Effect of jaw-thrust and continuous positive airway pressure on tidal breathing in deeply sedated infants

doi:10.1067/mpd.2001.114478

The Journal of Pediatrics

Volume 138, Issue 6, June 2001, Pages 826-830

https://doi.org/10.1067/mpd.2001.114478 Get rights and content

Abstract

Objectives: To examine the physiologic impact of the jaw-thrust maneuver or the administration of continuous positive airway pressure (CPAP) on tidal breathing in deeply sedated infants. Study design: Prospective, non-randomized study of infants undergoing elective fiberoptic bronchoscopy while sedated with intermittent doses of propofol. Methods: Spontaneous tidal breathing was measured in the supine position by means of a spirometer attached to a bronchoscopy face mask. Tidal breaths were recorded under the following conditions: (1) neutral sniffing position, (2) jaw-thrust, (3) neutral sniffing position, and (4) CPAP of 5 cm H₂O. Improvement was defined as a change of more than twice the coefficient of variation of repeated measurements of tidal volume and flows from baseline. Results: Jaw-thrust increased tidal volume, minute ventilation, and peak tidal inspiratory and expiratory flows significantly in all 13 infants studied (mean ± SEM age = 8 ± 2 months). CPAP increased peak tidal inspiratory and expiratory flows by more than twice the coefficient of variation of baseline measurements in 6 patients and tidal volume and minute ventilation in 5 of 10 patients studied. Conclusion: Jaw-thrust and CPAP are effective techniques to improve ventilation of sedated infants undergoing interventions that compromise upper airway patency. (J Pediatr 2001;138:826-30)

Section snippets

Methods

We studied 13 infants <2 years of age ([mean ± SEM] = 8 ± 2 months; weight, 7.2 ± 0.9 kg) undergoing elective fiberoptic bronchoscopy. The clinical indications for fiberoptic bronchoscopy evaluation were stridor (n = 7), chronic or unexplained cough (n = 4), cystic hygroma of the neck (n = 1), and bronchoalveolar lavage (n = 1). The study was approved by the local ethics committee, and informed consent was obtained. Patients received no solid food or breast milk for 4 hours and no liquids for 2

Results

Breathing patterns of all infants studied before and during the jaw-thrust maneuver and before and after the administration of CPAP of 5 cm H₂O are shown in Table I.

Table. Effect of jaw-thrust and CPAP on tidal breathing pattern

Tidal breathing indices	Baseline	Jaw-thrust	Baseline	CPAP 5 cm H₂O
RR (min^–1)	37 ± 2	38 ± 3	36 ± 2	40 ± 3
V’_E (L/min)	0.83 ± 0.19	1.34 ± 0.26*	0.86 ± 0.21	1.11 ± 0.27
PTIF (mL/s)	58 ± 14	98 ± 17*	58 ± 14	81 ± 17*
t_I/t_TOT	0.39 ± 0.02	0.36 ± 0.01	0.40 ± 0.02	0.38 ± 0.02
PTEF (mL/s)	42 ± 7	62 ± 9*	41

Discussion

The jaw-thrust technique and the application of CPAP caused a significant improvement in spontaneous tidal breathing in deeply sedated infants. Overall, the jaw-thrust technique seemed more effective in improving ventilation than the application of CPAP.

The jaw-thrust technique is taught world-wide in life support courses, anesthesia, and critical care medicine to achieve airway control in comatose or anesthetized patients. Its physiologic impact, however, has never been formally measured.

References (25)

MP. Boidin
Airway patency in the unconscious patient
Br J Anaesth
(1985)
J Kattwinkel et al.
Apnea of prematurity
J Pediatr
(1975)
MJ Miller et al.
Continuous positive airway pressure selectively reduces obstructive apnea in preterm infants
J Pediatr
(1985)
CL Marcus et al.
Use of continuous positive airway pressure as a treatment of childhood obstructive sleep apnea
J Pediatr
(1995)
AR Stark et al.
Mechanisms of airway obstruction leading to apnea in newborn infants
J Pediatr
(1976)
S Morikawa et al.
Influence of head-jaw position upon upper airway patency
Anesthesiology
(1961)
K Murashima et al.
Effect of jaw-thrust manoeuvre on the laryngeal inlet
Anaesthesia
(1998)
P Scalfaro et al.
In vitro assessment of an ultrasonic flowmeter for use in ventilated infants
Eur Respir J
(2000)
FJ Frei et al.
The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway
Paediatr Anaesth
(1995)
American Heart Association and American Academy of Pediatrics
Pediatric advanced life support
(1997)

P Kulkarni et al.

Ventilatory parameters in children during propofol anaesthesia: a comparison with halothane

Can J Anaesth

(1996)

PD Sly et al.

Do wheezy infants recovering from bronchiolitis respond to salbutamol?

