Bag valve mask ventilation: Indications, equipment & techniques

Bag valve mask ventilation: Indications, equipment & techniques

Ahmed Raza

Reviewed by , providing nurse training at Yale New Haven Health-Bridgeport Hospital since 2022. Previously in healthcare and education at Griffin Hospital, St. Vincent's College of Nursing and Sacred Heart University Medical Center.

Bag valve mask (BVM) ventilation is critical for medical professionals, especially in emergencies. Effective use of BVM ventilation requires deliberate practice and proper patient positioning. One of the most crucial aspects of this procedure is ensuring an open airway, as airway occlusion can occur due to the tongue falling back against the pharynx. Techniques such as the chin lift, head tilt, or jaw thrust maneuver can help maintain airway patency. The sniffing position, which aligns the external auditory meatus with the sternal notch through slight neck flexion and head extension, can optimize airway management and facilitate successful ventilation.
Many BVMs have features like one-way or pressure valves to regulate ventilation. A continuous oxygen supply is required to deliver oxygen effectively. Acronyms such as MOANS (Mask seal, Obesity, Aged patients, no teeth, Stiff lungs) and BONES (Beard, Obesity, no teeth, Elderly, Snoring/sleep apnea) help identify patients who may be difficult to ventilate. In cases where BVM ventilation is challenging, using supraglottic airway devices may improve success rates.

Indications

Bag valve mask ventilation is indicated in the following conditions:

  • Hypercapnic respiratory failure: Elevated carbon dioxide levels with reduced oxygenation.
  • Impaired airway protection: Due to altered mental status or loss of consciousness.
  • Apnea: Cessation of breathing.
  • Hypoxic respiratory failure: Low oxygen levels with near-normal carbon dioxide levels.
  • Anesthesia induction: Used during elective surgical procedures to support ventilation.

Equipment Required

Essential equipment for BVM ventilation includes:

  • A bag valve mask.
  • An oxygen source with appropriate tubing.
  • Basic airway adjuncts such as a nasopharyngeal airway (NPA) or oropharyngeal airway (OPA).
  • A PEEP (Positive End-Expiratory Pressure) valve, if needed.

While one provider can perform BVM ventilation, a two-person technique is generally more effective, as one rescuer maintains the mask seal while the other squeezes the bag.

Preparing for Bag Valve Mask Ventilation

An oropharyngeal airway (OPA) is often used when the patient is unconscious to prevent airway occlusion due to the tongue falling back. The OPA can be inserted directly or rotated 90 to 180 degrees before positioning it behind the tongue. Nasopharyngeal airways (NPAs) can also be used in semi-conscious patients.
Positioning is critical for effective ventilation. The rescuer should stand at the head of the patient, ensuring the mask forms a tight seal over the nose and mouth. The pointed end of the mask should rest over the nasal bridge, and the curved end should cover the lower lip.

One-Person BVM Technique

If only one rescuer is available, the E-C seal technique is used:

  • The thumb and index finger form a “C” over the mask, pressing it firmly against the patient’s face.
  • The middle, ring, and little fingers form an “E,” applying pressure to the mandible to maintain an open airway.
  • If necessary, the head-tilt chin-lift or jaw-thrust maneuver can be used to further open the airway.

Two-Person BVM Technique

Research suggests that two-person BVM ventilation is more effective than the single-rescuer method. When two providers are available:

  • One rescuer maintains an effective mask seal using both hands.
  • The second rescuer squeezes the bag to deliver the appropriate tidal volume.
  • Replacing the standard E-C clamp with a thenar eminence grip can improve the mask seal and ventilation efficiency.

A BVM with a minimum oxygen flow of 15 liters per minute and a full reservoir bag can deliver nearly 100% oxygen. Care should be taken to avoid excessive ventilation, which can lead to gastric insufflation, vomiting, or barotrauma due to overdistension of the lungs. Low-volume, low-pressure ventilation strategies can help mitigate these risks.

Conclusion

Bag valve mask ventilation is a vital, life-saving technique used by EMS personnel, nurses, intensivists, and respiratory therapists. There are two primary methods: the one-person and two-person techniques, with the latter being more effective. Compared to intubation, BVM ventilation is simpler and faster to perform, making it an essential skill in emergency airway management.

Reviewed by , providing nurse training at Yale New Haven Health-Bridgeport Hospital since 2022. Previously in healthcare and education at Griffin Hospital, St. Vincent's College of Nursing and Sacred Heart University Medical Center.

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This page was last updated on Feb 20, 2025. of this page.