Effect of jaw-thrust and continuous positive airway

pressure on tidal breathing in deeply sedated infants

Jürg Hammer, MD, Adrian Reber, MD, Daniel Trachsel, MD, and Franz J. Frei, MD
thrust technique (Esmarch maneuver)
Objectives: To examine the physiologic impact of the jaw-thrust maneuver can re-open the obstructed airway by
or the administration of continuous positive airway pressure (CPAP) on lifting the base of the tongue and the
tidal breathing in deeply sedated infants. epiglottis in anesthetized patients. 1
The jaw-thrust maneuver can reverse
Study design: Prospective, non-randomized study of infants undergoing
the collapse of the laryngeal inlet,
elective fiberoptic bronchoscopy while sedated with intermittent doses of
which has occurred in patients during
propofol.
general anesthesia2; hence, this is an
Methods: Spontaneous tidal breathing was measured in the supine position established method for effective mask
by means of a spirometer attached to a bronchoscopy face mask. Tidal ventilation during resuscitation or
breaths were recorded under the following conditions: (1) neutral sniffing anesthesia.
position, (2) jaw-thrust, (3) neutral sniffing position, and (4) CPAP of 5 cm The application of continuous posi-
H2O. Improvement was defined as a change of more than twice the coeffi- tive airway pressure by face mask may
cient of variation of repeated measurements of tidal volume and flows from prevent upper airway structures from
baseline. collapsing during inspiration in sedat-
ed infants and is a treatment for ob-
Results: Jaw-thrust increased tidal volume, minute ventilation, and peak
structive sleep apnea in all age groups.
tidal inspiratory and expiratory flows significantly in all 13 infants studied
Although the anatomic effects of these
(mean ± SEM age = 8 ± 2 months). CPAP increased peak tidal inspiratory
interventions on upper airway patency
and expiratory flows by more than twice the coefficient of variation of base- have been widely investigated with
line measurements in 6 patients and tidal volume and minute ventilation in 5 various imaging techniques, no study
of 10 patients studied. has measured their physiologic impact
Conclusion: Jaw-thrust and CPAP are effective techniques to improve on spontaneous respiration. We as-
ventilation of sedated infants undergoing interventions that compromise sessed the physiologic effect of jaw-
upper airway patency. (J Pediatr 2001;138:826-30) thrust and CPAP on tidal breathing
parameters in deeply sedated infants
undergoing fiberoptic endoscopy of
the upper and lower airways.
The pharynx is composed entirely of passive posterior displacement of the
soft tissues and is kept patent during tongue cause soft tissue obstruction of
CPAP Continuous positive airway pressure
inspiration by the dilating actions of the upper airway. Maintenance of a
PTEF Peak tidal expiratory flow
local pharyngeal muscles. In the un- patent airway is of critical importance PTIF Peak tidal inspiratory flow
conscious or deeply sedated infant, during sedation or anesthesia of spon- tI/tTOT Inspiratory time over total breathing
cycle time
loss of pharyngeal muscle tone and taneously breathing infants. The jaw-
VT Tidal volume
V’E Minute ventilation

From the Division of Pediatric Intensive Care and Pulmonology and the Division of Pediatric Anesthesia, University
Children’s Hospital Basel, Basel, Switzerland.
Supported by a grant from the Swiss Society of Pulmonology METHODS
Submitted for publication Aug 16, 2000; revision received Jan 2, 2001; accepted Jan 18, 2001.
Reprint requests: Jürg Hammer, MD, Division of Pediatric Intensive Care and Pulmonology,
University Children’s Hospital Basel, Postfach, 4005 Basel, Switzerland. We studied 13 infants <2 years of age
Copyright © 2014 by Mosby, Inc. ([mean ± SEM] = 8 ± 2 months;
0022-3476/2001/$35.00 + 0 9/21/114478 weight, 7.2 ± 0.9 kg) undergoing elec-
doi:10.1067/mpd.2014.114478 tive fiberoptic bronchoscopy. The clin-

