Bag-Mask Ventilation - Curbside
Bag-Mask Ventilation
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Clinical need for assisted ventilation (poor respiratory effort , airway obstruction)
Exclusion Criteria
  • Acute airway obstruction unlikely to be resolved with positive pressure alone
  • Airway/facial anatomy or trauma that prevents air tight seal of mask
  • Trachostomy or other artificial airway device or surgical history
Consider other airway device or consult advanced airway provider

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Total Notes: 7

1 Bag-mask ventilation

One of the most likely procedures to save a patient's life that a provider can learn is bag-mask ventilation. Patients in respiratory distress who are resuscitated prior to progressing to cardiovascular arrest have much higher chances of survival. This need for assisted ventilation usually arises from either poor respiratory effort (opioid overdose, sedation, brain injury, asthma, etc.) or airway obstruction (soft tissue obstruction, secretions, etc.). After identifying the acute need for assisted ventilation immediate use of bag-mask ventilation is usually indicated.

  1. Outcome of out-of-hospital cardiorespiratory arrest in children.
    López-Herce J, García C, Domínguez P, Rodríguez-Núñez A, Carrillo A, Calvo C, Delgado MA, Spanish Study Group of Cardiopulmonary Arrest in Children
    Pediatr Emerg Care. 2005;21(12):807.
  2. Outcome of out-of-hospital cardiac or respiratory arrest in children.
    Schindler MB, Bohn D, Cox PN, McCrindle BW, Jarvis A, Edmonds J, Barker G
    N Engl J Med. 1996;335(20):1473.
  3. Characteristics and outcome among children suffering from out of hospital cardiac arrest in Sweden.
    Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S
    Resuscitation. 2005;64(1):37.
  4. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest.
    Young KD, Gausche-Hill M, McClung CD, Lewis RJ
    Pediatrics. 2004;114(1):157.
  5. Learning curves for bag-and-mask ventilation and orotracheal intubation: an application of the cumulative sum method.
    Komatsu R, Kasuya Y, Yogo H, Sessler DI, Mascha E, Yang D, Ozaki M
    Anesthesiology. 2010;112(6):1525.

2 C-spine injury

In any patient with suspected c-spine injury, immediate immobilization of their spine is indicated. Bag-mask ventilation can still be performed with a c-collar in place as can a jaw-thrust. However, movement of the head into optimal positioning (head tilt, chin lift) is not possible and may make ventilation more difficult. Patients expected to require bag-mask ventilation for an extend period of time should undergo endotracheal intubation.

  1. Spine and spinal cord trauma.
    Manual of Advanced Trauma Life Support, 7th ed
    American College of Surgeons, Chicago 2004.p.177.
  2. The Textbook of Pediatric Emergency Procedures, 2nd
    King C, Rappaport LD.
    Lippincott Williams & Wilkins, Philadelphia 2008.p.159.
  3. The effect of airway maneuvers on the unstable C1-C2 segment. A cadaver study.
    Donaldson WF 3rd, Heil BV, Donaldson VP, Silvaggio VJ
    Spine (Phila Pa 1976). 1997;22(11):1215.
  4. Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers.
    Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F
    Anesth Analg. 2000;91(5):1274.
  5. Etiology and clinical course of missed spine fractures.
    Reid DC, Henderson R, Saboe L, Miller JD
    J Trauma. 1987;27(9):980.

3 Airway positioning

Optimizing airway positioning assists the effectiveness of both the patient's own ability to breath and with bag-mask ventilation. Adults may benefit from support behind their occiput to bring their airway into a strait line position. Infants have large occiputs and anterior airways and benefit from support behind their shoulders allowing their occiput to fall back and their chin to be tilted up (hyperextension should be avoided however). Young children fall in-between these two anatomical situations and are best ventilated flat with their airways midline. In patients where c-spine injury is NOT a concern, a head tilt - chin lift maneuver can help lift the tongue from the posterior pharynx and improve ventilation. A jaw thrust can be used even in c-spine patients and also improves airway patency.

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    Ann Emerg Med. 1993;22(2 Pt 2):440.
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    Pediatr Clin North Am. 1994;41(6):1147.
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    Ruben M, Elam J, Ruben A, Greene, D
    Anesthesiology. 1961;22:271.
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    Guildner CW
    JACEP. 1976;5(8):588.
  5. Effectiveness of the jaw-thrust maneuver in opening the airway: a flexible fiberoptic endoscopic study.
    Uzun L, Ugur MB, Altunkaya H, Ozer Y, Ozkocak I, Demirel CB
    ORL J Otorhinolaryngol Relat Spec. 2005;67(1):39.

