Noninvasive Ventilation in the Delivery Room for

the Preterm Infant

Heather Weydig, MD,* Noorjahan Ali, MD, MS,* Venkatakrishna Kakkilaya, MD*
*Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX

Education Gaps
The preterm lung is highly susceptible to injury from exposure to mechanical
ventilation in the delivery room. It is important to use optimal noninvasive
ventilation strategies and continuous positive airway pressure to establish
functional residual capacity during resuscitation to avoid intubation and
mechanical ventilation.

Abstract
A decade ago, preterm infants were prophylactically intubated and
mechanically ventilated starting in the delivery room; however, now the shift
is toward maintaining even the smallest of neonates on noninvasive
respiratory support. The resuscitation of very low gestational age neonates
continues to push the boundaries of neonatal care, as the events that
transpire during the golden minutes right after birth prove ever more
important for determining long-term neurodevelopmental outcomes.
Continuous positive airway pressure (CPAP) remains the most important
mode of noninvasive respiratory support for the preterm infant to establish
AUTHOR DISCLOSURE Drs Weydig, Ali,
and maintain functional residual capacity and decrease ventilation/perfusion
and Kakkilaya have disclosed no financial
relationships relevant to this article. This mismatch. However, the majority of extremely low gestational age infants
commentary does not contain a discussion of require face mask positive pressure ventilation during initial stabilization
an unapproved/investigative use of a
commercial product/device.
before receiving CPAP. Effectiveness of face mask positive pressure
ventilation depends on the ability to detect and overcome mask leak and
ABBREVIATIONS airway obstruction. In this review, the current evidence on devices and
BPD bronchopulmonary dysplasia
techniques of noninvasive ventilation in the delivery room are discussed.
CPAP continuous positive airway pressure
DR delivery room
EtCO2 end-tidal carbon dioxide
FRC functional residual capacity
GA gestational age
Objectives After completing this article, readers should be able to:
HFNC high-flow nasal cannula
1. Describe the fetal to neonatal transition in the lung.
IVH intraventricular hemorrhage
NRP neonatal resuscitation program 2. Explain the importance of establishing functional residual capacity for
PEEP positive end-expiratory pressure
successful noninvasive respiratory support.
PIP peak inspiratory pressure
PPV positive pressure ventilation 3. Describe the modes of noninvasive respiratory support and list the devices
RCT randomized controlled trial
used for premature infants at time of birth.
SI lung inflation
VT tidal volume

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 FETAL TO NEONATAL TRANSITION
The critical period of fetal lung development occurs during
the canalicular to saccular stages. Premature infants are
born in this critical period and therefore are at highest risk
for lung underdevelopment and injury. For the lung to
develop properly, the lung must be fluid-filled. In utero,
the fetal lung epithelium secretes liquid, allowing for the
lungs to be fluid-filled. (1)(2) With the help of a closed fetal
larynx that prevents fluid from flowing out of the lung, the
fluid creates lung expansion that is important for the nor-
mal development of the lung. During this time, fetal gas
exchange relies solely on the placenta. (1)(2) The low oxygen
tension in the alveoli results in a state of constant pulmonary
vasoconstriction in the fetus, which diverts blood from the
lungs to the systemic circulation.
As gestation advances, multiple changes prepare the
fetal lung for an ex utero environment, including the differ-
entiation of type I and II pneumocytes, the secretion of
surfactant to reduce alveolar surface tension, and the mod-
ification of epithelial sodium channels. Signals around the
time of birth lead to an increase in catecholamine release
that downregulates fluid secretion by the lung epithelium
and stimulates fluid resorption by the sodium channels,
changing the lungs from fluid-filled to gas-filled. (1) Once
the lung is gas-filled, the oxygen tension increases and leads
to nitric oxide–mediated pulmonary vasodilation and gas
exchange. At birth, all of these pulmonary changes help to
facilitate the neonatal lung in establishing functional resid-
ual capacity (FRC). However, several factors impede the
development of adequate FRC among preterm infants,
including immature lung parenchyma, surfactant defi-
ciency, a compliant chest wall, slower lung fluid clearance,
weak respiratory muscle, poor laryngeal tone leading to
decreased ability to grunt, and an immature respiratory
drive. (3)(4)(5) Preterm infants often require positive pres-
sure ventilation (PPV) soon after birth because of poor FRC
and ineffective respiration that may be associated with
bradycardia.
