NRP Does NOT Use Continuous Chest Compressions
No, the Neonatal Resuscitation Program (NRP) does not recommend continuous chest compressions. Instead, NRP uses coordinated compressions and ventilations at a 3:1 ratio (3 compressions followed by 1 ventilation), delivering 90 compressions and 30 breaths to achieve approximately 120 events per minute. 1
The Standard NRP Approach to Chest Compressions
Coordinated 3:1 Compression-to-Ventilation Ratio
The NRP explicitly recommends coordinating compressions and ventilations to avoid simultaneous delivery, maintaining the traditional 3:1 ratio where compressions are paused for ventilation 1
This approach delivers 90 compressions and 30 breaths per minute, totaling approximately 120 events per minute 1
Each event is allotted approximately 0.5 seconds, with exhalation occurring during the first compression after each ventilation 1, 2
Rationale for the 3:1 Ratio
Ventilation is prioritized as the most effective action in neonatal resuscitation because bradycardia in newborns is nearly always the result of inadequate lung inflation or profound hypoxemia, not primary cardiac pathology 1, 2
The 3:1 ratio is specifically designed to maximize ventilation at an achievable rate, recognizing that gas exchange compromise is the primary cause of cardiovascular collapse in neonates 1
Chest compressions are only indicated when the heart rate remains below 60 beats per minute despite 30 seconds of adequate ventilation with supplemental oxygen 1, 2
Exception: Cardiac Etiology
NRP guidelines acknowledge that rescuers may consider using higher ratios (e.g., 15:2) if the arrest is believed to be of cardiac origin rather than respiratory 1
This represents the only scenario where deviation from the 3:1 ratio is mentioned, but this still involves coordinated (not continuous) compressions
Emerging Research vs. Current Guidelines
Animal Studies on Continuous Compressions
While recent animal research has explored continuous chest compressions with asynchronous ventilation (CCCaV), these findings have not been incorporated into NRP guidelines:
A 2021 lamb study found that continuous compressions at 120/min with asynchronous ventilation increased carotid blood flow and cerebral oxygen delivery compared to 3:1 3
A 2024 preterm lamb study using continuous compressions with high-frequency percussive ventilation showed improved gas exchange and cerebral oxygen delivery, though no difference in return of spontaneous circulation 4
Why Guidelines Haven't Changed
These are pre-clinical animal studies only - the authors themselves acknowledge that neurodevelopmental outcomes and tissue injury studies are warranted before clinical trials 3, 4
Current NRP guidelines from 2015 remain the standard of care, emphasizing the proven 3:1 coordinated approach 1
The 3:1 ratio has been consistently supported through multiple guideline iterations (2010 and 2015) 1
Key Technical Points
Compression Technique
The 2-thumb encircling hands technique is preferred over the 2-finger technique because it generates higher blood pressure and coronary perfusion pressure with less rescuer fatigue 1
Compressions are delivered on the lower third of the sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest 1
The chest should be allowed to re-expand fully during relaxation, but the rescuer's thumbs should not leave the chest 1
Critical Pitfall to Avoid
- Do not start chest compressions until you have ensured that ventilation is being delivered optimally - inadequate ventilation is the most common reason for persistent bradycardia, and compressions may actually compete with effective ventilation 1