Clearing Secretions and Positioning the Baby’s Head and Neck

The team member responsible for PPV is positioned at the head of the bed. Before initiating PPV, the team member must clear secretions in the baby’s mouth and nose with a bulb syringe. They also open the newborn’s airway. 

The baby’s head and neck should be put in either a neutral position or slightly extended (the sniffing position) so that the infant’s chin and nose point toward the ceiling. Sometimes the newly born presents with an elongated occiput. A rolled-up towel placed under the baby’s shoulders helps maintain the head and neck in a neutral position. 

Other team members position themselves at either side of the bed. One person connects the baby to a pulse oximeter. Team members also assess the infant’s chest rise, breath sounds, and heart rate.

Infant in sniffing position.

Mask Selection and Placement

Face masks of different sizes must be available to the resuscitation team. The properly sized mask covers the nose and mouth, but not the eyes, and forms a tight seal. If a mask is too large, it will not form a tight seal, and if too small, it may not cover the nose and mouth.

The mask must have a cushioned rim that allows a tight seal without causing harm to the baby’s face. Some masks are round, while others are anatomically (pear) shaped. The pointed edge of an anatomically shaped mask sits on the nose, and the rounded edge rests on the chin. 

When placing the mask, one must keep in mind the delicate nature of the newborn’s anatomy. Caution must be taken around the infant’s face. Too much pressure may cause a leak around the rim of the mask. Also, too much pressure can cause trauma to the infant. The team must avoid putting pressure on the baby’s eyes or compressing the neck. The infant’s head and neck position should be reassessed frequently to ensure airway patency throughout the intervention.

Correct and Incorrect Size and Placement of Infant Face Mask

One-Handed Technique

The E-C Technique allows the clinician to hold the mask in place and simultaneously deliver breaths with the resuscitation bag or T-piece resuscitator. With the E-C technique, the mask is stabilized with the thumb and index finger while the remaining three fingers rest at the angle of the mandible. A tight seal is formed by applying downward pressure on the rim of the mask. The three fingers cupping the mandible help keep the head and neck in the neutral or sniffing position.

Some masks can be held by the stem. In this situation, the thumb and index finger grasp the mask, and then downward pressure is applied to the baby’s face.

Two-Handed Technique

When resources allow, the two-handed technique is the preferred method for achieving a tight seal and maintaining the head and neck position to allow airway patency. One provider uses the thumbs and index fingers of both hands to hold the mask against the baby’s face. The remaining fingers are placed under the angle of the mandible. Then the provider gently lifts the jaw toward the mask. Another team member is responsible for delivering PPV by squeezing the bag or occluding the cap on the T-piece resuscitator. 

Setting the Oxygen Concentration

The oxygen concentration on the bag or T-piece resuscitator should be titrated to achieve and maintain the predicted preductal oxygen saturation. Once PPV begins, a team member places a pulse oximeter on an extremity with preductal circulation, usually the right hand or wrist. 

Initial PPV should begin with the oxygen concentration set to room air (i.e., 21%) for babies born at 35 weeks and up. The team can set the initial oxygen concentration for babies born < 35 weeks gestation between 21% and 30%. The flow meter should be set to 10 L/min.

Positive Pressure Ventilation Rate

The baby needs 40–60 breaths per minute. Counting out loud with the following rhythm helps the person delivering the breaths maintain a constant rhythm, “Breathe, two, three, breathe, two, three, breathe, two, three….”

Pressure Settings (PIP and PEEP)

Functional residual capacity (FRC) is the volume of air present in the lungs at the end of expiration. At birth, the alveoli are filled with fluid, so the baby has not yet established FRC. For the baby requiring PPV, the team must use a high enough pulmonary inflation pressure (PIP) to replace the fluid with air. An initial inflation pressure of 20–25 cm H₂O is recommended for preterm babies; full term infants may require somewhat higher pressures for the first few breaths.

PEEP helps to quickly remove the fluid in the lungs by preventing the alveoli from collapsing during exhalation. Thus, the resuscitator must have a PEEP setting of at least 5 cm H₂O.

Once lung inflation is achieved, there should be a visible rise and fall of the newborn’s chest with each breath. If the newborn’s chest rise is excessive, PIP settings may be too high, and volutrauma or barotrauma may occur. Excessive pressure delivery can cause a pneumothorax. The person bagging the baby should decrease the PIP delivery.

Preterm babies may be successfully ventilated without obvious chest rise. Premature lungs are particularly vulnerable to volutrauma. Breath sounds and an improvement in HR are the best guides to effective PPV.