While the majority of preterm infants (65%–77%) born at
less than 28 weeks’ gestational age (GA) require PPV in the
delivery room (DR), (6)(7) they are also the most vulnerable
to the adverse consequences that may arise from exposure to
PPV. Even brief exposure to large tidal volume (VT) breaths
can initiate an inflammatory cascade that alters lung archi-
tecture and contributes to the development of bronchopul-
monary dysplasia (BPD). (8)(9)(10) Meta-analyses of large,
multicenter, randomized controlled trials (RCTs) that eval-
uated invasive and noninvasive respiratory support in the
DR show that avoiding intubation and stabilizing infants on
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continuous positive airway pressure (CPAP) decreases the
composite outcome of death or BPD. (11)(12) DR manage-
ment for the premature infant may have an extremely
important effect on survival and survival without severe
illness. (13)(14) These findings have resulted in a practice
change, with an increasing number of infants in the DR
being stabilized on CPAP. (15)(16)(17) The aim of this article
is to provide an updated review of noninvasive devices and
strategies used in the DR for premature infants (Table 1).
INTERFACES FOR DELIVERING NONINVASIVE PPV IN
THE DR
Face Mask
Administration of noninvasive PPV via face mask is the
current standard of care. Two different types of masks are
available for use: an anatomic shaped mask and a round
mask. Face mask PPV is dependent on achieving an ade-
quate seal to avoid mask leak. Commercially available masks
vary in shape and size (Fig 1). Palme et al compared 5 widely
used round and triangular masks for mask leak in 44
newborns in the DR. (18) They assessed the percentage
of leak by calculating the difference between set pressure
and the average peak pressure. This study reported less leak
with the use of the round silicone mask compared with the
triangular mask. (18) However, O’Donnell et al compared
round and anatomic masks using mannequins and found
no difference in the air leak between the 2 different mask
types. (19)
O’Shea et al evaluated the facial measurements of pre-
term infants born between 24 and 33 weeks’ GA and
suggested that masks of 35-mm diameter are suitable
for infants of less than 29 weeks’ GA and 42-mm diameter
masks are suitable for infants between 27 and 33 weeks’
GA. Interestingly, the standard commercially available face
mask measures 50 mm while small round face masks are
available in 35-mm and 42-mm inner diameter sizes. (20)
The correct mask size should be determined by placing the
bottom of the mask on the tip of the chin to cover the
mouth and the nose but the top of the mask not reaching
the eyes. However, a recent RCT that measured the mask
leak using respiratory function monitoring did not show
any difference in the mask leak between standard and
small round masks. (21)
There are several ways to hold the face mask (Fig 2). A
recent study looking at corrective ventilation strategies for
infants of less than 32 weeks’ GA in the DR found that the
most frequent mask holds were 1-handed (95%), 2-handed
(63%), stem hold (23%), and modified spider hold (6%). (22)
The mask hold also depends on the face mask that is being

TABLE 1. Delivery Room Interfaces and Devices
for Resuscitation
Interfaces for delivering positive pressure ventilation
• Face mask (anatomical shaped vs round)
• Single nasal tube
• Short binasal prongs
Pressure delivery devices for delivering positive
pressure ventilation
• T-piece resuscitator
• Flow-inflating bag
• Self-inflating bag
used, because a different hold may be necessary for the
silicone face mask versus the bubble face mask.
There is a theoretical concern that when the face mask is
placed, it overlies the nasotrigeminal area and can influence
ventilation by stimulating the trigeminal nerve, resulting in
cessation of a normal breathing pattern, bradycardia, periph-
eral vasoconstriction, and closure of the larynx. (23) This
further necessitates proper face mask positioning and size to
limit stimulation of this nerve.
Single Nasal Tube
To overcome the shortcomings of the face mask, other
interfaces such as nasal tubes and short binasal prongs
are being studied for the delivery of noninvasive ventilation.
