APPENDIX C: BAG-VALVE-MASK TECHNIQUE

Proper technique is essential to perform successful bag-valve-mask (BVM) airway management. Patients should be in the supine position, neck in a neutral position and the occiput slightly elevated (on a folded blanket, sheet, small pillow, etc.) to achieve a “sniffing position,” with the opening of the ears at the same level as the sternal notch. Masks should be of the proper size and should be fitted to the face to obtain a seal. This is best achieved by first placing the tapered portion of the opening of the mask over the bridge of the nose, then covering the patient’s mouth. If using the one-person method, the non-dominant had should use the “C & E” method with the thumb and index finger forming a C to cover the mask, and the middle, ring and small fingers forming an E on the bone of the mandible effectively lifting the jaw into the mask (rather than pressing the mask onto the face).

The other hand should gently squeeze the bag delivering a breath at a rate of one squeeze every 5-6 seconds. There should not be a leak around the mask, and you should be able to observe the rise and fall of the patient’s chest. An ETCO2 monitor may be placed in-line with the bag and mask. PEEP should be used with the BVM and initially set to 5mmHg. Every attempt should be made to maintain a seal to ensure continued PEEP. If the patient is breathing spontaneously, careful observation and delivery of an assisted synchronous breath should be a priority.

Some additional considerations are below:

1. If unable to perform adequate single hand C & E clamp, use two handed technique with a second person to bag.
2. Don’t press mask down onto face when performing C & E clamp, visualize you are lifting face into mask.
3. Be aware fingertips on “E-clamp” should be positioned on the bones of the mandible and not on soft tissue, which could possibly occlude the airway.
4. Use “BOOTS” to predict difficult face-mask seals: Bearded, Obese, Old, Toothless, Snoring. In addition, maxillofacial trauma and edema from burns may prevent effective ventilation by BVM.
5. NPA should be used to assist with face mask ventilations (unless obvious contraindications such as mid-face trauma). OPA are also effective in obtunded patients or those who have received chemical sedation or neuromuscular blockade.
6. For bearded patients, lubrication of mask may assist seal. Tegaderm occlusive dressings over beard may also help if available. (If Tegaderm is used in sedated patient, consider pulling off before medication wears off, to lessen pain).
7. Consider mask straps to make face-mask seal more "hands free", especially if a non-medic is assisting you with BVM.