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Not sure whether to use endotracheal (ET) intubation, laryngeal mask airways, or bag-mask ventilation to support a child’s airway? New pediatric advanced life support (PALS) guidelines from the Dallas-based American Heart Association (AHA)1 give you clear-cut recommendations, says Teresa Ostler, RN, ED educator and PALS coordinator at Primary Children’s Medical Center in Salt Lake City. (See "Resources" at the end of this article for information on how to obtain the guidelines.)
Here are current recommendations for each method of advanced airway support:
• Bag-mask ventilation. Because bag-mask ventilation is safe, efficacious, and performed by all levels of emergency personnel with minimal training, and because a misplaced ET tube is lethal, bag-mask ventilation is now recommended unless the rescuer is experienced at pediatric intubation, says Barbara Weintraub, RN, MPH, MSN, pediatric critical care nurse practitioner at Northwest Community Hospital in Arlington Heights, IL.
She stresses that proper bag-mask ventilation takes practice. "Failure to make an adequate seal with the face mask leads to underventilation and, as a result, hypoxemia," Weintraub says. All nurses who are expected to perform bag-mask ventilation as part of their job should receive training in this skill from experienced practitioners, such as in a PALS course, and then practice this skill on a regular basis, she advises.
Bag-mask ventilation is an effective airway maneuver for most situations, says Weintraub. "Bag-mask ventilation should be a priority in airway management, rather than endotracheal intubation, in most pediatric critical care situations," she adds. Bag-mask ventilation using the "E-C" hand position is the recommended technique, says Wolff. "The thumb and forefinger ("C") encircle the top of the mask. The remaining three fingers ("E") are used to stabilize the mask by holding the jaw," she explains.
• Endotracheal intubation. According to the guidelines, the primary emphasis will be on improved bag-mask technique and use of laryngeal mask airways (LMAs), instead of endotracheal intubation, says Ostler.
The AHA recognizes the difficulty in maintaining the skill level of pre-hospital providers who don’t have the opportunity to practice their skills on a regular basis, says Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA.
• Laryngeal mask airways. The new guidelines recommend the use of LMAs, when properly placed by trained professionals, says Wolff. The LMA is a tube with a large cuff on the distal end that is placed in the child’s pharynx and advanced to the point of resistance, Wolff explains. "When the balloon is inflated, the hypopharnyx is sealed, leaving an opening in the airway above the glottis," she says.
These devices can be safely used in children who do not have a gag reflex, advises Wolff. "They have most frequently been used in the operating room," she says. "As with tracheal intubation, proper training and practice are needed for providers to learn and retain their skills."
There is evidence that LMA placement techniques may be easier to master than tracheal intubation techniques, notes Wolff. "As with any new practice, nurses are advised to consult their state boards of nursing to determine their scope of practice related to placement of these devices," she advises.
It might be more difficult to maintain proper LMA placement during transport as compared to tracheal intubation, says Wolff. "Therefore, use of these devices for transport may be problematic," she says. "Currently, pediatric-sized LMAs are only available as a relatively expensive, nondisposable item. There is a limited range of sizes available, so this device may not fit some infants and children properly."
1. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2000; 102:suppl I.
The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were published in the Aug. 22, 2000, issue of Circulation, the official journal of the American Heart Association (AHA). Reprints are available for $20 plus $7 shipping and handling. To order, contact:
• Channing L. Bete, 200 State Road, South Deerfield, MA 01373-0200. Telephone: (800) 611-6083 or (413) 665-7611. Fax: (800) 499-6464 or (413) 665-2671. Web: www.channing-bete.com.
Key changes are outlined on the AHA web site: www.cpr-ecc.americanheart.org. Click on "What’s New" for information on major changes in the guidelines, training materials, training courses, and international programs.
The Fall 2000 issue of Currents contains a 28-page summary of the new guidelines. Individual copies are available for $5, including shipping and handling. To order a copy, contact Pro Education International, 27500 I-45 N., Suite 124, Spring, TX 77386. Telephone: (888) 999-4210 or (281) 419-8596. Fax: (281) 419-8238. E-mail: support@CurrentsOnLine.com. The complete guidelines are available in CD-ROM format with full search capability for $20 plus a $4.95 shipping charge. They can be ordered at: www.CurrentsOnLine.com/sales/guidelines2000.htm.