PALS Face Mask Ventilation Guidelines for Infants
For infants requiring positive-pressure ventilation during resuscitation, use a self-inflating bag with a volume of at least 450-500 mL, deliver breaths over approximately 1 second until visible chest rise is achieved, and avoid excessive ventilation which is harmful. 1, 2
Equipment Selection
Bag Size and Type
- Infants and young children: Use a self-inflating bag with minimum 450-500 mL volume 1, 2
- Smaller bags cannot deliver adequate tidal volume or the longer inspiratory times required by full-term neonates and infants
- Self-inflating bags deliver only room air unless supplementary oxygen is attached
Oxygen Delivery
- To achieve high oxygen concentration (60-95%): Attach an oxygen reservoir to the self-inflating bag 1
- Maintain oxygen flow of 10-15 L/min into the reservoir attached to a pediatric bag 1, 2
- Without a reservoir, delivered oxygen concentration varies from only 30-80% even with 10 L/min flow
Proper Technique
Creating an Effective Seal
Open the airway by lifting the jaw TOWARD the mask (not pushing the mask down onto the face), creating a tight seal, then squeeze the bag until the chest rises 1, 2
Ventilation Parameters
- Breath duration: Deliver each breath slowly over approximately 1 second 1
- Visual endpoint: Watch for visible chest rise—this is your target 1
- Avoid excessive force: Use only the tidal volume necessary to just make the chest rise
Critical Precautions
Dangers of Excessive Ventilation (Class III: Harm)
Excessive ventilation causes 1:
- Increased intrathoracic pressure → impedes venous return → decreased cardiac output, cerebral blood flow, and coronary perfusion
- Air trapping and barotrauma in patients with small-airway obstruction
- Increased risk of regurgitation and aspiration
Pressure-Relief Valve Considerations
- Some patients with airway obstruction or poor lung compliance require high inspiratory pressures 1
- Ensure your bag-mask device allows you to bypass the pressure-relief valve if necessary to achieve visible chest expansion
Rescuer Configuration
Single Rescuer
Bag-mask ventilation is NOT recommended for a lone rescuer during CPR 1, 2
- The lone rescuer should use mouth-to-barrier device techniques for ventilation
- Bag-mask ventilation requires complex steps that are difficult for one person to perform effectively
Two-Person Technique (Preferred)
When skilled rescuers are available, use a two-person technique 1, 2:
- First rescuer: Uses both hands to open the airway and maintain a tight mask-to-face seal
- Second rescuer: Compresses the ventilation bag
- Both rescuers: Observe the chest to ensure chest rise
- This technique is often required when there is significant airway obstruction, poor lung compliance, or difficulty creating a tight seal
Troubleshooting Failed Ventilation
If the chest does not rise 1:
- Reopen the airway
- Verify tight seal between mask and face
- Reattempt ventilation
- Consider two-person technique if not already using it
Alternative Airway Devices
If bag-mask ventilation fails in infants ≥34 weeks gestation:
- Supraglottic airway device (laryngeal mask) is suggested as an alternative 3, 4
- Easier to insert than endotracheal intubation
- More effective than face mask for achieving ventilation
Minimizing Gastric Inflation
To prevent gastric inflation that interferes with ventilation and causes regurgitation 1:
- Deliver each breath over approximately 1 second (avoid excessive peak inspiratory pressures)
- Cricoid pressure may be considered in unresponsive victims if an additional healthcare provider is available
- Avoid excessive cricoid pressure to prevent tracheal obstruction
Common Pitfalls to Avoid
- Using inadequate bag size (<450 mL for infants)
- Pushing mask down onto face instead of lifting jaw toward mask
- Delivering breaths too rapidly (increases gastric inflation and intrathoracic pressure)
- Excessive ventilation rate or volume during CPR
- Attempting single-rescuer bag-mask ventilation during CPR (use mouth-to-barrier instead)
- Failing to verify chest rise with each breath