Paeds · investigations-procedures-and-technology

Bag-mask ventilation and basic airway adjuncts

Also known as Paediatric bag-mask ventilation · BMV in children · Self-inflating bag ventilation · Oropharyngeal airway insertion · Guedel and nasopharyngeal airway · Two-person mask ventilation

Fellowship guide to the two skills that stand between a hypoxic child and a cardiac arrest: ventilating through a face mask, and holding a blocked airway open with an adjunct. Covers manual ventilation device classification, one- and two-person technique, ventilation rates for rescue breathing and arrest, oropharyngeal and nasopharyngeal airway sizing and insertion, the laryngeal mask airway as a rescue device, the paediatric difficult-mask-ventilation predictors, gastric insufflation, and the neonatal T-piece resuscitator.

high12 referencesUpdated 17 July 202622 min readVerification in progress

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RACP DWERACP DCEMRCPCH TheoryMRCPCH ClinicalABP General Pediatrics

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 risesForceful 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 riseOver-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 adultsA 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 reflexIn 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 stabilisationPersisting 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

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

delivery-roomed-acutewardpicunicuretrievalrural-remote

Clinical exam formats

written-only

Board mappings

Opens a child's airway and performs effective one- and two-person bag-mask ventilation with correct mask sizing and head positionSelects and inserts an oropharyngeal or nasopharyngeal airway correctly and knows the contraindicationsStates the correct ventilation rates for rescue breathing and for CPR, and recognises effective ventilation by chest riseLeads the failed-airway escalation from bag-mask to two-person technique to supraglottic airway using current AHA, ERC and ILCOR guidanceJustifies oxygen concentration, ventilation rate and pressure by the clinical context, including the neonate and the trauma patientApplies the paediatric difficult-mask-ventilation predictors and the physiology of gastric insufflation to avoid the common errorsBedside technique for opening the airway and ventilating an apnoeic or exhausted child by bag-maskCorrect mask size, head position, ventilation rate, and recognition of effective ventilationCommunication of the immediate airway and ventilation plan to the team and familyRecognition of when bag-mask ventilation or an airway adjunct is needed and when to escalate to a supraglottic airwayInterpretation of a child who is not being ventilated effectively despite apparently correct techniqueSafety-netting and family communication around the airway and the risk of re-obstructionLevel 1: Opens the airway and performs one-person bag-mask ventilation under supervisionLevel 2: Performs two-person ventilation, inserts airway adjuncts, and sets the correct rate by contextLevel 3: Leads the failed-airway algorithm and integrates ventilation strategy with the underlying diagnosisClassification of manual ventilation devices (self-inflating bag, flow-inflating bag, T-piece resuscitator) and basic airway adjunctsVentilation rates for rescue breathing, single- and two-rescuer CPR, and arrest with an advanced airwaySizing and insertion of the oropharyngeal and nasopharyngeal airway, and the contraindicationsDemonstration of airway opening, mask sizing, and one- and two-person bag-mask ventilation on a manikinStructured assessment of whether ventilation is effective, and escalation to a supraglottic airwayCommunication of the airway and ventilation plan and the safety-net to the familyOpens the airway and provides effective bag-mask ventilation with correct rate and techniqueSelects and inserts the correct airway adjunct and knows the contraindicationsEscalates from bag-mask to supraglottic airway using current AHA and AAP guidancePerforms one- and two-person bag-mask ventilation safely with monitoringInserts an oropharyngeal or nasopharyngeal airway correctlyRecognises ineffective ventilation and escalates appropriatelyCanadian approach to paediatric bag-mask ventilation and basic airway adjunctsDevice classification, ventilation rates, and adjunct sizing and contraindicationsEscalation to a supraglottic airway and the evidence base from AHA, ERC and ILCOR

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Saved locally on this device.

Practise this topic

Target exams

RACP DWERACP DCEMRCPCH TheoryMRCPCH ClinicalABP General Pediatrics

Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

delivery-roomed-acutewardpicunicuretrievalrural-remote

Clinical exam formats

written-only

Board mappings

Overview & Definition

A floppy, blue infant pulled from a swimming pool, a bronchiolitic baby who has finally exhausted, and a child who has stopped breathing after a seizure all need the same two hands-on skills, and they need them in the next ten seconds: open the airway, and squeeze air into the lungs through a mask held tight to the face. These skills — bag-mask ventilation and the basic airway adjuncts that hold a blocked airway open — are bundled as one topic because they are done together, at the bedside, in the first minutes of every paediatric resuscitation, and because the same small set of anatomy and physics decides whether each of them works. They are also the most decisive skills in paediatrics: respiratory failure and apnoea, not primary cardiac events, cause the great majority of paediatric arrests, so the provider who can ventilate a child keeps the heart beating. [3]

Each skill rests on one idea. Bag-mask ventilation moves gas into the lungs by squeezing a bag through a sealed mask, and whether it works depends almost entirely on whether the airway is open and the mask sealed — not on the bag. An airway adjunct is a shaped piece of plastic that lifts the tongue off the back of the throat when the head position cannot, holding open the passage that the bag then fills. Get the airway open and the seal right and almost any child can be ventilated; get either wrong and the most expensive bag in the hospital delivers nothing to the lung. [1]

