NRP 9th Edition PPV settings: rate, PIP, PEEP and FiO₂
Ventilating the lungs is the single most important and most effective step in neonatal resuscitation. After the initial steps, start assisted ventilation if the newborn is apneic, gasping, or has a heart rate below 100 bpm, and start it within 1 minute of birth. These are the settings NRP 9th Edition has you start with.
Initial settings at a glance
| Setting | Starting value |
|---|---|
| Gas flow | 10 L/min |
| Rate | 30 to 60 breaths/min |
| PIP | 25 cm H₂O. Acceptable range: 25 to 30 cm H₂O at ≥32 weeks; 20 to 25 cm H₂O at <32 weeks |
| PEEP | 5 cm H₂O to start |
| FiO₂ | ≥35 weeks: 21% 32 to 34 weeks: 21% to 30% <32 weeks: ≥30% may be considered |
Want the numbers for a specific baby? The PPV settings calculator gives them by gestational age.
Rate: 30 to 60 breaths per minute
Count out loud to hold the rate: "Breathe, two, three; breathe, two, three." Squeeze the bag or occlude the T-piece cap on "breathe," and release on "two, three."
PIP: start at 25 and use only what the lungs need
Before the first breath, the air spaces are full of fetal lung fluid, so the first few assisted breaths may need more pressure than usual to clear it and open the alveoli. Once the lungs are inflated you can often bring the pressure down.
Aim for a gentle rise and fall of the chest. Breaths that look deep suggest too much pressure, which overinflates the lungs and raises the risk of a pneumothorax. In preterm babies, chest movement is harder to judge and overinflation is more dangerous; it's possible to ventilate them well without obvious chest rise.
PEEP: start at 5 cm H₂O
PEEP during the first inflating breaths helps the lungs stay open, clears fluid faster and keeps the air spaces from collapsing on exhalation. For preterm babies, NRP prefers a device that can deliver it, such as a T-piece resuscitator or a flow-inflating bag.
Treat 5 cm H₂O as a starting point, not a ceiling. The 2025 AHA/AAP guidelines state that the optimal PEEP level hasn't been determined, and NRP notes that babies with underlying lung disease in the NICU may need higher PEEP than is usual in the delivery room. For a baby who is breathing and only needs CPAP, NRP starts at 5 to 6 cm H₂O and says not to use more than 8 cm H₂O. For PEEP during PPV, NRP gives only the 5 cm H₂O starting value.
FiO₂: start by gestational age, then titrate
Put a pulse oximeter sensor on the right hand or wrist as soon as possible after ventilation starts. Once it reads reliably, compare the pre-ductal saturation with the target for that minute and adjust the blender:
| Minute after birth | Target pre-ductal SpO₂ |
|---|---|
| 2 min | 65% to 70% |
| 3 min | 70% to 75% |
| 4 min | 75% to 80% |
| 5 min | 80% to 85% |
| 10 min | 85% to 95% |
NRP doesn't mandate a specific titration method. A reasonable approach is to change the FiO₂ by 20% to 30% every 30 seconds until you reach the target. For babies under 32 weeks, reaching 80% to 85% by 5 minutes appears to matter, which is why they may need a higher starting FiO₂ or faster titration. More on the targets in preductal SpO₂ targets by minute.
Is it working? Watch the heart rate
A rising heart rate is the most important sign that ventilation is working. If the heart rate isn't rising within 15 to 30 seconds and the chest isn't moving, start the MR SOPA corrective steps. Once the chest moves, say "The chest is moving now" and give 30 seconds of that ventilation before checking the heart rate:
- 100 bpm or more: ventilation is working. Keep going at 30 to 60 breaths/min and titrate FiO₂. When the heart rate stays above 100, gradually lower the rate and pressure. Stop once the heart rate is continuously above 100 and the baby is breathing on their own.
- 60 to 99 bpm: if it's improving, keep ventilating. If not, recheck your technique, adjust FiO₂, consider a cardiac monitor and a laryngeal mask or endotracheal tube, and call for help.
- Below 60 bpm: recheck technique, place a cardiac monitor and an alternative airway if you haven't. If the heart rate stays below 60 after at least 30 seconds of ventilation that moves the chest, preferably through a laryngeal mask or tube, increase the FiO₂ to 100% and begin chest compressions.
Frequently asked questions
What is the PPV rate in NRP 9th Edition?
30 to 60 breaths per minute. Counting "Breathe, two, three" out loud helps keep the rate steady.
What is the initial PIP for neonatal PPV?
25 cm H₂O. The acceptable starting range is 25 to 30 cm H₂O at 32 weeks or more, and 20 to 25 cm H₂O below 32 weeks.
What PEEP does NRP recommend?
The suggested starting PEEP is 5 cm H₂O. It's a starting point: the 2025 AHA/AAP guidelines note that the optimal PEEP level hasn't been determined.
What initial FiO₂ should you use for PPV?
21% at 35 weeks or more, 21% to 30% at 32 to 34 weeks, and 30% or more may be considered below 32 weeks. Then adjust by pre-ductal pulse oximetry.
When do you increase FiO₂ to 100% in NRP?
When the heart rate stays below 60 bpm after at least 30 seconds of ventilation that moves the chest, preferably through a laryngeal mask or endotracheal tube, and you start chest compressions.
Studying for the NRP exam? NeoCPR's interactive algorithm covers these settings and every decision point that follows once PPV starts. See NeoCPR ($29) →
References
- American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 9th ed. Itasca, IL: American Academy of Pediatrics; 2025. Lesson 4: Ventilation, Tables 4-1 and 4-2.
- 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