INTRODUCTION — Basic airway management (including positioning to open the airway and positive pressure ventilation with mouth-to-mouth and bag and mask) will be reviewed here.

The following related topics are discussed separately:

●Advanced airway management in children (see "Emergency endotracheal intubation in children")

●Basic life support in infants and children (see "Pediatric basic life support (BLS) for health care providers")

●The initial assessment and stabilization of critically ill or injured (see "Initial assessment and stabilization of children with respiratory or circulatory compromise" and "Pediatric advanced life support (PALS)")  

●Basic airway management in adults (see "Basic airway management in adults")

BACKGROUND — Effective airway support is an essential component of successful cardiopulmonary resuscitation. Respiratory insufficiency leading to respiratory arrest typically precedes cardiac arrest for most children. Survival rates between 43 and 82 percent have been reported for children who have been resuscitated from respiratory arrest [1,2]. By contrast, between 4 and 14 percent of children who go on to develop cardiac arrest survive [1,3,4].

ANATOMIC CONSIDERATIONS — A clear, patent airway is a fundamental requirement for effective resuscitation. Anatomic features that make the airways of infants and children more susceptible to obstruction and that must be considered in order to maintain an adequate airway include the following (see "Emergency airway management in children: Unique pediatric considerations", section on '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 upper airway.

●Because the airways of children are smaller, they are more susceptible to obstruction from edema, mucous plugs, or foreign body.

●The relatively larger occiput causes passive flexion of the cervical spine in the supine position, which contributes to a tendency for the posterior pharynx to buckle during resuscitation. This can be prevented by maintaining the head in the sniffing position. Placing a rolled towel under the child's occiput or upper shoulders may help to maintain proper positioning.

●A common cause of airway obstruction in the unresponsive child is the tongue, which is relatively larger compared to the oral cavity in the child than in the adult and can fall back against the hypopharynx in a child with a decreased level of consciousness.

NONINVASIVE RELIEF OF OBSTRUCTION — The head tilt-chin lift and/or jaw-thrust maneuvers should be performed to open the airway in an unresponsive child before any more invasive airway adjuncts are utilized [5]. These maneuvers place the airway in a neutral position and move the tongue and palatal tissues away from the posterior wall of the pharynx. In-line immobilization of the cervical spine is essential during these procedures if trauma is suspected. (See "Pediatric cervical spinal motion restriction".)

The placement of an airway adjunct such as a nasopharyngeal or oral airway may be necessary if neither the chin-lift nor the jaw thrust maneuvers open the airway. The indications and procedures for placement of these airways are discussed below. (See 'Airway adjuncts' below.)

Head tilt-chin lift — In children who are suspected of having head or neck injuries, the head-tilt-chin-lift maneuver should not be used prior to attempting to open the airway with a jaw thrust [6]. (See 'Jaw thrust' below.)

To perform the head-tilt-chin lift technique, the fingers of one hand are placed under the mandible, which is gently lifted upward to move the chin anteriorly. The thumb of the same hand lightly depresses the lower lip to open the mouth. The thumb may also be placed behind the lower incisors to gently lift the chin so that the lower central incisors are anterior to the maxillary central incisors. One hand may be placed on the child's forehead to gently tilt the head into a neutral position if there is no suspicion of neck injury (figure 1 and picture 1).

During the chin lift procedure, care must be taken to avoid closing the mouth, pushing on the soft tissues under the chin, or hyperextending the neck [7] (figure 2) because these actions contribute to airway obstruction.

Jaw thrust — The jaw thrust is the preferred method for opening the airway when trauma is suspected, in which case, cervical spine motion restriction should also be maintained. (See "Pediatric cervical spinal motion restriction", section on 'Motion restriction during airway management'.)

It is also useful for any patient when assisted ventilation with a bag-valve-mask is required. (See 'Bag-mask ventilation' below.)

The jaw thrust maneuver is performed by grasping the angles of the lower jaw with one hand on each side, and moving the mandible forward so that the lower central incisors are anterior to the upper central incisors (picture 2). If the jaw thrust alone does not restore airway patency, a careful head tilt may be added [8,9].

