Bag-Valve-Mask Ventilation

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Bag-valve-mask (BVM) ventilation ^[1] is an essential emergency skill. This basic airway management technique allows for oxygenation and ventilation of patients until a more definitive airway can be established and in cases where endotracheal intubation or other definitive control of the airway is not possible. For the emergency medical technician, basic BVM ventilation is most often the only option for airway management. ^{[2, 3, 4]}

In the pediatric population, BVM may be the best option for prehospital airway support. ^{[5, 6]}  BVM ventilation is also appropriate for elective ventilation in the operating room (OR) when intubation is not required, ^[7]  but it is now often replaced in this setting by the laryngeal mask airway. ^[8]

BVM ventilation requires a good seal and a patent airway. Practice with this important skill increases the clinician’s ability to provide effective ventilation. Adjuncts such as oral and nasal airways can aid with ventilation by relieving physiologic obstruction and by opening up the hypopharynx. Certain factors predict difficult BVM ventilation. These include the presence of facial hair, lack of teeth, a body mass index (BMI) greater than 26, age older than 55 years, and a history of snoring. ^[9]

Masks come in many sizes, including newborn, infant, child, and adult (small, medium, and large). Choosing the appropriate size helps create a good seal and thereby facilitates effective ventilation.

Bags for BVM ventilation also come in different types. Newer bags are equipped with a pressure valve. Some bags have one-way expiratory valves to prevent the entry of room air; these allow for delivery of more than 90% oxygen to ventilated and spontaneously breathing patients. Bags lacking this feature deliver a high concentration of oxygen during positive-pressure ventilation (PPV) but deliver only 30% oxygen during spontaneous breaths. ^[8]

Indications for BVM ventilation include respiratory failure (failure of ventilation, oxygenation, or both) and failed intubation.

BVM ventilation is absolutely contraindicated in the presence of complete upper-airway obstruction. It is relatively contraindicated after paralysis and induction (because of the increased risk of aspiration).

Bucher JT, Cooper JS. Bag Mask Ventilation (Bag Valve Mask, BVM). Treasure Island, FL: StatPearls; 2018. [Full Text].

Levitan RM. The Airway Cam Guide to Intubation and Practical Emergency Airway Management. Wayne, PA: Airway Cam Technologies; 2004. 49-54.

Steuerwald MT, Robinson BR, Hanseman DJ, Makley A, Pritts TA. Prehospital airway technique does not influence incidence of ventilator-associated pneumonia in trauma patients. J Trauma Acute Care Surg. 2016 Feb. 80 (2):283-8. [Medline].

Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, et al. Airway management by physician-staffed Helicopter Emergency Medical Services – a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med. 2015 Aug 7. 23:57. [Medline].

Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000 Feb 9. 283 (6):783-90. [Medline].

Hansen ML, Lin A, Eriksson C, Daya M, McNally B, Fu R, et al. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation. 2017 Nov. 120:51-56. [Medline].

Hagberg CA, Artime CA. Airway management in the adult. Miller RD, Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, eds. Miller’s Anesthesia. 8th ed. Philadelphia: Elsevier Saunders; 2015. Vol 1: 1647-83.

Carleton SC, Reardon RF, Brown CA III. Bag-mask ventilation. Brown CA III, Sakles JC, Mick NW, eds. The Walls Manual of Emergency Airway Management. 5th ed. Philadelphia: Wolters Kluwer; 2018. Chap 9.

Reardon RF, Mason PE, Clinton JE. Basic airway management and decision making. Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia: Elsevier Saunders; 2014. 39-61.

[Guideline] Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3. 132 (18 Suppl 2):S414-35. [Medline]. [Full Text].

Joffe AM, Hetzel S, Liew EC. A two-handed jaw-thrust technique is superior to the one-handed “EC-clamp” technique for mask ventilation in the apneic unconscious person. Anesthesiology. 2010 Oct. 113 (4):873-9. [Medline].

[Guideline] Kleinman ME, Goldberger ZD, Rea T, Swor RA, Bobrow BJ, Brennan EE, et al. 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2018 Jan 2. 137 (1):e7-e13. [Medline]. [Full Text].

Kovacs G, Law JA. Oxygen delivery devices and bag-mask ventilation. Kovacs G, Law JA, eds. Airway Management in Emergencies. 2nd ed. Shelton, CT: People’s Medical Publishing House USA; 2011. 35-62.

Nichole Bosson, MD Base Hospital Medical Director, Harbor-UCLA Medical Center; Medical Director, Paramedic Training Institute, LA County EMS Agency

Nichole Bosson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Peter E Gordon, MD, FACEP Clinical Assistant Professor of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Service, Bellevue Hospital Center

Peter E Gordon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Michael R Filbin, MD, FACEP Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital

Michael R Filbin, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Bag-Valve-Mask Ventilation

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