4 Airway devices

Oropharyngeal (OPA) and nasopharyngeal (NPA) airway devices may be helpful during bag mask ventilation to remove or bypass obstruction of the airway by the soft tissues of the pharynx. OPAs should only be used in unconscious or deeply sedated patients as they may cause an awake patient to gag and vomit. They need to be properly sized to the angle of the jaw and when inserted care should be made not to push the tongue deeper into the pharynx. NPAs (nasal trumpets) can be used in awake patients and patients who have clenched their jaw. They also need to be sized to the mandible and require lubrication. Patients with severe mid-face or basilar skull fractures should likely not have a NPA.

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    King BR, King C, Coates WC.
    Jones and Bartlett, Sudbury 2004.p.692.
  2. The nasopharyngeal airway: dispelling myths and establishing the facts.
    Roberts K, Whalley H, Bleetman A
    Emerg Med J. 2005;22(6):394.

5 Bag type

There are two common bag types available to most providers: flow-inflating or self-inflating bags. Flow-inflating bags required a continuous air pressure source to fill and are generally more difficult to use and less preferred for resuscitation. Self-inflating bags conversely are easier to use and have been found to deliver less oxygen at higher ventilation rates. They also do not require an oxygen source and thus are more mobile. Until a provider is adequately experienced with a flow-inflating bag, a self-inflating bag should be used in most cases.

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    Circulation. 2010;122(18 Suppl 3):S862.
  2. Evaluation of mask-bag ventilation in resuscitation of infants.
    Kanter RK
    Am J Dis Child. 1987;141(7):761.
  3. Comparison of self-inflating bags with anesthesia bags for bag-mask ventilation in the pediatric emergency department.
    Mondolfi AA, Grenier BM, Thompson JE, Bachur RG
    Pediatr Emerg Care. 1997;13(5):312.
  4. Venting vs ventilating. A danger of manual resuscitation bags.
    Hirschman AM, Kravath RE
    Chest. 1982;82(3):369.

6 Mask techniques

Bag-mask ventilation can be performed by one or more providers. The American Heart Association teaches the "E-C clamp technique" if only one provider is present. In this technique the provider places the mask with the narrow part resting on the bridge of the nose. Then with one hand, the provider grips the mask with the webbing between their thumb and first finger resting on top of the mask. The other three fingers are placed along the mandible allowing for a chin lift (in patients with no risk for c-spine injury) and jaw thrust. The mask should fit tightly to the face with no air leak.

If two airway providers are available then the two handed technique can be used. This method has been shown to provide better airway seal, decreased provider fatigue and increase total effectiveness of ventilation (greater minute ventilation and tidal volumes). This technique is similar to the one-handed method, but allows one provider to place both hands on the mask and grips on the mandible while the other provider can focus on delivering the breaths via the bag.

In both techniques the provider holding the mandible should take care to avoid compressing the soft tissue of the neck as this may lead to worsening airway obstruction.

  1. Efficacy of facemask ventilation techniques in novice providers.
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    J Clin Anesth. 2013 May;25(3):193-7.
  2. A two-handed jaw-thrust technique is superior to the one-handed "EC-clamp" technique for mask ventilation in the apneic unconscious person.
    Joffe AM, Hetzel S, Liew EC
    Anesthesiology. 2010;113(4):873.
  3. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
    Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, Berg RA, Sutton RM, Hazinski MF
    Circulation. 2010;122(18 Suppl 3):S862.
  4. Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children.
    Davidovic L, LaCovey D, Pitetti RD
    Ann Emerg Med. 2005;46(1):37.

7 Ventilation

Chest rise is often the best first indicator of adequate ventilation of a patient via bag-mask techniques. The provider can then titrate the volume required by assessing for adequate chest rise with each breath remembering that lower tidal volumes may be sufficient in patients with reduced cardiac output (i.e. CPR) and that larger tidal volumes and ventilation rates increase intrathorasic pressure thereby decreasing coronary/cerebral perfusion pressures.

Ventilation rates are usually adequate at 8 - 10 breaths/min for infants, children and adults with greater than 12 breaths/min rarely needed. Providing these breaths slowly (long inspiration time) allows the full tidal volume to be provided with low pressures and reducing the amount of gastric distention.

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    Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, Berg RA, Sutton RM, Hazinski MF
    Circulation. 2010;122(18 Suppl 3):S862.
  2. Asynchronous and other alternative methods of ventilation during CPR.
    Melker RJ
    Ann Emerg Med. 1984;13(9 Pt 2):758.
  3. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans. Insights into mechanisms.
    Paradis NA, Martin GB, Goetting MG, Rosenberg JM, Rivers EP, Appleton TJ, Nowak RM
    Circulation. 1989;80(2):361.
  4. Hyperventilation-induced hypotension during cardiopulmonary resuscitation.
    Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG
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  5. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.
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    Crit Care Med. 2004;32(9 Suppl):S345.
  6. Reducing ventilation frequency during cardiopulmonary resuscitation in a porcine model of cardiac arrest.
    Yannopoulos D, Tang W, Roussos C, Aufderheide TP, Idris AH, Lurie KG
    Respir Care. 2005;50(5):628.