A nasal tube is a single tube that enters one nare and ends in
the nasopharynx and is used to deliver PPV. Van Vonderen
et al, in their study of 43 infants, used nasal tubes as the
primary mode to deliver noninvasive ventilation and found
Figure 1. Examples of face masks. A. The top row demonstrates anatomic face masks. The bottom row demonstrates round face masks. B. Anatomic
masks (mask at far right) have an air-filled balloon whereas round masks (mask at far left and in the middle) have a silicone flap to promote adherence to
the face without excessive downward pressure.
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more leak and tube obstruction with the nasal tube com-
pared with a face mask. (24) In addition, using the nasal tube
delayed PPV initiation because of placement of the tube, and
was also noted to be associated with inadequate VT. (24)
Short Binasal Prongs
Although binasal prongs are widely used to provide CPAP in
the DR, the experience with its application for providing
PPV in the DR is limited. To date, the RAM Cannula
(Neotech, Valencia, CA) is the only nasal prong that is able
to directly interface with the T-piece resuscitator. A single-
center retrospective study reported a decrease in DR intu-
bation rate after instituting these particular short binasal prongs
to provide noninvasive ventilation compared with historical
cohorts who were resuscitated with a face mask. (25) However,
theoretical concerns exist including possible higher intrinsic
resistance (26) and insignificant VT delivery with ventilator-
delivered noninvasive positive pressure breaths. (27)
In summary, there is no current evidence to suggest one
mask is better than another for neonatal DR resuscitation,
although mask size is important. Other interface options
such as a single nasal tube and short binasal prongs need to
be evaluated further in well-designed RCTs before being
adopted for routine clinical practice. Simulation-based train-
ing has been shown to decrease mask leak and improve the
effectiveness of face mask PPV.
MODES OF NONINVASIVE RESPIRATORY SUPPORT IN
THE DR
Positive Pressure Ventilation
The Neonatal Resuscitation Program (NRP) currently rec-
ommends initiating PPV in the DR for bradycardia
(HR<100) and/or when respiratory effort by the neonate
is inadequate. (28) The recommended initial settings are an
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 Figure 2. Examples of mask holds. A. Stem hold. B. One-handed (“C”) hold.
inflation pressure of 20 cm H2O, and positive end-expiratory
pressure (PEEP) of 5 cm H2O at a rate of 40 to 60 breaths/
min, with the pressure being adjusted depending on the
patient’s response. Response to PPV can be evaluated by
improvement in heart rate which can be monitored using
electrocardiographic waveforms or pulse oximetry.
There are 3 modes to deliver PPV: a T-piece resuscitator,
a self-inflating bag, or a flow-inflating bag (Fig 3), which
are all approved by NRP to be used for resuscitation in the
DR, depending on resources available at the hospital. It
should be noted that only the flow-inflating bag and T-
piece resuscitator can be used to provide PPV and CPAP.
Use of a T-piece is gaining favor for DR use because of its
ability to deliver controlled pressures. However, 3 RCTs
comparing the use of a T-piece resuscitator versus a self-
inflating bag for ventilation of extremely preterm infants
in the DR did not show improvement in long-term out-
comes. (29)(30)(31) A single-center observational study
comparing the self-inflating bag to the T-piece resuscitator in
very-low-birthweight neonates showed that the latter modality
had an increased hospital survival rate without BPD, intra-
ventricular hemorrhage (IVH), and periventricular leuko-
malacia. (32)
It is difficult for practitioners to estimate the VT being
delivered during PPV despite the use of advanced resusci-
tation devices such as the T-piece resuscitator. One study
showed that of 218 neonates born at less than 29 weeks’ GA
resuscitated in the DR, with the T-piece resuscitator set at a
peak inspiratory pressure (PIP) of 24 and PEEP of 6 cm
H2O, 75% of patients received ventilation with VT greater
than 6 mL/kg, which can injure the lungs and contribute
to IVH. (33) Fifty-one percent of infants who received
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ventilation with large VT were diagnosed with IVH com-
pared with a 13% rate of IVH in the group with a VT less than
6 mL/kg. (33) Hinder et al investigated T-piece devices on
mannequins and showed that despite a set PEEP and PIP,
the pressure being delivered to the individual neonate
varied, depending on the changes in lung compliance.
