Bag-mask ventilation and basic airway adjuncts: Case

This infant is apnoeic, cyanosed, bradycardic and limp after a seizure — the pre-terminal signature of hypoxia — so the immediate priority is to open the airway and ventilate. The slow heart rate is the heart's response to hypoxia, and effective ventilation with oxygen usually reverses it within seconds once the chest rises, which is why airway and breathing come before compressions. [2]

Clinical findings

The key findings are the apnoea, the central cyanosis, the bradycardia with a heart rate of 52, the hypoxaemia with a saturation of 70 percent, and the limp tone, which together are the pre-terminal picture of a hypoxic infant. The copious secretions and the stertorous breathing show that the airway is obstructed at the level of the tongue and oropharynx, which is the first problem to fix. [1]

The candidate should recognise that this is a respiratory problem masquerading as a cardiac one. The slow heart rate in a sick child is the heart's response to hypoxia, so the treatment is ventilation, not compressions; compressions are added only if the heart rate stays below 60 beats per minute despite at least 30 seconds of effective ventilation with oxygen. They should also note that there is no sign of trauma, so head tilt-chin lift is permissible here, though a jaw thrust is the more reliable manoeuvre for an obstructing tongue. [1]

Management

The first step is to open the airway. The candidate suctions the visible secretions from the mouth and oropharynx, performs a jaw thrust to lift the tongue off the posterior pharyngeal wall, and positions the infant head neutral, because over-extension of an infant's neck folds the high anterior airway and worsens the obstruction. They apply a mask sized from the bridge of the nose to the chin with a C-E grip. [2]

The candidate ventilates with a paediatric self-inflating bag and an oxygen reservoir, squeezing slowly over about one second to produce visible bilateral chest rise, and deliberately avoids a forceful squeeze that would overcome the lower oesophageal sphincter and insufflate the stomach. Because the infant has a pulse, this is rescue breathing, and the rate is one breath every 2 to 3 seconds, about 20 to 30 breaths per minute, with 100 percent oxygen during active resuscitation. They watch the chest rise, the heart rate and the saturation, and expect the heart rate to rise and the colour to improve within seconds. [1]

If the chest does not rise despite a correct mask, head position and a jaw thrust, the candidate adds an oropharyngeal airway sized from the mouth angle to the jaw angle, passing it directly along the curve of the tongue, and escalates immediately to the two-person technique — one rescuer performing a two-handed jaw thrust with a tight mask seal, the second squeezing the bag — because that is the single most effective improvement. They state the trigger for chest compressions: a heart rate that stays below 60 despite at least 30 seconds of effective ventilation. [4]

Complications and follow-up

The complications to avoid are those of the technique itself. A forceful squeeze insufflates the stomach, which splints the diaphragm, reduces the tidal volume, and precipitates regurgitation and aspiration, which is why the slow one-second squeeze is the technique and the corrective-steps evidence for mask ventilation reinforces a gentle, well-sealed breath. A poor mask seal or a blocked airway produces hypoventilation, the silent killer, whose sign is a chest that never rises while the rescuer believes they are ventilating. [3]

The candidate calls for senior and intensive care help early and reassesses continuously, because the infant who cannot be ventilated despite a correct mask, an open airway and an adjunct is reassessed for a treatable obstruction rather than squeezed harder. Once the infant stabilises and the heart rate and saturation recover, they wean the oxygen to a target saturation of 94 to 98 percent, arrange definitive airway management as needed, investigate and treat the underlying seizure cause, and ensure the family leaves with a clear written safety-net for any recurrence. [1]