Difficult Bag Mask Ventilation in Children

2016-07-06 23:08:21 | BioPortfolio


Unanticipated difficult airway comprises of unexpected difficult bag mask ventilation or unforeseen difficult laryngoscopy. The incidence of difficult laryngoscopy or unanticipated difficult intubation in children was varied from 1.2 %to 4.77% depending on general or specific population and type of surgery. The known risk factors of difficult intubation in children were young age, associated syndrome or congenital abnormality and obstructive sleep apnea. Moreover, the predictors of difficult laryngoscopy by physical examination were associated with short interincisors distance, high frontal plane to chin distance, short thyromental distance and Cormack & Lehane classification 3 or 4. However, little knowledge is known regarding difficult bag mask ventilation in children. The incidence of difficult bag mask ventilation was 6.6% according to the single study. A few study reported the independent risk factor of difficult bag mask ventilation in children which were young age, obesity, use of neuromuscular blocking agent and airway surgery. In addition, the association between difficult bag mask ventilation and difficult intubation are still unknown. To understand more of difficult bag mask ventilation in children and factor-association may reduce incidence of morbidity and mortality by identifying difficult airway, preparing personnel and equipment tool in order to improve clinical outcome in pediatric anesthesia. The objectives of the study were to determine the predictors of difficult bag mask ventilation and the association with unexpected difficult intubation in children who came for elective surgery in tertiary care hospital of southern Thailand.


Study protocol and anesthesia practice Patient's demographic and history of snoring or asthma/hyper-reactive airway were obtained by research assistant at preinduction period. Standard monitoring including non-invasive blood pressure, pulse oximetry, electrocardiography and capnography were applied to all patients before starting general anesthesia. All patients were received general anesthesia with oroendotracheal tube intubation. Induction techniques were either inhalation anesthetic agent by N2O-O2-sevoflurane or intravenous agent with 100% O2. Type of anesthetic circuit used (Circle or Jackson-Rees) was depending on anesthesiologist in charge. Patients head position were in neutral under small head ring to prevent head movement during induction. Maneuvers on bag mask ventilation such as application of CPAP with opening airway maneuvers, oropharyngeal airway or two person ventilations were recorded by research assistant at induction period. When positive pressure ventilation was difficult after the patients had been slept, the CPAP ≥5 cmH2O was applied incorporated with opening airway by head tilt/chin lip or jaw thrust until assisted spontaneous ventilation was successful. Then the next maneuvers on bag mask ventilation described above would be followed if bag mask ventilation was still not possible. Neuromuscular blocking agents for intubation were used or not depending on the discretion of the attending anesthesiologist. If anesthesiologist in charge found the bag mask ventilation was difficult, non-depolarizing muscle relaxant may be held until bag mask ventilation was successful or succinylcholine was given to assist laryngoscopy procedure. The laryngoscopists were nurse anesthetists student, anesthesia residents, nurse anesthetist and anesthesiologist staff. Number of intubation attempts, Cormack-Lehane laryngoscopic view, intubation time in second and presence of desaturation (SpO2 < 95%) were recorded by research assistant at intubation period. There were many optioned used to aid successful intubation such as applying BURP maneuver, endotracheal tube with stylet used, change to smaller endotracheal tube size, change laryngoscope type or change to more experience laryngoscopists. Attending anesthesiologists take responsibility over nurse anesthetists student, anesthesia resident and nurse anesthetists for first or second failure of intubation attempts.

Outcome of interest Primary outcomes were to determine the predictors of difficult bag mask ventilation. The difficult bag mask ventilation was defined as the occurrence at least 2 following events which were requiring application of CPAP with opening airway maneuvers, requiring oropharyngeal airway or nasopharyngeal airway, requiring 2- person bag mask ventilation, unable to perform bag mask ventilation or presence of desaturation (SpO2 < 95%).

Secondary outcome was to find out the association between difficult bag mask ventilation and unexpected difficult intubation and potential predictors of unexpected difficult intubation if possible.

Unexpected difficult intubation was defined as the presence of at least 2 following conditions which were laryngoscopic view 3 or 4, attempted intubation > 3 times, total intubation time > 300 second or presence of desaturation (SpO2 < 95%). The intubation time was defined as the time starting from applying laryngoscope to presence of positive capnography wave form. In case of fail intubation, the intubation time started from applying laryngoscope to remove laryngoscope from children's mouth. The total intubation time was the combined timing of each intubation attempts

Study Design

Observational Model: Cohort, Time Perspective: Prospective


Inadequate or Impaired Breathing Pattern or Ventilation




Faculty of Medicine, Prince of Songkla University
Hat Yai




Prince of Songkla University

Results (where available)

View Results


Published on BioPortfolio: 2016-07-06T23:08:21-0400

Clinical Trials [1517 Associated Clinical Trials listed on BioPortfolio]

Change in Breathing Pattern on Non-invasive Ventilation of COPD Patients Under Home Mechanical Ventilation

Acute exacerbation of COPD (AECOPD) worsen prognosis and quality of life of COPD patients. Telemonitoring could be a useful tool for early identification of AECOPD. Parameters that have to...

