NextGen Learning To Elevate Your Airway Practice

Explore the pediatric airway learning space and its pediatric bag-valve-mask ventilation lesson alongside this neonatal-focused resource.

Tools of the Trade – Self-Inflating & Flow Inflating Options

When your neonate needs immediate positive pressure ventilation, there are options, but only if you know how to use them. Let’s discuss both the flow inflating and self-inflating options.

Positive Pressure Ventilation

This device is usually the go-to option when a neonate needs immediate positive-pressure ventilation. Let’s discuss some of its features and how to use it correctly.

10 Rules of Expert Face Mask Ventilation

Good face mask ventilation has rules. Learn and follow them, and ensure everyone on your team knows them to protect your littlest patients from harm.

1. Anatomical Considerations

• Small and Delicate Airway: Neonates have smaller airways that are more prone to obstruction and trauma.
• Prominent Occiput: The large occiput can cause the neck to flex, leading to airway obstruction unless appropriately positioned.
• Flexible Chest Wall: Neonates have a compliant thorax, making adequate ventilation and assessment of chest rise challenging.
• Obligate Nasal Breathers: Neonates rely heavily on nasal breathing, so ensuring a clear nasal passage is essential.

2. Proper Equipment

• Correct Mask Size: Use a mask that covers the nose and mouth without overlapping the eyes or chin.
• Resuscitation Device:
  • Self-inflating bag
  • Flow-inflating bag
  • T-piece resuscitator (e.g., Neopuff) for precise control of pressure.
• Suction Equipment: Have appropriate-sized catheters ready to clear secretions if needed.

3. Proper Positioning

• Neutral “Sniffing” Position:
  • Align the airway using a small shoulder roll to extend the neck and open the airway slightly.
  • Avoid hyperextension or excessive flexion.
• Head Tilt and Chin Lift: Gently tilt the head back and lift the chin to ensure the airway is open.

4. Effective Mask Seal

• Two-Handed Technique (when possible):
  • One hand forms a “C” shape to hold the mask on the face, while the other performs the “E” shape to lift the jaw.
• Avoid Over-Compression: Excessive pressure can distort the face, obstruct the airway, or cause leaks.
• Adjust for Leaks: Check for audible or visible leaks and adjust the mask or head position as needed.

5. Optimal Ventilation Technique

• Gentle and Controlled Ventilation:
  • Deliver breaths just enough to see visible chest rise (approximately 4-6 mL/kg tidal volume).
  • Avoid excessive pressure to reduce the risk of barotrauma or pneumothorax.
• Ventilation Rate:
  • Use a rate of 40-60 breaths per minute if the neonate is apneic or not breathing adequately.
• Inspiratory Time:
  • Aim for 0.5–1 second per breath, ensuring adequate oxygen delivery.

6. Continuous Monitoring and Assessment

• Chest Rise:
  • Watch for visible chest rise to confirm adequate ventilation.
  • If there is no chest rise, reassess the mask seal and airway position or consider airway obstruction.
• Color and Heart Rate:
  • Monitor the neonate’s color and heart rate. A rising heart rate indicates adequate ventilation.
• Pulse Oximetry:
  • Use a pulse oximeter on the right hand or wrist to monitor oxygenation.

7. Be Ready to Troubleshoot

• Airway Obstruction:
  • Reassess position, clear secretions, or consider suction.
• Mask Leak:
  • Adjust the mask position, reapply the seal, or use a two-handed technique.
• Gastric Insufflation:
  • Minimize peak pressures and consider inserting an orogastric tube to decompress the stomach if ventilation is prolonged.
• Apnea or Persistent Bradycardia:
  • Ensure effective ventilation and consider intubation if bradycardia persists despite adequate efforts.

8. Prevent Complications

• Barotrauma:
  • Limit peak inspiratory pressures to avoid lung injury.
• Aspiration:
  • Be cautious of gastric regurgitation, particularly in preterm or low-birth-weight neonates.
• Over-Ventilation:
  • Prevent hypocapnia by using appropriate ventilation rates and pressures.

9. Escalate When Necessary

• Persistent Hypoxia or Bradycardia:
  • Consider intubation or advanced airway management if face mask ventilation is not effective.
• Difficult Airway:
  • Use adjuncts like an oropharyngeal or nasopharyngeal airway to maintain patency.

10. Train and Practice

• Neonatal mask ventilation requires frequent practice to maintain skills.
• Use simulation-based training to build confidence and proficiency in identifying and addressing ventilation challenges.

By mastering these principles, providers can ensure effective and safe face mask ventilation for neonates, a critical step in neonatal resuscitation and stabilization.

Hands-On Practice

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This poster has associated hands-on learning opportunities in our immersive and interactive physical space. If you’re with us in person, please visit the related station.

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