What is the recommended initial peak inspiratory pressure (PIP) for positive pressure ventilation (PPV) in a term newborn?

Initial Peak Inspiratory Pressure for PPV in Term Newborns

For term newborns requiring positive pressure ventilation, start with an initial peak inspiratory pressure of 20 cm H₂O, but be prepared to increase to 30-40 cm H₂O if you do not see prompt improvement in heart rate or visible chest rise. 1

Starting Pressure Algorithm

Step 1: Begin with 20 cm H₂O

• Start PPV at 20 cm H₂O as your initial pressure if monitoring is available 1
• This pressure may be effective in some term infants, though it is more reliably effective in preterm infants 1

Step 2: Assess Response Within Seconds

• Immediately evaluate for two key indicators: 1
  • Increase in heart rate
  • Visible chest movement/expansion

Step 3: Titrate Upward as Needed

• If no improvement in heart rate or chest rise occurs, increase PIP to 30 cm H₂O 1
• This pressure (30 cm H₂O) can usually achieve adequate ventilation in term infants 1
• Some term babies will require 30-40 cm H₂O to establish effective ventilation 1
• Higher pressures are occasionally necessary, but should only be used when lower pressures fail 1

Step 4: Use Clinical Response, Not Arbitrary Limits

• The goal is the minimal inflation pressure required to achieve heart rate improvement—individualize each breath based on response 1
• If pressure monitoring is unavailable, use the minimal inflation that produces visible chest rise and heart rate increase 1

Critical Rationale and Evidence Strength

The 2010 International Consensus guidelines from both the American Academy of Pediatrics and American Heart Association provide consistent, high-quality guidance on this question 1. These guidelines emphasize that initial peak inflating pressures are variable and unpredictable—they must be individualized with each breath based on the infant's response 1.

The evidence base shows that term infants typically require higher initial pressures than preterm infants (30 cm H₂O versus 20-25 cm H₂O) to overcome the higher compliance requirements of fluid-filled lungs at birth 1. However, starting conservatively at 20 cm H₂O allows you to avoid unnecessarily high pressures in infants who respond to lower settings 1.

Common Pitfalls and How to Avoid Them

Pitfall 1: Using Excessive Pressure from the Start

• Avoid starting at 40 cm H₂O without first trying lower pressures 1
• Animal studies demonstrate that high tidal volumes and peak pressures cause lung injury, impaired gas exchange, and reduced compliance even after just a few minutes 1
• There is no evidence supporting pressures higher than necessary to achieve clinical response 1

Pitfall 2: Failing to Escalate When Needed

• Do not persist with inadequate pressures if there is no heart rate improvement or chest rise 1
• Delayed effective ventilation compromises outcomes more than brief exposure to higher pressures 1

Pitfall 3: Not Monitoring Pressure

• When possible, use pressure monitoring to provide consistent inflations and avoid unnecessarily high pressures 1
• Measured peak inflation pressure does not correlate perfectly with delivered volume, but monitoring helps maintain consistency 1

Pitfall 4: Ignoring Device Limitations

• Self-inflating bags may deliver inconsistent pressures and cannot reliably provide PEEP even with a PEEP valve attached 2, 3
• T-piece resuscitators deliver more consistent and accurate pressures compared to manual bags 3

PEEP Considerations for Term Infants

• There is no evidence to support or refute routine PEEP use during resuscitation of term infants 1
• If using a device capable of delivering PEEP (T-piece resuscitator or flow-inflating bag), approximately 5 cm H₂O is reasonable based on preterm infant data, though evidence is limited 2, 4
• Avoid high PEEP levels (8-12 cm H₂O) as these may reduce pulmonary blood flow and increase pneumothorax risk 1, 2, 5, 4