Basic Airway Management:

Bag-Mask Ventilation
Pat Melanson, MD

BVM Ventilation
The most important airway skill
Always the first response to inadequate
oxygenation and ventilation
The first bail-out maneuver to a failed
intubation attempt
Attenuates the urgency to intubate

Golden Rules of Bagging

Anybody ( almost ) can be oxygenated
and ventilated with a bag and a mask
The art of bagging should be mastered
before the art of intubation
Manual ventilation skill with proper
equipment is a fundamental premise of
advanced airway Rx

BVM Ventilation
Requires practice to master
One hand to
maintain face seal
position head
maintain patency

Other hand ventilates

BVM Ventilation: Technique

insert oropharyngeal/nasopharyngeal
Sniffingposition if C-spine OK
Thumb + index to maintain face seal
Stem of mask in thenar webspace

Middle finger under mandibular symphysis

Ring/little finger under angle of mandible
Maintain jaw thrust/mouth open

BVM Ventilation:
Assessment of Efficacy

Observe the chest rise and fall

Good bilateral air entry
Lack of air entering the stomach
Feeling the bag
Pulse oximetry

BVM Ventilation:
Mask Seal Tips and Pearls
Easier to get seals with masks too large than
too small
Inflate mask collar correctly
Apply lubricant to beards to mat down
hair
It is easier to bag with dentures in place
If edentulous insert gauze sponges into
cheeks

Predictors of a Difficult Airway :

Bag-Valve-Mask Ventilation

Upper airway obstruction

Lack of dentures
Beard
Midfacial smash
facial burns, dressings, scarring
poor lung mechanics( resistance or
compliance )

Difficult Airway : BVM

degree of difficulty from zero to infinite

zero = no external effort or internal device required
one person jaw thrust/ face seal
oropharyngeal or nasopharyngeal AW
two person jaw thrust / face seal
both internal airway devices
infinite = no patency despite maximal external
effort and full use of OP/NP

Algorithm for Difficulty

Bagging
Remove FB - Magill forceps
Triple maneuver if c-spine clear
Head tilt, jaw lift, mouth opening
Nasal or oropharyngeal airways
two-person, four-hand technique
Do not abandon bagging unless it is impossible
with two people and both an OP and NP airway

Difficult Ventilation:
Obese Patients

excess soft tissue causes obstruction

Use both OP and NP airways
Two hands for mask seal and jaw thrust
Avoid pushing in on soft tissue under jaw
may force into airway, worsen obstruction

Place patient in reverse Trendelenburg

decreases abdo pressure on diaphragm
lowers amount of pressure needed to bag

Difficult Ventilation :
Edentulous Patients
Cheeks fall inward; difficult seal
Inflate mask cuff to maximum
Allow weight of bag to fall down over side of
leak
Place gauze at site of leak or inside mouth to
puff out cheek
Two-handed technique using 3rd and 4th
fingers to bunch up cheek

Difficult Ventilation :
Beards and Mustaches
Water soluable lubricant applied to facial
hair may improve the mask seal

Difficult Ventilation : Upper

Airway Obstruction (Epiglottitis)
The pop-off valve is designed to prevent
delivering excessive volume and pressure
Higher pressures may be required in
upper airway obstruction
Occlude valve manually or with the built
in occluding device

Cant Ventilate,Cant Intubate

Laryngeal Mask Airway

Combitube
Cricothyroidotomy
Needle Cricothyroidotomy and
Transtracheal Jet Ventilation

Difficult Airway Maxims

The first response to failure of bag-mask
ventilation is always better bag-mask
ventilation

optimize airway position

place OP and NP airways
two-handed technique
try lifting head off pillow to open airway

Generate as much positive pressure as

possible without inflating the stomach