Providing Ventilation to the Newborn Infant
in the Delivery Room
AUTHOR DISCLOSURE Drs Josephsen and
Strand have disclosed no financial
relationships relevant to this article. This
commentary does not contain a discussion of
an unapproved/investigative use of
a commercial product/device.
ABBREVIATIONS
BPD bronchopulmonary dysplasia
CPAP continuous positive airway pressure
ETT endotracheal tube
FiO2 fraction of inspired oxygen
NRP Neonatal Resuscitation Program
PEEP positive end-expiratory pressure
PIP peak inspiratory pressure
PPV positive pressure ventilation
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Justin B. Josephsen, MD,* Marya L. Strand, MD, MS*
*Department of Pediatrics, Saint Louis University, St. Louis, MO
Education Gap
Ventilating the lungs of the newborn is the most important element of
neonatal resuscitation. Recognizing and delivering effective ventilation
remains a critical skill for all attendants at a newborn delivery.
Objectives After completing this article, readers should be able to:
1. Recognize the critical role of ventilation in the delivery room.
2. Identify the signs of effective ventilation.
3. Understand devices that deliver positive pressure ventilation.
INTRODUCTION
The Neonatal Resuscitation Program (NRP) emphasizes the importance of ven-
tilation in the resuscitation of compromised newborns. (1) The purpose of this re-
view is to explain the physiologic necessity of ventilation in newborn resuscitation
and to describe the different methods of providing ventilation in the delivery room.
We will also discuss the assessment of ventilation to ensure efficacy.
CARDIORESPIRATORY TRANSITION AT BIRTH
Blood flow during fetal life is focused on perfusion of the brain and major organs
with oxygenated blood and avoidance of fluid-filled lungs (Fig 1A). This blood flow
is dependent on oxygenated umbilical venous blood from the placenta.
Normal cardiopulmonary transition of the newborn from intra- to extrauterine life
requires a rapid and complex process of fetal lung fluid clearance, expansion of the al-
veolar spaces with air, and redirection of cardiac output toward the lungs. All of these
events take place independent of intervention in most newborns at the time of delivery.
(2) Failure of any of these events can cause delays in transition or progress to asphyxia.
Fetal lung fluid produced by the pulmonary epithelium fills the pulmonary
spaces during gestation. The pressure of fluid within air spaces and resistance
to outflow through the glottis facilitates the growth and development of lung
parenchyma. Rapid fluid clearance at birth likely occurs via several mechanisms,
Figure 1. A. Fetal circulation path. Only a small amount of blood travels to the lungs. There is no gas exchange in the lung. Blood returning to the right
side of the heart from the umbilical vein has the highest oxygen saturation. B. Transitional circulation path. The infant breathes, pulmonary resistance
decreases and blood travels to the lungs. Gas exchange occurs in the lungs. Blood returning to the left side of the heart from the lungs has the highest
oxygen saturation. (From Textbook of Neonatal Resuscitation, 7th ed., 2016. Reproduced with permission from the American Academy of Pediatrics.)

including fetal postural changes, cellular sodium channel
pumps, and transpulmonary pressure from inspiration after
delivery. (3) Infants with apnea are unable to contribute to
the transpulmonary pressure (which can range from –28 to
–105 cm H2O pressure), (4) which can significantly com-
promise fluid clearance from the air spaces.
Once the fetal lung fluid is cleared and air fills the alveoli,
the pulmonary arterial pressure drops precipitously to
increase blood flow from the heart to the lungs. With this
change in cardiac output and transition of gas exchange to
the pulmonary bed, the left ventricular preload shifts from
the umbilical venous return from the placenta to pulmonary
venous return (Fig 1B). The systemic vascular resistance
increases simultaneously to result in left-to-right flow
through the ductus arteriosus and the beginning of ductal
closure.
Lung expansion and establishment of pulmonary functional
residual capacity and respiration is vital to the normal transi-
tion of the newborn. When the umbilical cord is clamped after
delivery, the venous return from the placenta abruptly ceases. If
the lungs have not yet expanded before the clamping of the
umbilical cord, the preload to the left ventricle is compromised
and cardiac output falls. With the resultant hypoxemia, brady-
cardia ensues with further respiratory failure and asphyxia.
The newborn’s physiologic response to asphyxia was
established in animal experiments in the 1960s. (5)(6)(7)(8)
The sequence of responses to asphyxia is the same for
newborn animals and humans. Primary apnea occurs when
the pulmonary expansion and perfusion are compromised,
usually from the fluid-filled alveoli. Gasping then precedes
a period of secondary apnea. Secondary apnea is followed by
bradycardia and eventual hypotension. (7)
These early animal studies also showed that ventilation
of the lungs is sufficient, by itself, for resuscitation of the as-
phyxiated newborn. (6)(7)(8)(9) Only newborns with critically
low mean arterial pressure were unable to be resuscitated with
ventilation alone. It is important to note that effective ventilation
(with adequate expansion of the pulmonary air spaces and
perfusion of the lungs) is the required resuscitative measure.
Chest compressions alone do not revive asphyxiated newborns,
and are useful only as an adjunct to adequate ventilation. (9)
Assessment of Ventilation Efficacy
An increasing heart rate response is the most reliable indi-
cator of adequate ventilation. (10) Upon initiation of positive
pressure ventilation (PPV) during a neonatal resuscitation,
the assessment must include an indication of heart rate
response. (1) Other ancillary indicators of effective ventilation
in the delivery room include visible chest wall rise, exhalation
of carbon dioxide, and respiratory function monitoring.
Rise of the chest wall during PPV is a quick and easily
assessed marker of effective ventilation. The accuracy of the
human perception of chest rise has been questioned, however.
(11) Visual impediments, such as equipment or other person-
nel, practitioner positioning, and abdominal movement instead
of chest wall movement, can impede proper interpretation.
Studies have reported that accurate assessment of chest wall
rise in the preterm population is particularly difficult. (12)(13)
Colorimetric carbon dioxide monitoring has been stud-
ied as a proxy for adequacy of gas exchange during PPV.

