The Art of Pediatric Ventilation: Flow Inflating Bags

Positioning the patient

The best way to set yourself up for airway success is by placing the pediatric patient in the proper position. Proper positioning and manual maneuvers to relieve tongue and soft tissue obstruction of the upper airway are crucial in the pediatric population. Often times laying a child supine may force their chin onto their chest resulting in less than optimal airway positioning. A neutral “sniffing” position without hyperextension of the neck is appropriate for infants and toddlers. Extreme hyperextension in small children will result in airway obstruction. A shoulder roll can help create a simple extension of the neck and bring a child into sniffing position

Adequate Seal

Selecting the proper size mask is crucial to ventilating the patient. Inflatable masks range from sizes 00 to 5 in the neonatal-pediatric population. When placed on the patient’s face, a properly sized mask will completely cover the nares and mouth without any gaps between the mask and face.  The mask should measure from the bridge of the nose to the cleft of the chin.  The EC clamp technique of bag-mask ventilation can be utilized with careful hand placement. In the sole rescuer technique, the thumb and index finger hold the mask down over the nose and mouth forming a C while the other three fingers of the hand grasp the patient’s mandible forming an E.  It is important to be mindful to minimize pressure on the submental tissue to avoid tongue obstruction. Often times, it is more effective to ventilate with two rescuers. The rescuer who is positioning the airway should seat the mask at the apex of the narrow portion on the bridge of the nose and seal the mask to the patient’s face by positioning the rescuer’s thumbs on each side of the mask, being careful not to push the mask down into the face.

Proper Tidal Volume and Monitoring Pressures

Because the flow inflating bag is soft, you can easily feel lung compliance and respiratory effort. With spontaneous ventilation, the skilled clinician can see and feel the bag partially deflate with each inspiration before it inflates with the gas flow. The amount the bag deflates gives the clinician a good indication of tidal volume.  Experienced personnel will know immediately when you have lost a good seal because the bag will go flat and tidal volume will not be delivered.  Due to extremely fine control, flow inflating bags are capable of delivering tiny tidal volumes. Monitoring airway pressures while maintaining adequate ventilation is crucial. Many flow inflating bags are equipped with either a pressure manometer or a port to attach an optional manometer. Ventilating with the lowest pressure to achieve appropriate chest rise is key. Targeted pressures of less than 20 cm H20 are ideal. Bags are furnished with a pop-off valve safety feature to ensure patient safety and reduce the effects of ventilation such as barotrauma.

Conclusion

Airway management is a key skill for the respiratory therapist and their team. The airway of the pediatric patient has a number of significant differences when compared to the adult airway and presents some unique challenges. Bag mask ventilation plays a vital role in effective manual ventilation, improving both oxygenation and ventilation as well as buying time while preparations are made for endotracheal intubation. 

Editors Notes 

“Flow inflating bags offer many advantages over self-inflating bags in infants. It is the preferred device for manual ventilation by most neonatal resusitationists. However, you need experience using these devices! It takes practice to assure you maintain PEEP with the flow and the valve wheel and to assure you are giving adequate breaths without over-inflating your bag. If you are inexperienced with a flow inflating bag and are struggling to ventilate an infant, consider switching to a self-inflating bag.”

-Steve Haywood MD.