Airway adjuncts — Oral and nasopharyngeal airways may be useful to improve ventilation, particularly when oropharyngeal structures, such as the tongue, are obstructing the airway [10,11].

Oral airway — An oral airway can be used in an unconscious child to lift the tongue and pharyngeal soft tissues off of the posterior pharynx to maintain a patent airway (picture 3) [11]. Direct contact with the tongue and supraglottic structures may stimulate vomiting.

An oral airway is optimally used as a bridge to recovery for a patient whose condition is expected to be temporary (such as a child who is post-ictal or recovering from sedation). However, prolonged tolerance of an oral airway usually suggests the need for endotracheal (ET) intubation.

Selection of the appropriate size and careful placement are necessary to use this device effectively and safely [11]. To choose the correctly sized oral airway, hold it along the side of the child's face with the flange at the corner of the mouth. The tip of the airway should reach the angle of the mandible (picture 4). It should be inserted using a tongue depressor to push the tongue to the floor of the mouth to avoid pushing the device into the base of the tongue, thereby obstructing the child's airway.

Nasopharyngeal airway — A flexible nasal airway bypasses obstruction caused by the tongue and pharyngeal soft tissues with minimal contact with the tongue [11]. It is much less likely to induce emesis than an oral airway and is frequently tolerated by conscious patients.

Thus, this device is particularly useful for children with soft tissue upper airway obstruction such as macroglossia or tonsillar hypertrophy, who have normal mentation and respiratory function.

For nasal trumpets without an adjustable flange (picture 5), the correctly sized nasal airway is more accurately determined by the length of the device rather than by the bore. The distance from the patient’s nostril to the tragus has been shown to correlate well with the length from the nostril to the vocal cords in normal children and is our preferred method for sizing [12]. Alternatively, the distance from the nostril to the mandible may be used. However, the accuracy of this method has not been studied.

For nasal trumpets with an adjustable flange, the bore can be chosen to match the size of the nares, and the cuff adjusted to the proper length. The bore should be large enough to avoid obstruction by secretions but small enough to permit atraumatic passage and to avoid pressure necrosis of the nasal mucosa.  

The nasal airway should be well-lubricated and gently inserted into the nostril to avoid bleeding from injury to nasal mucosa or adenoidal tissue (picture 6). The bevel of the airway should face the nasal septum to minimize obstruction of the tip with nasal pharyngeal mucosa.

VENTILATION — Once the airway has been secured, if the child is not breathing spontaneously, the rescuer should administer two breaths. Each breath should be given over one second [6]. Breaths may be administered using mouth-to-mouth, mouth-to-mouth-and-nose, mouth-to-nose techniques, or with bag-mask ventilation.

Chest compressions should also be initiated when there is no pulse or the heart rate is <60 beats per minute. Under these circumstances, one cycle of compressions should precede the first breaths. (See "Pediatric basic life support (BLS) for health care providers", section on 'Basic life support approach'.)

General considerations — The following general principles should be applied no matter which method of ventilation is used (see "Pediatric basic life support (BLS) for health care providers", section on 'Breathing'):

●Rescue breathing is performed while maintaining the airway with the chin lift or jaw thrust. Only the jaw thrust maneuver should be performed in patients with head or neck trauma.

●The rescuer administers two slow breaths, delivering each breath over one second. There should be a short pause between breaths to maximize oxygen content and minimize carbon dioxide concentration in the delivered breaths .

●The volume that is delivered should be sufficient to make the chest wall rise.

●Rescue breaths in perfusing patients who have inadequate breathing should be provided every two to three seconds (20 to 30 breaths/minute).

●During cardiopulmonary resuscitation, the timing of rescue breaths depends on whether or not the trachea is intubated:

•For lone rescuers, two ventilations should be delivered during a short pause at the end of every 30^th compression.

•For two rescuers, two ventilations should be delivered at the end of every 15^th compression.

•Once the trachea is intubated, ventilations and compressions can be performed independently. For infants and children, ventilations are given at a rate of 20 to 30 breaths per minute. Compressions are delivered at a rate of 100 to 120 per minute without pauses.

Coordination of compression and ventilation may be facilitated by counting compressions aloud or using an audio-prompted rate guide [13].

