Bag-mask ventilation and basic airway adjuncts: SAQ

This infant is apnoeic, cyanosed and bradycardic with a limp tone — the pre-terminal signature of hypoxia — so the immediate priority is to open the airway and ventilate, because the slow heart rate is the heart's response to hypoxia and ventilation usually reverses it within seconds once the chest rises. Each step rests on choosing the right device, the right technique, and the right rate. [2]

Question 1 (10 marks)

Classify the manual ventilation devices, describe your immediate airway and ventilation technique for this infant including the mask and the rate, and state when you would add chest compressions. [1]

Manual ventilation devices sort by how they generate the breath. A self-inflating bag re-expands on its own after every squeeze whether or not it is connected to oxygen, so it is the only device that works in a solo resuscitation and is the resuscitation standard. A flow-inflating (anaesthesia) bag needs a continuous gas source and a seal to inflate, so it is for the trained anaesthetist. A T-piece resuscitator delivers a set peak inspiratory pressure and a consistent positive end-expiratory pressure, and is the neonatal standard. For this infant I use a paediatric self-inflating bag with an oxygen reservoir. [2]

My technique is to position the infant head neutral — over-extension would obstruct the high anterior airway — suction the visible secretions, and apply a mask that spans the bridge of the nose to the chin with a C-E grip. I squeeze the bag slowly over about one second to produce visible bilateral chest rise, deliberately avoiding a forceful squeeze that would overcome the lower oesophageal sphincter and insufflate the stomach. I use 100 percent oxygen during active resuscitation and wean to a target once return of circulation is achieved. [1]

Because this infant is apnoeic with a pulse, this is rescue breathing, and my rate is one breath every 2 to 3 seconds, about 20 to 30 breaths per minute. I would add chest compressions only if the heart rate stays below 60 beats per minute despite at least 30 seconds of effective ventilation with oxygen, at a ratio of 15 compressions to 2 breaths with two rescuers, or 30 to 2 as a single rescuer. I escalate to the two-person technique the moment the chest does not rise, because that is the single most effective improvement. [1]

Question 2 (10 marks)

Describe how you select and insert the basic airway adjuncts, including the contraindications, and outline the escalation if bag-mask ventilation fails. [2]

If the chest does not rise with a correct mask, head position and a jaw thrust, I add an airway adjunct, chosen by the child's conscious level. For this deeply unconscious infant with no gag reflex, I insert an oropharyngeal airway (a Guedel), sized from the angle of the mouth to the angle of the jaw so its tip sits at the base of the tongue and lifts it off the posterior pharyngeal wall. In the infant and small child I pass it directly along the curve of the tongue rather than rotating it 180 degrees, because the adult rotation can push the tongue back and worsen the obstruction. A Guedel is contraindicated in a child with an intact gag, because it would provoke vomiting. [2]

For a semi-conscious child with a gag, I would instead use a nasopharyngeal airway, sized from the nostril to the tragus and lubricated before gentle insertion, with the depth predictable by the published estimation formulas. A nasopharyngeal airway is contraindicated in suspected basilar skull fracture or a coagulopathy, because it can enter the cranial vault. [3]

If bag-mask ventilation fails despite a correct mask, an open airway and an adjunct, I escalate to the failed-airway ladder. First the two-person technique, where one rescuer performs a two-handed jaw thrust and forms a tight mask seal while the second squeezes the bag; then a supraglottic airway, the laryngeal mask airway, which is the supported rescue device when bag-mask fails or intubation is unsuccessful; and finally endotracheal intubation by a skilled provider. I call for senior and intensive care help early, because the child who cannot be ventilated and oxygenated is the failed airway and the algorithm should start from the first minute, not after a quiet deterioration. [4]