What PEEP should I set on a pediatric bag‑valve‑mask for infants and children?

PEEP Settings for Pediatric Bag-Valve-Mask Ventilation

For pediatric bag-valve-mask ventilation, use approximately 5 cm H₂O PEEP for preterm newborns and 5-8 cm H₂O PEEP for infants and children, recognizing that self-inflating bags require a PEEP valve attachment to deliver consistent positive end-expiratory pressure. 1

Age-Specific PEEP Recommendations

Neonates and Preterm Infants

• Apply approximately 5 cm H₂O PEEP when providing positive pressure ventilation to preterm newborns during resuscitation 1
• This recommendation is based on evidence suggesting slightly reduced supplementary oxygen requirements, though studies showed no improvement in mortality, need for intubation, or chronic lung disease 1
• The evidence quality is low, but the recommendation reflects standard neonatal intensive care practice 1

Infants and Children Beyond the Neonatal Period

• Use 5-8 cm H₂O as baseline PEEP for most pediatric conditions 1, 2
• Higher PEEP levels may be necessary based on underlying disease severity 1, 2
• For healthy lungs, keep PEEP ≤10 cm H₂O 1, 2

Critical Equipment Considerations

Self-Inflating Bags and PEEP Delivery

• Self-inflating bags cannot deliver continuous positive airway pressure (CPAP) and may not achieve PEEP reliably during positive pressure ventilation, even with a PEEP valve attached 1
• A PEEP valve must be added to self-inflating bags to provide any positive end-expiratory pressure 1
• The delivered PEEP is rate-dependent and lung compliance-dependent, with lower rates delivering less PEEP than the set value 3
• At 20 inflations per minute with PEEP set at 5 cm H₂O, actual delivered PEEP may be only 3.6 cm H₂O 3
• At 60 inflations per minute with PEEP set at 5 cm H₂O, delivered PEEP improves to approximately 4.8 cm H₂O 3

Alternative Ventilation Devices

• Flow-inflating bags and T-piece resuscitators can deliver PEEP more reliably than self-inflating bags 1
• T-piece resuscitators can consistently provide target inflation pressures and PEEP 1
• However, self-inflating bags remain the only device that can be used when a compressed gas source is not available 1

Bag Size Selection

For Infants and Young Children

• Use a self-inflating bag with a volume of at least 450-500 mL for infants and young children 1
• Smaller bags may not deliver an effective tidal volume or the longer inspiratory times required by full-term neonates and infants 1

For Older Children and Adolescents

• An adult self-inflating bag (1000 mL) may be needed to reliably achieve chest rise in older children or adolescents 1
• Research shows that adult-sized bags deliver higher tidal volumes (290 mL) compared to pediatric bags (197 mL) in simulated adult patients 4

Oxygen Delivery Optimization

• Attach an oxygen reservoir to the self-inflating bag to deliver high oxygen concentration (60-95%) 1
• Maintain oxygen flow of 10-15 L/min into a reservoir attached to a pediatric bag 1
• Without supplementary oxygen, self-inflating bags deliver only room air 1
• Even with 10 L/min oxygen inflow, delivered oxygen concentration varies from 30-80% without a reservoir 1

Ventilation Technique to Avoid Complications

Preventing Excessive Ventilation

• Deliver each breath slowly over approximately 1 second, using only the force and tidal volume necessary to make the chest rise 1
• Excessive ventilation increases intrathoracic pressure, impedes venous return, decreases cardiac output, cerebral blood flow, and coronary perfusion 1
• Excessive ventilation causes air trapping and barotrauma in patients with small-airway obstruction 1
• Excessive ventilation increases the risk of regurgitation and aspiration in patients without an advanced airway 1

Two-Person Technique

• A 2-person bag-mask technique may provide more effective ventilation than single-person technique, particularly when there is airway obstruction, poor lung compliance, or difficulty creating a tight seal 1
• One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal while the other compresses the ventilation bag 1
• Both rescuers should observe the chest to ensure chest rise 1
• Be careful to avoid delivering too high a tidal volume with the 2-person technique 1

Common Pitfalls and How to Avoid Them

Pressure Relief Valve Issues

• Ensure the bag-mask device allows you to bypass the pressure-relief valve if necessary to achieve visible chest expansion 1
• Patients with airway obstruction or poor lung compliance may require high inspiratory pressures 1
• Pop-off valves can malfunction and become seated in an intermediate position, causing inadequate ventilation 5
• When pop-off valves are in intermediate positions, delivered tidal volumes can drop to only 92 mL or become unrecordable (<50 mL) 5

Gastric Inflation Prevention

• Avoid creation of excessive peak inspiratory pressures by delivering each breath over approximately 1 second 1
• Cricoid pressure may be considered in an unresponsive victim if there is an additional healthcare provider, but avoid excessive pressure to prevent tracheal obstruction 1

Inadequate Seal and Airway Positioning

• If the chest does not rise, reopen the airway and verify a tight seal between the mask and face 1
• Open the airway by lifting the jaw toward the mask to make a tight seal 1

Lone Rescuer Limitations

• Bag-mask ventilation is not recommended for a lone rescuer during CPR due to the complex steps required 1
• During CPR, the lone rescuer should use mouth-to-barrier device techniques for ventilation 1
• Bag-mask ventilation can be provided effectively during 2-person CPR 1