Timing of Chest Compressions in Neonatal Resuscitation
Chest compressions should be initiated after 30 seconds of adequate positive pressure ventilation if the heart rate remains below 60 beats per minute. 1
Critical Timing Algorithm
The sequence is straightforward:
- Begin positive pressure ventilation (PPV) immediately for a bradycardic newborn with impaired breathing efforts 1
- Ensure ventilation is truly adequate for a full 30 seconds 1
- If heart rate remains <60 bpm after these 30 seconds of effective ventilation, start chest compressions 1, 2
Why Ventilation Must Come First
Ventilation is the single most critical intervention in neonatal resuscitation because bradycardia in newborns is nearly always caused by inadequate lung inflation or profound hypoxemia, not primary cardiac pathology. 1, 3
The 30-second window before starting compressions is essential because:
- It allows time to establish effective ventilation and lung recruitment 1
- Most bradycardic newborns will respond to ventilation alone without requiring chest compressions 4
- Starting compressions prematurely can actually interfere with effective ventilation 1, 3
Once Compressions Begin: The 3:1 Ratio
When compressions are indicated, they must be coordinated with ventilations at a 3:1 ratio (90 compressions and 30 breaths per minute, totaling approximately 120 events per minute). 1, 3
This means:
- Each compression-ventilation cycle takes approximately 0.5 seconds 1, 3
- Three compressions are delivered, followed by one ventilation 1, 3
- Compressions and ventilations should NOT be delivered simultaneously 1, 3
- Exhalation occurs during the first compression after each ventilation 1, 3
Critical Pitfalls to Avoid
The most common error is starting chest compressions without ensuring ventilation is truly adequate. 3 Before initiating compressions, verify:
- The chest is visibly rising with each breath 2
- Adequate inflation pressures are being used (may need 30-40 cm H₂O) 3, 2
- The airway is properly positioned 1
- If using an endotracheal tube, confirm proper placement 1
Another critical mistake is using asynchronous compressions that compete with the heart's intrinsic activity during bradycardia. 5, 4 The current guidelines recommend coordinated 3:1 compressions specifically to maximize ventilation while the heart still has some activity 1
Emerging Evidence Considerations
Recent animal studies suggest that continuing ventilation beyond 30 seconds (even up to complete cardiac arrest) may reduce the need for chest compressions and improve outcomes. 4 However, current American Heart Association and American Academy of Pediatrics guidelines remain clear: initiate compressions at 30 seconds if heart rate is <60 bpm despite adequate ventilation. 1, 6
Oxygen Management
Increase oxygen concentration to 100% when chest compressions are started. 1, 3 Once heart rate recovers, wean supplemental oxygen promptly to reduce hyperoxia-related complications 1, 3