Continuing Education Activity

Bag-valve-mask (BVM) ventilation is a manual resuscitation technique used to provide positive pressure ventilation to patients with inadequate or absent spontaneous breathing. The procedure involves the use of a self-inflating bag attached to a 1-way valve and a face mask, which delivers ambient air or supplemental oxygen when compressed. BVM ventilation serves as a critical intervention in both prehospital and in-hospital settings for patients experiencing respiratory failure or cardiac arrest or undergoing induction of anesthesia.

Indications include apnea, severe hypoventilation, and ineffective respiratory effort, while relative contraindications include complete upper airway obstruction and facial trauma that precludes adequate mask seal. Proper technique requires maintaining a patent airway, ensuring an effective mask seal, and delivering visible chest rise with each ventilation. Inadequate ventilation may be indicated by gastric insufflation, lack of chest rise, or declining oxygen saturation, necessitating reassessment of positioning and technique.

This activity for healthcare professionals is designed to enhance learners' proficiency in performing BVM ventilation and identifying individuals who require this lifesaving procedure. Participants will deepen their understanding of the indications and contraindications of this intervention. Proper techniques and methods for ensuring adequate ventilation will be emphasized. Improved skills will enable clinicians to collaborate successfully within an interprofessional team caring for individuals experiencing respiratory distress.

Objectives:

• Identify the indications for bag-valve-mask ventilation in patients experiencing respiratory distress.
• Apply the proper technique when performing bag-valve-mask ventilation.
• Assess for adequacy of ventilation when using the bag-valve-mask technique to manage impaired or absent spontaneous breathing.
• Apply effective strategies to improve care coordination among interprofessional team members to facilitate positive outcomes for patients undergoing bag-valve-mask ventilation.

Introduction

Bag-valve-mask (BVM) ventilation is a critical skill for emergency providers. Mastery requires practice, as this intervention is frequently used in emergent settings. Proper patient positioning is essential for effective ventilation. The tongue may fall to the back of the pharynx, occluding the airway.

The head tilt-chin lift or jaw thrust maneuver is crucial for maintaining airway patency (see Image. Head Tilt-Chin Lift Maneuver). The "sniffing" position, achieved by flexing the neck forward and aligning the sternal notch with the angle of the mandible, aids in airway opening. An oropharyngeal (OPA) or nasopharyngeal (NPA) airway can also be used to maintain an open airway. In addition to assisting with airway patency, the sniffing position can improve glottic visualization and increase 1st-pass success during endotracheal intubation. BVMs often feature a 1-way valve or pressure valve and require a high-flow oxygen supply to deliver oxygen to the patient effectively.[1][2][3][4]

Anatomy and Physiology

A review of oropharyngeal anatomy is essential for understanding the implications of BVM ventilation. Anatomical variations may present challenges with ventilation. Predicting which patients may be difficult to ventilate is crucial. Several acronyms, such as MOANS ("mask seal, obesity, advanced age, no teeth, stiffness") and BONES ("beard, obese, no teeth, elderly, sleep apnea or snoring"), help identify these patients. Individuals with these characteristics may require an OPA, NPA, or supraglottic airway device to improve ventilation success.

Studies have identified factors such as having a beard, obesity, tooth loss, snoring, older age, and limited jaw protrusion as common predictors of difficulty with ventilation. Keeping dentures in place, when applicable, helps improve the mask seal. Facial hair, such as a beard, can hinder ventilation. Using a water-soluble lubricant or performing rapid electric shaving can help achieve a proper seal.

Indications

Indications for performing BVM ventilation include the following:

• Hypercapnic respiratory failure
• Hypoxic respiratory failure
• Apnea
• Altered mental status with the inability to protect the airway
• Anesthesia for elective surgical procedures
• Cardiac arrest

These conditions involve respiratory insufficiency or compromise, requiring immediate intervention to maintain oxygenation and ventilation. BVM ventilation serves as a crucial life-saving technique, ensuring adequate airway management and oxygen delivery in these critical situations.

Contraindications

Total upper airway obstruction, as well as conditions that increase the risk of aspiration, such as paralysis and induction, are contraindications for BVM ventilation. These factors prevent effective airway access and ventilation. In such cases, alternative airway management strategies, such as advanced airway devices, are required to ensure adequate oxygenation and prevent complications like aspiration.