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 Figure 2. The 6 ventilation corrective steps: MR. SOPA (From Textbook of Neonatal Resuscitation, 7th ed., 2016. Reproduced with permission from the
American Academy of Pediatrics.)

Placement of the carbon dioxide monitor in line with the of troubleshooting ventilation, in the face of nonresponse
PPV device and mask can reflect the inspiratory/expiratory of the newborn, should be completed in 15 to 30 seconds,
cycle of PPV. A cycling color change during exhalation exclusive of alternative airway placement. A video demon-
indicates the presence of a patent airway. (14) A change in strating the troubleshooting can be found by clicking on
color on the monitor, when used, is also observed before the the Video link below or on the free NRP mobile application,
response in heart rate, indicating that efficacy of ventilation available at https://itunes.apple.com/us/app/nrp-app-neonatal-
precedes a heart rate response. (15) resuscitation/id1125320382?mt=8 or https://play.google.com/store/
Higher technology devices to monitor respiratory func- apps/details?id=com.nrp.nrp.
tion have also been used to assess ventilatory efficacy in the
delivery room. These monitoring devices allow for inspira-
tory and expiratory tidal volume measurements, gas flows,
and mask leak and pressures. (13) The use of such high-
technology monitoring allows practitioners to adjust mask
position, view tidal volume being delivered, and more fully
understand the physiology of the infant during resuscita-
tion. Concern remains, however, about how much informa-
tion a health care practitioner can integrate and properly use
in a crisis such as a delivery room resuscitation. (16)

Troubleshooting Ineffective Ventilation Video: Click here to view the video.

A lack of heart rate response to PPV requires investigation.
The mnemonic MR. SOPA was introduced by the NRP (Fig 2).
(1) This mnemonic addresses the fact that most of the difficulty
with effective PPV results from mask leak or position as well
as airway patency. (13) If repositioning the airway and adjusting
the mask to eliminate leak do not result in lung expansion with
improvement in heart rate, there may be a blockage to airway
patency. Suctioning with a bulb or catheter may be indicated.
Opening the mouth of the newborn decreases resistance to
airflow compared with the nares. If PPV remains ineffective, the
newborn may require increased pressure to establish lung
inflation and functional residual capacity. (17) If the newborn
does not respond to increased inspiratory pressure, an
alternative airway may be required. This entire process
VENTILATION TECHNIQUES
PPV administration is currently recommended for newborns
(preterm and term) who have poor respiratory effort, apnea,
or bradycardia. Positive end-expiratory pressure (PEEP) to
maintain functional residual capacity is postulated to be
beneficial when administered with PPV, though there are
few studies available to support this speculation. Two recent
studies showed more rapid improvement in heart rate and no
reduction in mortality, need for chest compressions, or need
for delivery room intubation when PPV was applied with
a device supplying PEEP. (18)(19) In one of these studies, the
highest need for supplemental oxygen to reach saturation

