilation is the single most important intervention in neonatal resuscitation. Most infants who end up needing compressions or medications would have responded to PPV alone if it had been started sooner or performed more efficiently. That's why PPV proficiency is where everything starts.
Indications for PPV
PPV is indicated in any newborn who, after completion of the initial steps, meets one or more of the following criteria:
- Apnea or gasping respirations
- Heart rate below 100 bpm
- Persistent central cyanosis despite free-flow supplemental oxygen
The threshold for initiating PPV is intentionally low. If there is any doubt about whether a newborn's respiratory effort is adequate, PPV should begin.
Device selection
Three devices are used to deliver PPV in neonatal resuscitation. Each has distinct advantages and limitations that influence which is appropriate in a given setting (Table 7):
Device | Advantage | Limitation |
|---|---|---|
| Self-inflating bag | No gas source required; always ready | Cannot deliver free-flow O₂; PEEP requires valve attachment; risk of over-inflation |
| Flow-inflating bag | Provides free-flow O₂; allows PEEP control; experienced providers can feel compliance | Requires compressed gas source; technical skill required to maintain seal |
| T-piece resuscitator | Delivers consistent, preset PIP and PEEP; preferred for preterm | Requires compressed gas source; cannot adjust pressure mid-breath |
The T-piece resuscitator is the preferred device for preterm infants when available, because it delivers consistent pressure with each breath regardless of provider fatigue. For term infants, any of the three devices is appropriate, provided the provider is trained in its use.
Mask selection and seal technique
Mask selection is critical to PPV effectiveness. The mask must cover the nose and mouth completely without covering the eyes or extending below the chin. Two sizes are standard: size 0 for preterm and small term infants, size 1 for term infants.
Achieving an effective seal is more important than device selection. The recommended technique is the E-C hold: the thumb and index finger form a C shape over the mask, while the remaining three fingers form an E shape under the jaw to lift the chin and maintain the airway in the sniffing position. Avoid applying excessive downward pressure, which compresses the airway rather than opening it.
Initial ventilation parameters
Once the mask is seated and the seal confirmed, ventilation begins using the parameters in Table 8.
Parameter | Term infant | Preterm infant |
|---|---|---|
| Rate | 40-60 breaths/min | 40-60 breaths/min |
| Initial PIP | 20-25 cmH₂O | 20-25 cmH₂O |
| Sustained PIP (if no chest rise) | Up to 30 cmH₂O | Up to 30 cmH₂O (with caution) |
| PEEP | ~5 cmH₂O | ~5 cmH₂O |
| Initial FiO₂ - term | 21% | - |
| Initial FiO₂ - preterm <35 weeks | - | 21–30% |
Current guidelines acknowledge that individual infant response varies and that the rate target remains 40-60/min for most infants in practice.
A rate of 40-60 breaths per minute can be maintained using the verbal cue "breathe-two-three, breathe-two-three" (one breath delivered on "breathe," passive recoil occurring during "two-three").
PEEP prevents alveolar collapse between breaths. Self-inflating bags do not deliver PEEP without a PEEP valve attachment; therefore, always confirm PEEP valve is in place if using a self-inflating bag.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
