Chapter 004 · Head Tilt-Chin Lift Procedure 11 Peds Pearl Hyperextension of the patient’s neck or compression of the soft tissue under the patient’s chin can obstruct the airway

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Chapter 04

Respiratory Interventions

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Objectives

Describe the head tilt-chin lift and jaw-thrust without head tilt methods for opening the airway.

Describe the preferred method of opening the airway in cases of suspected cervical spine injury.

Describe the procedures used to relieve foreign body airway obstruction in infants and children.

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Objectives

Describe correct suctioning technique and complications associated with this procedure.

Discuss oxygen delivery systems used for infants and children.

Describe the oxygen liter flow per minute and estimated oxygen percentage delivered for a nasal cannula, simple face mask, partial nonrebreather mask, nonrebreather mask, and bag-mask device.

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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Objectives

Describe the method of correct sizing, insertion technique, and possible complications associated with insertion of the oropharyngeal airway and nasopharyngeal airway.

Discuss appropriate ventilation devices for infants and children.

Discuss complications of improper use of ventilation devices with infants and children.

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Objectives

Discuss appropriate tracheal intubation equipment for infants and children.

Describe methods to confirm correct placement of an advanced airway.

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Airway Maneuvers


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Airway Obstruction

In the unresponsive patient, a partial airway obstruction may occur if: The tongue falls back

against the back of the throat due to a loss of muscle control

The epiglottis acts as a flap to obstruct the airway at the level of the larynx

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Head Tilt-Chin Lift

Indications Unresponsive patient that does not have a

mechanism for cervical spine injury

Unresponsive patient that is unable to protect his/her own airway

Contraindications Awake patient

Known or suspected cervical spine injury

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Head Tilt-Chin Lift

Advantages No equipment required,

simple, noninvasive

Disadvantages Head tilt hazardous to

patients with cervical spine injury

Does not protect the lower airway from aspiration


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Head Tilt-Chin Lift

Procedure

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Peds Pearl

Hyperextension of the patient’s neck or compression of the soft tissue under the patient’s chin can obstruct the airway.

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Indications Unresponsive patient with possible cervical spine

injury

Unable to protect own airway

Contraindications Awake patient

Jaw Thrust without Head Tilt Maneuver


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Advantages Noninvasive

Requires no special equipment

May be used with cervical collar in place

Disadvantages Difficult to maintain Requires second rescuer for bag-mask ventilation Does not protect against aspiration


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Procedure

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Peds Pearl

The combination of a head tilt, forward displacement of the jaw, and opening of the mouth is called the triple airway maneuver, or jaw thrust maneuver.

The manual maneuver described and recommended for opening the airway of a patient with suspected cervical spine injury is the jaw thrust without head tilt maneuver.


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Rescue Breathing

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Rescue Breathing

Assess level of responsiveness

Quickly determine if the child is breathing

If the child is unresponsive and is not breathing (or only gasping), check for a pulse

Begin chest compressions if: No pulse is present

You are unsure if there is a pulse

A pulse is present but the rate is slower than 60 beats/min and there are signs of poor perfusion despite support of oxygenation and ventilation

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Rescue Breathing

If the child is responsive or unresponsive but has a pulse: Determine if breathing is adequate or inadequate

Look for rise and fall of the chest and abdomen

Listen and feel for exhaled air

Perform rescue breathing if a pulse of 60 beats per minute or more is present but breathing is inadequate


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Rescue Breathing

Mouth-to-mouth ventilation Basic method for providing positive pressure

ventilation

Requires no special equipment to perform

Delivery of excellent tidal volumes possible

Rarely performed due to risk of communicable disease

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Rescue Breathing

Mouth-to-barrier device ventilation

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Rescue Breathing

Mouth-to-mask ventilation Use a mask equipped with a one-way valve or

similar device

Deliver two breaths (1 second per breath)

Volume of air delivered should be sufficient to cause gentle chest rise


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Relief of Foreign Body Airway Obstruction

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Relief of Foreign Body Airway Obstruction If the infant or child is conscious and

maintaining his or her own airway withoutrespiratory distress: Do not interfere

Allow the child to assume a position of comfort

Administer supplemental oxygen if indicated

Encourage child to cough

Provide emotional support

Removal of the foreign body by bronchoscopy or laryngoscopy should be attempted in a controlled environment

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Relief of FBAO—Conscious Choking Infant


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Peds Pearl

Back slaps are performed in an attempt to loosen the foreign body.

