Bag Valve Mask: When to use Bag Valve Mask Ventilation and How to use it?

What is BVM: Bag valve mask (BVM) is a hand-held device that can provide manual ventilation to a patient who is not breathing or breathing inadequately. It is also known as an Ambu bag or mechanical ventilator. The BVM has a bag the rescuer squeezes to deliver oxygen to the patient. A one-way valve between the bag and the patient allows oxygen to flow into the patient's lungs but prevents exhaled air from entering the bag. The BVM also has a mask that covers the patient's mouth and nose to deliver the oxygen.

When to use a BVM: A BVM should be used when a patient is not breathing or is not breathing adequately. The BVM can provide positive pressure ventilation (PPV) to a patient who is not breathing or breathing inadequately. PPV is a type of mechanical ventilation in which the patient's lungs are inflated with oxygen-enriched air using a hand-held device, such as a BVM.

How to use a BVM: To use manual ventilation like BVM, ,the rescuer squeezes the bag to deliver oxygen-enriched air to the patient. The one-way valve between the bag and the patient allows oxygen to flow into the patient's lungs but prevents exhaled air from entering the bag. The mask covers the patient's mouth and nose to deliver the oxygen.

When a patient has a respiratory failure or difficulty breathing, the Bag Valve Mask or Pulmonary Manual Resuscitator enables rescuers operating within almost any environment or situation to deliver lifesaving oxygen to the patient's lungs.

Key Takeaway

  • Bag Valve Mask is manual ventilation, sometimes called an Ambu bag or Pulmonary Manual Resuscitator.
  • For the emergency medical services team, a manual resuscitator using bag-mask ventilation is the only option for airway management.
  • BVM ventilation is a beneficial technique when encountering patients in respiratory distress.
  • The BVM can provide positive pressure ventilation (PPV) to a patient who doesn't have adequate breathing.
  • Using Bag Valve Mask requires training and practice, even for emergency medical responders.
  • Bag mask ventilation can be done with one person or two, but the two-person BVM ventilation technique is easier and more effective.
  • Excessive ventilation may lead to gastric insufflation and pulmonary aspiration.
  • Cardiopulmonary Resuscitation and Basic life support training will help you learn how to manage the airway and ensure adequate Bag-Mask ventilation.
  • Manual ventilation has to be performed by healthcare workers with professional experience.

What is a BVM Ventilation?

Bag mask ventilation is a manual resuscitator or ventilation technique that allows patients oxygenation until a more definitive airway can be established. It is also used in cases where an oropharyngeal airway, endotracheal tube, or other definitive airway control is impossible.

You can use bag-mask ventilation in the field, ambulance, helicopter, the emergency department, the intensive care unit, and the operating room. This may be the only type of ventilator that can work during disasters because they do not require electricity. However, if you use it incorrectly, manual ventilation using BVM can result in serious death or injury. Excessive ventilation may also lead to gastric insufflation and pulmonary aspiration.

The BVM resuscitator is available in a full range of sizes:

  • Adult (1.5 liters)
  • Adult (1 liter)
  • Pediatric (550ml)
  • Infant (280ml)

What are the essential parts of a Bag-Valve Mask?

BVM is a manual resuscitator that consists of a self-inflating bag, oneway valve, mask, and an oxygen reservoir. There are no parts made from metal, no screws, no washers, springs, or anything else of a complicated nature. The main components are:

  • A self-inflating bag with two valves.
  • An inlet port for fresh gas.
  • An outlet port that ventilates the patient and expires that ventilation.

Who can administer a Bag Valve Mask Ventilation?

BVM is mainly used in prehospital settings to ventilate patients in respiratory failure/respiratory distress and cardiac arrest. Manual ventilation has to be performed by healthcare workers with professional experience who are regularly trained in various medical emergencies like respiratory arrest. It's easier and more effective if two responders are doing the ventilation. The techniques described in this article should be practiced to guarantee successful resuscitation.

Emergency Situations Where Bag Valve Mask Ventilation is Needed

For the emergency medical services team, a manual resuscitator using bag-mask ventilation is the only option for airway management. In addition, it is the best option for prehospital airway support in the pediatric population. BVM ventilation is also appropriate for elective ventilation in the operating room when intubation is not required, but it is now often replaced in this setting by the laryngeal mask airway.

BVM ventilation is indicated in the following conditions:

  • Respiratory failure/respiratory distress
  • Failed intubation or insertion of an artificial ventilation tube into the trachea
  • Patients who are undergoing anesthesia for elective surgical procedures
  • Apnea (slowed or stopped breathing)

How to check if BVM is working?

The BVM can be checked by:

  • Squeeze to make sure it self-inflates
  • Block the patient connection and attempt to squeeze the bag. It should not collapse without a pop-off valve OR collapse only if a pop-off valve is present and opens.
  • Remove the reservoir bag, squeeze the bag and block the intake valve. The bag should not inflate.

