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Basic airway management in children

Basic airway management in children
Literature review current through: Jan 2024.
This topic last updated: Sep 29, 2022.

INTRODUCTION — Basic airway management in infants and children (including techniques to open the airway and positive pressure ventilation with mouth-to-mouth and a bag-mask device) will be reviewed here.

The following related topics are discussed separately:

Advanced airway management in children (see "Technique of emergency endotracheal intubation in children")

Basic life support in infants and children (see "Pediatric basic life support (BLS) for health care providers")

Emergency management of foreign body airway obstruction in children (see "Emergency evaluation of acute upper airway obstruction in children")

The initial assessment and stabilization of critically ill or injured children (see "Initial assessment and stabilization of children with respiratory or circulatory compromise" and "Pediatric advanced life support (PALS)")

Basic airway management in newborn infants (see "Neonatal resuscitation in the delivery room")

BACKGROUND — Effective airway support is an essential component of successful cardiopulmonary resuscitation (CPR). Respiratory insufficiency leading to respiratory arrest typically precedes cardiac arrest for most children. Survival rates are much higher for children who have been resuscitated from respiratory arrest compared with children who develop cardiac arrest. (See "Pediatric basic life support (BLS) for health care providers", section on 'Epidemiology and survival'.)

ANATOMIC CONSIDERATIONS — A patent airway is a fundamental requirement for effective resuscitation. Anatomic features that make the airways of infants and children more susceptible to obstruction and that must be considered in order to maintain an adequate airway include the following (see "Emergency airway management in children: Unique pediatric considerations", section on 'Anatomic considerations'):

Larynx – The position of the larynx in infants and children is higher and more anterior than in adults (figure 1). As a result, hyperextension of the neck may worsen obstruction of the upper airway.

Airway – Because the airways of infants and children are smaller, they are more susceptible to obstruction from secretions, mucous, blood, vomitus, other debris, or a foreign body. Suctioning of the oropharynx and nasopharynx is essential to clearing the airway in infants and children with respiratory distress and failure (see "Airway management for pediatric anesthesia"). Relief of airway obstruction by a foreign body in infants and children requires separate management. (See "Emergency evaluation of acute upper airway obstruction in children".)

Head – The relatively larger occiput of the infant and young child causes passive flexion of the cervical spine in the supine position, which contributes to a tendency for the posterior pharynx to buckle during resuscitation. This can be prevented by maintaining the head in the sniffing position, which extends the neck and aligns the pharyngeal and tracheal axes. Placing a rolled towel under the shoulders of the infant may help to maintain proper positioning for airway management (picture 1) [1]. In children over two years old and adolescents, a towel under the occiput provides the necessary alignment (picture 2).

Allow a spontaneously breathing child with upper airway obstruction to maintain an open airway with a position of comfort (picture 3).

Tongue – The tongue is relatively larger compared with the oral cavity in infants and children than in adults. In an infant or child with a decreased level of consciousness, the tongue commonly falls back against the hypopharynx, resulting in airway obstruction [2,3].

EMERGENCY AIRWAY APPROACH — For the infant or child with respiratory distress or failure, initiate basic airway management while providing 100 percent supplemental oxygen [4]:

Assess the airway and breathing

Look for movement of the chest or abdomen

Listen for air movement and sounds

Feel for air movement at the nose and mouth

Determine the status of the airway

Clear – Airway is patent for normal breathing

Maintainable – Airway is not patent but can be opened and maintained with basic measures

Not maintainable – Airway is not patent and cannot be opened and maintained without advanced measures

Open and maintain airway as needed with basic measures

Positioning – Maintain the head in the sniffing position or allow a spontaneously breathing child to remain in a position of comfort.

Noninvasive maneuvers – Perform the head tilt-chin lift maneuver. At the same time, place the other hand on the child's forehead and gently tilt the head into a neutral position (figure 2) or, in the patient with possible C-spine injury, jaw-thrust maneuver (figure 3) with in-line C-spine stabilization (figure 4). (See 'Noninvasive relief of obstruction' below.)

Suctioning – Perform suctioning to remove secretions, mucous, blood, vomitus, and/or particulate matter from the nose and mouth.

Airway adjuncts – If the airway is not maintained with positioning and noninvasive maneuvers, place either an oropharyngeal airway (unconscious patient only) (figure 5) or nasopharyngeal airway (any patient) (figure 6). (See 'Airway adjuncts' below.)