Pediatr Pulmonol

(1991)

Cited by (45)

Unusual pediatric airway: Clinical case report series
2023, Trends in Anaesthesia and Critical Care
Airway management in pediatric patients with craniofacial dysmorphism is even more difficult for the clinician. It is important for the clinician to have experience in pediatric airway management, because pediatric airway management can quickly become a disaster. Preoperative anesthetic assessment is vital while mapping out perioperative airway management. In children with craniofacial dysmorphism, planning should be performed on a case-by-case basis and according to the clinician's experience. In this clinical case report series, we will share our experience with difficult airways in pediatric patients with craniofacial dysmorphism.
Induction, Maintenance, and Recovery
2016, Smith's Anesthesia for Infants and Children, Ninth Edition
Motion generated in the unstable upper cervical spine during head tilt-chin lift and jaw thrust maneuvers
2014, Spine Journal
Citation Excerpt :
The same authors who did not advocate the use of the jaw thrust based this on five level 4 studies that were all published from 2001 onward. On close examination, three of these studies were actually supportive of using the jaw thrust [32–34], one neutral [35], and one opposed [36]. The neutral study examined the ability of the two maneuvers to improve stridor in children with adenotonsillar hyperplasia [35].
Although it is essential to maintain a secure airway in a trauma patient, it is also critical to protect the potentially injured cervical spine. It has previously been suggested that the jaw thrust maneuver be used in place of the head tilt–chin lift in the suspected spine-injured patient.
We sought to examine whether the jaw thrust was in fact safer to use in the setting of an unstable upper cervical spine injury.
Unstable, dissociative C1–C2 injuries were surgically created in nine fresh, lightly embalmed human cadaver specimens. An electromagnetic motion analysis device was used to assess the amount of angular and linear motion with sensors placed above and below the injured segment. Measurements were recorded during execution of the two airway maneuvers. Trials were performed both with and without a cervical immobilization collar in place.
There was almost twice as much angular motion in all planes when performing a head tilt–chin lift as compared with the jaw thrust, and this was statistically significant (p<.013). In addition, there was more displacement at the injured level with a head tilt–chin lift as compared with the jaw thrust. This was statistically significant for axial displacement and anteroposterior translation (p=.003 for both), and approached significance for mediolateral translation (p=.056).
The jaw thrust maneuver results in less motion at an unstable C1–C2 injury as compared with the head tilt–chin lift maneuver. We therefore recommend the use of the jaw thrust to improve airway patency in the trauma patient with suspected cervical spine injury.
Acute respiratory failure in children
2013, Paediatric Respiratory Reviews
Acute respiratory failure is the most common medical emergency in children. One aim of this review is to discuss the physiologic peculiarities that explain the increased vulnerability of infants and children to any pathology affecting the respiratory tract. The other aim is to highlight the importance of history taking and correct physical examination for early recognition of an impending catastrophic progression of respiratory failure. Under most circumstances, correct physical examination alone allows one to pinpoint the cause to a particular part of the respiratory system and to make the appropriate decisions for a proactive and life-saving management of the critically ill child.
Airway manoeuvres to achieve upper airway patency during mask ventilation in newborn infants - An historical perspective
2012, Resuscitation
Citation Excerpt :
These radiological studies demonstrated that forward placement of the mandible (chin lift with head tilt and jaw thrust) is the most effective technique to achieve upper airway patency.25,55,62,31 A series of bronchoscopy studies evaluated jaw thrust and CPAP in deeply sedated infants.46–49 Hammer et al. demonstrated that jaw thrust increases VT delivery, minute volume and peak inspiratory and expiratory flows compared to the sniffing position.47
Maintenance of upper airway patency remains a cornerstone of adequate airway management. Although various opening manoeuvres are recommended by neonatal resuscitation guidelines, none of these have been well evaluated in newly born infants.
The aim of this article was to review the available literature about airway opening manoeuvres in newborn infants. We reviewed books, resuscitation manuals and articles from 1860 to the present with the search terms “Infant, Newborn”, “airway management”, “airway manoeuvres”, “chin lift”, “jaw thrust”, “neutral position”, “shoulder roll”, “neonatal resuscitation”, “positive pressure respiration” and “continuous positive airway pressure”. Only human studies were included.
During mask PPV, jaw thrust appears to be more effective in achieving a patent upper airway and might help to reduce airway obstruction. The additional application of chin lift might reduce leak during mask ventilation. However given the lack of available data these conclusions remains speculative and further research in this area is required.
Induction, Maintenance, and Recovery
2011, Smith's Anesthesia for Infants and Children: Expert Consult Premium Edition - Enhanced Online Features and Print

View all citing articles on Scopus

^☆: Supported by a grant from the Swiss Society of Pulmonology

^☆☆: Reprint requests: Jürg Hammer, MD, Division of Pediatric Intensive Care and Pulmonology, University Children’s Hospital Basel, Postfach, 4005 Basel, Switzerland.

View full text

Original ArticlesEffect of jaw-thrust and continuous positive airway pressure on tidal breathing in deeply sedated infants☆,☆☆

Abstract

Section snippets

Methods

Results

Discussion

Br J Anaesth

J Pediatr

J Pediatr

J Pediatr

J Pediatr

Influence of head-jaw position upon upper airway patency

Anesthesiology

Effect of jaw-thrust manoeuvre on the laryngeal inlet

Anaesthesia

In vitro assessment of an ultrasonic flowmeter for use in ventilated infants

Eur Respir J

The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway

Paediatr Anaesth

Pediatric advanced life support

Ventilatory parameters in children during propofol anaesthesia: a comparison with halothane

Can J Anaesth

Do wheezy infants recovering from bronchiolitis respond to salbutamol?

Pediatr Pulmonol

Original Articles
Effect of jaw-thrust and continuous positive airway pressure on tidal breathing in deeply sedated infants☆,☆☆