Bag-mask ventilation and basic airway adjuncts: Viva

This infant is apnoeic, cyanosed, bradycardic and limp — 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, which is why airway and ventilation come before compressions. [3]

Branch 1: Opening the airway and ventilating

The candidate should lead with the airway manoeuvre and the device. They 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. They squeeze a paediatric self-inflating bag with an oxygen reservoir slowly over about one second to produce visible bilateral chest rise, deliberately avoiding a forceful squeeze that would insufflate the stomach. They state the rate: because the infant has a pulse, this is rescue breathing at one breath every 2 to 3 seconds, about 20 to 30 breaths per minute, with 100 percent oxygen. [1]

The examiner should probe the device classification and the technique. The candidate distinguishes the self-inflating bag (re-expands alone, the resuscitation standard) from the flow-inflating anaesthesia bag (needs a gas source and a seal) and the T-piece resuscitator (controlled pressure, the neonatal standard). They justify the slow squeeze on the physics: a forceful squeeze spikes the peak inspiratory pressure, overcomes the lower oesophageal sphincter, and fills the stomach, which splints the diaphragm and risks regurgitation and aspiration. [3]

If the examiner pivots to when compressions begin, the candidate adds chest compressions only if the heart rate stays below 60 beats per minute despite at least 30 seconds of effective ventilation with oxygen, at 15:2 with two rescuers, and switches to about 10 breaths per minute (one every 6 seconds) once an advanced airway is in place with continuous compressions. [1]

Branch 2: Adjuncts and contraindications

The candidate adds an adjunct when the chest does not rise despite a correct mask, head position and a jaw thrust, chosen by the conscious level. For this unconscious infant with no gag, they insert an oropharyngeal airway (Guedel) sized from the mouth angle to the jaw angle, passing it directly along the curve of the tongue rather than rotating it 180 degrees, because the adult rotation can push the tongue back. They state that a Guedel is contraindicated in a child with an intact gag. [3]

The examiner should test the alternative. For a semi-conscious child with a gag, the candidate uses a nasopharyngeal airway sized from the nostril to the tragus, lubricated and inserted gently, and states clearly that it is contraindicated in suspected basilar skull fracture or a coagulopathy because it can enter the cranial vault. They note that the cricoid ring, not the glottis, is the narrowest point of the child's airway, which is why subglottic obstruction raises the pressure the bag must generate. [3]

If pushed on the trauma patient, the candidate switches to a jaw thrust without head tilt and maintains manual in-line stabilisation of the cervical spine, because head tilt-chin lift is unsafe when a cervical spine injury is possible, while the mask, the rate and the adjuncts are unchanged. [4]

Branch 3: The failed airway and escalation

The candidate states the escalation ladder and the trigger for each rung. The moment the chest is not rising and the heart rate is not responding, they move from one-person bag-mask to the two-person technique (one rescuer two-handed jaw thrust and tight mask seal, the second squeezes), then to a supraglottic airway, then to endotracheal intubation. They justify the supraglottic airway as the supported rescue device when bag-mask fails, and call for senior and intensive care help early. [4]

The examiner should test the evidence and the neonatal special case. The candidate cites the Cochrane review that the laryngeal mask airway is as effective as bag-mask or intubation for neonatal resuscitation, and the randomised trial that it reduced the need for further resuscitation where intubation was scarce. If the scenario shifts to the delivery room, they ventilate the neonate with a T-piece resuscitator at a peak inspiratory pressure of about 20 to 25 cm of water, at 40 to 60 breaths per minute, with blended oxygen titrated to the pre-ductal saturation target, because the T-piece gives a controlled pressure and consistent positive end-expiratory pressure that a self-inflating bag cannot. [2]

If the examiner escalates to a child who still cannot be ventilated, the candidate reassesses for a treatable obstruction rather than squeezing harder — a tension pneumothorax needing decompression, a blocked tracheostomy tube, or a solid foreign body — because more ventilation makes each of those worse. They frame the principle: persisting with ineffective one-person ventilation when a two-person technique, an adjunct or a supraglottic airway was available is the classic avoidable error. [4]