(34) Hinder et al also found that T-piece devices delivered
inadvertent PEEP above the set value, possibly because of a
number of factors, including accidental rotation of the PEEP
knob, finger distance over the PEEP valve, presence of an
endotracheal tube, use of surfactant, high airway resistance,
and low delivery gas flowrate. (34) Further studies are
needed to verify these findings.
Sustained Lung Inflation
Sustained lung inflation (SI) is the use of distending pres-
sure PIP applied for a certain duration with the goal of
establishing FRC. In animal models, SI performed during
the first inflations after birth helped to clear liquid from the
airways and helped in establishing FRC. To date, 5 RCTs
have investigated the use of SI in preterm infants using
different durations and SI pressures. A meta-analysis com-
paring all patients from these trials showed no significant
difference in the rate of BPD or death. (35) Recently, the
Sustained Inflation of Infant Lung (SAIL) trial randomized
426 extremely preterm infants with bradycardia with inad-
equate respiratory effort in 9 countries to either 2 sustained
inflations to maximal peak pressure of 25 cm H2O for 15
seconds or standard bag and mask. (36) The trial was
stopped early because of increased death in the first 48
hours after birth in the sustained inflation group. (36)
Currently, there is not enough evidence to recommend
Figure 3. Comparison of devices used to deliver positive pressure ventilation. CPAP¼continuous positive airway pressure; PEEP¼positive end-
expiratory pressure; PIP¼peak inspiratory pressure.
routine SI in the DR, and one RCT suggests potential harm
with this approach.
Intervention to Overcome Mask Leak and Airway
Obstruction
The best evidence that a neonate is receiving effective ven-
tilation after initiation of PPV is a rising heart rate. Most
premature infants will receive PPV in the DR. (6) When the
heart rate fails to increase, the first step in troubleshooting
is to address mechanical issues such as airway obstruction
and mask leak. Premature infants are placed in plastic bags
for thermoregulation and it is often difficult to assess chest
rise through the bag. (37) To diagnose the potential issue
leading to ineffective PPV, some studies suggest that the use
of colorimetric end-tidal carbon dioxide (EtCO2) detection
during face mask ventilation may be beneficial. Using a
disposable EtCO2 detector attached to a face mask dur-
ing PPV, providers can assess the patency of the airway.
(38)(39)(40)(41) In one observational study using EtCO2
detectors, 18 infants received a median of 14 obstructed
breaths defined by no color change on the EtCO2 despite
reaching a target pressure. (38) The authors concluded that
airway obstruction is extremely common in very-low-birthweight
infants and that EtCO2 detectors can help recognize this
obstruction. (38) In addition, in the neonate undergoing
PPV with good chest rise, but continued bradycardia leading
to poor cardiac output and insufficient carbon dioxide delivery
to the lungs, EtCO2 detectors may not change. This was found
in a piglet model in which low quantitative EtCO2 values
were directly related to low cardiac output states, leading
to decreased pulmonary blood flow. (42) Figure 4 describes
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an algorithm for the practical use of EtCO2 detectors in
the DR. Importantly, when a target pressure cannot be
obtained despite colorimetry change, this most likely repre-
sents mask leak. Of note, when using a T-piece device with a
face mask, significant leak can occur while still visualizing the
pressure reading on the manometer. Therefore, visualization
of manometry pressures cannot be used to ensure reliable
mask seal; practitioners must consider mask leak as a pos-
sible cause of ineffective PPV whether or not target pressure
readings are obtained on the T-piece resuscitator.