Basic life support – If signs of total or near-total airway obstruction due to a foreign body are present, perform basic life support to relieve upper airway obstruction as described in the algorithm (algorithm 1).

Open and maintain airway with advanced measures If the airway cannot be opened or maintained with basic measures, immediately seek assistance from available airway specialists (eg, pediatric anesthesiology, pediatric otolaryngology, and/or pediatric critical care) and proceed to advanced airway management (algorithm 2). (See "The difficult pediatric airway for emergency medicine".)

Once the airway is opened with various basic airway management techniques as needed, assisted ventilation may be provided in infants and children with inadequate breathing using mouth-to-mouth, mouth-to-mouth-and-nose, and mouth-to-nose techniques, or with bag-mask ventilation. (See 'Assisted ventilation' below.)

NONINVASIVE RELIEF OF OBSTRUCTION

Head tilt-chin lift maneuver

Indications and contraindications – The head tilt-chin lift maneuver is the preferred method for opening the airway in infants and children except when cervical spine injury is suspected [5,6].

In infants and children with suspected cervical spine injury, the head tilt-chin lift maneuver should not be used prior to attempting to open the airway with a jaw thrust maneuver while maintaining in-line manual C-spine stabilization (figure 4) [6,7]. If the jaw thrust maneuver does not open the airway, then the head tilt-chin lift maneuver should be attempted with continued C-spine stabilization [4,6].

Procedure – Place the fingers of one hand under the mandible and lift upward to move the chin anteriorly. At the same time, place the other hand on the child's forehead and gently tilt the head into a neutral position (figure 2 and figure 7 and picture 4).

With the thumb of the same hand, lightly depress the lower lip to open the mouth. Alternatively, place the thumb behind the mandibular incisors to gently lift the chin so that the mandibular central incisors are anterior to the maxillary central incisors.

During the head tilt-chin lift procedure, avoid closing the mouth, pushing on the soft tissues under the chin, or hyperextending the neck (figure 8) [5], because any of these actions can cause airway obstruction.

Jaw thrust maneuver

Indications – The jaw thrust maneuver is the preferred method for opening the airway in infants and children when there is concern for cervical spine injury [6]. During airway management, in-line manual cervical spine stabilization should also be maintained during airway maneuvers (figure 4).

The jaw thrust maneuver is also useful for any patient when assisted ventilation with a bag-mask device is required. (See 'Bag-mask ventilation' below.)

Procedure – With one hand on each side, grasp the angles of the mandible and move the mandible forward until the mandibular central incisors are anterior to the maxillary central incisors (figure 3 and picture 5).

SUCTIONING — For many infants and children with respiratory distress or failure, suctioning is essential to reestablish or maintain airway patency [4]. Because infants are typically obligate nasal breathers until about two to six months of age [8,9], suctioning of nasal secretions to remove airway obstruction in these patients can rapidly improve respiratory status.

Indications and contraindications – Suctioning is indicated in all infants and children who have copious oral secretions, vomiting, or bleeding and who are showing signs of airway obstruction (eg, hypoxemia, respiratory distress, upper airway noise [snoring or stertor], and/or poor aeration despite adequate chest wall movement) or cannot properly protect their airway (eg, patients with altered mental status or difficulty swallowing).

Care must be taken in all patients to avoid trauma to the oropharynx, nasal passages, or larynx; patients with bleeding disorders require particular attention. In patients with signs of facial or head trauma and possible cribriform plate disruption, avoid nasopharyngeal suctioning.

Procedure – Suction the patient for brief intervals <30 seconds while monitoring breathing and oxygenation [10]:

Oropharynx – Using a tonsil tip suction device, gently perform suctioning by advancing it along the sides of the mouth and avoid the posterior pharynx to reduce the risk of gagging and vomiting. A flexible suction catheter may be used instead of a tonsil tip suction device for thin secretions.

Use two tonsil tip suction devices for patients with copious bleeding or emesis.

Nasopharynx – Gently advance a flexible suction catheter with a bore size that easily passes into the nasal passage but is large enough to effectively clear nasal secretions. Occlude the side opening of the suction catheter and gently withdraw.

Provide supplemental oxygen during intervals between suctioning.

Complications – If vomiting occurs, rapidly place the patient on their side (recovery position; log roll trauma patients with possible spinal injury while maintaining spinal motion restriction (figure 9)) and continue to suction to clear the airway and avoid aspiration.

If significant oxygen desaturation occurs during suctioning, stop and provide supplemental oxygen and, as needed, assisted ventilation. Once oxygen saturation has returned to a normal range, resume suctioning if needed.