Chest thrusts increase intrathoracic pressure, which may cause expulsion of the foreign body.

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Unconscious Choking Infant or Child

If the victim becomes unresponsive: Begin CPR starting with chest compressions

Do not take the time to check for a pulse.

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After 30 chest compressions, open the airway Look into the mouth and remove the foreign body,

if visualized

Attempt to give 2 breaths

Continue with cycles of chest compressions and ventilations until the object is expelled

Activate the emergency response system after 2 minutes


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If the obstruction is removed: Assess breathing

• If breathing is effective, place the child in the recovery position (if trauma is not suspected)

• If breathing is absent, give two breaths

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If the obstruction is removed:

Assess circulation

• Begin chest compressions if there is no pulse or other signs of circulation, or if the heart rate is less than 60 beats per minute with signs of poor perfusion

• If breathing is absent but a pulse is present:

Deliver one breath every 3 to 5 seconds (12 to 20 breaths/min) and monitor the patient's pulse

Use higher rate of ventilations for the younger child

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If basic airway maneuvers are not successful in clearing an obstructed airway: Perform direct laryngoscopy

Remove the foreign body using pediatric Magill forceps if it is clearly visible

If unsuccessful, attempt tracheal intubation


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Conscious Choking Child

Universal choking sign

Ask, “Are you choking?”

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Conscious Choking Child

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Suctioning


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Suctioning—Purpose

Remove vomitus, saliva, blood, meconium (in newly born infants), and other secretions from the patient’s airway

Improve gas exchange

Prevent atelectasis

Obtain secretions for diagnosis

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Suction Devices

Bulb aspirator (syringe)

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Suction Devices

Soft suction catheterRigid suction catheter


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Peds Pearl

Before suctioning, note the child’s heart rate, oxygen saturation, and color.

Monitor the child’s heart rate and clinical appearance during suctioning.

Bradycardia may result from stimulation of the posterior pharynx, larynx, or trachea.

If bradycardia occurs or the child’s clinical appearance deteriorates, interrupt suctioning and ventilate with supplemental oxygen until the child’s heart rate returns to normal.

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Soft Suction Catheter

When preparing to suction the mouth, estimate the depth to suction by holding the catheter next to the child's face and measuring from the tip of the nose to the ear lobe

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Soft Suction Catheter


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Rigid Suction Catheter

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Rigid Suction Catheter

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Peds Pearl

Insertion of a suction catheter and suctioning should take no longer than 10 seconds per attempt.

When suctioning to remove material that completely obstructs the airway, more time may be necessary.


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Suctioning—Complications

Hypoxia

Arrhythmias

Increased intracranial pressure

Local edema

Hemorrhage

Tracheal ulceration

Tracheal infection

Bronchospasm

Bradycardia and hypotension because of vagal stimulation

Tachycardia may result from sympathetic stimulation

Hypertension

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Airway Adjuncts

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Oral Airway

J-shaped plastic device

Designed for use in an unresponsive patient without a gag reflex

When correctly positioned, OPA extends from the patient’s lips to the pharynx

Flange rests on patient’s lips or teeth

Distal tip lies between base of tongue and back of throat


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Oral Airway

Indications

To aid in maintaining an open airway in an unresponsive patient who is not intubated

To aid in maintaining an open airway in an unresponsive patient with no gag reflex who is being ventilated with a BVM or other positive-pressure device

May be used as a bite block after insertion of a tracheal tube or orogastric tube

