4.3 Bag-Mask Ventilation & Advanced Airways During CPR

Why Bag-Mask Ventilation Comes First

Most pediatric arrests are hypoxic in origin. Restoring oxygenation and ventilation is therefore as important as compressions. Bag-mask ventilation (BMV) is the primary skill that every PALS provider must perform effectively. An advanced airway (supraglottic airway or endotracheal tube) is a tool—not a mandatory early step—when BMV produces chest rise and the team can maintain it.

Elements of effective BMV

1. Airway position: Neutral or slight sniffing in infants (avoid extreme extension); sniffing position in children. Use jaw-thrust if cervical injury is a concern.
2. Mask seal: Correct mask size (bridge of nose to cleft of chin without covering eyes or extending over the mandible edge). Use E-C clamp (thumb and index form a C on the mask; remaining fingers lift the jaw) for one-rescuer technique; two-rescuer BMV (one seals, one squeezes) is more reliable when available.
3. Open airway adjuncts: Oropharyngeal airway if unconscious without gag; nasopharyngeal airway if some tone/gag and no midface trauma contraindication—sized correctly (OPA: corner of mouth to angle of mandible; NPA: nostril to tragus).
4. Volume: Squeeze only until visible chest rise—not a full adult squeeze into a toddler. Excessive volume causes gastric insufflation, aspiration risk, and hemodynamic compromise.
5. Rate (pulse present, respiratory failure): Age-appropriate assisted rate with just enough volume for chest rise; reassess constantly.
6. During CPR without advanced airway: Coordinate breaths with compressions using pediatric BLS ratios (30:2 single rescuer, 15:2 two-rescuer for infants and children), minimizing interruptions.

Troubleshooting failed chest rise

Use a systematic approach (often remembered with mnemonics such as MOANS/ROMAN for difficult mask or a simple checklist):

• Reposition head and jaw.
• Suction secretions.
• Check mask size and seal; switch to two-person technique.
• Insert OPA/NPA as indicated.
• Consider foreign body (look for visible object; no blind sweeps).
• Consider advanced airway or alternative device if BMV remains ineffective despite optimization.

Never abandon ventilation attempts while only watching the monitor. If the chest is not rising, the child is not being ventilated.

2025 OHCA vs IHCA: Bag-Mask vs Advanced Airway

The 2025 AHA/AAP Pediatric Advanced Life Support recommendations refine when to prioritize advanced airways during cardiac arrest. The practical exam message is: effective ventilation matters more than the specific device, and delayed or failed intubation must not interrupt compressions excessively.

Out-of-hospital cardiac arrest (OHCA)

For pediatric OHCA, it is reasonable to perform bag-mask ventilation rather than placement of an advanced airway. Prehospital intubation can be difficult in children, may cause long hands-off intervals, and has not shown consistent outcome superiority over good BMV when BMV is effective. Teams should still ensure:

• High-quality compressions with minimal interruptions.
• Effective BMV with oxygen and visible chest rise.
• Transport and ALS intercept per system protocols.
• Advanced airway later if BMV fails or if a skilled provider can place it without harming CPR quality.

In-hospital cardiac arrest (IHCA)

For pediatric IHCA, either bag-mask ventilation or an advanced airway may be reasonable. Hospital teams often have more airway expertise, monitoring (including capnography), and equipment. Choose based on:

• Effectiveness of current BMV.
• Anticipated duration of resuscitation.
• Provider skill and equipment readiness.
• Ability to place the airway with brief, coordinated pauses only if needed.

Shared rules regardless of setting

• Do not repeatedly attempt intubation at the expense of compressions and basic ventilation.
• If an advanced airway attempt fails, resume effective BMV immediately.
• Once an advanced airway is in place, confirm placement and transition to the continuous-compression ventilation strategy below.
• Supraglottic airways are acceptable advanced options in many protocols when endotracheal intubation is not feasible.

Megacode communication

Team leader language that matches guidelines: "BMV is effective—continue bag-mask and high-quality CPR." Or: "BMV not effective despite two-person technique and OPA—prepare advanced airway with continuous compressions as able; pause only briefly if essential."

Ventilation With an Advanced Airway During CPR

Once a supraglottic airway or endotracheal tube is confirmed, the coordination rules change:

Rate and coordination (2025 PALS)

• Provide continuous chest compressions (no pausing for breaths).
• Deliver asynchronous ventilations at 20 to 30 breaths per minute for infants and children—approximately 1 breath every 2 to 3 seconds.
• Each breath still aims for visible chest rise with modest tidal volume—not large adult bags emptied fully.
• Do not hyperventilate (rates well above 30/min or excessive volumes).

This 20–30/min pediatric advanced-airway rate differs from older habits of very slow adult-style rates applied uncritically to small children and also differs from panicked over-bagging at 40–60/min. Memorize the numeric range for the written exam and call it out in megacodes.

Why hyperventilation is harmful

Positive-pressure breaths raise intrathoracic pressure. When breaths are too large or too frequent:

• Venous return to the heart falls.
• Coronary perfusion pressure during CPR declines.
• Cerebral venous drainage may be impaired.
• Air trapping (especially in asthma) worsens hypotension and risk of pneumothorax.
• Gastric inflation increases regurgitation/aspiration risk when no advanced airway is present; with an advanced airway, volume trauma and hemodynamic effects remain.

Teams should assign a dedicated ventilator who watches the clock or uses a metronome/feedback device and reports rate aloud if asked.

Oxygen during arrest

Use high inspired oxygen during CPR. After ROSC, titrate oxygenation to avoid prolonged unnecessary hyperoxia (post-arrest care chapter)—but do not under-oxygenate during active arrest to chase a theoretical post-ROSC target.

