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]