Bag-mask ventilation and basic airway adjuncts

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Target exams

Red flags

• A slow heart rate in a sick, hypoxic child is a pre-terminal sign, not a primary cardiac problem; the treatment is opening the airway and ventilating, and the rate usually rises within seconds once the chest rises
• Forceful or too-rapid bag squeezing insufflates the stomach, splints the diaphragm, and precipitates regurgitation and aspiration; squeeze slowly over about one second to produce visible chest rise
• Over-extending an infant's neck obstructs the airway; hold the infant head in a neutral position, not the sniffing extension used for older children and adults
• A nasopharyngeal airway is contraindicated in suspected basilar skull fracture or coagulopathy, because it can enter the cranial vault; an oropharyngeal airway is unsafe in a child with an intact gag reflex
• In the trauma patient, never use head tilt-chin lift when cervical spine injury is possible; use a jaw thrust without head movement and maintain manual in-line stabilisation
• Persisting with ineffective one-person ventilation when a two-person technique or a supraglottic airway was available loses the child; escalate the moment the chest is not rising and the heart rate is not responding

Life stages

Care settings

Clinical exam formats

Board mappings

• Opens a child's airway and performs effective one- and two-person bag-mask ventilation with correct mask sizing and head position
• Selects and inserts an oropharyngeal or nasopharyngeal airway correctly and knows the contraindications
• States the correct ventilation rates for rescue breathing and for CPR, and recognises effective ventilation by chest rise
• Leads the failed-airway escalation from bag-mask to two-person technique to supraglottic airway using current AHA, ERC and ILCOR guidance
• Justifies oxygen concentration, ventilation rate and pressure by the clinical context, including the neonate and the trauma patient
• Applies the paediatric difficult-mask-ventilation predictors and the physiology of gastric insufflation to avoid the common errors
• Bedside technique for opening the airway and ventilating an apnoeic or exhausted child by bag-mask
• Correct mask size, head position, ventilation rate, and recognition of effective ventilation
• Communication of the immediate airway and ventilation plan to the team and family
• Recognition of when bag-mask ventilation or an airway adjunct is needed and when to escalate to a supraglottic airway
• Interpretation of a child who is not being ventilated effectively despite apparently correct technique
• Safety-netting and family communication around the airway and the risk of re-obstruction
• Level 1: Opens the airway and performs one-person bag-mask ventilation under supervision
• Level 2: Performs two-person ventilation, inserts airway adjuncts, and sets the correct rate by context
• Level 3: Leads the failed-airway algorithm and integrates ventilation strategy with the underlying diagnosis
• Classification of manual ventilation devices (self-inflating bag, flow-inflating bag, T-piece resuscitator) and basic airway adjuncts
• Ventilation rates for rescue breathing, single- and two-rescuer CPR, and arrest with an advanced airway
• Sizing and insertion of the oropharyngeal and nasopharyngeal airway, and the contraindications
• Demonstration of airway opening, mask sizing, and one- and two-person bag-mask ventilation on a manikin
• Structured assessment of whether ventilation is effective, and escalation to a supraglottic airway
• Communication of the airway and ventilation plan and the safety-net to the family
• Opens the airway and provides effective bag-mask ventilation with correct rate and technique
• Selects and inserts the correct airway adjunct and knows the contraindications
• Escalates from bag-mask to supraglottic airway using current AHA and AAP guidance
• Performs one- and two-person bag-mask ventilation safely with monitoring
• Inserts an oropharyngeal or nasopharyngeal airway correctly
• Recognises ineffective ventilation and escalates appropriately
• Canadian approach to paediatric bag-mask ventilation and basic airway adjuncts
• Device classification, ventilation rates, and adjunct sizing and contraindications
• Escalation to a supraglottic airway and the evidence base from AHA, ERC and ILCOR