Sniffing position combined with mouth opening improves facemask ventilation in children with adenotonsillar hypertrophy

Abstract

Background: This study evaluates the influence of sniffing position combined with mouth opening on the effectiveness of facemask ventilation in paralyzed pediatric patients undergoing adenotonsillectomy during sevoflurane-N 2 O anesthesia. Methods: After Institutional Ethics Committee approval, 40 children 5-11 years of age who were scheduled for an elective adenotonsillectomy operation were enrolled in this prospective randomized study. After routine monitoring and pre-oxygenation, anesthesia was induced with sevoflurane 8% in a mixture of 50% N 2 O-O 2 . Three minutes after the administration of vecuronium, the sequence of the positions was randomized. Three positions were applied during facemask ventilation: Position CN (closed mouthneutral head and neck position), position CS (closed mouth-sniffing position) and position OS (opened mouthsniffing position). Volume-controlled ventilation was started. Peak inspiratory pressure (PIP), tidal volume (V T ), expired tidal volume (V Texp ) and end-tidal CO 2 pressure were recorded. The percent of leakage was calcu-

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

“… 48 The combination of the sniffing position, mouth opening, and continuous positive pressure (CPAP) with a maximum inspiratory pressure of 10 cmH 2 O set on an adjustable pressure-limiting (APL) valve improves the expiratory tidal volume and peak inspiratory pressure, optimizing face mask ventilation. 49 Another useful alternative for improving face mask ventilation is the bimanual technique. 3 …”

“…However, most airway emergencies leading to “cannot intubate, cannot ventilate” occur in children under one year of age, restricting the usefulness of the technique. 49 , 51 In children over eight years of age, the size of the cricothyroid membrane allows percutaneous cricothyroidotomy. 54 …”