According to the Neonatal Resuscitation Program, what should the positive end‑expiratory pressure (PEEP) be set to on a NeoPuff T‑piece resuscitator?

PEEP Setting for NeoPuff T-Piece Resuscitator

According to the 2025 NRP guidelines, while PEEP is recognized as advantageous for maintaining lung inflation during neonatal resuscitation, the optimal level of PEEP remains undetermined due to limited human studies. 1

Guideline Recommendation

The most recent 2025 American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Guidelines explicitly state that:

• PEEP improves lung function and oxygenation and maintains lung inflation during expiration, particularly in sick or preterm infants whose lungs are prone to collapse 1
• The optimal level of PEEP remains undetermined in human neonates 1

Standard Practice Setting

Despite the lack of a specific guideline recommendation, the standard PEEP setting used in clinical practice and research studies is 5 cm H₂O 2, 3, 4, 5, 6, 7, 8. This is the most commonly referenced setting across multiple studies examining T-piece resuscitator performance.

Key Clinical Considerations

Device-Specific Issues with NeoPuff

Critical safety concern: The NeoPuff can deliver inadvertently elevated PEEP levels when:

• Gas flow is increased above the recommended 10 L/min - PEEP can rise from the set 5 cm H₂O to as high as 26.4 cm H₂O at 15 L/min 4
• The PEEP adjustment dial is accidentally manipulated during resuscitation, potentially increasing PEEP to 15 cm H₂O or higher 9
• Maximum gas flow is used - PEEP can reach dangerous levels of 71 cm H₂O 5

Practical Algorithm for PEEP Management

1. Initial setting: Set PEEP at 5 cm H₂O 2, 3, 4, 5
2. Gas flow: Maintain at 10 L/min maximum - never increase flow to compensate for poor ventilation 4, 5
3. If ventilation inadequate: Adjust mask seal or reposition airway - do NOT increase gas flow 4
4. Monitor continuously: Watch for inadvertent PEEP changes, especially in extremely low birth weight infants 9

Evidence on PEEP Benefits

PEEP administration during neonatal resuscitation reduces mortality in preterm infants (OR: 0.57,95% CI: 0.46-0.69), though evidence for term infants remains inconclusive 7. This mortality benefit supports the use of PEEP even though the optimal level is not definitively established.

Common Pitfalls to Avoid

• Never increase gas flow beyond 10 L/min - this dramatically increases PEEP and mask leak while reducing tidal volume 4, 5
• Avoid accidental manipulation of the PEEP adjustment dial during active resuscitation 9
• Do not assume set PEEP equals delivered PEEP - device characteristics and lung compliance affect actual delivered pressures 3, 8
• Be aware that higher lung compliance (more mature infants) can result in inadvertently elevated PEEP with the NeoPuff 3, 8