826
HAMMER ET AL
ical indications for fiberoptic bron-
choscopy 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 con-
sent was obtained. Patients received no
solid food or breast milk for 4 hours
and no liquids for 2 hours before the
procedure. The patients were studied
during spontaneous breathing while
deeply sedated with intermittent doses
of propofol (1-2 mg/kg). Topical 0.05%
xylometazoline and 2.5 mg of 1% lido-
caine were administered in the right
nostril before the study. All procedures
were performed in the pulmonary in-
tervention laboratory according to cur-
rent routine institutional practice.
Routine monitoring included 3-lead
continuous electrocardiogram, pulse
oximetry, and noninvasive blood pres-
sure measurements.
Tidal breathing was measured with
an ultrasonic flowmeter (Spiroson, Eco
Medics AG, Dürnten, Switzerland) at-
tached to a specially designed face
mask (model 30-40-001, VBM Medi-
zintechnik GmbH, Sulz am Neckar,
Germany). The flowmeter’s accuracy
was validated previously in ventilated
infants.3 The endoscopy mask was de-
scribed previously and consists of a
regular face mask in which the original
adapter for the fresh gas flow was re-
placed with a disposable silicon mem-
brane to allow the leak-free passage
of a 3.5-mm flexible bronchoscope
(Olympus BF3C20), which was used
for all procedures.4 The flexible bron-
choscope, passed though the right nos-
tril, was used to visualize the pharyn-
geal space and the laryngeal opening
during the different maneuvers and to
provide suction. An anesthesia circle
system was used to administer 100%
oxygen and CPAP of 5 cm H 2O.
Measurements were first performed
with the infants in the supine position
and the head in a neutral, sniffing posi-
tion (baseline). Then, measurements
were repeated while performing the
ftable. Effect of jaw-thrust and CPAP on tidal breathing pattern
Tidal breathing
indices Baseline
RR (min–1) 37 ± 2
V’E (L/min) 0.83 ± 0.19
PTIF (mL/s) 58 ± 14
tI/tTOT 0.39 ± 0.02
PTEF (mL/s) 42 ± 7
Data = means ± SEM of 13 infants for the jaw-thrust data and of 10 infants for the CPAP data.
CPAP, Continuous positive airway pressure; RR, respiratory rate; V’E, minute ventilation; PTIF,
peak tidal inspiratory flow; tI/tTOT, inspiratory time over total breathing cycle time; PTEF, peak
tidal expiratory flow.
*P < .05.
jaw-thrust maneuver.5 The person con-
trolling the airway and performing the
different airway maneuvers was a fully
trained anesthesiologist. Subsequently,
the baseline position was resumed, and
measurements of tidal breathing were
repeated. Finally, a CPAP of 5 cm
H2O was applied without changing the
head or neck position, and measure-
ments were repeated. At least 20 to 30
consecutive, spontaneous tidal breaths
were recorded and analyzed for each
maneuver. The order in which the
measurements were performed was
not randomized, but meticulous atten-
tion was given to a constant head posi-
tion and to demonstrating that tidal
breathing measurements returned to
baseline values after each maneuver.
The total duration of the study was
about 5 to 8 minutes. The short dura-
tion of the study was chosen to ensure
stable conditions in terms of anesthetic
depth because this is known to affect
ventilatory variables in children.6 All
physiologic measurements were per-
formed with the bronchoscope insert-
ed in the upper airway to visualize the
laryngeal opening.
The technique required the presence
of two investigators—one to control
the bronchoscope, provide suction,
and record the readings of the flowme-
ter and the other to maintain the posi-
tion of the baby’s head and to control
the face mask and the application of
jaw-thrust and CPAP. The operator
THE JOURNAL OF PEDIATRICS
JUNE 2014
Jaw-thrust Baseline CPAP 5 cm H2O
38 ± 3 36 ± 2 40 ± 3
1.34 ± 0.26* 0.86 ± 0.21 1.11 ± 0.27
98 ± 17* 58 ± 14 81 ± 17*
0.36 ± 0.01 0.40 ± 0.02 0.38 ± 0.02
62 ± 9* 41 ± 8 58 ± 10*
controlling the airway was unable to
see the display of the flow tracings.
