Bag valve mask ventilation: Indications, equipment & techniques

Bag valve mask ventilation is a skill of sheer importance for medical professionals and healthcare providers. The use of bag valve mask ventilation in emergency settings requires deliberate practice. The most critical part of this procedure is the positioning of the patient. Sometimes the airway is occluded because the tongue falls at the back of the pharynx. The appropriate way to keep the airway open is the use of chin lift, head tilt maneuvers, or jaw thrust method. The sniffing positions help to open the airway as needed. It also helps to have a clear view of the vocal cords as well as the glottis opening and increases the chances of success for the first-pass success of endotracheal intubation. The sniffing position is achieved by equilibrating the angle of the mandible and sternal notch and forwarding flexion of the neck².

Many BVMs are now equipped with a pressure valve or a one-way valve. In order to deliver oxygen to the patient, they require continuous oxygen supply. Acronyms like moans (mask seal, obesity, elderly age, no teeth, stiffness) and bones (beard, obese, no teeth, elderly, snoring/sleep apnea) are formed to identify people who will be hard to ventilate. These patients then require the use of supraglottic airway to increase the chances of successful ventilation¹.

Indications

Conditions that lead to the use of bag valve mask ventilation include:

Hypercapnic respiratory failure (An increased amount of carbon dioxide, and less amount of oxygen in the blood)
Abnormal psychological state with an inability to protect an airway
Apnea (cessation of breathing)
Hypoxic respiratory failure (less amount of oxygen and an almost normal amount of carbon dioxide in the blood)
Patients who undergo anesthesia for elective surgical procedures

Equipment required

The equipment that is required for bag valve mask ventilation includes a bag valve mask, a PEEP valve (i.e., a simple spring-loaded valve against which the patient exhales), an oxygen source along with oxygen tubing, and elementary airway adjuncts (like nasopharyngeal airway and oropharyngeal airway).

Generally, bag valve mask ventilation requires only one provider however, two are better as one holds the mask seal and the second helps to squeeze the bag.

Preparing for bag valve mask ventilation

In order to displace the tongue forward, an oropharyngeal airway is commonly used. This helps to avoid occlusion when the patient is lying supine. The most common contraindication for the use of bag valve mask ventilation is the patient having contraindication. The airway can either be inserted directly or rotated to 90 or 180 degrees in order to successfully place it behind the tongue.

The rescuer should be positioned at the head of the patient. The mask should be placed on the face such that the curved end is below the lower lip and the pointed end masks over the nose to establish a great face seal.

One person BVM technique

If one person is providing the bag valve mask ventilation then the E-C seal is used:

In this technique, the rescuer’s first and the second digit forms a ‘C’ over the mask while the thumb presses the nasal bridge down.
The second digit is placed over the bottom of the mask by the mouth.
The third to the fifth digits form an ‘E’ and apply pressure to the mandible in order to hold the mask tightly.
No gap should be left between the skin and the mask.
If needed, the head-tilt chin-lift maneuver can be used to tilt the head backward, or the jaw-thrust method can be used in order to open the airway.

Two-person BVM technique

Results after thorough research show that bag valve mask ventilation provided by two rescuers is far more effective than the single person technique. If two rescuers are providing BVM ventilation then:

One rescuer squeezes the bag to deliver the recommended tidal volume.
While the second rescuer provides an effective mask seal on the face of the patient by using both hands.
Replacing the double-handed EC clamp with the thenar eminence grip is said to improve the efficiency of ventilation for the rescuer holding the seal.

Bag valve mask with a minimum of 15 liters/min oxygen being supplied and a full reservoir can provide almost 1.5 liters of oxygen per breath. Ventilation should always be provided with caution to avoid the risk of gastric insufflation which can consequently cause vomiting and barotrauma because of overdistension. However, Low volume, low-pressure insufflation can help to prevent gastric distention.

Conclusion

While encountering patients in respiratory distress, bag valve mask ventilation proves to be a very useful technique. This technique is used by EMS, ICU nurses, intensivists, respiratory therapists, etc., There are two approaches to providing BVM ventilation (i.e., one person technique, two-person technique). Bag valve mask ventilation performed by two rescuers are proved to be more efficient. This technique is life-saving and is much easier as compared to intubation.

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