Contraindications

Patient with an intact gag reflex

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Oral Airway

Advantages Positions the tongue forward and away from the

posterior pharynx

Easily placed

Disadvantages Does not protect the lower airway from aspiration

May produce vomiting if used in a responsive or semi-responsive patient with a gag reflex

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Oral Airway—Sizing


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Oral Airway—Insertion

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Oral Airway—Improper Size

Too long Too short

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Nasal Airway

Soft, uncuffed rubber or plastic tube designed to keep the tongue away from the posterior pharynx

Available in many sizes varying in length and internal diameter


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Nasal Airway—Indications

To aid in maintaining an airway when use of an OPA is contraindicated or impossible (e.g., trismus, seizing patient, biting, clenched jaws or teeth)

May be useful in patients requiring frequent suctioning (decreases tissue trauma, bleeding)

Dental or oral trauma

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Nasal Airway—Contraindications

Patient intolerance

Nasal obstruction

Significant mid-face trauma

Presence of CSF drainage from the nose

Moderate to severe head trauma

Known or suspected basilar skull fracture

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Nasal Airway

Advantages Provides a patent airway

Reasonably well tolerated in the responsive patient

Does not require the mouth to be open

Less likely than an OPA to stimulate a gag reflex and cause vomiting


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Nasal Airway

Disadvantages Improper technique may result in severe bleeding


Small internal size of an airway that will fit a child does not allow adequate air flow

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Nasal Airway—Sizing

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Nasal Airway—Insertion


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Nasal Airway—Special Considerations


Use does not eliminate need for maintaining proper head position

Small diameter NPAs can become easily obstructed with blood, mucus, vomitus, or the soft tissues of the pharynx

Suctioning may be necessary to keep the NPA open; however, suctioning through a NPA is difficult

Gag reflex may be stimulated in sensitive patients, precipitating coughing, laryngospasm, or vomiting

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Laryngeal Mask Airway (LMA)

Consists of a tube fitted with an oval mask and an inflatable rim

Tube opens into the middle of the mask by means of vertical slits

Prevents the tip of the epiglottis from falling back and blocking the lumen of the tube

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LMA—Insertion

A, A laryngeal mask airway (LMA) with the cuff inflated. B, LMA placement into the pharynx. C, LMA placement using the index finger as a guide. D, LMA in place with cuff overlying pharynx.


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Laryngeal Mask Airway (LMA)

Does not ensure an airtight seal to protect the airway against gastric regurgitation Leakage of the mask may allow aspiration of

emesis

Gastric distention may occur with misplacement

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Oxygen Delivery Systems

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Peds Pearl

Administer supplemental oxygen to any child who exhibits signs of respiratory distress, failure, or arrest, or any time you are in doubt about the child’s respiratory status.


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Nasal Cannula

Oxygen flow rate: 1 to 6 L/min

Concentration delivered: Up to 50%

Secure the nasal cannula in place and then slowly start the oxygen flow to avoid frightening the child

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Nasal Cannula

Advantages Easy to use

Allows the patient to eat and drink

Does not require humidification

No rebreathing of expired air

Does not interfere with patient assessment or impede patient communication with healthcare personnel

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Nasal Cannula

Disadvantages Can only be used in the spontaneously breathing

patient

Easily displaced

Nasal passages must be patent

Drying of mucosa

May irritate nose

May cause sinus pain


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Simple Face Mask


Concentration delivered: 35% to 60%

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Peds Pearl

When using a simple face mask, the oxygen flow rate must be at least 6 L/min to flush the accumulation of the patient’s exhaled carbon dioxide from the mask.

