Basic Airway Management: Bag-Mask Ventilation

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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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 )

9. 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

10. 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

11. 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

12. 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

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

14. 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

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

16. 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