What is the next step in resuscitating a 36-week gestation newborn with gasping respirations and a heart rate of 28 beats per minute (bradycardia)?

Immediate Positive-Pressure Ventilation with 21% Oxygen

The next step is to immediately initiate positive-pressure ventilation (PPV) with 21% oxygen (room air) for this 36-week gestation newborn with gasping respirations and severe bradycardia (heart rate 28 bpm). 1, 2

Rationale for This Approach

Why PPV is the Priority

• Ventilation is the cornerstone of neonatal resuscitation because bradycardia in newborns results from inadequate lung inflation and profound hypoxemia, not primary cardiac pathology 3, 1, 2
• A heart rate of 28 bpm with gasping respirations indicates severe respiratory compromise requiring immediate establishment of effective ventilation 1, 2
• The American Heart Association recommends initiating PPV immediately for infants with apnea, gasping respirations, or heart rate <100 bpm 1, 2
• Approximately 60 seconds after birth is allotted to complete initial steps and determine heart rate, after which PPV should be initiated if the heart rate remains inadequate 2

Why 21% Oxygen (Not 100%)

• The American Heart Association strongly recommends starting with 21% oxygen (room air) rather than 100% oxygen for term and late-preterm newborns (≥35 weeks gestation) receiving respiratory support at birth 3
• 100% oxygen should NOT be used to initiate resuscitation because it is associated with excess mortality 3
• At 36 weeks gestation, this infant qualifies as late-preterm (≥35 weeks), making 21% oxygen the evidence-based initial concentration 3
• Oxygen concentration should be titrated upward based on pulse oximetry readings if the heart rate does not improve with adequate ventilation 1, 2

Why Other Options Are Incorrect

Endotracheal Intubation (Option A)

• Endotracheal intubation is NOT the first-line intervention and is reserved for situations where mask ventilation is ineffective, prolonged ventilation is required, or chest compressions are needed 2
• The vast majority of bradycardic newborns will respond to effective PPV with a face mask alone 2
• Delaying ventilation to establish advanced airway access worsens outcomes 2

Nonrebreather Mask (Option B)

• A nonrebreather mask provides passive oxygen delivery without positive pressure and is completely inadequate for a severely bradycardic, gasping newborn 1, 2
• This infant requires active lung inflation with positive pressure, not just supplemental oxygen 3, 1

PPV with 100% Oxygen (Option D)

• Starting with 100% oxygen is explicitly NOT recommended (Class 3: Harm) for late-preterm and term infants 3
• The 2019 American Heart Association guidelines state that 100% oxygen should not be used to initiate resuscitation due to association with excess mortality 3
• While oxygen concentration should be increased to 100% if chest compressions become necessary, this is a subsequent step only after adequate ventilation with lower oxygen concentrations has been attempted 3

Implementation Algorithm

1. Immediately begin PPV with 21% oxygen using a face mask and appropriate device (flow-inflating bag, self-inflating bag, or T-piece resuscitator) 1, 2
2. Apply ventilation at 40-60 breaths per minute with initial pressure of 20 cm H₂O (though 30-40 cm H₂O may be necessary in some term infants) 2
3. Reassess heart rate after 30 seconds of adequate ventilation 3, 2
4. If heart rate improves to >60 bpm, continue PPV until heart rate >100 bpm and spontaneous respirations establish 2
5. If heart rate remains <60 bpm after 30 seconds of adequate ventilation, increase oxygen to 100% and prepare to initiate chest compressions 3
6. Use pulse oximetry to guide oxygen titration, targeting preductal saturations that match healthy term newborns (60-65% at 1 minute, gradually reaching 85-95% by 10 minutes) 2

Critical Pitfalls to Avoid

• Do not delay ventilation to establish IV access, prepare for intubation, or perform unnecessary procedures 2
• Do not start with 100% oxygen – begin with room air and titrate based on pulse oximetry and clinical response 3, 2
• Do not start chest compressions until after 30 seconds of adequate ventilation, as the vast majority of bradycardic newborns will respond to effective ventilation alone 2
• Ensure adequate ventilation technique before escalating interventions – the primary indicator of effective ventilation is a rising heart rate, not just chest rise 2