An example of such a policy would be:

Standard of practice for basic airway management in infants and children

Introduction- effective airway management in infants and pediatrics is an essential component of successful cardiopulmonary resuscitation (CPR) and treatment of respiratory insufficiency (i.e, hypoxemia, bradycardia, hypercarbia, decreased LOC).

Anatomic considerations- the position of the larynx in infants and children is higher and more anterior than in adults.  As a result, hyperextension of the neck may worsen obstruction of the airway; infants and children have airways that are anatomically smaller than adults.  This inherent difference makes them more prone to obstruction from secretions, blood, debris, mucous, vomitus, or a foreign body; a relatively larger occiput of the infant and young child causes passive flexion of the cervical spine in the supine position which increases the likelihood for upper airway obstruction; a relatively large tongue in relation with the oral cavity can, in an infant or child with decreased LOC, increase the likelihood for upper airway obstruction.

Emergency Airway Approach- for the infant or child with respiratory distress or failure, initiate basic airway management while providing 100% supplemental oxygen.  When assessing airway and breathing, start with confirming respiratory effort by: looking for movement of the chest or abdomen or listening to the chest for breath sounds.  After confirming respiratory effort, the next step would be to assess the patency of the upper airway.  The status of the upper airway can be either: patent (i.e, clear, pt is breathing normally); maintainable (i.e, airway is non-patent but can be opened and maintained with basic measures); non-patent (i.e, airway is not patent and cannot be opened and maintained without advanced measures).

Basic ways for opening and maintaining a patent airway

1) Positioning- maintain the head in the sniffing position or allow a spontaneously breathing child to remain in a position of comfort.
2) Noninvasive maneuvers- the two primary noninvasive airway maneuvers include: placing the child in the sniffing position (i.e, head-tilt chin-lift) or performing a jaw thrust (i.e, in the patient where c-spine precautions are necessary).
3) Suctioning- removes secretions, mucous, blood, vomitus, and/or particulate from the nose and mouth.
4) Airway adjuncts- if the airway is not maintained with positioning and non-invasive measures, place either an oropharyngeal airway (unconscious patient) or nasopharyngeal airway (conscious patient).
5) Open and maintain airway with advanced measures- if the airway cannot be opened or maintained with basic measures, immediately seek assistance (i.e, EMS, pediatric anesthesiologist) and proceed to advance airway management (i.e, intubation, supra-glottic airway)

Noninvasive relief of obstruction: techniques

Head tilt chin lift maneuver- place the fingers of one hand under the mandible and lift upward to move the chin anteriorly while at the same time, place the other hand on the child's forehead and gently tilt the head into the neutral position.​

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​​Cautions when performing the head-tilt chin-lift maneuver- avoid closing the mouth, pushing on the soft tissues under the chin, or hyperextending the neck, because any of these actions can cause airway obstruction.

Jaw thrust maneuver- is the preferred method for opening the airway in infants and children when there is a concern for cervical spine injury.  During airway management, in-line manual cervical spine stabilization  should be considered during the airway maneuver.  To perform the skill, place one hand at each side of the face, grasp the angles of the mandible and move the mandible anteriorly.

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Suctioning- is indicated in all infants and children who have copious oral secretions, bleeding, or vomiting and who are showing signs of airway obstruction (i.e, hypoxemia, respiratory distress, or poor air entry despite adequate chest wall movement) or cannot properly protect their airway (i.e, patients with altered mental status or swallowing abnormalities).  The procedure involves suctioning the patient for brief intervals (i.e, less than 30 seconds) while taking into account their breathing and oxygenation.   The yonker is the recommended instrument for clearing oral secretions.  The posterior pharynx should be avoided in order to reduce the risk of gagging and vomiting.  For suctioning the nasopharynx, use a suction catheter with a bore size that easily passes into the nasal passage but is also effective at clearing secretions.

Potential complications associated with suctioning includes vomiting and/or desaturations.  If vomiting occurs, rapidly place the patient on their side or elevate the head of the bed and proceed to suction the oropharyngeal space.  If significant oxygen desaturations occur, stop suctioning and provide supplemental oxygen as needed.  Suctioning can be re-commenced as needed once the patient's oxygen saturation returns to baseline levels.   

Airway Adjuncts- the oropharyngeal airway (OPA) is indicated in the unconscious infant or child to relieve upper airway obstruction caused by the tongue that is unresponsive to simple airway maneuvers (i.e, head-tilt/chin lift or jaw thrust).   An OPA should never be placed in the conscious infant or child as it can stimulate gagging and or vomiting.  Sizing the OPA involves holding it along the side of the face with the phalange at the corner of the mouth and the tip of the airway directed to the angle of the mandible.  The procedure involves depressing the tongue to the floor of the mouth using a tongue depressor and gently inserting the OPA in-line with the curve of the mouth and pharynx.  Avoid inserting and then 360-degrees rotating an OPA in an infant or smaller child as it may cause abrasion or injury to the tonsils or soft palate with bleeding. 

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Complications of incorrect sizing include: obstruction of the larynx, laryngeal injury, or laryngospasm ( i.e, if too large) and obstruction of the airway by the tongue (i.e, if too small).  

The nasopharyngeal airway (NPA) maybe used in the conscious or unconscious infant or child to bypass airway obstruction caused by the tongue and pharyngeal soft tissues.  It is particularly useful to relieve obstruction caused by macroglossia or tonsillar hypertrophy in infants and children with normal mentation and respiratory function.   Sizing the NPA involves choosing a size where the length is equal to the distance between the nostril and tragus of the ear.

 

 

 

 

 

 

 

 

NPA placement- placing the NPA involves lubricating the distal 1/3 of the appliance with a water soluble substance (i.e, muco-jelly or sterile water or normal saline) and inserting it along the floor of the nasopharynx posteriorly with the bevel facing the nasal septum.  If the NPA doesn't advance easily, remove it and insert into the opposite nostril.