After recognition of ineffective ventilation, NRP advises the
use of the “MRSOPA” mnemonic to further correct ventilatory
steps in a neonate with a decreasing heart rate. (28) Mask
adjustment, repositioning the airway, suctioning, opening the
mouth, increasing inspiratory pressure, and alternate airway
(MRSOPA) are the most important steps in correcting venti-
lation. One observational study on the frequency and use of
MRSOPA strategies in the DR found that infants less than 32
weeks’ gestation who received more MRSOPA interventions
were more likely to be intubated. (22) However, a quality
improvement project reported decreased DR intubation rates
and improved outcomes with simulation-based peer-to-peer
training on MRSOPA strategies by using small round masks,
EtCO2 detectors, increasing pressure, and increasing inspira-
tory time to 1 second when indicated. (17) Wood et al reported
that team training using written instruction and photographs
of the optimal techniques can help decrease mask leak during
PPV. (43) Such interventions to improve ventilation via correc-
tive steps conducted in individual centers can help decrease the
need for intubation and increase stabilization of infants receiv-
ing noninvasive respiratory support in the DR.
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 Figure 4. Using end-tidal carbon dioxide (CO2) detectors attached to a face mask in the delivery room can help detect an obstructed airway. HR¼heart
rate; PPV¼positive pressure ventilation; MRSOPA¼mask adjustment, repositioning the airway, suctioning, opening the mouth, increasing inspiratory
pressure, and alternate airway.
CPAP for DR Resuscitation
CPAP has been widely used for the respiratory support of
preterm infants in the NICU over the last 5 decades.
(28)(44) CPAP increases FRC, (44) decreases airway resis-
tance, (45) decreases thoracoabdominal asynchrony, (46) and
decreases intrapulmonary shunting, (44) thus leading to better
oxygenation and ventilation in spontaneously breathing pre-
term infants. In addition, CPAP helps decrease obstructive
apnea (47) and augments surfactant production. (48) The devices
and interfaces of CPAP use in the DR are listed in Table 2.
Constant-Flow CPAP Devices. T-piece resuscitator use
with a face mask is recommended by NRP for CPAP delivery in
the DR. (49) The desired PEEP level can be adjusted at the PEEP
valve. The T-piece is used with a face mask, single nasal tube, or
specific type of short binasal prongs (RAM cannula). Bubble CPAP
uses the water column at the end of the expiratory limb to generate
pressure in the CPAP circuit. CPAP level is determined by the
immersion length of the expiratory tubing. (50) The gas exiting
from the underwater tubing creates bubbles. Bubbling may pro-
vide additional benefits with mechanisms such as stochastic
resonance (51) and high-frequency oscillatory waveforms (52) in
improving gas exchange and lung recruitment. CPAP can also be
delivered in the DR using an adjustable PEEP valve connected to
the expiratory limb of the CPAP circuit. The inspiratory limb is
connected to the gas source from the blender, usually set at a flow
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rate of 8 to 10 L/min. Both bubble CPAP and the adjustable PEEP
valve can be used with binasal prongs of many different types or
small nasal masks. Ventilators are commonly used for CPAP
delivery during transport and in the NICU rather than in the DR.
Interfaces. Although the face mask was routinely used to
administer CPAP to infants with respiratory distress syn-
drome in the 1970s, it fell out of favor because of the difficulty
in maintaining a proper seal. (53) However, CPAP is com-
monly administered with the T-piece resuscitator with the
face mask in the DR because of the ability to provide PPV
when indicated. As discussed before, maintaining a proper
seal is important to provide the desired CPAP level. In
addition, the increased dead space of the face mask also
may decrease the effectiveness of CPAP delivery. (54)
Binasal prong CPAP has been effectively used since 1973.
(50)(55) De Paoli et al demonstrated that short binasal
prongs offered the lowest resistance to flow compared with
the single nasal tube. (56) Prong size is an important
consideration because the smaller prongs may generate
higher resistance to flow. (56)(57) Small nasal masks can
be used as an alternative to binasal prongs. Recently, Green
et al reported that these small nasal masks pose less intrinsic
resistance compared with short binasal prongs. (26)
CPAP Delivery in the DR. Face mask CPAP provided at
5 cm H2O using a T-piece generator should be initiated at

TABLE 2. CPAP Devices and Interfaces for DR
Resuscitation
Constant flow CPAP generators
• T-piece resuscitator
• Bubble CPAP
• Adjustable PEEP valve
• Ventilator
Interfaces
• Face mask
• Single nasal tube
• Binasal prongs
• Small nasal masks
CPAP¼continuous positive airway pressure; PEEP¼positive end-expiratory
pressure.
birth for all spontaneously breathing infants. Face PPV
should be provided when the infant has bradycardia, poor
respiratory effort, or both. CPAP should be restarted when
the infant shows spontaneous respiratory effort and a stable
heart rate. Manometer reading and EtCO2 detectors can
help in identifying mask leak while administering CPAP.