Equipment

The required equipment includes a BVM, oxygen source, oxygen tubing, a positive end-expiratory pressure (PEEP) valve, and simple airway adjuncts such as an OPA and NPA (see Images. Bag Valve Mask and Airway Adjuncts). These items are necessary to ensure effective ventilation, maintain airway patency, and provide adequate oxygenation, especially in patients with compromised respiratory function.

Personnel

BVM ventilation typically requires 1 provider. However, a 2nd provider may assist by squeezing the bag while the primary provider maintains the mask seal. This 2-person approach is often preferred as it improves the mask seal, reducing leaks, and helps prevent provider fatigue, as holding the mask in position can be cumbersome and lead to rapid hand fatigue.

Preparation

An OPA may be inserted to displace the tongue forward, thereby preventing airway occlusion when the patient is in a supine position. The only true contraindication is the presence of a gag reflex. The airway may be inserted directly or rotated 90° or 180° to facilitate placement behind the tongue. Care should be taken when rotating the device to prevent damage to the palate.

An NPA is useful when ventilation via BVM is hindered by a large tongue or other obstruction, allowing air to reach the posterior pharynx. The use of this device is contraindicated in cases of facial trauma with potential for facial fractures, as insertion may compromise the intracranial space. The airway should be inserted with the bevel facing the septum, lubricated appropriately, and rotated as needed to extend into the posterior pharynx. These basic airway adjuncts help maintain a patent airway, enabling effective ventilation.

The rescuer should position themselves at the patient's head and ensure a tight mask seal, with the pointed end over the nose and the curved end below the lower lip. In the 1-person technique, the "E-C seal" is used: the 1st and 2nd digits form a "C" over the mask, the thumb presses the nasal bridge, the 2nd digit applies pressure to the mask's bottom, and the 3rd through 5th digits form an "E" to apply pressure to the mandible. No gaps should remain between the mask and skin. The head may be tilted backward using the "head tilt-chin lift" or the jaw displaced forward with a "jaw-thrust" maneuver, if necessary, to open the airway and facilitate ventilation.

In a 2-person technique, 1 provider squeezes the bag while the rescuer applies the E-C technique with both hands. This method has been demonstrated to deliver higher tidal volumes in simulations and achieve a more effective mask seal. Care must be taken to avoid compressing the soft tissue of the neck with the rescuer's fingers, ensuring that adequate force is applied to achieve an effective seal.[5]

Proper patient positioning can enhance the effectiveness of ventilation. The sniffing position, with the ear aligned to the sternal notch in the same plane, optimizes airflow. Using a mask that is slightly larger than expected may improve the seal, but a smaller mask may increase the likelihood of a leak.

Mastering BVM ventilation is challenging. A retrospective review of the Resuscitation Outcomes Consortium found that less than half of cardiac arrest patients ventilated during cardiopulmonary resuscitation pauses had detectable waveforms, indicating inadequate ventilation. Thorough preparation is essential to ensure sufficient ventilation.[6][7][8][9]

Apneic oxygenation, involving the use of a nasal cannula placed under the BVM at a flow rate of at least 15 LPM, can improve preoxygenation before intubation, reducing the risk of hypoxia.[10][11]

Technique or Treatment

An adult BVM with oxygen supplied at a minimum of 15 liters per minute and a full reservoir can provide up to 1.5 L of O2 per breath. Ventilation should be provided with caution and only until chest rise is observed to reduce the risk of gastric insufflation, which may cause vomiting and barotrauma from overdistention.

The appropriate ventilation rate for an adult is 10 to 12 breaths per minute, or 1 breath every 5 to 6 seconds. In an emergent situation, such as respiratory distress or cardiac arrest, deliberate concentration is required to maintain this rate. The tendency to hyperventilate must be avoided. Similarly, the tidal volume required for an adult is 500 to 600 mL, although the bag can deliver up to 1,600 mL if fully squeezed. The bag should only be squeezed until some chest rise is observed, approximately 1/3 full. The bag should be squeezed slowly, as rapid squeezing increases peak inspiratory pressure, which can contribute to pulmonary barotrauma.

