Inhalation Inducation
Bailey Freeman, DNP, CRNA and Angela Mordecai
Quick Facts
- Inhalation induction is commonly used in pediatric patients to avoid needle trauma.
- Sevoflurane is the agent of choice due to non-pungency and rapid onset.
- Always ensure close monitoring and preparation for airway complications.
Procedure
Indications
- Needle phobia
- Difficult IV access
- Uncooperative child behavior
- Parental preference
Contraindications
- Full stomach or aspiration risk
- Severe airway obstruction
- Suspected or known malignant hyperthermia
Equipment and Preparation
- Functional anesthesia machine with pediatric circuit
- Appropriately sized face mask
- Standard ASA monitors: ECG, SpO₂, NIBP, capnography
- Emergency airway and resuscitation equipment
Technique
-
Explain the process to the child using age-appropriate language:
Use calm, reassuring words and avoid medical jargon. For example, say “This mask gives you sleepy air” instead of “We’re going to put you to sleep with anesthesia.” Allow the child to touch or play with the mask if time permits. Use storytelling, singing, or distraction toys to ease anxiety. -
Allow parent presence if feasible:
When appropriate, allow one parent to accompany the child during induction. Position the parent at the child’s head to maintain safety and comfort. Instruct them to remain calm, avoid touching equipment, and provide verbal reassurance during mask induction. -
Preoxygenate with 100% oxygen:
Place the mask gently over the child’s nose and mouth, ensuring a good seal without excessive pressure. Deliver 100% oxygen for 30–60 seconds to increase oxygen reserves in case of apnea. Engage the child during this phase with singing or distraction. -
Begin sevoflurane at a low concentration and gradually increase to desired level:
Start with 0.5% to 1% sevoflurane in oxygen and increase by 0.5–1% every 2–3 breaths, aiming for 6–8%. This helps prevent coughing, laryngospasm, or breath-holding. Watch for loss of eyelash reflex and decrease in spontaneous movement as signs of deepening anesthesia. -
Once unconscious, secure the airway and obtain IV access:
Once the child is unresponsive and tolerates the mask, insert an oral or nasal airway as needed and ensure effective ventilation. Check for chest rise, ETCO₂ waveform, and oxygen saturation. Establish IV access quickly and administer any planned IV medications. Intubate or place an LMA based on the anesthetic plan.
Confirmation Steps
- Observe visible chest rise and confirm ETCO₂ waveform.
- Monitor pulse oximetry and check for clinical signs of unconsciousness.
- Verify secure airway and proper IV access before proceeding.
Documentation Requirements
- Preoperative assessment: fasting status, allergies, airway evaluation
- Consent and indication for inhalation induction
- Agent and concentration used, duration of induction
- Any adverse events or airway interventions
Scope Guide
Strategies
- Engage the child with age-appropriate explanations and familiar terms (e.g., “bubble mask” or “magic air”).
- Allow the child to see, touch, or play with the mask before placing it on their face.
- Offer parental presence if appropriate, positioning them near the child’s head to provide comfort.
- Use distraction techniques—videos, storytelling, or singing—to reduce anxiety and increase cooperation.
Clinical Optimization
- Start sevoflurane at low concentrations and titrate gradually to minimize coughing or laryngospasm.
- Ensure a gentle but effective mask seal using the “EC-clamp” technique with minimal pressure.
- Preoxygenate with 100% oxygen for at least 30 seconds prior to increasing volatile agent concentration.
- Have airway adjuncts, suction, and emergency medications (e.g., atropine, succinylcholine) readily available.
Pearls
- Loss of the eyelash reflex is a reliable sign of adequate depth for IV placement or airway instrumentation.
- Preschool-aged children are at higher risk for emergence delirium—use comfort and a calm environment during emergence.
- Wait for regular spontaneous breathing and complete stillness before attempting IV insertion or airway manipulation.
- Document all induction steps, agents used, and any complications or airway interventions immediately.
References
- Inhalational induction in paediatric anaesthesia – PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC9805937/
- BJA Education. Inhalational induction in paediatric anaesthesia. https://www.bjaed.org/article/S2058-5349(22)00142-1/fulltext
- UMass Pediatric Anesthesia Primer. https://www.umassmed.edu/link/b12124ee286146a8b963807dc827fc8a/