AIRWAY ADJUNCTS — The oropharyngeal airway (OPA) or the nasopharyngeal airway (NPA) may be useful to improve ventilation, particularly when oropharyngeal structures, such as the tongue, are obstructing the airway [4,11].

Oropharyngeal airway — The OPA is composed of a flange, short bite-block segment, and curved body. It is designed to lift the tongue and hypopharyngeal soft tissues off the posterior pharynx to maintain a patent airway without damaging the laryngeal structures (picture 6) [4].

Indications and contraindications – An OPA may be used in the unconscious infant or child to relieve airway obstruction caused by the tongue that has not been relieved by maneuvers (ie, head tilt-chin lift or jaw thrust). The OPA is optimally used as a bridge to recovery for a patient whose condition is expected to be temporary (such as a child who is postictal or recovering from sedation). However, prolonged tolerance of an OPA usually suggests the need for endotracheal intubation (ETI).

Do not use an OPA if the infant or child has an intact cough and gag reflex. In addition, an OPA should not be used in a semiconscious infant or child because direct contact with the tongue and supraglottic structures may stimulate gagging and vomiting [4].

Sizing – To choose the correct OPA size, hold it along the side of the face with the flange at the corner of the mouth. The tip of the airway should reach the angle of the mandible (picture 7).

Procedure – With a tongue blade, depress the tongue to the floor of the mouth, then gently insert the OPA in-line with the curve of the mouth and pharynx (figure 5). Depression of the tongue avoids inadvertently pushing the OPA into the base of the tongue and obstructing the airway.

After the OPA is inserted, continue to monitor the infant or child for airway patency [12].

Do not insert the OPA upside-down (ie, not in-line with the curve of the mouth and pharynx) and then rotate it 180 degrees into place because it may cause abrasion or injury to the tonsils or soft palate with bleeding that can lead to aspiration and/or push the tongue posteriorly causing airway obstruction.

Complications – Selection of the appropriate OPA size and careful placement are necessary to use this device effectively and safely [4]. Complications of incorrect sizing include (figure 10):

Too large – Obstruction of the larynx, laryngeal injury, or laryngospasm

Too small – Obstruction of the airway caused by displacement of the tongue base posteriorly

Nasopharyngeal airway — The NPA is a flexible tube with a flange, which provides a conduit for airflow between the nares and the pharynx with minimal contact with the tongue [4].

Indications – The NPA may be used in the conscious or unconscious infant or child to bypass airway obstruction caused by the tongue and pharyngeal soft tissues [4]. It is particularly useful to relieve obstruction caused by macroglossia or tonsillar hypertrophy in infants and children with normal mentation and respiratory function. The NPA is frequently helpful to relieve airway obstruction in infants and children with neurological impairment. In addition, an NPA minimizes nasopharyngeal trauma for patients who require frequent suctioning.

The NPA is much less likely to induce vomiting than the OPA and can be used in infants and children with an intact cough and gag reflex.

Sizing – The approach to sizing varies by the type of NPA:

-Adjustable flange – For the NPA with an adjustable flange, choose the NPA with a bore that matches the size of the nares. Set the length of insertion by placing the NPA along the face from the tragus of the ear to the nostril and slide the flange to match the distance.

The distance from the nostril to the tragus has been shown to correlate well with the length from the nostril to the vocal cords in most infants and children and is our preferred method for sizing [13]. Alternatively, the clinician can use distance from the nostril to the mandible. However, the accuracy of this method has not been studied.

-No adjustable flange – For an NPA without an adjustable flange (picture 8), choose the NPA whose length is equal to the distance from the nostril to the tragus of the ear, then ensure that the bore of the NPA matches the size of the nostril.

Procedure – To place the NPA [10]:

-Copiously lubricate the NPA with a water-soluble substance and, if time allows, instill a topical vasoconstrictor (eg, oxymetazoline 0.05%, 1 spray in each nostril).

-Optional: During spontaneous breathing, occlude each nostril to determine which one is more patent; use this side for placement.

-Gently insert the NPA along the floor of the nasopharynx in a posterior direction perpendicular to the plane of the face with the bevel facing the nasal septum (figure 6 and picture 9).

-If the NPA does not pass readily, withdraw it and reattempt insertion in the other nostril.

After the NPA is inserted, continue to monitor the infant or child for obstruction of the adjunct by secretions, mucous, blood, or vomitus as well as by the soft tissues of the pharynx. The inserted NPA may require frequent suctioning to maintain patency.