How to know if BVM Ventilation is effective?

You can determine the effectiveness of BVM ventilation by watching if the patient's chest will rise and fall and feeling the resistance of the patient's lungs as they expand. If the ventilation is effective, you will also hear and feel the air escape as the patient exhales.

If the patient is a cardiac arrest victim, your breaths do not need to be synchronized to chest compressions. But ensure that you provide the right number of breaths per minute for the patient's age.

For rescue breathing in adults:

  • 10-12 respirations per minute (every 5 to 6 seconds)
  • Achieve chest rise, using up to 500 ml of attached oxygen, regardless of established airway adjunct.
  • Do not hyperventilate

For rescue breathing in pediatrics:

  • 20-30 respirations per minute (every 2 to 3 seconds)
  • Achieve chest rise and fall
  • Do not hyperventilate

For cardiac arrest, follow established ratios of:

  • Adult without an advanced airway: 30 compressions to 2 breaths
  • Pediatric without an advanced airway: 30 compressions to 2 breaths for a single rescuer (15:2 for two rescuers)
  • Adult with an advanced airway: Continuous compressions between 100-120 bpm and one breath every 6 seconds (10 breaths per minute)

Positioning for Bag Valve Mask Ventilation

Place the patient in a proper sniffing posture to ensure an excellent nasal breathing pattern. This position aligns the external auditory canal with the sternum. You may need folded towels to achieve the sniffing position. For obese, you may need a commercial ramp device to elevate their shoulders and neck sufficiently. If there is a concern for cervical spine injury:

  • Position the patient supine.
  • Stand at the head of the stretcher.
  • Avoid moving the neck.
  • To open the upper airway manually, use the jaw-thrust or chin lift without the head tilt maneuver.

Sizing of face mask: Face mask sizing is performed by first checking that the mask covers the bridge of the nose and then correctly seats on the chin, ensuring that the lower lip is inside the mask.

How to maintain a tight seal?

To maintain a tight seal, you must perform a C & E hold: With the mask on the patient's face, place your middle, ring and little fingers on the jawbone (forming E) and pull upwards. Concurrently, position your thumb on the bridge of the nose and your index finger below the mask connection and on the chin to make a seal.

  • The index finger placement helps control the mask's angle and pressure on the patient's face.
  • Since the head tends to move during ventilation and provided treatment like Cardiopulmonary Resuscitation, the index finger facilitates the continuous optimization of the mask seal on a breath-to-breath basis.
  • Don't push the mask against the patient's face, which forces the patient's head into flexion and airway obstruction.
  • Conversely, pull the patient's face into the mask by pulling up on the jaw while pressing the mask down on the bridge of the nose using your thumb. This action extends the head, thus opening the airway while maintaining a better seal.
  • When holding the chin, grasp the jawbone, NOT the soft tissue. The soft tissue will push the tongue up against the hard palate, causing airway obstruction.

How to Use BVM Ventilation?

Manual ventilation using a bag mask can be done with one person or two, but two-person BVM ventilation is easier and more effective. Your goal is to achieve a tight seal, which usually requires two hands on the mask.

Two-person Bag Valve Mask Ventilation technique

If there are two responders, the experienced emergency medical personnel will handle the mask because maintaining a proper mask seal is the most challenging task. Then, the second responder will squeeze the bag. Remember that excessive ventilation may lead to gastric insufflation and pulmonary aspiration.

  • The first responder will stand at the head of the stretcher and the 2nd responder to the side.
  • Using two hands, the first responder will hold the mask between the thumbs and index fingers on either side of the connector stem.
  • The first responder will place the nasal portion of the bag valve mask over the patient's nose high enough to cover the bridge without air leaks. Then lower the mask over the chin and allow it to seal along with the two malar eminences.
  • Achieve a patent airway and a proper seal by covering the bridge of the nose, the two malar eminences, and the lower lip. To help create a tighter seal, you may stretch the internal portion of the BVM before placing it over the nose and mouth.
  • Once the first responder has achieved a tight and proper seal on the patient's face, the second responder attaches the airway device to the mask and begins ventilation.
  • Responder 2 will squeeze the bag smoothly just until the chest starts to rise.
  • Continue the bag-mask ventilation until either a definitive airway or spontaneous adequate ventilation is achieved.

One-person Bag Valve Mask Ventilation technique

  • Place the BVM between your thumb and index finger, wrapped around the stem with one hand.
  • Do not place your hand or the mask on the patient's eyes.
  • Place the nasal portion of the mask over the nose. Then lower the mask over the patient's mouth.
  • Achieve a patent airway and a proper seal by covering the nose bridge, the two malar eminences, and the mandibular alveolar ridged by the mask.
  • After achieving a tight seal, start ventilating using your other hand.
  • Squeeze the bag smoothly just until the chest starts to rise.
  • Continue the bag-mask ventilation until either a definitive airway or spontaneous adequate ventilation is achieved.

