This document discusses various airway adjuncts used in pediatrics including oral/nasal airways, bag mask ventilation, and laryngeal mask airways. It provides guidance on proper size selection and insertion techniques for each device. Potential complications are also reviewed such as aspiration, injury, and laryngospasm. The objectives are to learn to choose the correctly sized airway adjunct based on anatomy and patient size, understand complications associated with each device, and master techniques for bag mask ventilation and laryngeal mask airway insertion.

1. Pediatrics
Matthew Musick, MD
Fellows Boot Camp 2013
Airway Adjuncts, Bag Mask
Ventilation, and Laryngeal
Mask Airways

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Pediatrics
Objectives
•Be able to choose proper size oral/nasal airway,
facemask (for BMV), and LMA according to
anatomic landmarks and patient age/size
•Learn complications from various airway
maneuvers
‐5 complications related to use of airway adjuncts
‐3 complications related to BMV
‐3 complications related to LMAs

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Pediatrics
Pediatric vs Adult Airway
Infant Adult

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Pediatrics
Positioning (“sniffing”)

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Pediatrics
Positioning - Infant
R

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Pediatrics
Positioning - Comparison

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Pediatrics
Obstruction

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Pediatrics
Options – Chin lift

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Pediatrics
Options – Jaw Thrust

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Pediatrics
Options – Oral Airway

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Pediatrics
Oral Airway

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Pediatrics
Oral Airway – Too Small

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Pediatrics
Oral Airway – Too Large

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Pediatrics
Insertion Technique
•First open mouth (can use cross finger scissor
technique)
•Option # 1 – push tongue down w/ tongue
depressor and insert “straight in”
•Option # 2 – insert “upside down” and then
rotate 180 degrees as oral airway is being
advanced to back of oropharynx

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Pediatrics
Oral Airway Complications
•Yak*$%! (ie the gag reflex)
•Obstruction (not really your desired effect)
•Laryngospasm
•Tooth/mouth injury

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Pediatrics
Nasopharyngeal Airways
•Same concept of relieving tongue obstruction
•Better tolerated than oral airway if patient semi-
conscious or awake
•Contraindicated with:
‐Significant facial trauma (esp basilar skull fracture)
‐Severe coagulopathy

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Pediatrics
Size Selection

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Pediatrics
Nasopharyngeal Airway Insertion
•Don’t forget the lube!

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Pediatrics
Bag Mask Ventilation
•True life saving technique
•Can oxygenate and ventilate
•Helpful during intubation
‐Can “improve” patient so that intubation is less
strenuous
‐Can “rescue” patient if intubation attempt fails
•May need airway adjunct and two people!

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Pediatrics
Equipment
•Self inflating reservoir bag, unidirectional valve,
standard mask connector, oxygen hook-up
‐Manometer, PEEP valve
•Different size masks

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Pediatrics
Mask Size and Fit
•Extend from bridge of nose to chin (covering
mouth and nose)
•Inflatable rim can help assure seal
•“E-C” hold is preferred technique
‐Thumb and forefinger form C on top of mask
‐Middle/ring fingers on ridge of mandible (chin lift)
‐Pinky behind angle of mandible (jaw thrust)

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Pediatrics
E-C Hold

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Pediatrics
Successful BMV
•Chest rise
•Chest rise
•Chest rise
•Increased O2 sats, auscultation, condensation
in mask

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Pediatrics
Complications of BMV
•Excessive air in stomach
‐Aspiration risk
‐Decreases lung volume/requires higher PIPs
•Corneal abrasions
•Injury to lips/gums and nasal bridge
•Excessive bagging due to user exuberance

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Pediatrics
Laryngeal Mask Airway
•Many uses/indications for our anesthesia
colleagues
•Rescue airway device in PICU
•Supraglottic airway that can be placed “blindly”
but is temporary in nature

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Pediatrics
LMA

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Pediatrics
LMA

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Pediatrics
LMA Notes
•Size selection is based
on weight – look at
package!
•It will “pop up” slightly
after cuff is inflated if
seated correctly
•Don’t forget the lube

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Pediatrics
LMA Insertion
•Few methods…
•Forefinger guiding
technique

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Pediatrics
LMA Insertion
•Rotational method
‐Similar to oral airway rotation
‐“Cuff” is pointed up towards palate
‐After advancing past the tongue, you rotate 180 degrees

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Pediatrics
LMA Insertion
•Just stick it
in
•Works best
for curved
LMA

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Pediatrics
LMA Complications
•Aspiration (although much less than
traditionally feared)
•Gagging and possibly laryngospasm
•Difficult to achieve high peak inspiratory
pressures

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Pediatrics
Questions???