Complications – Selection of the appropriate NPA size and careful placement are necessary to use this device effectively and safely.

If the NPA is too long, it may contact the larynx and/or lower pharynx and cause:

-Bradycardia through vagal stimulation

-Laryngeal injury with airway bleeding or swelling

-Laryngospasm

-Vomiting with risk of aspiration

-Coughing

If the NPA bore is too large, it can cause:

-Injury to the nasal mucosa or adenoidal tissue and cause bleeding with risk for aspiration

-Pressure necrosis of the soft tissue and cartilage of the nose (alae nasi)

If the NPA bore is too small, it is easily obstructed by nasal secretions and ineffective.

ASSISTED VENTILATION — Once the airway is open and maintained, patients with inadequate breathing require assisted ventilation using bag-mask ventilation or, when bag-mask ventilation is not immediately available, mouth-to-mouth and/or nose techniques. If the airway cannot be opened or maintained to perform assisted ventilation, then the provider should obtain immediate expert airway assistance whenever available and proceed to advanced airway management (algorithm 2). (See "The difficult pediatric airway for emergency medicine".)

General principles — The following general principles of ventilation should be applied no matter which method of ventilation is used (see "Pediatric basic life support (BLS) for health care providers", section on 'Breathing'):

Airway – Continue to maintain the airway with positioning, noninvasive maneuvers, suctioning, and airway adjuncts as described above. (See 'Emergency airway approach' above.)

If the airway is not "maintainable" with these basic techniques, the provider should proceed to advanced airway management. (See "The difficult pediatric airway for emergency medicine".)

Breathing – Deliver each breath over one second [7]. There should be a short pause between breaths to maximize oxygen content and minimize carbon dioxide concentration in the delivered breaths. The volume of each breath should be sufficient to see the chest wall rise.

Rescue breathing – An infant or child with a heart rate ≥60/minute without normal breathing should receive one breath every two to three seconds (20 to 30 breaths per minute) [6].

Ventilation during cardiopulmonary resuscitation (CPR) – For an infant or child requiring chest compressions (ie, pulseless or heart rate <60/minute), the timing of ventilation depends on whether or not the trachea is intubated and the number of rescuers (see "Pediatric basic life support (BLS) for health care providers", section on 'Basic life support approach'):

Single rescuer – Two breaths should be delivered at the end of every 30th compression.

Two rescuers – Two breaths should be delivered at the end of every 15th compression.

Advanced airway – Once the trachea is intubated, ventilations and compressions can be performed independently. Ventilations are given every two to three seconds (20 to 30 breaths per minute). Compressions are delivered at a rate of 100 to 120 per minute without pauses.

Gastric insufflation – Bag-mask ventilation and mouth-to-mouth/nose techniques may cause gastric insufflation, particularly if the breath is delivered too quickly or breaths are given too rapidly. This can interfere with effective ventilation by elevating the diaphragm and compromising lung expansion.

Minimize gastric insufflation by giving breaths slowly, so that an effective tidal volume is delivered at a lower inspiratory pressure [14]. When two rescuers are present, cricoid pressure is optional during bag-mask ventilation to compress the esophagus, thereby reducing gastric distension [6,15-19]. Evidence that compression of the esophagus decreases the risk of regurgitation and aspiration is limited. Care must be taken to not obstruct the airway if cricoid pressure is applied. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach", section on 'Protection'.)

Mouth-to-mouth and/or nose — A barrier should be used for infection control whenever possible during mouth-to mouth, mouth-to-mouth-and-nose, and mouth-to-nose breathing [7].

Mouth-to-mouth breathing – For children, the rescuer's mouth is placed over the victim's mouth to create a tight seal while the victim's nose is pinched closed (figure 11) [7].

Mouth-to-mouth-and-nose breathing – For infants, the rescuer's mouth is placed over the victim's mouth and nose (figure 11).

Mouth-to-nose breathing – This technique is an alternative to mouth-to-mouth-and-nose breathing for infants. When the mouth-to-nose technique is used, it is necessary for the rescuer to close the infant's mouth during rescue breathing.

Bag-mask ventilation — Health care providers who are properly trained can use a bag-mask device to provide adequate oxygenation and ventilation during pediatric resuscitation [7]. (See "Pediatric basic life support (BLS) for health care providers", section on 'Epidemiology and survival' and "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

Indications – Bag-mask ventilation may be provided to infants and children in the settings of respiratory distress and failure (including respiratory arrest) and cardiac arrest:

Respiratory distress and failure – Positive pressure ventilation should be provided to the infant or child with inadequate spontaneous breathing effort (ie, insufficient respiratory rate for age, chest expansion, or air movement). Bag-mask ventilation is successful in most infants and children in this setting with either an open airway or partial airway obstruction [20].