How to achieve successful adequate ventilation?

Rapid provision of successful spontaneous ventilation and oxygenation is the goal when using a bag valve mask. Successful Bag Valve Mask ventilation requires technical competence and depends on these four things:

  • An adequate mask seal
  • Proper ventilation technique
  • PEEP valve as needed to improve oxygenation
  • A patent airway

Establishing a patent airway for manual ventilation requires keeping the oropharynx clear of physical obstructions, proper positioning and manual maneuvers to relieve tongue and soft tissue obstruction of the upper airway, and airway adjuncts such as a nasopharyngeal or oropharyngeal airway to facilitate effective air exchange.

BVM Ventilation Aftercare

It's essential to continue bag-valve-mask ventilation until either a definitive artificial airway is achieved or spontaneous ventilation is adequate. If a gag reflex returns while you're doing BVM ventilation with an oropharyngeal airway, remove the oropharyngeal airway and provide continued treatment. A nasopharyngeal airway may be reasonably accepted.

If endotracheal intubation is required, ventilate using maximum FiO2 through a non-rebreather mask for 3 to 5 minutes before inserting the tube. If this is not possible because endotracheal intubation must proceed immediately, pre-oxygenate the patient by giving 5 to 8 vital capacity breaths using a PEEP valve.

Contraindications to Bag-Mask Ventilation

Bag mask ventilation should be contraindicated in case of paralysis and induction (because of the increased risk of aspiration). It's also contraindicated if the upper airway or passage by which air reaches the lungs is completely blocked.

Complications of Bag-Mask Ventilation

The complications of BVM Ventilation include barotrauma from too much lung inflation and gastric insufflation, leading to vomiting and aspiration. In addition, if bag-valve-mask ventilation is used for a prolonged period or improperly performed, air may be introduced into the stomach.

BVM on Opioids Emergency

Untrained individuals cannot use bag valve masks in response to an overdose event. Spontaneous ventilation is crucial to responding to an opioid overdose to restore breathing, get oxygen into the blood, and keep the brain alive. If you are not trained in using BVM, give breaths, call 911 and give naloxone instead of initiating BVM.

What are the potential harms if Bag Masks are misused?

Although Bag Valve Masks are appropriate for trained first responders, effective and adequate ventilation of BVM is an advanced skill that requires training and hands-on practice. You will not be able to use them correctly if you have not been trained. The following are the potential harms if BVM ventilation was performed incorrectly:

  • BVM ventilation can accelerate hypoxia
  • BVM ventilation can exacerbate the airway obstruction that naturally occurs during profoundly depressed levels of consciousness
  • BVM ventilation raises the risk of air entering the stomach, decreasing the oxygen delivery to the patient's lungs.
  • BVM ventilation raises the risk of aspiration of stomach contents into the airways and lungs

What is the Equipment for BVM Ventilation?

  • Bag-valve apparatus
  • Gloves, mask, gown, and eye protection
  • Oropharyngeal airways, nasopharyngeal airways, lubricating ointment
  • PEEP valve
  • Variably sized ventilation face masks.
  • Oxygen source
  • Suctioning device and Yankauer catheter
  • Pulse oximeter
  • Capnography equipment
  • Nasogastric tube

Frequently Asked Questions

Is a bag valve mask considered mechanical ventilation?

No. Mechanical ventilation refers to using a specialized machine called a ventilator, while a bag valve mask falls under manual ventilation.

Can anyone perform a bag valve mask ventilation?

Bag Valve Mask requires training and practice to use it effectively. Even emergency medical responders with much practice find it difficult to maintain adequate mask seals and ventilate sufficient volumes when only one responder can use it.

Are bag valve masks reusable?

Bag Valve Mask can either be reusable or disposable.

Do oxygen masks expire?

Most disposable respirators have an expiry date; once this date has passed, you should not use the bag-mask ventilation.

What is the correct volume of air during BVM?

A normal adult BVM holds about 1.5 L of air, almost three times the American Heart Association's recommended 600 mL tidal volume for an adult patient.

What is the preferred technique for BVM ventilation?

Two-person bag-mask ventilation technique is preferred because two trained and experienced rescuers will perform it. Rescuer 1 opens the airway and seals the mask to the face while rescuer 2 squeezes the bag. Both rescuers watch for visible chest rise.

Do you connect the bag valve mask to oxygen?

You can use a bag valve mask even though it's not connected to an oxygen tank. You can use it to provide room air or 21% oxygen to the patient.

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