Rescue breathing, particularly if performed rapidly, may cause gastric distention. This can interfere with effective rescue breathing by elevating the diaphragm and compromising lung expansion. Gastric distention can be minimized by giving rescue breaths slowly, which allows an effective tidal volume to be delivered at a lower inspiratory pressure [14]. When two rescuers are present, cricoid pressure may be applied to compress the esophagus, thereby reducing gastric distension. Evidence that compression of the esophagus decreases the risk of regurgitation and aspiration is limited. Care must be taken not to obstruct the airway if the technique is applied. (See "Rapid sequence intubation (RSI) outside the operating room in children: Approach", section on 'External laryngeal manipulation (bimanual laryngoscopy)'.)

Mouth-to-mouth/nose — A barrier should be used for infection control whenever possible during mouth-to mouth, mouth-to-mouth-and-nose, and mouth-to-nose breathing [6].

In mouth-to-mouth breathing (for victims older than one year of age), the rescuer takes a deep breath and places his or her mouth over the victim's mouth to create a tight seal, while pinching the victim's nose closed [6,11]. For victims younger than one year, the rescuer takes a deep breath and places his or her mouth over the victim's mouth and nose.

Mouth-to-nose breathing is a reasonable alternative to mouth-to- mouth-and-nose breathing for infants younger than one year of age. When the mouth-to-nose technique is used, it is necessary for the rescuer to close the infant's mouth during rescue breathing.

Bag-mask ventilation — Health care providers who are properly trained can use a bag and mask device to provide ventilation during pediatric resuscitation [6]. Furthermore, the use of bag-mask ventilation rather than endotracheal intubation during cardiac arrest has been associated with higher survival in children treated in both the prehospital and hospital settings. (See "Pediatric basic life support (BLS) for health care providers", section on 'Epidemiology and survival' and "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

Bag — Two types of ventilation bags are available, flow-inflating (anesthesia) or self-inflating bags. The self-inflating bag is generally preferred for resuscitation. Advantages of this device include the following:

●The self-inflating bag reinflates when it is released and does not require a gas source to deliver breaths.

●The self-inflating bag is easier to use. When compared to the flow-inflating bag, effective bag-mask ventilation can be performed more reliably by health care providers with variable levels of expertise using the self-inflating device [15,16].

Unlike the flow-inflating bag, the self-inflating ventilation bag requires an oxygen reservoir system to reliably deliver oxygen concentrations above 40 percent. This is because room air is entrained in the system when the bag reinflates. With an oxygen flow rate of 15 L/min, oxygen concentrations between 95 and 100 percent can be delivered using a 2.5 L bag reservoir system [17]. Less oxygen is delivered at higher ventilation rates.

Self-inflating ventilation bags typically have a safety pop-off valve that reduces the risk of barotrauma by limiting peak inspiratory pressures to between 35 and 45 cm H₂O. However, higher levels of peak inspiratory pressure may be required to provide adequate tidal volume and oxygenation when airway resistance is high or lung compliance is poor. In this situation, the pop-off valve can usually be disabled [18]. Whenever possible, a manometer should be used to monitor peak inspiratory pressure when the pop-off valve is disabled. Clinicians should be familiar with the type of ventilation bags that are used in their facilities.

The ventilation bag should have a minimum volume of 450 to 500 mL, even for newly born full-term infants [19-21].

Mask — Effective bag-mask ventilation requires a mask that fits properly. The correct size is the smallest mask that completely covers the victim's mouth and nose without covering the eyes or overlapping the chin (picture 7) [11].

E-C clamp technique — The "E-C clamp technique" has been described by the American Heart Association [6]. Utilizing this method, the rescuer can optimally position the airway to deliver effective breaths, while applying the mask tightly to the victim's face to avoid air leaks (picture 8). The technique is performed as follows [6]:

●Positioning of the child's head requires two maneuvers (picture 9):

•The neck is flexed forward on the shoulders, such that the external auditory canal is anterior to the shoulder. 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 pointing toward the ceiling.

●The mask is placed on the child's face, with the narrowest portion of the mask over the bridge of the nose.

●The little, ring, and middle fingers of one hand are then spread from the angle of the mandible forward along the mandible forming the "E." These fingers lift the jaw, pulling the face into the mask.