Cardiac arrest – During pediatric out-of-hospital cardiac arrest (OHCA), bag-mask ventilation appears to result in similar outcomes (eg, intact neurologic survival and survival to hospital discharge) compared with placement of an advanced airway, including endotracheal intubation (ETI) and supraglottic airway (SGA such as a laryngeal mask airway), when transport times are short (<30 minutes). (See "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

During pediatric in-hospital cardiac arrest, data comparing rates of survival for bag-mask ventilation with ETI are limited but suggest that outcomes with bag-mask ventilation are at least as good as ETI during the initial stages of CPR. (See "Pediatric basic life support (BLS) for health care providers", section on 'In-hospital cardiac arrest'.)

Ventilation bag — Bag-mask ventilation is performed with a bag-mask device consisting of a ventilation bag and a ventilation mask. Two types of ventilation bags are available, the self-inflating bag and the flow-inflating bag.

Self-inflating bag — The self-inflating bag provides a rapid means of ventilation and is preferred for assisted ventilation during initial resuscitation [4,6].

Size – The self-inflating ventilation bag should have a minimum volume of 450 to 500 mL, even for newly born full-term infants [21-23]. For older children and adolescents, use an adult self-inflating bag (at least 1000 mL or larger) to ensure adequate ventilation with chest rise [4].

Testing – Prior to use, the self-inflating bag should be checked [21-23]:

Leaks: Occlude the patient outlet and squeeze the bag

Gas flow control valves: Check for proper functioning

Pop-off valve: Ensure it can be easily disabled

Oxygen tubing: Check for secure connections to the bag-mask device and oxygen source

Oxygen flow: Set the flow rate to 10 to 15 L/minute into the bag and attach an oxygen reservoir to deliver 95 to 100 percent fraction of inspired oxygen (FiO2)

Ventilation mask cuff: Ensure adequate size and seal (see 'Ventilation mask' below)

Oxygen delivery – The self-inflating bag requires an oxygen reservoir to reliably deliver oxygen concentrations above 40 percent. This is because room air is entrained in the system when the bag reinflates. A minimum oxygen flow rate of 10 to 15 L/min is required to maintain an adequate oxygen volume in the reservoir [24]. With an oxygen flow rate of 15 L/min, oxygen concentrations between 95 and 100 percent can be delivered using a 2.5 L bag reservoir system [25].

Pop-off valve – Self-inflating bags typically have a safety pop-off valve that reduces the risk of barotrauma by limiting peak inspiratory pressure (PIP) to between 35 and 45 cm H2O. However, higher levels of PIP may be required to provide adequate tidal volume and oxygenation when airway resistance is high or lung compliance is poor [26]. In this setting, an automatic pop-off valve may result in delivery of insufficient tidal volume and can usually be disabled [27]. Whenever possible, an in-line manometer should be used to monitor PIP when the pop-off valve is disabled.

Mechanism – When the self-inflating bag is released, the bag recoil mechanism reinflates the self-inflating bag from room air or, if available, from an oxygen source. During bag reinflation, the gas intake valve opens and allows the bag to fill. During bag compression, the gas intake valve closes, and a second valve (fish-mouth or leaf-flap, non-rebreathing outlet valve) opens to permit gas flow to the patient. During patient exhalation, the outlet valve closes, and the patient's exhaled gases are released to the atmosphere to prevent rebreathing of carbon dioxide.

Advantages:

-An oxygen source is not required for use (it can be used with room air if no oxygen is available).

-It is easier to use (effective bag-mask ventilation can be performed more reliably by health care providers with variable levels of expertise using the self-inflating bag compared with the flow-inflating bag) [28,29].

Disadvantages:

-Supplementary "blow-by" oxygen cannot be provided to the spontaneously breathing infant or child (this is due to the outlet valve, which does not open to provide a continuous flow of oxygen to the mask).

-FiO2 is limited (<100 percent) unless an oxygen reservoir is added and allowed to fill.

-A positive end-expiratory pressure (PEEP) valve (if present) cannot be used to provide continuous positive airway pressure (CPAP) during spontaneous breathing (this is due to the outlet valve, which opens only with high negative inspiratory pressure).