Adequate ventilation is confirmed by observing visible chest rise and fall, auscultating for bilateral breath sounds, and monitoring oxygen saturation. Capnography, when available, provides real-time feedback on the efficacy of ventilation. Poor compliance, absent breath sounds, or a lack of waveform on capnography may signal ineffective ventilation or the need for reassessment.

Complications

Complications include barotrauma from excessive lung inflation and gastric insufflation, which may result in vomiting and aspiration. Hyperventilation reduces exhalation time and can cause pulmonary barotrauma, including pneumothorax and possible arterial gas embolism. Since the BVM delivers positive pressure ventilation, hyperventilation also maintains elevated intrathoracic pressure, which decreases central venous return to the heart, reduces right ventricular preload, and hinders effective cardiac resuscitation efforts.

Clinical Significance

The routine use of cricoid pressure during BVM ventilation and endotracheal intubation was once standard practice but has never consistently shown improvements in patient-oriented outcomes. Originally, cricoid pressure was intended to occlude the esophagus and prevent gastric regurgitation, thereby reducing the risk of aspiration. However, some studies have indicated that cricoid pressure may displace the esophagus rather than occlude it. Additionally, research has shown that the esophagus may remain incompletely occluded, depending on the force applied. Further studies have found that cricoid pressure can inhibit the laryngeal view during intubation, complicating the procedure.[12][13][14]

BVM ventilation may be enhanced with the use of a PEEP valve, which may be titrated from 5 to 15 cm H2O to improve oxygenation in patients who cannot be adequately preoxygenated with standard methods. However, PEEP should not exceed 20 cm H2O, as this pressure may open the lower esophageal sphincter, resulting in gastric insufflation and vomiting. Trials have demonstrated that this approach reduces the incidence of preintubation hypoxia.[15] Additionally, low-pressure, low-volume insufflation techniques can help prevent gastric distention during ventilation, further reducing the risk of complications.

Some BVMs are equipped with an attachment site for a pathogen filter, although these filters are not completely foolproof. Personal protective equipment remains necessary for every patient contact, even when using these filters.

Additionally, the BVM adapter can accommodate an end-tidal monitor or nebulizer reservoir, expanding the device's functionality. However, the utility of these devices is compromised if the mask seal is inadequate, as end-tidal readings will be inaccurate, and nebulized medications may leak.

Outcomes for patients in cardiac arrest have shown mixed results across different studies, with some suggesting similar outcomes between BVM and endotracheal intubation, while others highlight the importance of mastering BVM alone. These findings underscore the importance of proficiency in the BVM technique.[16]

Enhancing Healthcare Team Outcomes

BVM ventilation is a crucial technique for managing respiratory distress, commonly employed by emergency medical services personnel, anesthesiologists, intensive care nurses, respiratory therapists, and intensivists. This lifesaving procedure is often easier than intubation and, when performed correctly, provides effective oxygenation until an anesthesiologist can secure the airway. An interprofessional approach ensures optimal patient care.

Nursing, Allied Health, and Interprofessional Team Interventions

A team approach allows for the 2-person application of BVM ventilation, with additional team members preparing for more definitive airway management, such as rapid sequence intubation. Other tasks include monitoring pulse oximetry and electrocardiogram telemetry, establishing intravenous access, obtaining blood samples for gas analysis, administering medications, setting up and using suction, maintaining records, and coordinating additional resources.

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

Strzelecki C, Shelton CL, Cunningham J, Dean C, Naz-Thomas S, Stocking K, Dobson A. A randomised controlled trial of bag-valve-mask teaching techniques. Clin Teach. 2020 Feb;17(1):41-46. [PubMed: 30811881]

2.

Carlson JN, Wang HE. Updates in emergency airway management. Curr Opin Crit Care. 2018 Dec;24(6):525-530. [PubMed: 30239412]

3.

Kroll M, Das J, Siegler J. Can Altering Grip Technique and Bag Size Optimize Volume Delivered with Bag-Valve-Mask by Emergency Medical Service Providers? Prehosp Emerg Care. 2019 Mar-Apr;23(2):210-214. [PubMed: 30130437]

4.

