5.3 Infant Ventilation & Bag-Mask Technique

5.3 Infant Ventilation & Bag-Mask Technique

Infants are especially vulnerable to respiratory failure, so effective ventilation is a central BLS skill. The goal is not to force a large breath; it is to open the airway, create a seal, and deliver just enough air over about 1 second to produce visible chest rise.

Position the airway

Place the infant supine on a firm surface. Because the back of an infant's head is relatively large, it can push the neck into flexion. Position the head neutrally or with slight extension so the nose points generally upward. A small roll under the shoulders can help when body shape causes flexion.

Use a head-tilt/chin-lift when trauma is not suspected. Lift on the bony chin and avoid pressure on the soft tissue beneath it. If cervical injury is suspected, a trained rescuer begins with a jaw thrust; if that does not open the airway, establish an airway with a head-tilt/chin-lift.

Avoid marked extension. An infant's airway can narrow when the neck is either too flexed or too extended.

Select and hold the mask

The mask should cover the nose and mouth, rest above the cleft of the chin, and stay below the eyes. A mask that is too large can leak or press on the eyes; one that is too small may not cover both nose and mouth.

Place the narrow portion at the bridge of the nose and lower the mask over the mouth and chin. Form an E-C clamp: the thumb and index finger hold the mask while the remaining fingers lift the bony jaw. Do not press into the soft tissue under the chin.

When two trained rescuers are available, one can use both hands to maintain the seal and jaw position while the other squeezes the bag. This often produces a more reliable seal.

Deliver the breath

Squeeze the bag smoothly over about 1 second and stop when the chest visibly rises. Allow exhalation before the next breath. Do not empty the bag and do not use a fixed volume as a substitute for watching the infant.

If the chest does not rise:

1. Reposition the head.
2. Reapply the mask and improve the seal.
3. Lift the jaw.
4. Look for a visible obstruction when the airway is opened.
5. Try another controlled breath.

If the infant is in CPR and breaths still do not produce rise after repositioning, continue the CPR/foreign-body obstruction sequence. Do not perform blind finger sweeps.

Match ventilation to the clinical situation

Definite pulse, absent or inadequate breathing

Give 1 breath every 2-3 seconds—20-30 breaths/min. Reassess pulse and breathing about every 2 minutes. If the pulse drops below 60/min with poor perfusion despite effective oxygenation and ventilation, or if no definite pulse remains, begin CPR.

CPR without an advanced airway

Use 30:2 for one rescuer and 15:2 for 2 or more healthcare rescuers. Pause compressions briefly for 2 breaths, then restart compressions. Keep the pause under 10 seconds.

CPR with an advanced airway

Give continuous compressions at 100-120/min and 1 breath every 2-3 seconds without pausing compressions. Continue to watch for visible chest rise and avoid excessive ventilation.

Excessive ventilation

Too many breaths, too much volume, or a rapid forceful squeeze can inflate the stomach and increase pressure in the chest. Count the interval, squeeze only to visible rise, and let the bag refill. More air is not better when adequate rise is already present.

Common errors

• Extending the infant's neck as far as an adult's.
• Using a mask that covers the eyes or hangs below the chin.
• Pressing fingers into the soft tissue beneath the jaw.
• Emptying the bag with every breath.
• Using the adult rescue-breathing interval of 1 breath every 6 seconds.
• Pausing compressions for breaths after an advanced airway is in place.

The exam pattern asks for the correct interval and visible chest rise. With an infant pulse, or with an advanced airway during infant arrest, the ventilation interval is 1 breath every 2-3 seconds.

Mask-and-rate rehearsal

Practice with more than one infant mask size so you can recognize a seal that covers the nose and mouth without covering the eyes. Have one rescuer deliberately overextend the head, then correct to neutral or slight extension and compare chest rise. Finish by timing 1 breath every 2-3 seconds for a full minute. A steady count helps prevent the very common tendency to speed up when the scene becomes stressful.