Bag valve mask ventilation

Overview

Oral cavity and oropharynx.

Sagittal section through the head and neck showing the subdivisions of the pharynx.

• Simple, life-saving skill that is critical in airway management
• Deliver oxygen at positive pressure via a bag containing oxygen connected to a mask placed over a patient's nose and mouth
• Oxygenation and ventilation prior to definitive airway placement or bridge to sedative metabolization

Indications

• Respiratory failure
• Pre-oxygenation
• Emergent need to oxygenate/ventilate

Contraindications

No absolute contraindications

Difficult BVM (MOANS)

• Mask seal
• Obesity
• Aged
• No teeth
• Stiffness (resistance to ventilation)

Equipment Needed

• Bag connected to oxygen at 15L/min
• Mask connected to the bag
• Consider PEEP valve (provides PEEP between ventilations)
• OPA/NPA/adjuncts to facilitate successful BVM ventilation
• Suction
• SpO2 monitor helpful

Children

• Proper-sized mask (covers nose and chin)
• Proper bag (enough to see chest rise)

Procedure

EC technique with modified chin lift.

EC technique with modified chin lift.

Two-handed technique.

"EC" Hand Position

• Thumb and index finger holding mask in a "C" position
  • Thumb superior and index inferior
• 3rd, 4th, 5th finger hold the mandible and perform a jaw thrust
• Other hand used to bag

2-person

• This technique provides an objectively better seal than the "EC" hand position
• One person holds the mask with both hands (lateral edges)
  • With double EC technique, index fingers and thumbs of both hands form C over mask and digits 3-5 lift the jaw at the rami of mandible
  • Can also press thumbs and thenar eminences over lateral edges of mask and use digits 2-5 to lift jaw at the rami of the mandible
  • Important to life jaw into mask and not press mask down into jaw; can occlude the airway and cause difficulty with ventilation
• 2nd person bags

Rate

• Adult bag at 10-12/min
• Children 16-20/min
• Infants 30/min
• Neonates 40-60/min

Tidal Volume

• Avoid hyperinflation
  • Average bag volume is approximately 1600 cc; only necessary to delivery approximately 500 cc
• Bag until chest rise is seen

Complications

• Poor seal
  • Remove dentures to intubate; keep them in to bag/mask ventilate
  • For a beard smear lube to help create better seal or cut the center out of a tegaderm and apply to the patient's perioral area
• Poor oxygenation/ventilation
  • Readjust head-tilt-chin-lift or jaw thrust
  • Utilize oropharyngeal airway/nasopharyngeal airway
• Overinflation of the stomach causing emesis/aspiration

See Also

• Intubation
• Oropharyngeal airway

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

External Links

Videos

• Medscape (1:33) https://www.youtube.com/watch?v=zUGw90iL0Qw
• For Covid19
  • WakeMed (1:22) https://www.youtube.com/watch?v=JT4RC1TsTPo