Sall FS, De Luca A, Pazart L, Pugin A, Capellier G, Khoury A. To intubate or not: ventilation is the question. A manikin-based observational study. BMJ Open Respir Res. 2018;5(1):e000261. [PMC free article: PMC6089311] [PubMed: 30116535]

5.

Uhm D, Kim A. Tidal volume according to the 4-point sealing forces of a bag-valve-mask: an adult respiratory arrest simulator-based prospective, descriptive study. BMC Emerg Med. 2021 May 01;21(1):57. [PMC free article: PMC8088565] [PubMed: 33932998]

6.

Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023 Dec 05;148(23):1847-1856. [PMC free article: PMC10840971] [PubMed: 37952192]

7.

Cierniak M, Maksymowicz M, Borkowska N, Gaszyński T. Comparison of ventilation effectiveness of the bag valve mask and the LMA Air-Q SP in nurses during simulated CPR. Pol Merkur Lekarski. 2018 May 25;44(263):223-226. [PubMed: 29813039]

8.

Delorenzo A, St Clair T, Andrew E, Bernard S, Smith K. Prehospital Rapid Sequence Intubation by Intensive Care Flight Paramedics. Prehosp Emerg Care. 2018 Sep-Oct;22(5):595-601. [PubMed: 29405803]

9.

Becker HJ, Langhan ML. Can Providers Use Clinical Skills to Assess the Adequacy of Ventilation in Children During Bag-Valve Mask Ventilation? Pediatr Emerg Care. 2020 Dec;36(12):e695-e699. [PubMed: 29084068]

10.

Uzun DD, Hezel F, Mohr S, Weigand MA, Schmitt FCF. Apnoeic oxygenation in pediatric anesthesia: better safe than sorry! BMC Anesthesiol. 2025 Mar 08;25(1):116. [PMC free article: PMC11889762] [PubMed: 40055595]

11.

Tang H, Yang Y, Li H. High-flow nasal cannula for pre- and apneic oxygenation during rapid sequence induction intubation in emergency surgery: A systematic review and meta-analysis. PLoS One. 2025;20(1):e0316918. [PMC free article: PMC11760591] [PubMed: 39854507]

12.

Costello JT, Allen PB, Levesque R. A Comparison of Ventilation Rates Between a Standard Bag-Valve-Mask and a New Design in a Prehospital Setting During Training Simulations. J Spec Oper Med. 2017 Fall;17(3):59-63. [PubMed: 28910470]

13.

Lacerda RS, de Lima FCA, Bastos LP, Fardin Vinco A, Schneider FBA, Luduvico Coelho Y, Fernandes HGC, Bacalhau JMR, Bermudes IMS, da Silva CF, da Silva LP, Pezato R. Benefits of Manometer in Non-Invasive Ventilatory Support. Prehosp Disaster Med. 2017 Dec;32(6):615-620. [PubMed: 28743318]

14.

Pearson DA, Darrell Nelson R, Monk L, Tyson C, Jollis JG, Granger CB, Corbett C, Garvey L, Runyon MS. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation. 2016 Aug;105:165-72. [PubMed: 27131844]

15.

Dai Y, Dai J, Walline JH, Fu Y, Zhu H, Xu J, Yu X. Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A prospective, randomized, double-blind trial. Trials. 2021 Jul 17;22(1):460. [PMC free article: PMC8285778] [PubMed: 34274023]

16.

Yuksen C, Phattharapornjaroen P, Kreethep W, Suwanmano C, Jenpanitpong C, Nonnongku R, Sittichanbuncha Y, Sawanyawisuth K. Bag-Valve Mask versus Endotracheal Intubation in Out-of-Hospital Cardiac Arrest on Return of Spontaneous Circulation: A National Database Study. Open Access Emerg Med. 2020;12:43-46. [PMC free article: PMC7075431] [PubMed: 32210644]

Disclosure: Joshua Bucher declares no relevant financial relationships with ineligible companies.

Disclosure: Rishik Vashisht declares no relevant financial relationships with ineligible companies.

Disclosure: Jeffrey Cooper declares no relevant financial relationships with ineligible companies.