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

The mnemonic "<i>MR SOPA</i>" (<i>M</i>ask adjustment, <i>R</i>epositioning head/airway, <i>S</i>uctioning, <i>O</i>pen mouth, <i>P</i>ressure increase and <i>A</i>lternative 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: <i>Mask:</i> 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. <i>Repositioning:</i> A neutral head position in newborns may improve airway patency. <i>Suctioning:</i> Suctioning should be reserved for infants with perceived airway obstruction to reduce vagal stimulation or tissue damage. <i>Open the mouth/airway:</i> There is no data on opening the mouth <i>per se</i>. Airway maneuvers like chin lift and jaw thrust may improve airway patency. <i>Pressure increase:</i> 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. <i>Alternative airway:</i> 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.