-Feeling for changes in lung compliance and airway resistance is not easy (this is due to the stiffness of the bag).

-Loss of ventilation mask seal is not readily apparent (this is due to the recoil mechanism, which always refills the bag after it is compressed).

Flow-inflating bag — The flow-inflating bag is used more often in in-hospital settings such as delivery rooms, intensive care units, and operating rooms. Effective use of the flow-inflating bag requires a trained provider who is able to adjust the flow of oxygen, adjust the PEEP valve, and ensure a proper seal with the ventilation mask [29]. Because of a longer time to first breath, a flow-inflating bag is typically not used in emergency settings.

Size – The flow-inflating ventilation bag should have a volume of 500 mL in infants, 600 to 1000 mL in children, and 1000 mL or greater in older children and adolescents.

Testing – Prior to use, test for:

Leaks: Provide flow to the circuit and occlude the patient outlet

Functioning gas flow values: Ensure that all valves, including PEEP valve and, if present, pop-off valve, are functioning properly

Oxygen tubing: Check connections to the bag-mask device and oxygen source

Oxygen flow: Set the flow rate to ensure rapid refilling of the bag (eg, 250 mL/kg/min up to 15 L/min)

Manometer port: Ensure tight connection to manometer, or if a manometer is not being used, check that the port is plugged

Ventilation mask cuff: Ensure adequate size and seal (see 'Ventilation mask' below)

Manometer – The clinician should use adequate chest rise as a marker of effective ventilation. However, an in-line manometer may be used to monitor PIP and PEEP.

Mechanism – Because the flow-inflating bag does not contain a non-rebreathing valve, the composition of inhaled gas is determined by the rate of fresh gas flow. The PEEP valve is adjusted to maintain volume in the reservoir bag necessary for appropriate positive pressure and allow an oxygen inflow rate sufficient to wash out exhaled gases. During ventilation, the fresh gas inflow is adjusted to at least 250 mL/kg/min. Increasing the oxygen inflow rate decreases the risk of rebreathing exhaled carbon dioxide.

Advantages:

-Supplementary "blow-by" oxygen may be provided to the spontaneously breathing infant or child

-FiO2 is always 100 percent

-PEEP or CPAP may be delivered with a tight-fitting ventilation mask by adjusting the PEEP usually to 5 to 10 cm H2O

-Feeling for changes in lung compliance and airway resistance is easy due to the compliance of the bag

-Loss of ventilation mask seal is readily apparent with poor bag filling

Disadvantages:

-Cannot provide ventilation without an oxygen source

-Time to first breath is prolonged compared with a self-inflating bag

-Requires more experience and training to use safely

Complications – Complications from inappropriate PIP and PEEP include:

PIP – Excessive PIP can lead to barotrauma and is avoided by careful monitoring with the manometer.

PEEP – Inappropriate adjustment of the PEEP valve can lead to potential barotrauma and impedance to venous return with potential risk for hypotension (if the valve is opened too little, leading to higher resistance to flow out of the bag); inadequate ventilation rate and/or tidal volume (if the valve opening leads to slow refilling of the bag); and loss of ventilation rate and/or tidal volume (if the valve is opened too much, leading to bag collapse when compressed).

Ventilation mask — Effective bag-mask ventilation requires a ventilation mask that fits properly. The correct size is the smallest mask that completely covers the victim's mouth and nose without covering the eyes or overlapping the chin (picture 10) [4]. An airtight seal is required to deliver adequate inflation volume for effective ventilation. In older children and adolescents with facial hair, application of water or water-soluble lubricating jelly may be needed to obtain an adequate seal.

Technique — Bag-mask ventilation using the "E-C clamp technique" has been described by the American Heart Association and may be performed by a single rescuer or two rescuers [7]. For children with suspected cervical spine injury, airway management must be accomplished without moving the neck. In-line manual stabilization must be maintained. (See "Pediatric cervical spinal motion restriction", section on 'Motion restriction during airway management'.)

Single-rescuer E-C clamp technique

Procedure – Utilizing the single-rescuer E-C clamp technique, the rescuer can optimally position the airway to deliver effective breaths while applying the ventilation mask tightly to the victim's face to avoid air leaks (picture 11). The technique is performed as follows [7]:

Positioning of the head requires two maneuvers (picture 2):

-Neck flexion – The neck is flexed forward on the shoulders such that the external auditory canal is anterior to the shoulder. This may be accomplished in children by placing a towel or roll under the occiput. In infants, the towel must be placed under the shoulders to achieve this position because of a prominent occiput.

