Basic Airway Management: Bag-Mask Ventilation Pat Melanson, MD

BVM Ventilation The most important airway skill Always the first response to inadequate oxygenation and ventilation The first “bail-out” maneuver to a failed intubation attempt Attenuates the urgency to intubate

Golden Rules of Bagging “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “ The art of bagging should be mastered before the art of intubation Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

BVM Ventilation Requires practice to master One hand to –maintain face seal –position head –maintain patency Other hand ventilates

BVM Ventilation: Technique insert oropharyngeal/nasopharyngeal “Sniffing”position if C-spine OK Thumb + index to maintain face seal –Stem of mask in thenar webspace Middle finger under mandibular symphysis Ring/little finger under angle of mandible Maintain jaw thrust/mouth open

BVM Ventilation: Assessment of Efficacy Observe the chest rise and fall Good bilateral air entry Lack of air entering the stomach Feeling the bag Pulse oximetry

BVM Ventilation: Mask Seal Tips and Pearls Easier to get seals with masks too large than too small Inflate mask collar correctly Apply lubricant to beards to “mat down” hair It is easier to bag with dentures in place If edentulous insert gauze sponges into cheeks

Predictors of a Difficult Airway : Bag-Valve-Mask Ventilation Upper airway obstruction Lack of dentures Beard Midfacial smash facial burns, dressings, scarring poor lung mechanics( resistance or compliance )

Difficult Airway : BVM degree of difficulty from zero to infinite zero = no external effort or internal device required one person jaw thrust/ face seal oropharyngeal or nasopharyngeal AW two person jaw thrust / face seal –both internal airway devices infinite = no patency despite maximal external effort and full use of OP/NP

Algorithm for Difficulty “Bagging” Remove FB - Magill forceps Triple maneuver if c-spine clear – Head tilt, jaw lift, mouth opening Nasal or oropharyngeal airways two-person, four-hand technique Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

Difficult Ventilation: Obese Patients excess soft tissue causes obstruction Use both OP and NP airways Two hands for mask seal and jaw thrust Avoid pushing in on soft tissue under jaw –may force into airway, worsen obstruction Place patient in reverse Trendelenburg –decreases abdo pressure on diaphragm –lowers amount of pressure needed to bag

Difficult Ventilation : Edentulous Patients Cheeks fall inward; difficult seal Inflate mask cuff to maximum Allow weight of bag to fall down over side of leak Place gauze at site of leak or inside mouth to “puff out” cheek Two-handed technique using 3rd and 4th fingers to “bunch up” cheek

Difficult Ventilation : Beards and Mustaches Water soluable lubricant applied to facial hair may improve the mask seal

Difficult Ventilation : Upper Airway Obstruction (Epiglottitis) The pop-off valve is designed to prevent delivering excessive volume and pressure Higher pressures may be required in upper airway obstruction Occlude valve manually or with the built in occluding device

“Can’t Ventilate,Can’t Intubate ” Laryngeal Mask Airway Combitube Cricothyroidotomy Needle Cricothyroidotomy and Transtracheal Jet Ventilation

Difficult Airway Maxims The first response to failure of bag-mask ventilation is always better bag-mask ventilation –optimize airway position –place OP and NP airways –two-handed technique –try lifting head off pillow to open airway Generate as much positive pressure as possible without inflating the stomach