CPAP vs. PPV: when to escalate in the delivery room
CPAP and PPV are not two intensities of the same intervention. They answer two different questions. PPV asks "is this infant breathing at all, adequately?" CPAP asks "is this infant breathing on their own, but struggling?" Confusing the two, or staying on one when the infant's status has moved to the other, is a common source of delay.
Where each one sits in the algorithm
After the initial steps, the first evaluation branches on breathing and heart rate. Apnea, gasping, or a heart rate under 100 bpm sends the infant down the ventilation branch: PPV, active breaths delivered under pressure, because the infant isn't moving enough air on their own.
An infant who is breathing, with a heart rate at or above 100, but showing labored breathing or persistent central cyanosis, follows a different branch: respiratory support, starting with blended oxygen titrated to preductal SpO₂ targets and consideration of CPAP, continuous distending pressure that keeps the airway and alveoli open between the infant's own spontaneous breaths, without taking over the work of breathing.
| PPV | CPAP | |
|---|---|---|
| Infant's own breathing | Absent, ineffective, or too slow to matter | Present and adequate in rate |
| What it delivers | Active breaths at a set rate and pressure | Constant background pressure only |
| Typical setting | PIP ~20-25 cm H₂O, rate 40-60/min | ~5 cm H₂O, continuous |
| Indication | Apnea, gasping, or HR <100 | Labored breathing or cyanosis with adequate HR |
Escalating from CPAP to PPV
CPAP is not a lower-stakes holding pattern. It's the right tool right up until it stops being enough. Watch for the signs that mean an infant on CPAP needs to move to PPV:
- Increasing FiO₂ requirement despite CPAP, rather than trending down
- Worsening retractions, grunting, or nasal flaring instead of improving
- Heart rate drifting toward 100 bpm from above
- Any apnea or gasping, which is an immediate, not gradual, indication to start PPV
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References
- American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 9th ed. Itasca, IL: American Academy of Pediatrics; 2025. Lesson 3: Initial Steps of Newborn Care; Lesson 4: Ventilation.
- Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16 Suppl 2):S385–S423. doi:10.1161/CIR.0000000000001367