Positive Pressure Ventilation
Getting the basics right
The single most influential intervention in neonatal resuscitation is effective ventilation. Start with a PIP of about 20–25 cmH2O and PEEP of 5 cmH2O, rate 40–60 breaths per minute, using a T-piece resuscitator or a self-inflating bag with reservoir (which needs a PEEP valve to deliver PEEP). Ensure a good mask seal over mouth and nose with the head neutral, and watch for chest rise.
Assess by response
The best bedside measure of effective ventilation is a rising heart rate, supported by chest movement and improving SpO2. Reassess after roughly 30 seconds of ventilation, then at 15-second intervals as the situation evolves. If the heart rate does not rise or the chest does not move, run through corrective steps: Mask adjustment, Reposition the head, Suction mouth and nose, Open the mouth, Pressure increase, Alternative airway (intubation or laryngeal mask). Consider a pneumothorax if ventilation suddenly becomes difficult in an infant whose heart rate was improving.
Traps
Ventilating at too high a rate with insufficient pressure; forgetting PEEP with a self-inflating bag; increasing oxygen before fixing a mask leak; assuming an endotracheal tube is placed correctly without clinical confirmation.
Rule of thumb
Heart rate is the monitor that matters. Worked example: 90 seconds of PPV at 20 cmH2O with no chest movement and HR 80 - fix the seal, reposition, suction, then raise pressure toward 25–30 cmH2O before reaching for a tube.