MR. SOPA: when the chest won't move

When positive-pressure ventilation (PPV) fails to move the chest, squeezing the bag harder usually just inflates the stomach or leaks around the mask. Heart rate only recovers once the lungs inflate. If the infant's heart rate is not rising within 15 to 30 seconds of starting PPV and you see no chest movement, pause and troubleshoot with MR. SOPA.

1. M

   Mask adjustment

   Re-seat the mask to stop leaks around the bridge of the nose and cheeks. Lift the infant's mandible into the mask instead of pressing the mask down onto the face. If air keeps escaping, switch to a two-person mask hold with jaw thrust where one clinician seals the mask with both hands while the second operates the bag or T-piece.

2. R

   Reposition head and neck

   Place the head in a neutral or slightly extended sniffing position. A newborn's prominent occiput naturally flexes the neck on a flat warmer, so a small shoulder roll (a 1 to 2 cm folded towel) helps keep the airway open. Avoid hyperextension or deep flexion, which collapse the compliant neonatal pharynx.

3. S

   Suction mouth and nose

   Clear secretions with a bulb syringe or an 8F to 10F suction catheter set to 80 to 100 mmHg negative pressure. Clear the mouth before the nose ("M before N") because suctioning the nares first can trigger a reflex gasp and aspiration.

4. O

   Open the mouth

   Gently open the lips and lift the jaw forward. When a depressed newborn loses pharyngeal muscle tone, the tongue falls against the posterior pharyngeal wall (glossoptosis). Opening the mouth and elevating the jaw clears this obstruction.

5. P

   Pressure increase

   Increase Peak Inflation Pressure (PIP) in 5 cm H₂O steps until the chest moves gently. Stay within recommended face mask safety limits: 40 cm H₂O in term infants and 30 cm H₂O in preterm infants.

6. A

   Airway alternative

   If steps M through P still produce no chest movement, mask ventilation has failed. Insert a laryngeal mask or an endotracheal tube (ETT). Confirm placement right away with an exhaled CO₂ detector (purple turning yellow), bilateral breath sounds, and heart rate response.

Running MR. SOPA during resuscitation

During a resuscitation, the most common delay is staying on an ineffective mask seal while the heart rate drops. In practice, seasoned teams work through three paired actions:

Start with M + R (Mask and Reposition) to reset the seal and head alignment; this fixes most ventilation problems. If the chest remains still, move to S + O (Suction and Open) to clear secretions and drop the jaw. If you still have no chest rise, move to P + A (Pressure and Alternative airway), stepping up PIP in 5 cm H₂O increments and placing a laryngeal mask or endotracheal tube if mask ventilation fails.

Once you achieve chest movement, announce "The chest is moving now" and deliver 30 seconds of effective PPV before re-assessing heart rate. If the heart rate remains below 60 bpm despite 30 seconds of ventilation that visibly moves the chest (ideally with an ETT or laryngeal mask), increase FiO₂ to 100% and initiate chest compressions synchronized 3:1 with ventilation.