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Simple Face Mask

Advantages Higher oxygen concentration delivered than by

nasal cannula

Patient accessibility


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Simple Face Mask

Disadvantages Can only be used with spontaneously breathing patients

Not tolerated well by severely dyspneic patients

FiO2 varies with inspiratory flow rate

Can be uncomfortable

Dangerous for the child with poor airway control and at risk for emesis

Difficult to hear the patient speaking when the device is in place

Must be removed at meals

Requires a tight face seal to prevent leakage of oxygen

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Partial Rebreather (Rebreathing) Mask



Fill the reservoir bag with oxygen before placing the mask on patient

After placing the mask on the patient, adjust the flow rate so the bag does not completely deflate when patient inhales

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nasal cannula

Patient accessibility


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Disadvantages Can only be used with spontaneously breathing

patients

Not tolerated well by severely dyspneic patients


Difficult to hear patient speaking when device is in place


Dangerous for child with poor airway control and at risk for emesis

Requires a tight face seal to prevent leakage of O2

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Peds Pearl

When using a nonrebreather or partial rebreather mask, ensure that the bag does not collapse when the child inhales.

Should the bag collapse, increase the oxygen flow rate in small increments until the bag remains inflated.

The reservoir bag must remain at least 2/3 full so that sufficient supplemental oxygen is available for each breath.

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Nonrebreather (Nonrebreathing) Mask


Concentration delivered: up to 95%


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nasal cannula, simple facemask, and partial rebreather mask

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Disadvantages Can only be used with spontaneously breathing patients

Mask must fit snugly on patient’s face to prevent room air from mixing with oxygen inhaled from reservoir bag

Not tolerated well by severely dyspneic patient


Difficult to hear patient speaking when device is in place


Dangerous for child with poor airway control and at risk for emesis

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Face Tent (Face Shield)

Large, soft plastic bucket that fits loosely around child’s face and lower jaw

Advantages Permits access to face and nose for

suctioning

Can provide warmed or cooled humidified oxygen

Disadvantages Oxygen concentrations in excess of

40% cannot be reliably provided, even with an O2 flow rate of 10 to 15 L/min


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Oxygen Hood

Clear plastic dome that encircles the child’s head

Used for neonates and infants weighing less than 10 kg who will not tolerate a face mask

Permits control of O2

concentration, temperature, and humidity Oxygen flow rate: 10 to 15

L/min


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Oxygen Hood

Advantages O2 concentration can be continuously monitored by means

of a meter

Permits access to chest, trunk, and extremities for continued care

Disadvantages Generally not large enough to be used for children older than

1 year of age

“Raining out” on the walls of the hood may obscure the patient’s head from observation

Noisy for the patient

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Blow-by Oxygen Delivery

“Drink from the cup”


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Oxygen Percentage Delivery by Device

DeviceApproximate Inspired

Oxygen Concentration

Liter Flow

(L/min)

Nasal Cannula Up to 50% 1 to 6

Simple Face Mask 35 to 60% 6 to 10

Partial Rebreather Mask

35 to 60% 6 to 10

Nonrebreather Mask 60 to 95% 10 to 15

Face Tent 35 to 40% 10 to 15

Oxygen Hood 80 to 90% 10 to 15

Blow-by (via face mask)

30 to 40% 10

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Ventilation Devices

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Positive-Pressure Ventilation (PPV)

PPV is used if the patient’s respiratory efforts are inadequate PPV = Forcing air into the lungs

Several methods may be used including: Mouth-to-mask ventilation Bag-mask ventilation

Effective PPV requires: Delivery of an adequate volume of air Appropriate rate of ventilation


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Peds Pearl

Positive-airway pressure therapy refers to the application of higher than ambient airway pressures during inspiration and/or exhalation for the purpose of improving pulmonary and respiratory function.

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Peds Pearl

Positive pressure applied during inspiration is usually referred to as positive-pressure ventilation (PPV).

Positive pressure applied during exhalation is usually referred to as positive end-expiratory pressure (PEEP).

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Cricoid Pressure

Compresses laryngopharynx

May help minimize gastric distention and aspiration during positive-pressure ventilation


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Cricoid Pressure

In an infant or young child, cricoid pressure is applied using only one finger

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Cricoid Pressure

Cricoid pressure:

May be considered to minimize gastric inflation in an unresponsive patient

May require a third rescuer if cricoid pressure cannot be applied by the rescuer who is securing the mask (of a bag-mask device) to the face

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Cricoid Pressure

If excessive pressure is applied, cricoid pressure can cause complete airway obstruction.