Statistical Analysis
Data are presented as means ± SEM.
For paired data analysis, the Wilcoxon
signed-rank test and the paired 2-tailed
t test were used to determine a signifi-
cant difference between the means of
the tidal breathing indices at baseline
and during jaw-thrust or CPAP. P val-
ues <.05 were considered to indicate
statistical significance. We used the
recommendations of Sly et al7 to define
a significant change in tidal breathing
indices in the individual patient as a
change of more than twice the coeffi-
cient of variation for repeated baseline
measurements.
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. CPAP data
for 3 infants were excluded because of
doubts that leak-free conditions were
reliably achieved. The infants tolerated
the different maneuvers well and did
not demonstrate changes in heart rate,
desaturations, or apnea during the
study period.
Opening the airway by the jaw-thrust
technique resulted in a significant in-
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 THE JOURNAL OF PEDIATRICS
VOLUME 138, NUMBER 6
Fig 1. Individual changes in VT after jaw-thrust in deeply sedated infants. Individual data points rep-
resent the mean of at least 20 consecutive breaths.
Fig 2. Representative flow-time tracing demonstrating effect of jaw-thrust on tidal breathing in a
sedated infant.
crease in tidal volume, minute ventila-
tion, peak tidal inspiratory flow, and
peak tidal expiratory flow compared
with baseline measurements (P < .05).
There was no significant change in in-
spiratory time over total breathing cycle
time or respiratory rate as a result of
jaw-thrust. Individual changes in VT
after jaw-thrust are displayed in Fig 1.
Fig 2 shows a representative flow trac-
ing. The mean ± SEM intra-individual
coefficients of variation for repeated
measures of the baseline measurements
were 14% ± 2% for VT, 14% ± 1% for
PTEF, 14% ± 2% for PTIF, 8% ± 2% for
828
tTOT, and 15% ± 4% for tI/tTOT. In all
our patients the increase in VT, V’E,
PTIF, and PTEF after jaw-thrust was
greater than 2 times the coefficients of
variation of the baseline measurements.
CPAP significantly increased PTIF and
PTEF (P < .05). Individual changes in
VT are displayed in Fig 3. The increase
in VT and V’E did not reach statistical
significance for the whole group (P =
.06). Nevertheless, there was a change
in VT and V’E of more than twice the co-
efficients of variation of baseline mea-
surements in 5 of 10 infants and of PTIF
and PTEF in 6 of the 10 infants studied.
HAMMER ET AL
We had no means to measure objec-
tively the effect of the different maneu-
vers on upper airway dimensions.
Nevertheless, visualization by bron-
choscopy revealed remarkable differ-
ences in upper airway dimensions be-
tween the different maneuvers in all
infants. As shown in Fig 4, jaw-thrust
resulted in an anterior displacement of
the epiglottis and an enlargement of
the whole oropharynx, thereby pre-
venting any inward movement of the
lateral pharyngeal structures that oc-
curred during inspiration in the neu-
tral position. CPAP reduced the inspi-
ratory inward movement of the lateral
pharyngeal structures, but its visual ef-
fect on upper airway dimension was
less impressive than the effect of jaw-
thrust. Improvement of airway visual-
ization as shown in Fig 4 occurred in
every infant, and the improvements
were also clinically evident.
DISCUSSION
The jaw-thrust technique and the ap-
plication 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 for-
mally measured. Previous studies on
airway-clearing maneuvers have usual-
ly assessed the effect of jaw-thrust or
chin lift by measuring the upper airway
cross-sectional area with various imag-
ing techniques.8-10 Guildner11 com-
pared the effect of different airway
opening techniques by spirometry
in unconscious adult patients who
had complete respiratory obstruction.
Most of these patients were adequately
ventilated when the jaw-thrust or the
HAMMER ET AL THE JOURNAL OF PEDIATRICS
JUNE 2014

