# Corrective steps during neonatal mask ventilation – a narrative review of the evidence behind the MR SOPA acronym

## TL;DR

This paper reviews the evidence behind corrective steps in neonatal mask ventilation using the MR SOPA acronym, highlighting gaps in scientific support.

## Contribution

The paper critically evaluates the scientific basis of each MR SOPA step and highlights the lack of evidence for their sequential use.

## Key findings

- Mask size and placement are crucial for minimizing airway obstruction, with firm top and flexible edges improving seal.
- There is no strong evidence supporting the specific sequence of MR SOPA steps for airway management in newborns.
- Alternative airways like nasopharyngeal tubes and laryngeal masks are valid when face mask ventilation fails.

## Abstract

The mnemonic “MR SOPA” (Mask adjustment, Repositioning head/airway, Suctioning, Open mouth, Pressure increase and Alternative airway) facilitates remembering corrective steps when ventilation during neonatal resuscitation is inadequate. Here, we critically evaluate the scientific evidence for each step and appraise the usefulness of the mnemonic as a sequential guidance in airway management of newborn infants:

Mask: Size and placement are crucial to minimize mask leak and airway obstruction. Firm top and flexible edges may help form a better seal, while mask shape seems to be less important. Two-person holding technique may optimize applied tidal volumes.

Repositioning: A neutral head position in newborns may improve airway patency.

Suctioning: Suctioning should be reserved for infants with perceived airway obstruction to reduce vagal stimulation or tissue damage.

Open the mouth/airway: There is no data on opening the mouth per se. Airway maneuvers like chin lift and jaw thrust may improve airway patency.

Pressure increase: Despite weak evidence, increased PIP of ≥25 cmH2O may be necessary to overcome closed glottis and fluid-filled lungs in non-breathing infants but must be titrated carefully to preclude lung injury.

Alternative airway: Nasopharyngeal tubes and laryngeal masks are valid options when face mask ventilation fails. Endotracheal intubation remains the gold standard but should be reserved for experienced staff.

These statements are based on scarce and limited evidence, largely from preclinical or smaller clinical studies. There is no evidence for performing the MRSOPA steps in its original sequence. Thus, more rigorous studies are needed to substantiate nature, timing and order of the interventions.