If active regurgitation occurs while performing cricoid pressure, release cricoid pressure to avoid rupture of the stomach or esophagus.


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Mouth-to-Mask Ventilation

A pocket mask: Should be made of transparent material to allow

evaluation of the patient’s lip color and detection of blood, vomitus, or secretions

Equipped with a one-way valve that diverts the patient’s exhaled gas, reducing the risk of infection

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Advantages

Aesthetically more acceptable than mouth-to-mouth ventilation

Easy to teach and learn

Physical barrier between the rescuer and the patient’s nose, mouth, and secretions

Reduces (but does not prevent) the risk of exposure to infectious disease

Use of a one-way valve at the ventilation port decreases exposure to patient’s exhaled air

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Advantages (continued)

Can be used as a simple face mask by administering supplemental oxygen through the oxygen inlet on the mask (if so equipped)

Can deliver a greater tidal volume with mouth-to-mask ventilation than with a bag-mask device

Rescuer can feel the compliance of the patient’s lungs


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Disadvantages Rescuer fatigue

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A ventilation mask should: Have limited dead space

Have an inflatable rim

Provide a tight seal without pressure on eyes

Extend from bridge of nose to crease of chin

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Stabilize narrow portion of mask with your thumbs

Stabilize wide end of mask with index fingers

Use remaining fingers to maintain head position


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Deliver each ventilation over 1 second

Stop when adequate chest rise is observed

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Bag-Mask Ventilation

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These bag-mask devices have pop-off valves If used for

resuscitation, the pop-off valve should be disabled

Depress the valve with a finger during ventilation or twist the pop-off valve into the closed position


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Select a device with sufficient volume for the patient’s size:

At least 450 to 500 mL (pediatric bag) for full-term neonates, infants, and young children

A 1000 mL or more (adult bag) for older children and adolescents

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A 250-mL (neonatal) bag may not provide sufficient volume or the longer inspiratory times required by term neonates and infants.

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Oxygen flow rate: None

Concentration delivered: 21% (room air)


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Pediatric bag Oxygen flow rate: 10 L/min


Adult bag Oxygen flow rate: 15 L/min


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Pediatric bag-mask Oxygen flow rate: 10 to 15 L/min


Adult bag-mask Oxygen flow rate: 15 L/min


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Advantages

Provides a means for delivery of an oxygen enriched mixture to the patient

Conveys a sense of compliance of the patient’s lungs to the bag-mask operator

Provides a means for immediate ventilatory support

Can be used with the spontaneously breathing patient as well as the apneic patient


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Disadvantages

Inability to deliver adequate ventilatory volumes

• May be due to difficulty in providing a leak proof seal to the face while simultaneously maintaining an open airway and/or incomplete bag compression

Gastric inflation

• May result if excessive force and volume are used during ventilation

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If the infant or child has a perfusing rhythm but absent or inadequate ventilatory effort:

Give 1 breath every 3 to 5 seconds (12 to 20 breaths per minute)

• Use higher rate for the younger child

Allow 1 second per breath while watching for chest rise

As soon as chest rise is visible, release the bag

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If the infant or child has no pulse and is not intubated: Pause after 30 chest compressions (1 rescuer) or

after 15 chest compressions (2 rescuers) to give 2 ventilations


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If the infant or child has no pulse and is intubated: Ventilate at a rate of about 1 breath every 6 to 8

seconds (8 to 10 times per minute) without interrupting chest compressions

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Assess the effectiveness of ventilation

Ensure the mask forms an airtight seal on the patient’s face

Evaluate lung compliance

Observe the rise and fall of the patient’s chest with each ventilation

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Assess the effectiveness of ventilation

Assess for an improvement in the color of the patient’s skin or mucous membranes

Assess for an improvement in the patient’s mental status, heart rate, perfusion, and blood pressure

