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.
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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.
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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.
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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.
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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.
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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.
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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.
• When the airway is obstructed by blood, vernix, or thick meconium, start with Suction & Open (S + O) before readjusting the mask.
• In infants with severe craniofacial anomalies (such as micrognathia in Pierre Robin sequence), mask ventilation rarely seals; place an Alternative Airway (A) right away.
- Do not start chest compressions or push epinephrine while the chest is motionless. Compressions without lung aeration circulate deoxygenated blood through constricted pulmonary vessels.
- The 30 seconds of effective PPV required before escalating to compressions only begins once you achieve visible chest movement.
- Troubleshoot in three logical pairs: M + R (seal and position), S + O (clear and open), and P + A (escalate pressure or place an advanced airway).
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.
Frequently asked questions
What does MR SOPA stand for?
MR SOPA is the NRP mnemonic for the 6 ventilation corrective steps: Mask adjustment, Reposition the head and neck, Suction the mouth and nose, Open the mouth, Pressure increase, and Alternative airway.
When do you start the ventilation corrective steps?
When the heart rate is not increasing within 15 to 30 seconds of starting ventilation and you don't see chest movement.
Do you have to do the MR SOPA steps in order?
No. Based on your assessment, you can choose the steps most likely to help and decide their order. After each step, try ventilating again and reassess chest movement. The alternative airway comes after the first 5 steps if the chest still isn't moving.
What is the maximum pressure for face mask ventilation?
40 cm H₂O for a term newborn and 30 cm H₂O for a preterm newborn. Raise the pressure in 5 cm H₂O steps until the chest moves.
What do you do once the chest is moving?
Say "The chest is moving now" so the team knows, then keep ventilating with chest movement for 30 seconds before checking the heart rate response.
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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 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