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Corrective steps to enhance ventilation in the delivery room
  1. Kesi C Yang1,
  2. Arjan B te Pas2,
  3. Danielle D Weinberg1,
  4. Elizabeth E Foglia1
  1. 1 Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2 Neonatology, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Dr Kesi C Yang, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; yangkc{at}


Objective The clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants.

Design Prospective observational study of delivery room PPV using video and respiratory function monitor recordings.

Setting Tertiary academic delivery hospital.

Patients Preterm infants <32 weeks gestation.

Main outcome measure Mean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4–8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate.

Results There were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7–29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these.

Conclusions Ventilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.

  • neonatology
  • resuscitation
  • respiratory

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  • Contributors Study design: All authors. Data collection and analysis: KCY. Drafting manuscript: KCY. Critically revise manuscript and final approval: all authors.

  • Funding EEF is supported by an NICHD Career Development Award, K23HD084727.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the HUP Institutional Review Board under a waiver of informed consent, as the study only involved data collected for routine clinical and quality improvement purposes.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.