Auscultate for bilateral breath sounds


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Tracheal Intubation

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Tracheal Intubation

Advantages Isolates the airway

Keeps the airway patent

Reduces the risk of aspiration of gastric contents

Ensures delivery of a high concentration of oxygen

Permits suctioning of the trachea

Provides a route for administration of some medications

Ensures delivery of a selected tidal volume to maintain lung inflation

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Tracheal Intubation

Disadvantages

Considerable training and experience required

Special equipment needed

Bypasses physiologic function of upper airway

Requires direct visualization of vocal cords


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Tracheal Tube Sizing

Length-based resuscitation tape Useful and more accurate than age-based formula

estimates for determining the correct tracheal tube size for children who weigh up to about 35 kg

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Uncuffed tracheal tube Infants up to one year: 3.5-mm ID tube

Child between 1 and 2 years: 4-mm ID tube

After age 2, estimate uncuffed tracheal tube size: • Uncuffed tracheal tube ID (mm) = 4 + (age in years/4)

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Cuffed tracheal tube Infants up to one year: 3-mm ID tube

Child between 1 and 2 years: 3.5-mm ID tube

After age 2, estimate cuffed tracheal tube size: • Cuffed tracheal tube ID (mm) = 3.5 + (age in years/4)


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Confirming Tracheal Tube Position

Visualizing the passage of the tracheal tube between the vocal cords

Auscultating the presence of bilateral breath sounds

Confirming the absence of sounds over the epigastrium during ventilation

Adequate chest rise with each ventilation

Absence of vocal sounds after placement of the tracheal tube

End-tidal carbon dioxide measurement

Use of esophageal detector device

Chest radiograph

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Confirming Tracheal Tube Position

Esophageal detector devices

Esophageal detector device. A, Syringe. B, Bulb.

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Troubleshooting Inadequate Ventilation or Oxygenation

Displaced tube Right primary bronchus or esophageal intubation Reassess tube position

Obstructed tube Blood or secretions are obstructing air flow Suction

Pneumothorax (tension) Needle thoracostomy

Equipment problem/failure Check equipment and oxygen source


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Pulse Oximetry

Oxygenation The process of getting oxygen into the body and

to its tissues for metabolism

Pulse oximetry A noninvasive method of measuring the

percentage of oxygen saturated in peripheral tissues

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Carbon Dioxide Monitoring

Capnography

The continuous analysis and recording of CO2

concentrations in respiratory gases

Enables early recognition of hypoventilation, apnea, or airway obstruction

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Examples of situations in which exhaled CO2

monitoring is commonly used include the following: Verification of tracheal tube placement

Procedural sedation and analgesia

Evaluation of mechanical ventilation and resuscitation efforts

Continuous monitoring of tracheal tube position (including during patient transport)

Monitoring of exhaled CO2 levels in patients with suspected increased intracranial pressure

Assessment of the adequacy of ventilation in patients with altered mental status, bronchospasm, asthma, anaphylaxis, heart failure, drug overdose, stroke, shock, or circulatory compromise


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Presence of CO2 suggests tracheal placement

Lack of CO2 suggests esophageal placement

Inaccurate results may occur Cardiopulmonary arrest

Ingestion of carbonated beverages

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Use a pediatric ETCO2 detector for patients weighing 2 kg to 15 kg

Use an adult ETCO2 detector if the patient weighs more than 15 kg

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Peds Pearl

Movement of the head and neck of an intubated infant or child can affect the placement of the tube.

Reassess and confirm tube position: Immediately after tube insertion Whenever the patient is moved or

repositioned Whenever a procedure is performed When there is a change in patient’s clinical

status During interhospital and intrahospital

transport


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Questions?


Documents

Chapter 004 · Head Tilt-Chin Lift Procedure 11 Peds Pearl Hyperextension of the patient’s neck or compression of the soft tissue under the patient’s chin can obstruct the airway