What's the next step in a premature neonate with no increase in heart rate and no chest movement after 15 seconds of Positive Pressure Ventilation (PPV)?

Immediate Corrective Steps for Ineffective PPV

If the chest is not moving after 15 seconds of PPV, you must immediately implement ventilation corrective steps (MR SOPA) before proceeding further, as effective ventilation is the cornerstone of neonatal resuscitation and chest compressions should never be started until adequate ventilation is established. 1, 2

The MR SOPA Algorithm for Corrective Ventilation

When chest movement is absent and heart rate is not increasing, systematically apply these corrective steps in sequence:

M - Mask Adjustment

• Reposition the mask to ensure proper seal - mask leak is one of the most common causes of ineffective PPV, particularly in preterm infants where available mask sizes are often too large 3
• Ensure the mask covers the nose and mouth completely without covering the eyes or overlapping the chin 2

R - Reposition Airway

• Place the head in the "sniffing" position - slight extension of the neck to open the airway 2, 4
• Avoid hyperextension or flexion, both of which can obstruct the airway 2

S - Suction

• Suction the mouth and nose if secretions are obstructing the airway 4
• Note: Routine tracheal suctioning is NOT indicated, even with meconium-stained fluid 2

O - Open Mouth

• Open the infant's mouth slightly and reposition the mask to improve ventilation 2

P - Pressure Increase

• Gradually increase inflation pressure if chest movement remains absent 5
• Start at 20 cm H₂O, but may need to increase to 30-40 cm H₂O in some term infants 5
• The primary measure of adequate ventilation is prompt improvement in heart rate, not just chest rise 5

A - Alternative Airway

• Consider an alternative airway if the above steps fail 2
• This may include endotracheal intubation or laryngeal mask (for infants ≥34 weeks gestation or ≥2000g) 1

Critical Timing Considerations

• Continue PPV for a full 30 seconds of EFFECTIVE ventilation before reassessing heart rate 2
• The 15-second mark mentioned in your question is for the initial check, but you need 30 seconds of adequate ventilation to expect heart rate improvement 2
• Research shows that even with adequate PPV, heart rate may not increase within 15 seconds in severely bradycardic infants 6
• Do NOT start chest compressions until you have achieved 30 seconds of effective ventilation with visible chest rise 1, 2

Common Pitfalls to Avoid

• Never proceed to chest compressions without first ensuring effective ventilation - bradycardia in newborns is almost always due to inadequate lung inflation, not primary cardiac pathology 2
• Avoid excessive interruptions in PPV - studies show that 56% of resuscitations have frequent interruptions with only 60% ventilation fraction during the first 30 seconds 7
• Do not delay ventilation to establish IV access or prepare for intubation 2
• Avoid starting with 100% oxygen - begin with room air (21%) for term infants or 21-30% for preterm infants and titrate based on pulse oximetry 1, 2

Next Steps After Corrective Measures

Once you achieve effective ventilation (chest rise visible):

• Reassess heart rate after 30 seconds of adequate ventilation 2
• If HR >60 bpm: Continue PPV until HR >100 bpm and spontaneous respirations return 2
• If HR remains <60 bpm after 30 seconds of adequate ventilation with 100% oxygen: Begin chest compressions using two-thumb encircling technique with 3:1 compression-to-ventilation ratio 1, 2