When You Do Intubate: The 2025 Intubation Recommendations

The 2025 pediatric guidelines carry a dedicated intubation module. Four of its recommendations are compact, testable, and reverse habits that many clinicians learned years ago.

Cuffed tubes are now the preferred choice

The old teaching that small children need uncuffed tubes "because of the narrow cricoid ring" is outdated. Cuff pressure is the thing to monitor: it drifts with altitude during transport and rises as airway edema develops, so recheck it rather than setting it once.

Routine cricoid pressure is out

Cricoid pressure is not recommended routinely during bag-mask ventilation (Class 3: No Benefit) and not recommended routinely during tracheal intubation (Class 3: No Benefit). If it is applied and it interferes with ventilation or with the speed or ease of intubation, discontinue it (Class 3: Harm). Registry data did not show lower regurgitation rates with cricoid pressure, and bronchoscopy showed airway distortion at forces below those usually taught.

Do not confuse cricoid pressure with external laryngeal manipulation, which presses on the larger thyroid cartilage to improve the laryngeal view—that remains a legitimate technique.

Confirm every tube with exhaled CO2

In a child with a perfusing rhythm, exhaled CO2 detection—colorimetric detector or capnography—should be used to confirm ETT placement (Class 1), and monitoring exhaled CO2 during out-of-hospital and intra-hospital transport is beneficial (Class 2a). Auscultation, mist in the tube, and chest rise are not reliable enough on their own. The caveat: in low cardiac output or arrest, pulmonary blood flow is so poor that exhaled CO2 may be low or absent even with a correctly placed tube—interpret it with that physiology in mind rather than pulling a good tube.

Atropine premedication is optional, and its dose rule differs

Atropine may be considered as premedication to prevent peri-intubation bradycardia (Class 2b), at 0.02 mg/kg with no minimum dose. That "no minimum" is specific to intubation premedication and differs from the 0.1 mg minimum printed on the bradycardia algorithm (Section 9.1). Peri-intubation bradycardia has several drivers—the underlying illness, hypoxemia, induction medications, the switch to positive pressure, and vagal stimulation from laryngoscopy—and atropine addresses only the vagal one.

Capnography: Confirmation and Quality

Waveform (quantitative) capnography is the gold-standard continuous method to confirm endotracheal tube placement and to monitor ventilation and CPR physiology.

Confirmation of advanced airway

After intubation (or when assessing a supraglottic device with capnography available):

• Look for a consistent exhaled CO2 waveform over multiple breaths.
• Combine with clinical signs: bilateral chest rise, bilateral breath sounds, absent epigastric sounds, improving color/SpO2 when perfusion allows.
• If ETCO2 is absent and the waveform is flat, assume esophageal intubation or complete disconnection/obstruction until proven otherwise—remove or replace the tube and ventilate with BMV.

Colorimetric detectors can be adjuncts but are less informative than continuous waveform ETCO2, especially during low-flow CPR states.

CPR quality and ROSC

During arrest, pulmonary blood flow (not only ventilation) largely determines ETCO2:

• Very low ETCO2 (e.g., persistently under about 10 mmHg) suggests poor CPR quality or dismal prognosis—improve depth, recoil, rate, and minimize interruptions.
• Improving ETCO2 with better compressions supports adequate pulmonary blood flow.
• An abrupt, sustained increase in ETCO2 often heralds ROSC—check rhythm and pulse when appropriate without long pauses.

Capnography also helps avoid hyperventilation by making respiratory rate visible on the monitor.

Practical team roles

• Airway clinician: seal/tube, reports chest rise and ETCO2 numbers.
• Compressor: continuous high-quality CPR once advanced airway is in.
• Ventilator: 20–30 breaths/min, modest volume.
• Leader: watches compression fraction, defibrillation timing, epinephrine timing, and asks for ETCO2 trends.

Putting Airway Strategy Together Across Chapters 3–4

Use this integrated checklist on exams and in practice:

1. Distress vs failure → if failure, support airway and ventilation now.
2. Classify upper vs lower vs lung tissue vs disordered control → add cause-specific therapy.
3. BMV first with visible chest rise; optimize position, seal, suction, adjuncts.
4. Arrest care: high-quality CPR; BMV with 30:2 or 15:2 until advanced airway; for OHCA prefer effective BMV when reasonable; for IHCA BMV or advanced airway may be reasonable.
5. With advanced airway: continuous compressions + 20–30 breaths/min; confirm with capnography; avoid hyperventilation.
6. After ROSC: reassess tube, oxygenation, ventilation, and hemodynamics (later chapter).

Clinical scenario (synthesis)

A 3-year-old in asystole is brought to the ED. Two rescuers perform CPR with BMV at a 15:2 ratio; chest rise is good and ETCO2 via mask adapter is low but present. The team continues high-quality CPR and epinephrine. After several minutes, an experienced clinician places an endotracheal tube during a brief coordinated pause. Waveform capnography shows a clear square waveform; bilateral breath sounds are present. Compressions resume without pausing for breaths, and the ventilator delivers about one breath every 2–3 seconds (roughly 20–30/min) with modest chest rise. ETCO2 rises from 12 mmHg to 18 mmHg as compression quality improves, then jumps to 40 mmHg—the leader calls for a rhythm/pulse check and identifies ROSC. Hyperventilation is avoided throughout.

Contrast a prehospital vignette: prolonged unsuccessful intubation attempts with no chest rise and long compression pauses would violate 2025 priorities—resume BMV and compressions rather than "one more look" repeatedly.

Mastering BMV, the OHCA/IHCA advanced-airway choice framework, the 20–30/min advanced-airway ventilation rate, and capnography completes the Respiratory Emergencies skill set for PALS and sets up high-quality CPR metrics covered in the pediatric BLS chapter.