How should we perform neonatal mask ventilation during MR SOPA corrective steps?

To the Editor,

Approximately 5% of neonates require positive pressure ventilation (PPV) after birth.¹ In newly born infants who remain apnoeic or whose breathing efforts are inadequate despite tactile stimulation, mask ventilation should be initiated without delay. The European Resuscitation Council (ERC) guideline from 2021 recommends starting with five inflation breaths where a high inflation pressure is maintained for 2–3 s.¹ The American Heart Association (AHA) guideline, on the other hand, recommends starting PPV with a rate of 40–60 per minute.² These discrepancies can be explained by the lack of evidence for either of the approaches.

Effective PPV with adequate lung aeration leads to bilateral chest rise with a subsequent increase in heart rate. In case of inadequate PPV, the ERC guideline recommends the following corrective steps: equipment check, recheck of airway and head position, recheck of the face mask for appropriate size, position and seal, 2-person face mask ventilation, insertion of an oro-/nasopharyngeal airway, laryngeal mask or endotracheal tube, and increasing the peak inspiratory pressure.¹ The Neonatal Resuscitation Program (NRP) summarizes these steps using the acronym “MR SOPA”.3, 4 Once effective ventilation has been established with the help of MR SOPA corrective steps, the ERC guideline suggests to repeat the five prolonged inflations with an inspiratory time of 2–3 s, before continuing with PPV with short ventilation breaths using an inspiratory time of 0.3–0.4 s.¹

However, the ERC guideline does not explicitly mention how PPV should be performed during MR SOPA corrective steps. When recommending a type of respiratory support in this situation, there are at least two aspects to be considered: First, neonatal resuscitation is a complex and dynamic situation, where focus and attention of involved care givers may shift frequently.⁵ Based on our observations from simulation-based trainings and research, shorter ventilation breaths may be delivered more easily in such situations of high mental workload and intrinsic stress. This may particularly be the case if the initial prolonged inflations were ineffective. Second, clinical effects and effectiveness of the MR SOPA interventions must be assessed rapidly, which again favours short ventilation breaths over those with a longer inspiratory time.

These thoughts represent our individual opinion about a specific, yet essential aspect of the ERC algorithm dedicated to postnatal resuscitation and the support of transition after birth. We are well aware that our speculation is based on pre-clinical studies and, thus, requires rigorous testing in a dedicated prospective study. Meanwhile, we ask the ERC to recommend the use of the internationally known and widely used acronym MR SOPA to provide healthcare professionals with an important cognitive aid, which can be trained regularly to improve clinical outcomes.⁶ Furthermore, we would appreciate if the next revision of the ERC guidelines offered an explicit recommendation regarding the type of PPV during MR SOPA corrective steps, aiming to unify the resuscitation of newly born infants during postnatal transition.

Author contributions

Lukas P. Mileder: Conceptualization, Writing - Original draft preparation.

Michael Wagner: Conceptualization, Writing - Reviewing and Editing.

Maxi Kaufmann: Conceptualization, Writing - Reviewing and Editing.

Vincent D. Gaertner: Conceptualization, Writing - Reviewing and Editing.

Christoph M. Rüegger: Conceptualization, Writing - Reviewing and Editing.

Laila Springer: Conceptualization, Writing - Reviewing and Editing.

Declarations of interest

None.