chin lift method was used. All our pa-

tients had preserved upper airways
during propofol sedation and were able
to maintain spontaneous ventilation.
The range of transmural pressures
encountered during quiet respiration is
more than sufficient to collapse the air-
way of the living infant when airway-
maintaining muscles are inactive. 12 In
unconscious subjects, upper airway
obstruction can occur at various
anatomic levels such as the tongue, the
soft palate, and the epiglottis.13,14 The
most important mechanism, however,
is the posterior displacement of the
hyoid bone in relation to the thyroid
cartilage in the supine position. This
affects the position of the epiglottis,
which is sucked over the entrance to
the trachea and reduces the size of the
airway lumen as its rims reach the pos-
terior pharyngeal wall during inspira-
tion. In our patients, additional upper Fig 3. Individual changes in VT after CPAP of 5 cm H2O in deeply sedated infants. Individual data
airway obstruction was caused by the points represent the mean of at least 20 consecutive breaths.
passage of the bronchoscope through
the nose into the oropharynx.
Using the flexible bronchoscope, we
observed that jaw-thrust caused an an-
terior displacement of the epiglottis
and an enlargement of the whole laryn-
geal inlet (Fig 4). Reed et al8 previous-
ly demonstrated in infant cadavers that
tension applied to the hyoid bone by
the genioglossus and geniohyoid mus-
cles also stabilizes the lateral and pos-
terior pharyngeal wall, thus correcting
any inward bowing of the pharyngeal
muscles and enlarging the cross-
sectional pharyngeal area. Maximal
protrusion of the mandible or tongue Fig 4. Position of epiglottis and laryngeal inlet before (left) and during (right) the jaw-thrust maneu-
ver viewed by fiberoptic endoscopy. Jaw-thrust caused an anterior displacement of the epiglottis and
results in a twofold increase in the opened the laryngeal entry.
upper airway cross-sectional area even
during wakefulness. 10 Chin lifting
alone counteracts the downward fold observed improvement reflects the also be partly explained by the facilita-
of the epiglottis and increases the an- physiologic consequences of an in- tion of mouth breathing.
teroposterior and transverse diameters crease in the pharyngeal airway cross- The benefit of CPAP is well docu-
of the upper airway in sedated infants, sectional area. However, another mented for the treatment of obstruc-
most significantly at the level of the mechanism worth mentioning is that tive sleep apnea.15-18 The physiology of
epiglottis.9 Therefore it is not surpris- applying jaw-thrust always opens the the upper airway during sleep mimics
ing that interventions that displace the mouth. Because the passage of the the behavior of a collapsible tube. Wil-
hyoid bone anteriorly, such as the jaw- bronchoscope through the nose caused son et al19 have demonstrated in infant
thrust maneuver, improve spontaneous partial upper airway obstruction, the cadavers that in the natural resting po-
tidal breathing in sedated infants. The improvement in tidal breathing may sition, the airway was closed at trans-

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 THE JOURNAL OF PEDIATRICS
VOLUME 138, NUMBER 6
mural pressure not exceeding those
normally measured during regular in-
spirations in the living infant. They
demonstrated that CPAP of 2 to 5 cm
H2O is of sufficient magnitude to
maintain airway patency in sleeping in-
fants. By acting as a pneumatic strut,
CPAP increases upper airway size pri-
marily in the lateral direction by dis-
tending the lateral pharyngeal walls,
which are thought to be the most com-
pliant structure in the upper air-
way.20,21 Nasal CPAP of 5 cm H2O
even increases the width of the compli-
ant laryngeal opening in preterm ba-
bies.22 We observed a weak dilating ef-
fect of CPAP at all levels of the upper
airway, but most importantly, it
seemed to reduce the inspiratory col-
lapse of the lateral pharyngeal struc-
tures. Although CPAP improved tidal
breathing parameters in about half of
our study patients, its effect was less
impressive than the effect of the jaw-
thrust maneuver. From our observa-
tions, jaw-thrust resulted in a greater
increase in the airway cross-sectional
area than the application of CPAP
alone. Although we have not examined
the combined effect of the two maneu-
vers, the application of both tech-
niques may be beneficial for patients
with severe upper airway obstruction.
The improvement of tidal breathing
after jaw-thrust suggests that these in-
fants had evidence of airflow obstruc-
tion in the neutral head-neck posture,
as has been demonstrated for awake,
healthy preterm infants.23,24 This posi-
tion, however, is the recommended
head-neck position for infants under-
going pulmonary function testing.25
Distortion of the upper airways may
also affect such measurements in se-
dated infants. The effect of jaw posi-
tion on measurements of pulmonary
mechanics, respiratory pattern, or
forced expiration has never been for-
mally measured. Although the im-
provement of tidal breathing with jaw-
thrust may be smaller in more lightly
sedated infants who have no fiberoptic
endoscope in the upper airways, fur-
830
ther studies on the standardization of
infant pulmonary function testing con-
ditions should address this issue.
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