Fraction of inspired oxygen is titrated using the NRP algo-
rithm. (49) Although the titration of CPAP level in DR
resuscitation has not been evaluated in clinical trials, one
large RCT that routinely used 8 cm H2O reported a higher
rate of pneumothoraces. (58) Subsequent trials that used
CPAP levels of 5 to 7 cm H2O did not report higher rates of
pneumothorax. (6) Higher CPAP levels can help achieve
higher FRC. (44)(59) Therefore, CPAP level may be titrated
higher—up to 7 cm H2O for infants requiring higher
supplemental oxygen in the DR. When the infant demon-
strates regular respiration, stable heart rate, and stable
oxygen saturation, the infant can be transitioned to either
binasal prong or small nasal mask for transport to the NICU.
CPAP can be provided during transport in multiple ways,
including bubble CPAP, an adjustable PEEP valve using gas
flow, or ventilator CPAP. When using binasal prongs, it is
important to use the binasal prong with the largest inner
diameter that can snugly fill the nares.
High-Flow Nasal Cannula
High-flow nasal cannula (HFNC) delivers heated and
humidified gas that aids in gas exchange by minimizing
dead space. (60) The pressure that is generated by HFNC is
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determined by the flow rate, size of the nasal cannula, and
amount of leak from the nose and mouth. (61)(62) Only 1
study has demonstrated the feasibility of using HFNC in the
DR for infants between 23 and 29 weeks’ GA. (63) HFNC in
the DR is not recommended before well-designed RCTs.
SUMMARY
During the delivery of premature infants, the DR can often
be chaotic, given that premature deliveries could happen
unexpectedly. A skilled resuscitation team is necessary to
provide initial lifesaving breaths to this vulnerable popula-
tion to quickly and effectively establish FRC. After estab-
lishment of FRC, maintaining neonates on CPAP to prevent
lung injury with mechanical ventilation is well-studied.
However, providing noninvasive ventilation can have chal-
lenges including mask leak, incorrect mask size, and airway
obstruction. Use of a properly sized mask with a colori-
metric EtCO2 detector provides early feedback for airway
obstruction and mask leak, though RCTs are still needed.
Performing MRSOPA in the event of ineffective ventilation
is the most important step to ensure the successful transi-
tion from PPV to CPAP in the DR.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the indications for assisted ventilation, including
continuous positive airway pressure, immediately after birth and
how to assess its effectiveness.
• Understand how to use self-inflating and flow-inflating bags or T-
piece resuscitators to provide assisted ventilation immediately
after birth.
• Know the mechanism of production and factors affecting the
clearance of fetal lung liquid, its contribution to amniotic fluid,
and its importance to fetal lung development.
• Know the effects of surface tension on alveolar and airway
stability and lung mechanics (LaPlace law).
• Know factors that determine residual lung volume, functional
residual capacity, and tidal volume, and how they change with
various pulmonary disorders.
• Know the clinical features of an infant with airway obstruction.
• Know the indications for and techniques of continuous positive
airway pressure (CPAP).
• Know the effects and risks of CPAP.
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1. The team is preparing for the delivery of an infant at 25 weeks’ gestational age. Which of NOTE: Learners can take
the following statements regarding anticipation of respiratory management for this infant NeoReviews quizzes and
