# Respiratory Support in Neonatal Resuscitation -- AHA/AAP 2020

## Positive Pressure Ventilation (PPV)

PPV is the single most important and effective step in neonatal resuscitation. Approximately 10% of newborns require some respiratory assistance, and approximately 1% require intensive resuscitative measures. PPV should be initiated within 60 seconds of birth ("the Golden Minute") if the newborn is apneic, gasping, or has a heart rate < 100 bpm after completion of the initial steps (COR 1, LOE C-EO).

### PPV Devices

Any of the following may be used to deliver PPV:

| Device | Characteristics |
|--------|----------------|
| **Self-inflating bag** | Does not require gas source; does not reliably deliver PEEP or CPAP; pop-off valve typically at 30-40 cmH2O. |
| **Flow-inflating bag** | Requires gas source; can deliver PEEP/CPAP; requires experience to use effectively. |
| **T-piece resuscitator** | Requires gas source; delivers consistent preset PIP and PEEP; preferred in many NICUs for consistency. |

### PPV Parameters

| Parameter | Term Infant (>= 37 weeks) | Preterm Infant (< 35 weeks) |
|-----------|---------------------------|----------------------------|
| **Rate** | 40-60 inflations per minute | 40-60 inflations per minute |
| **Peak Inspiratory Pressure (PIP)** | 20-25 cmH2O initial; may increase up to 30 cmH2O if no chest rise | 20-25 cmH2O initial; avoid > 30 cmH2O |
| **PEEP** | 5 cmH2O when using T-piece or flow-inflating bag | 5 cmH2O (COR 2b, LOE B-R) |
| **Inflation time** | Approximately 1 second | Approximately 1 second |

### Assessing Effectiveness of PPV

After 15 seconds of PPV, assess chest movement:
- **Visible chest rise present:** Continue PPV and reassess heart rate after 30 seconds of effective ventilation.
- **No visible chest rise:** Proceed through MR SOPA corrective steps (see below).

## MR SOPA Ventilation Corrective Steps

If PPV does not produce visible chest rise, correct ventilation problems in the following stepwise order:

| Step | Action | Detail |
|------|--------|--------|
| **M** | Mask adjustment | Reapply the mask to achieve a proper seal; consider two-hand jaw-thrust technique. |
| **R** | Reposition airway | Reposition the head to the neutral/sniffing position. |
| **S** | Suction mouth and nose | Suction the oropharynx then nasopharynx to clear secretions. |
| **O** | Open mouth | Open the mouth slightly to create an oral airway. |
| **P** | Pressure increase | Gradually increase PIP by 5-10 cmH2O increments (up to maximum 40 cmH2O). |
| **A** | Alternative airway | Insert an endotracheal tube (ETT) or laryngeal mask airway (LMA). |

After each corrective step, provide several ventilation breaths and reassess for chest rise before progressing to the next step.

## Oxygen Management

### Initial FiO2 by Gestational Age

- **Term infants (>= 35 weeks):** Initiate resuscitation with 21% oxygen (room air) (COR 2b, LOE B-R). Titrate based on pulse oximetry.
- **Preterm infants (< 35 weeks):** Initiate resuscitation with 21-30% oxygen (COR 2b, LOE C-LD). Titrate based on pulse oximetry. Use of 100% oxygen at initiation is not recommended due to increased risk of oxidative injury.
- **During chest compressions:** Increase FiO2 to 100% oxygen (COR 2a, LOE C-EO). Once heart rate recovers above 60 bpm, titrate FiO2 downward guided by pulse oximetry.

### Targeted Preductal SpO2 After Birth

Place the pulse oximeter probe on the right hand or wrist (preductal) immediately after initial steps.

| Time After Birth | Target SpO2 |
|-----------------|-------------|
| 1 minute | 60-65% |
| 2 minutes | 65-70% |
| 3 minutes | 70-75% |
| 4 minutes | 75-80% |
| 5 minutes | 80-85% |
| 10 minutes | 85-95% |

These targets approximate the interquartile range measured in healthy term infants after vaginal birth at sea level. Supplemental oxygen should be titrated to maintain SpO2 within these target ranges, avoiding both hypoxia and hyperoxia.

## CPAP (Continuous Positive Airway Pressure)

- For spontaneously breathing preterm infants with respiratory distress (grunting, nasal flaring, retractions), CPAP at 5-7 cmH2O may be considered as an alternative to intubation and mechanical ventilation (COR 2b, LOE B-R).
- CPAP is not a substitute for PPV in apneic or bradycardic neonates -- PPV must be initiated first.
- CPAP may reduce the need for mechanical ventilation and surfactant administration in preterm infants.

## Intubation

### Indications for Endotracheal Intubation

- PPV with face mask or LMA is ineffective after MR SOPA corrective steps.
- Chest compressions are required (to ensure reliable ventilation during coordinated compressions).
- Prolonged PPV is anticipated.
- Specific clinical indications: congenital diaphragmatic hernia, extremely low birth weight, surfactant administration.

### Endotracheal Tube Size by Weight and Gestational Age

| Weight | Gestational Age | ETT Internal Diameter | Insertion Depth (lip) |
|--------|----------------|----------------------|----------------------|
| < 1 kg | < 28 weeks | 2.5 mm | 6.5-7 cm |
| 1-2 kg | 28-34 weeks | 3.0 mm | 7-8 cm |
| 2-3 kg | 34-38 weeks | 3.5 mm | 8-9 cm |
| > 3 kg | > 38 weeks | 3.5-4.0 mm | 9-10 cm |

- Each intubation attempt should be completed within 30 seconds.
- Confirm ETT placement by: detection of exhaled CO2 (colorimetric or capnography), bilateral equal breath sounds, visible chest rise, improvement in heart rate.

### Laryngeal Mask Airway (LMA)

A laryngeal mask airway (size 1) may be considered when face mask ventilation is ineffective and intubation is unsuccessful, particularly for infants >= 34 weeks or weighing > 2000 g (COR 2a, LOE C-LD). LMA use in infants < 34 weeks or < 2000 g is not well studied.

## Surfactant

For intubated preterm infants with respiratory distress syndrome (RDS), surfactant administration should be considered. The guideline does not specify a preferred surfactant preparation or dose protocol; institutional protocols should be followed. There is insufficient evidence to recommend a specific technique (INSURE, LISA) over another.

## Limitations

- The optimal initial FiO2 for preterm infants remains uncertain; the range of 21-30% is based on limited evidence.
- SpO2 targets are derived from observational studies in healthy term neonates after vaginal delivery at sea level and may not apply to all clinical settings (e.g., high altitude, cesarean delivery).
- Sustained inflation breaths (longer than 5 seconds) are NOT recommended for initial ventilation of preterm neonates because of insufficient evidence of benefit and potential for harm (COR 3: No Benefit, LOE B-R).