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Complications associated with using an NPA that is too long include: bradycardia through vagal stimulation; laryngeal injury with airway bleeding or swelling; laryngospasm; vomiting with the risk of aspiration; pressure necrosis of the soft tissue and cartilage of the nose; and coughing.  If the NPA is too small, it can become easily obstructed by nasal secretions and become ineffective.

    
Assisted Ventilation- with the airway opened and maintained, the patient with ineffective breathing requires assisted ventilation using a positive-pressure device.   When providing assisted ventilation using a positive pressure device, ensure that: you maintain an open airway with either proper positioning (i.e, head-tilt chin-lift/jaw-thrust) or airway adjuncts (i.e, OPA, NPT); you support breathing by delivering breaths for a respiratory rate (RR) of 20-30 breaths per minute (bpm) and delivering the breath over 1- second.

Indications for positive-pressure ventilation include: for the infant or child with ineffective spontaneous breathing (i.e, bradypnea, diminished chest expansion, minimal air entry); supporting breathing during a cardiac arrest. 

Breathing during cardiac arrest for a non-protected airway (i.e, patient is not intubated) is provided sequentially after 15 chest compressions (2- breaths given).  Rescue breathing during a cardiac arrest for a protected airway can be provided during chest compressions at a rate of 20-30bpm.

Positive-pressure breathing is performed with a bag-mask device consisting of a ventilation bag and mask.  The bag-mask device that will be most commonly used in the setting which you work is the self-inflating bag.  The volume of the self-inflating pediatric bag is approximately 450-500cc's.  For larger children (i.e, post-pubescent), an adult bag-mask device should be used where the bag's volume is approximately 1000cc's.  Care must be taken with both devices to not depress the entire contents of the bag into the patient's chest as the volume of the bag is larger than the volume of the patient's lungs and can cause lung trauma.  The bag of a manual resuscitator should only be depressed to the point where chest rise is evident.   

To use a manual resuscitator, connect the oxygen tubing to an oxygen flowmeter, set the flow to 10-15LPM, place the manual resuscitators mask for the patient's nose and mouth, and provide breathing.

Testing the positive -pressure delivery device:  prior to use, the operator should ensure that the resuscitator: doesn't have any leaks (i.e, depress the bag while occluding the outlet- air should remain in the bag); that the pop-off valve can be disabled; that the gas control valves are functioning properly.  The gas control valves include the gas intake valve and the non-rebreathing outlet valve.  The gas intake valve should open after the operator stops depressing the bag, allowing air to refill the bag and priming the system for delivering the next breath.  At the same time, the non-rebreathing outlet valve closes, allowing the patient's exhaled gases to return to the atmosphere.  During bag compression, the gas intake valve closes, and the non-rebreathing outlet valve opens, allowing the contents of the bag to enter the patient's lungs; and that the mask is off adequate size for the patient.

A common complication associated with supporting a patient's breathing with positive pressure ventilation is gastric insufflation.   Gastric insufflation can result when breaths are delivered too quickly or too rapidly.    

Advantages of a self-inflating manual resuscitator:

​1. an oxygen source is not required for use.
2. it is easier to use when compared to a flow-inflating bag. 

Disadvantages of a self-inflating manual resuscitator:

1. supplementary blow-by oxygen can not be provided to a spontaneously breathing infant or child.
2. Fio2 is limited unless the manual resuscitator is attached to a oxygen reservoir.
3. A positive-end expiratory PEEP valve can not be used to provide CPAP in the spontaneously breathing patient. 
4.  Difficult to determine changes in lung compliance or resistance secondary to bag stiffness.
5. Loss of ventilation secondary to an ineffective mask seal less apparent.  The recoil mechanism of the bag always refills the bag despite the mask seal being compromised.

Techniques for holding the manual resuscitator

E-C clamp technique- the purpose behind the E-C clamp technique is to provide the operator with a means for opening the airway and applying an effective mask seal during positive-pressure breathing with a manual resuscitator.  To perform the technique, the patient's neck is positioned in the flexed position.  This may be accomplished in children by placing a towel or roll under the occiput.  In infants, the towel must be placed under the shoulders to achieve this position because of a prominent occiput.  The head is then extended on the neck such that the nose and mouth are pointed toward the ceiling.   After positioning the patient's airway, the mask is applied to the patient's nose and face with the narrowest portion of the mask over the bridge of the nose.  The little, ring, and middle finger are used to elevate the mandible anteriorly and into the mask while the thumb and index finger ensure an effective mask seal by forcing the mask to the patient's face.  Breaths are provided by using the other hand to compress the ventilation bag, paying attention to chest rise.

 

 

 

 

 

 

 

 

 

 

 

In the context where ventilation/oxygenation remains ineffective despite use of the E-C clamp technique, a two-person E-C clamp technique can be performed.  To accomplish this, one rescuer uses two hands to create the E-C hand positions and maintain the airway while a second rescuer depresses the bag of the manual resuscitator.

 

 

 

Troubleshooting inadequate ventilation

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• Reopen the airway- with basic techniques (i.e, repositioning the head, suctioning, rechecking placement of an OPA or NPT)

• Treat foreign body upper-airway obstruction as per the algorithm

• Increase the ventilation pressures- by checking the bag-valve-mask device, including verifying appropriate mask size, ensuring a tight mask seal, or disabling a pop-off valve on the self-inflating bag

• Assess for and treat gastric insufflation- gastric insufflation can be prevented by using smaller tidal volumes, giving the breath over 1-second, and reducing the respiratory rate so that the patient has a longer time to exhale.

• Assess and treat for pneumothorax