●Finally, the thumb and forefinger of the same hand are placed over the top of the mask in a "C" shape to squeeze it onto the face, forming a seal between the mask and the face.

For children with suspected injury to the cervical spine, positioning must be accomplished without moving the neck. In-line manual stabilization must be maintained. (See "Pediatric cervical spinal motion restriction", section on 'Motion restriction during airway management'.)

Breaths are provided by using the other hand to compress the bag until the chest visibly rises. The rescuer should use only the force and tidal volume required to make the chest rise.

For some patients, two rescuers may be required to provide effective ventilation (picture 10). In this situation, one rescuer uses both hands (each hand in the "E-C" configuration on either side of the face) to maintain the airway and hold the mask, while another rescuer compresses the ventilation bag. The effectiveness of two-person, bag-mask ventilation was demonstrated in a prospective observational study in which greater peak pressures and mean tidal volumes per weight were generated in manikin models with two-person, as compared with one-person, bag-mask ventilation [22].

MONITORING ADEQUACY OF VENTILATION — Chest motion should be constantly monitored as an indicator of the adequacy of ventilations. It must be assumed that if there is no chest motion during CPR, there is no ventilation. Possible reasons for impaired ventilation in a child without an artificial airway include [11]:

●A foreign body in the airway (see "Airway foreign bodies in children")

●Venting of a pop-off valve on the ventilation bag

●Inadequate pressure of ventilation

●Profound abdominal distension elevating the diaphragm and compromising lung expansion; placement of a nasogastric or orogastric tube can help to prevent this complication

●Bilateral pneumothoraces

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Basic and advanced cardiac life support in children" and "Society guideline links: Airway management in children".)

SUMMARY AND RECOMMENDATIONS

●Respiratory insufficiency leading to respiratory arrest typically precedes cardiac arrest for most children. Patients are much more likely to be successfully resuscitated from respiratory arrest as compared with cardiac arrest. (See 'Background' above.)

●Features of the pediatric airway make the airways of infants and children more susceptible to obstruction and must be considered in order to maintain an adequate airway. (See 'Anatomic considerations' above.)

●Maneuvers to relieve airway obstruction include chin lift and jaw thrust (figure 1 and figure 3). Chin lift should not be used for patients with suspected cervical spine injury. (See 'Noninvasive relief of obstruction' above.)

●Oral and nasopharyngeal airways may be useful to improve ventilation, particularly when oropharyngeal structures, such as the tongue, are obstructing the airway (picture 4 and picture 5 and picture 6). Oral airways are appropriate for unconscious patients. Nasopharyngeal airways are particularly useful for children with soft tissue upper airway obstruction such as macroglossia or tonsillar hypertrophy, who have normal mentation and respiratory function. (See 'Airway adjuncts' above.)

●Once the airway has been opened, if the child is not breathing spontaneously, the rescuer should administer two breaths. Each breath should be given over one second. Breaths may be administered using mouth-to-mouth, mouth-to-mouth-and-nose, mouth-to-nose techniques, or with bag-mask ventilation. Chest compressions should be initiated when there is no pulse or the heart rate is <60 beats per minute. Under these circumstances, one cycle of compressions should precede the first breaths. (See 'Ventilation' above.)

●Rescue breathing is performed while maintaining the airway with the chin lift or jaw thrust. Only the jaw thrust maneuver should be performed in patients with head or neck trauma. For patients in cardiac arrest, the ratio of ventilations to compressions varies according to the number of rescuers and whether or not the trachea is intubated. (See 'General considerations' above.)

●Ventilations should be delivered with sufficient pressure and volume to see the chest wall rise. Hyperventilation and gastric extension can be minimized by delivering ventilations slowly (over one second) and with only enough force and tidal volume required to make the chest wall visibly rise. (See 'Ventilation' above.)

●The E-C clamp technique is a useful method for bag-mask ventilation (picture 8). (See 'Bag-mask ventilation' above.)

●Poor chest wall movement suggests inadequate ventilation. (See 'Monitoring adequacy of ventilation' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Pamela Bailey, MD, who contributed to an earlier version of this topic review.