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targets was reduced when using a device that can supply
PEEP, though the clinical significance may be small (highest
oxygen needed 46% vs 50%). (18) This study also showed
a reduced maximum positive inspiratory pressure needed to
provide ventilation to the infant in the device that supplied
PEEP. The current NRP and International Liaison Committee
on Resuscitation guidelines recommend approximately 5 cm
H2O of PEEP when resuscitating preterm infants. (10)
The optimal length of the inspiratory time (i-time) and
the inspiratory-to-expiratory (I:E) ratio are unknown. The
current 2015 NRP guidelines do not offer guidance on
a recommended i-time, but do suggest an I:E ratio of 1:2,
using the “Breathe, Two, Three” sequence. (1) Using the
recommended respiratory rate of 40 to 60 breaths/min, this
would suggest an i-time of 0.25 to 0.33 seconds.
A sustained initial lung inflation of more than 5 seconds
has been postulated to be beneficial. Three randomized
controlled studies examining 404 premature newborns
showed that this approach decreased the need for intubation
in the first 72 hours after birth. (20)(21)(22) However, these
studies did not find a difference in either bronchopulmo-
nary dysplasia (BPD) or decreased mortality in these co-
horts. Because of this, routine use of sustained inflation for
more than 5 seconds is not currently recommended, though
in individual circumstances, it might be used. (23) Larger,
randomized controlled trials are currently ongoing, which
may change future practice recommendations.
Extremely premature infants with spontaneous breathing
and infants in respiratory distress may benefit from contin-
uous positive airway pressure (CPAP) without the need for
PPV. Compared with PPV and intubation, using CPAP for
initial ventilation support resulted in reduced delivery room
intubations for spontaneously breathing infants, but did not
result in a decrease in death, BPD, or intraventricular
Figure 3. Three types of devices are commonly used for positive pressure ventilation: a self-inflating bag, a flow-inflating bag, or a T-piece resuscitator.
(From Textbook of Neonatal Resuscitation, 7th ed, 2016. Reproduced with permission from the American Academy of Pediatrics.)
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hemorrhage. (24)(25)(26) Furthermore, similar respiratory
outcomes of former extreme premature infants at 8 years of
age were similar in an early cohort (1991–1992) that used
CPAP less frequently, compared with a later cohort (2005),
which used CPAP more frequently. (27) Given this, CPAP
may be preferred over intubation and mechanical ventila-
tion in spontaneously breathing premature infants. (10)
VENTILATION DEVICES
The current NRP guidelines suggest that PPV can be effectively
administered with any of 3 devices: a T-piece resuscitator, flow-
inflating bag, or a self-inflating bag (Fig 3). (10)(18)(19) Though
any of these is considered acceptable, each device has relative
strengths and weaknesses. The choice should be based on the
skills of the resuscitator, the availability of compressed gasses,
and the type of ventilation assistance needed (PPV or CPAP).
T-Piece Resuscitator
The T-piece resuscitator (Fig 3, last panel) requires compressed
air and oxygen sources with a blender. When PPV is needed,
the device provides reliable PEEP, and when PPV is not
needed, it also provides reliable CPAP. It delivers a consistent
peak inspiratory pressure (PIP) for each breath. A consistent
PIP allows for a more consistent tidal volume to be delivered
if lung compliance remains stable, reducing the potential
lung injury from higher pressures and tidal volumes. (28)
(29) Positive pressure is delivered by occluding the PEEP valve
at the end of the device. Increasing or decreasing the PIP or
PEEP delivered to the neonate is achieved by manually adjust-
ing the respective dials. Though this device may be easier to
use and even preferred by some experienced and inexperi-
enced providers, (30) PIP adjustment has been shown to occur
more slowly than with other ventilation devices. (31) This
device can deliver a fraction of inspired oxygen (FiO2) of 1.0.
Vol. 18 No. 11 NOVEMBER 2017 e661
 Flow-inflating Bag
The flow-inflating bag (Fig 3, middle panel) also requires
continuous compressed air and oxygen sources along with
a blender. It can deliver both reliable PEEP and CPAP, but
the delivery of effective PIP is operator-dependent. Positive
pressure is generated by squeezing the attached bag, which is
inflated with the compressed gas. To ventilate with a higher
PIP, the provider must squeeze the bag with more force. This
device may require more technical skill to operate compe-
tently. Similar to the T-piece resuscitator, the flow-inflating
bag is capable of delivering an FiO2 of 1.0 and can more
reliably provide a sustained breath of at least 5 seconds. (32)
Self-inflating Bag
The self-inflating bag (Fig 3, first panel) is the only device that
can deliver PPV without an external source of compressed gas
to ventilate the lungs. Supplemental oxygen can be provided
when the bag is attached to an oxygen source. Because of air
mixing in the self-inflating bag (pop-off valve, expiratory valve,
etc), oxygen concentrations delivered to the infant cannot be
precisely known. By supplying an FiO2 of 1.0 at 5 L/min flow
with NRP-recommended PIP and respiratory rates, more
than 80% oxygen may be delivered to the infant without
a reservoir. With the addition of a reservoir, higher oxygen
concentrations can be achieved. (33)
With the self-inflating bag, PEEP may be delivered with the
addition of a PEEP valve to the device, but it may not be
effective or reliable. (19)(34)(35)(36) This valve is typically
spring-loaded, and is affixed to the expiratory end of the device,
adjacent to the expiratory valve. During exhalation, the expira-
tory valve opens as a result of the pressure differential between
the high pressure at the end of inspiration and the lower
atmospheric pressure. The adjustable spring of the PEEP valve
compresses the expiratory valve, increasing expiratory resis-
tance, and thus, maintaining pressure during the exhalation
phase. As the intrathoracic and extrathoracic pressures equal-
ize, the resulting pressure differential at the end of exhalation
continues to fall until another breath is given through the self-
inflating device. Because the end-expiratory pressure will fall to
zero in the absence of ongoing PPV, this device cannot be used
to provide CPAP, even when a PEEP valve is present.
endotracheal tube (ETT) sizes of 2.5 to 3.5 mm, depending
on estimated infant size. The 4.0-mm ETT is no longer
recommended for use in the delivery room. (1)
Laryngeal Mask
The laryngeal mask device is an advanced airway that is inserted
in the mouth and rests on the hypopharynx, over the supra-
glottic structures, to provide ventilation through an isolated
trachea. This can be used as an alternative to endotracheal
intubation, and appears to provide more effective ventilation
than bag-mask ventilation alone. (37)(38) The laryngeal mask
can be placed quickly with success, which might provide an
advantage over endotracheal intubation when skilled providers
of intubation are not present. (39)(40) This device can provide
effective ventilation for infants of at least 34 weeks’ gestation with
a weight greater than 2,000 g. It is not well-studied in smaller or
more premature infants. It is also not well-studied when used
with coordinated neonatal chest compressions or for admin-
istration of emergency medications, such as epinephrine.
VIGNETTE
The video shows a newborn resuscitation in the delivery
room. Multiple, high-resolution cameras are able to record
the infant, personnel, and instrument panels during the
stabilization. A 605-g infant was born at 24 6/7 weeks’
gestation following unrelenting preterm labor. The neonate
received 60 seconds of delayed cord clamping. The heart
rate remained below 100 beats/min until corrective mea-
sures for ventilation were taken appropriately.