One-sentence answer for the exam

Bag-mask ventilation moves gas into an apnoeic or failing child's lungs by squeezing a self-inflating bag through a correctly-sized mask sealed to the face, using a one-person C-E grip for most and escalating to a two-person technique when the chest is not rising; rescue breathing is one breath every 2 to 3 seconds (20 to 30 per minute), CPR is 30:2 single-rescuer or 15:2 two-rescuer and about 10 breaths per minute once an advanced airway is in place; an oropharyngeal airway holds the tongue off the posterior pharynx in the unconscious child with no gag (sized mouth-angle-to-jaw-angle), a nasopharyngeal airway does the same in the semi-conscious child with a gag (sized nostril-to-tragus), and a laryngeal mask airway is the rescue device when bag-mask fails.

[1]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Joyner BL Jr, Dewan M, Bavare A, de Caen A, DiMaria K, Donofrio-Odmann J, et al Part 6: Pediatric Basic Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2025.PMID 41122891
[2]Lee HC, Strand ML, Finan E, Illuzzi J, Kamath-Rayne BD, Kapadia V, et al Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2025.PMID 41122887
[3]Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, et al European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation, 2021.PMID 33773830
[4]Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, et al 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation, 2022.PMID 36325905
[5]Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Bittencourt Couto T, et al Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics, 2021.PMID 33087557
[6]Grein AJ, Weiner GM Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev, 2005.PMID 15846656
[7]Pejovic NJ, Myrnerts Höök S, Byamugisha J, Alfvén T, Lubulwa C, Cavallin F, et al A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation. N Engl J Med, 2020.PMID 33252870
[8]Hawkes CP, Ryan CA, Dempsey EM Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: a qualitative review. Resuscitation, 2012.PMID 22227500
[9]Gaertner VD, Mileder LP, Springer L, Wagner M, Dvorsky R, Rüegger CM, et al Corrective steps during neonatal mask ventilation - a narrative review of the evidence behind the MR SOPA acronym. Resuscitation Plus, 2026.PMID 41909182
[10]Miller KA, Nagler J Advances in Emergent Airway Management in Pediatrics. Emerg Med Clin North Am, 2019.PMID 31262416
[11]Miller KA, Goldman MP, Nagler J Management of the Difficult Airway. Pediatr Emerg Care, 2023.PMID 36790950
[12]Nemeth M, Ernst M, Asendorf T, Richter J, von Gottberg P, Brandes IF, et al Working with estimation-formulas to predict nasopharyngeal airway insertion depth in children: Looking at magnetic resonance images - A prospective observational study (WEND:LI-Study). Resuscitation, 2021.PMID 34600970

Bag-mask ventilation and basic airway adjuncts

Also known as Paediatric bag-mask ventilation · BMV in children · Self-inflating bag ventilation · Oropharyngeal airway insertion · Guedel and nasopharyngeal airway · Two-person mask ventilation

high12 referencesUpdated 17 July 202622 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Joyner BL Jr, Dewan M, Bavare A, de Caen A, DiMaria K, Donofrio-Odmann J, et al Part 6: Pediatric Basic Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2025.PMID 41122891
[2]Lee HC, Strand ML, Finan E, Illuzzi J, Kamath-Rayne BD, Kapadia V, et al Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2025.PMID 41122887
[3]Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, et al European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation, 2021.PMID 33773830
[4]Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, et al 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation, 2022.PMID 36325905
[5]Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Bittencourt Couto T, et al Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics, 2021.PMID 33087557
[6]Grein AJ, Weiner GM Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev, 2005.PMID 15846656
[7]Pejovic NJ, Myrnerts Höök S, Byamugisha J, Alfvén T, Lubulwa C, Cavallin F, et al A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation. N Engl J Med, 2020.PMID 33252870
[8]Hawkes CP, Ryan CA, Dempsey EM Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: a qualitative review. Resuscitation, 2012.PMID 22227500
[9]Gaertner VD, Mileder LP, Springer L, Wagner M, Dvorsky R, Rüegger CM, et al Corrective steps during neonatal mask ventilation - a narrative review of the evidence behind the MR SOPA acronym. Resuscitation Plus, 2026.PMID 41909182
[10]Miller KA, Nagler J Advances in Emergent Airway Management in Pediatrics. Emerg Med Clin North Am, 2019.PMID 31262416
[11]Miller KA, Goldman MP, Nagler J Management of the Difficult Airway. Pediatr Emerg Care, 2023.PMID 36790950
[12]Nemeth M, Ernst M, Asendorf T, Richter J, von Gottberg P, Brandes IF, et al Working with estimation-formulas to predict nasopharyngeal airway insertion depth in children: Looking at magnetic resonance images - A prospective observational study (WEND:LI-Study). Resuscitation, 2021.PMID 34600970