is correct? claim credit online only
A. With optimal care including antenatal steroids and cesarean delivery, less than 20% at: http://Neoreviews.org.
of infants at this gestational age will require positive pressure ventilation in the To successfully complete
delivery room. 2019 NeoReviews articles
B. Brief exposure to large tidal volume breaths, even immediately after birth, can for AMA PRA Category 1
initiate an inflammatory cascade that alters lung architecture and contributes to CreditTM, learners must
the development of bronchopulmonary dysplasia. demonstrate a minimum
C. Even if it is not absolutely needed, the delivery of 10 to 20 carefully adjusted performance level of 60%
positive pressure ventilation breaths in a prophylactic fashion for all newborns in or higher on this
this circumstance will lead to decreased need for intubation and reduced incidence assessment, which
of respiratory distress syndrome and bronchopulmonary dysplasia. measures achievement of
D. Continuous positive airway pressure should be avoided until stabilization has the educational purpose
progressed in the NICU to avoid pneumothorax. and/or objectives of this
E. The main factor that will drive respiratory management in the first few minutes, activity. If you score less
particularly in the decisions surrounding positive pressure ventilation, is oxygen than 60% on the
saturation measurement. assessment, you will be
2. A male infant born at 26 weeks’ gestational age is handed to the pediatrics team after 60 given additional
seconds of delayed cord clamping. The infant has spontaneous respirations at first, but opportunities to answer
proceeds to have apnea and bradycardia. The patient is given positive pressure ventilation. questions until an overall
Which of the following statements regarding the interface for delivering positive pressure 60% or greater score is
ventilation is correct? achieved.
A. The first-line treatment for this patient should be endotracheal intubation. This journal-based CME
B. Nasal prongs have proven more effective than face mask for positive pressure activity is available
delivery in this population. through Dec. 31, 2021,
C. Triangular face masks have consistently been shown to have less air leak than however, credit will be
circular masks in this population. recorded in the year in
D. For face masks, the correct size should be determined by placing the bottom of the which the learner
mask on the tip of the chin to cover the mouth and nose, but with the top of the completes the quiz.
mask not reaching the eyes.
E. The optimal “hold” of a face mask for preterm infants is to place in the correct
position on the face, but actually not to hold it in place and let it lie there gently.
3. A female infant born at 27 weeks’ gestational age is delivered vaginally and is handed to
the pediatrics team after 60 seconds of delayed cord clamping. The infant has spontaneous
respirations before cord clamping. At the radiant warmer, the infant is gasping and is 2019 NeoReviews now is
determined to have inadequate respirations. The team initiates positive pressure approved for a total of 10
ventilation. Which of the following parameters for initial support for this patient is most Maintenance of
appropriate? Certification (MOC) Part 2
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4. The pediatrics team is preparing for the delivery of an infant at 27 weeks’ gestational age
for worsening preeclampsia in the mother. Several choices for delivering positive pressure
ventilation are available to the team. Which of the following are advantages of a T-piece
resuscitator over a self-inflating bag?
A. The ability to accurately detect tidal volumes.
B. Several studies showing improved neurodevelopmental outcomes at 2 years of
age.
C. Easier to deliver controlled positive pressure ventilation and continuous positive
airway pressure.
D. Safeguard mechanism to ensure that an exact positive end-expiratory pressure
never exceeds 5 mm H2O.
E. Capacity to work without a gas source.
5. A newborn infant delivered at 28 weeks’ gestational age is receiving positive pressure
ventilation by T-piece and mask at 2 minutes of age for apnea and heart rate of 60 beats/
min. Which of the following is the best indicator of the effectiveness of positive pressure
ventilation?
A. A rising heart rate.
B. Increasing pink color of the extremities.
C. Manometry pressures indicating a peak inspiratory pressure greater than 20 cm
H2O.
D. Oxygen saturation reading greater than 90%.
E. Consistent positive end-expiratory pressure reading of 5 cm H2O.

Vol. 20 No. 9 S E P T E M B E R 2 0 1 9 e499

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 Noninvasive Ventilation in the Delivery Room for the Preterm Infant
Heather Weydig, Noorjahan Ali and Venkatakrishna Kakkilaya
NeoReviews 2019;20;e489
DOI: 10.1542/neo.20-9-e489

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/20/9/e489
References This article cites 59 articles, 20 of which you can access for free at:
http://neoreviews.aappublications.org/content/20/9/e489.full#ref-list-
1
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 Noninvasive Ventilation in the Delivery Room for the Preterm Infant
Heather Weydig, Noorjahan Ali and Venkatakrishna Kakkilaya
NeoReviews 2019;20;e489
DOI: 10.1542/neo.20-9-e489

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/20/9/e489

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