Impact of Non-intentional Leaks on Noninvasive Ventilation

The investigators hypothesized that increasing non intentional leaks could increase work of breathing and could lead to patient/non-invasive ventilation (NIV) asynchrony. The main objecti...

Mechanical Ventilation Controlled by the Electrical Activity of the Patient's Diaphragm - Effects of Changes in Ventilator Parameters on Breathing Pattern

Neurally adjusted ventilatory assist (NAVA) is a new concept of mechanical ventilation. NAVA delivers assist to spontaneous breathing based on the detection of the electrical activity of t...

A Comparison of Different Ventilation Strategies in Infants Using the PLMA™

The purpose of this research study is to compare difference between breathing by oneself or with the partial help from an anesthesia machine in infants under general anesthesia. Hypothesi...

Proportional Assist Ventilation vs Pressure Support Ventilation

In this study, we want to compare two different kinds of artificial ventilation to see if one encourages faster weaning from breathing support and if one provides better sleep quality. The...

PubMed Articles [6847 Associated PubMed Articles listed on BioPortfolio]

Learning to Air-Breathe: The First Steps.

Air-breathing in vertebrates has evolved many times among the bony fish while in water. Its appearance has had a fundamental impact on the regulation of ventilation and acid-base status. We review the...

Beneficial effects of adaptive servo-ventilation on natriuretic peptides and diastolic function in acute heart failure patients with preserved ejection fraction and sleep-disordered breathing.

Adaptive servo-ventilation (ASV) is a ventilator algorithm able to correct breathing through anticyclic support of breathing in patients with central sleep apnea (CSA). So far, very few data exist reg...

Pressure-support ventilation or T-piece spontaneous breathing trials for patients with chronic obstructive pulmonary disease - A randomized controlled trial.

Little is known about the best strategy for weaning patients with chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Spontaneous breathing trials (SBT) using a T-piece or pressu...

Quiet Breathing in Hindlimb Casted Mice.

The hindlimb casting model was developed to study skeletal muscle reloading following a period of unloading. It is unknown if ventilation parameters of mice are affected by the casting model. We teste...

Effect of Nebulizer Location and Spontaneous Breathing on Aerosol Delivery During Airway Pressure Release Ventilation in Bench Testing.

Airway pressure release ventilation (APRV) maintains a sustained airway pressure over a large proportion of the respiratory cycle, and has a long inspiratory time at high pressure. The purpose of this...

Medical and Biotech [MESH] Definitions

Mechanical ventilation delivered to match the patient's efforts in breathing as detected by the interactive ventilation device.

Any method of artificial breathing that employs mechanical or non-mechanical means to force the air into and out of the lungs. Artificial respiration or ventilation is used in individuals who have stopped breathing or have RESPIRATORY INSUFFICIENCY to increase their intake of oxygen (O2) and excretion of carbon dioxide (CO2).

An abnormal pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. The cycle begins with slow, shallow breaths that gradually increase in depth and rate and is then followed by a period of apnea. The period of apnea can last 5 to 30 seconds, then the cycle repeats every 45 seconds to 3 minutes.

A pulmonary ventilation rate faster than is metabolically necessary for the exchange of gases. It is the result of an increased frequency of breathing, an increased tidal volume, or a combination of both. It causes an excess intake of oxygen and the blowing off of carbon dioxide.

Ventilatory support system using frequencies from 60-900 cycles/min or more. Three types of systems have been distinguished on the basis of rates, volumes, and the system used. They are high frequency positive-pressure ventilation (HFPPV); HIGH-FREQUENCY JET VENTILATION; (HFJV); and high-frequency oscillation (HFO).

More From BioPortfolio on "Difficult Bag Mask Ventilation in Children"

Quick Search


Relevant Topics

Pediatrics is the general medicine of childhood. Because of the developmental processes (psychological and physical) of childhood, the involvement of parents, and the social management of conditions at home and at school, pediatrics is a specialty. With ...

Surgical treatments
Surgery is a technology consisting of a physical intervention on tissues. All forms of surgery are considered invasive procedures; so-called "noninvasive surgery" usually refers to an excision that does not penetrate the structure being exci...

Congenital Diseases
Congenital conditions are those which are present from birth. They include structural deformities or loss of function in organs such as the <!--LGfEGNT2Lhm-->heart, gut or skeletal system. They can be corrected by <!--LGfEGNT2Lhm-->surgery, m...

Searches Linking to this Trial