-Head extension – The head is then extended on the neck such that the nose and mouth are pointing toward the ceiling.

The ventilation mask is placed on the child's face, with the narrowest portion of the mask over the bridge of the nose.

The little, ring, and middle fingers of one hand are then spread from the angle of the mandible forward along the mandible forming the "E." These fingers lift the jaw, pulling the face into the ventilation mask. The rescuer must be sure to keep the fingers on the mandible during assisted ventilation so that they do not compress the soft tissue of the inferior oropharynx.

Finally, the thumb and forefinger of the same hand are placed over the top of the ventilation mask in a "C" shape to squeeze it onto the face, forming a seal between the mask and the face.

Breaths are provided by using the other hand to compress the ventilation bag until the chest visibly rises. The rescuer should use only the force and tidal volume required to make the chest rise.

Two-rescuer E-C clamp technique

Procedure – For some patients, two rescuers may be required to provide effective bag-mask ventilation (picture 12). In this situation, one rescuer uses both hands (each hand in the "E-C" configuration on either side of the face) to maintain the airway and hold the ventilation mask, while another rescuer compresses the ventilation bag. The rescuer holding the mask may also provide a jaw thrust to maintain the airway during ventilation. (See 'Jaw thrust maneuver' above.)

Indications – Two-rescuer bag-mask ventilation may be necessary in the settings of:

Inadequate inflation pressure (ie, due to poor seal between the ventilation mask and the face)

Increased airway resistance (eg, acute severe asthma)

Poor lung compliance (eg, pneumonia or pulmonary edema) [30]

Cervical spine motion restriction (ie, suspected cervical spine injury)

Effectiveness – The effectiveness of two-rescuer bag-mask ventilation was demonstrated in a prospective observational study in which greater peak pressures and mean tidal volumes per weight were generated in manikin models with two-rescuer, as compared with single-rescuer, bag-mask ventilation [31]. In a randomized crossover study performed on 60 children aged one through eight years with obstructive sleep apnea due to adenotonsillar hypertrophy, a two-handed airway technique during inhalational induction of anesthesia provided superior airway patency that was not influenced by anesthetic depth compared with a one-handed technique [32].

Children with suspected or confirmed COVID-19 — When providing bag-mask ventilation to children with suspected or confirmed COVID-19, health care providers should wear a respirator (eg, N95 mask) and other personal protective equipment (PPE) including eye protection (goggles or face shield), gloves, and gown and use an in-line high-efficiency particular air (HEPA) filter with a low dead space. Mouth-to-mouth/nose ventilation should be avoided [33,34].

MONITORING ADEQUACY OF VENTILATION

Indicators of adequate ventilation – Among the clinical parameters, which should be constantly monitored as indicators of the adequacy of ventilation, visible chest rise with each breath is foremost. It must be assumed that if there is no chest motion during cardiopulmonary resuscitation (CPR), there is no ventilation. Other parameters include oxygen saturation, exhaled carbon dioxide, heart rate, blood pressure, distal air entry, and patient response (eg, appearance, color, and level of agitation).

Causes of inadequate ventilation – In the infant or child receiving bag-mask ventilation without an advanced airway, causes of inadequate ventilation include [4]:

Airway obstruction (due to congenital anomaly, trauma, burns, or foreign body in the airway (see "Airway foreign bodies in children"))

Insufficient ventilation pressure

Gastric insufflation

Bilateral pneumothorax

Troubleshooting inadequate ventilation – Perform the following to troubleshoot inadequate bag-mask ventilation in the infant or child without an advanced airway:

Reopen the airway – With basic techniques (including suctioning, repositioning to ensure a sniffing position, reattempting maneuvers including further lifting the jaw during a jaw thrust, rechecking placement of an oropharyngeal airway [OPA] or nasopharyngeal airway [NPA]).

Treat foreign body upper airway obstruction – Management of upper airway foreign body is provided in the algorithm (algorithm 1) and discussed separately. (See "Emergency evaluation of acute upper airway obstruction in children".)

Increase ventilation pressure – By checking the bag-mask device, including verifying appropriate ventilation mask size, ensuring a tight mask seal, or disabling a pop-off valve on a self-inflating bag.

Assess for and treat gastric insufflation – By modifying ventilation technique (delivering a breath over one second then allowing adequate time for exhalation, decreasing tidal volume to just produce visible chest rise, ventilating at a slower rate to avoid excessive peak inspiratory pressure [PIP]), inserting a nasogastric tube or orogastric tube, or applying cricoid pressure.

