FIGURE 9.5 Oropharyngeal airway: flange (A ), bite block (B ), stent (C ), and gas exchange or suction conduit (D ) FIGURE 9.6 Nasopharyngeal airways in a variety of sizes BREATHING Evaluation Breathing is assessed through observation of chest wall movement and auscultation Gas exchange is confirmed by auscultation and monitoring of ETCO2 and pulse oximetry MANAGEMENT Spontaneous Ventilation Supplemental oxygen is administered to the spontaneously breathing ill patient If the patient is not breathing spontaneously, positive pressure ventilation (PPV) is required Though the optimal concentration is not known, it is reasonable to provide 100% oxygen during CPR Hyperoxia is a mediator of postresuscitation injury, thus titration of FiO2 to the minimum concentration to achieve saturation of at least 94% is recommended Oxygen Delivery Devices A variety of oxygen delivery devices are available for use in patients who have patent airways The percent oxygen delivered depends on the child’s size and minute ventilation Nasal Cannulas One hundred percent humidified oxygen is delivered to the nares at a flow of to L/min Due to entrainment of room air, the final oxygen delivery is low, usually 30% to 40% High-Flow Nasal Cannulas High-flow nasal cannula (HFNC) delivers humidified and warmed oxygen/gas at flow rates up to 12 L/min in infants and 30 L/min in children HFNC supports respiration though noninvasive continuous positive airway pressure (CPAP), improved airway mechanics, reduction of metabolic expenditure, and improved clearance of secretions It has been used as an alternative to CPAP devices, especially for infants with bronchiolitis The initiation and management of HFNC requires close monitoring by a team skilled in its use Oxygen Masks There are several types of oxygen masks that offer a wide range of inspired oxygen concentrations Simple masks The simple face mask delivers a moderate FiO2 that varies from 35% to 60% Partial rebreathing masks Partial rebreathing masks allow reliable delivery of an FiO2 of 50% to 60% When the flow in the reservoir bag is greater than the patient’s minute ventilation and the oxygen is adjusted so the bag does not collapse during inhalation, there is negligible CO2 rebreathing allowing for more reliable oxygen delivery Nonrebreathing masks These masks have nonrebreathing valves incorporated into the face mask and the reservoir bag and reliably provide oxygen concentrations up to 95% with high flow rates of 10 to 15 L/min Continuous Positive Airway Pressure Devices CPAP provides positive pressure to stent open the child’s airways leading to improved ventilation and oxygenation CPAP can be applied with large nasal prongs, a nasal mask which covers just the nose of the patient, or a face mask which covers the mouth and nose Assisted Ventilation Basic Life Support (BLS) rescue breathing rate in infants and children with isolated respiratory arrest is 12 to 20 breaths/min, with higher rates for infants and younger children Newly born infants may need a rate of 40 to 60 breaths/min For children and infants who require CPR, the recommended respiratory rate is to 10 breaths/min Ventilations are asynchronous with chest compressions when an advanced airway is in place When an advanced airway is not in place, ventilations are coordinated with chest compressions with a rate of 15 compressions to ventilations for two providers and 30 compressions to ventilations for one provider (100 to 120 compressions/min) With all ventilation techniques, the force and volume needed to just see chest rise is recommended Overventilation is a common error in resuscitation; the AHA 2015 Update emphasizes a ventilation rate of less than 12 and a ventilation volume that causes no more than minimal chest wall rise during CPR Because of risk of infection transmission, mouth-to-mouth resuscitation is no longer recommended Instead, rescue breathing is done with a pocket mask Placement of the mask over the mouth alone, over the mouth and nose, or over a tracheostomy site depends on the patient and the equipment available Expired Air Techniques BVM ventilation is an essential skill for all emergency medicine clinicians and provides a rapid means to provide oxygenation and ventilation for children with respiratory and/or circulatory failure Masks The properly fit mask covers the tip of the chin, the mouth, and the nose, allowing for a tight seal against the skin Masks with a pneumatic cuff design allow for the easiest and most efficient fit that avoids air leaks When enough personnel are available, a two-person technique may improve oxygen delivery and ventilation One person uses both hands to correctly position the mask on the face, creating a good seal, while the other squeezes the bag, paying attention to ensure appropriate chest rise and ventilation FIGURE 9.7 Self-inflating hand-powered resuscitator: compressible unit (A ), oxygen source (B ), oxygen reservoir (C ), one-way valve assembly (D ), and mask with transparent body (E ) Hand-Squeezed, Self-Inflating Resuscitators ... the equipment available Expired Air Techniques BVM ventilation is an essential skill for all emergency medicine clinicians and provides a rapid means to provide oxygenation and ventilation for children