ADVANCED AIRWAYS

Endotracheal intubation is indicated if effective ventilation

cannot be provided with a standard face mask, if prolonged
ventilation is needed, if chest compressions are performed, or
in specific clinical circumstances (ie, congenital diaphrag-
matic hernia). The NRP currently recommends uncuffed Video: Click here to view the video.

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Key Events in Video
1. Team briefing
2. Mask and airway repositioning
3. Increase in positive airway pressure
4. Unsuccessful intubation
5. Improvement in heart rate and oxygen saturations after
correction of incorrect respiratory rate and a longer I:E ratio
6. Successful intubation with a stable heart rate
The infant was discharged from the hospital in room air
near term postmenstrual age. All individuals have provided
written permission for educational use of this video.
CONCLUSION
The establishment of effective ventilation is the most critical
aspect of neonatal resuscitation. In an infant with apnea or
bradycardia, this can be achieved using bag-mask ventila-
tion. All the available devices for bag-mask ventilation are
effective, but the provider must understand the relative
strengths and limitations of each device.
A rising heart rate is the most reliable marker of effective
ventilation. If this cannot be achieved with bag-mask ven-
tilation, ventilation corrective steps (MR. SOPA) must be
taken, and if the infant does not respond, alternative airway
placement is imperative. When endotracheal intubation is
not successful, or if the providers are not skilled in ETT
placement, a laryngeal mask should be strongly considered
as an alternative.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the proper approach to airway management in the
delivery room.
• Know the indications for assisted ventilation, including
continuous positive airway pressure, immediately after birth and
how to assess its effectiveness.
• Understand how to use self-inflating and flow-inflating bags
or T-piece resuscitators to provide assisted ventilation
immediately after birth.
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 Providing Ventilation to the Newborn Infant in the Delivery Room
Justin B. Josephsen and Marya L. Strand
NeoReviews 2017;18;e658
DOI: 10.1542/neo.18-11-e658

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 Providing Ventilation to the Newborn Infant in the Delivery Room
Justin B. Josephsen and Marya L. Strand
NeoReviews 2017;18;e658
DOI: 10.1542/neo.18-11-e658

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