Assess for and treat pneumothorax – Placement of thoracostomy tubes and catheters are discussed separately. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and "Thoracostomy tubes and catheters: Placement techniques and complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children" and "Society guideline links: Airway management in children".)

SUMMARY AND RECOMMENDATIONS

Emergency airway approach – For the infant or child with respiratory distress or failure, initiate basic airway management while providing 100 percent supplemental oxygen:

Assess airway for patency

-Look for movement of the chest or abdomen

-Listen for air movement and sounds

-Feel for air movement at the nose and mouth

Determine the status of the airway

-Clear – Airway is patent for normal breathing

-Maintainable – Airway is not patent but can be opened and maintained with basic measures

-Not maintainable – Airway is not patent and cannot be opened and maintained without advanced measures

Open and maintain airway with basic measures

-Positioning – Maintain the head in the sniffing position or allow a spontaneously breathing child to remain in a position of comfort.

-Noninvasive maneuvers – Perform the head tilt-chin lift (figure 2) or, in the patient with possible C-spine injury, jaw-thrust maneuver (figure 3) with in-line C-spine stabilization (figure 4). (See 'Noninvasive relief of obstruction' above.)

-Suctioning – Suction to remove secretions, mucous, blood, vomitus, and/or particulate matter from the nose and mouth.

-Airway adjuncts – If the airway is not maintained with positioning and noninvasive maneuvers, place either an oropharyngeal airway (OPA; unconscious patient only) (figure 5) or nasopharyngeal airway (NPA; any patient) (figure 6). (See 'Airway adjuncts' above.)

-Basic life support – If signs of total or near-total airway obstruction are present, perform basic life support to relieve upper airway obstruction as described in the algorithm (algorithm 1).

Open and maintain airway with advanced measures – If the airway cannot be opened or maintained with basic measures, immediately seek assistance from available airway specialists (eg, pediatric anesthesiology, pediatric otolaryngology, and/or pediatric critical care) and proceed to advanced airway management (algorithm 2). (See "The difficult pediatric airway for emergency medicine".)

Assisted ventilation – For children with respiratory failure or cardiac arrest, provide bag-mask ventilation with supplemental oxygen (picture 11 and picture 12). The self-inflating bag provides a rapid means of ventilation and is generally preferred to a flow-inflating bag during emergency resuscitation (see 'Bag-mask ventilation' above). If bag-mask equipment is not immediately available, provide mouth-to-mouth and/or nose ventilation (figure 11). (See 'Mouth-to-mouth and/or nose' above.)

The following general principles of ventilation should be applied regardless of the method of ventilation used (see 'General principles' above and "Pediatric basic life support (BLS) for health care providers", section on 'Breathing'):

Airway – Continue to maintain the airway with positioning, noninvasive maneuvers, suctioning, and airway adjuncts as described above. If the airway is not "maintainable" with these basic techniques, the provider should proceed to advanced airway management. (See "The difficult pediatric airway for emergency medicine".)

Breathing – Deliver each breath over one second. There should be a short pause between breaths to maximize oxygen content and minimize carbon dioxide concentration in the delivered breaths. The volume of each breath should be sufficient to see the chest wall rise.

Rescue breathing – An infant or child with a heart rate ≥60/minute without normal breathing should receive one breath every two to three seconds (20 to 30 breaths per minute).

Ventilation during cardiopulmonary resuscitation (CPR) – For an infant or child requiring chest compressions (ie, pulseless or heart rate <60/minute), the timing of ventilation depends on whether or not the trachea is intubated and on the number of rescuers (see "Pediatric basic life support (BLS) for health care providers", section on 'Basic life support approach'):

-Single rescuer – Two breaths should be delivered at the end of every 30th compression.

-Two rescuers – Two breaths should be delivered at the end of every 15th compression.

-Advanced airway – Once the trachea is intubated, ventilations and compressions can be performed independently. Ventilations are given every two to three seconds (20 to 30 breaths per minute). Compressions are delivered at a rate of 100 to 120 per minute without pauses.

Gastric insufflation – Minimize gastric insufflation by giving breaths slowly, so that an effective tidal volume is delivered at a lower inspiratory pressure. During bag-mask ventilation with two rescuers present, cricoid pressure is optional to compress the esophagus and reduce gastric distension. However, discontinue cricoid pressure if it hampers effective ventilation. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach", section on 'Cricoid pressure'.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Pamela Bailey, MD, who contributed to earlier versions of this topic review.

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References

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