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March 2, 2015

How to improve your bag-valve mask technique

Before EMS providers can deliver effective ventilation, they must control the airway. It is the single most important prehospital intervention. Although this sounds like a simple step, it is not always easy to do. Many experts attribute inadequate control of the airway as a major cause of preventable death in the prehospital environment.

Manual airway maneuvers

The most basic category of all techniques used to insure a patent airway is manual airway maneuvers. These techniques form the foundation for all airway control maneuvers both in the field and hospital.

Following unconsciousness in most patients, the muscles of the throat relax. In a supine position, this loss of muscle tone allows a portion of the tongue to shift from the oral cavity into the oropharynx. Tilting the head back and lifting the chin displaces the jaw toward the front of the body and pulls the tongue out of the patient’s airway. When properly performed, the head tilt/chin lift maneuver has no complications and is the preferred method of manual airway control in unconscious patients.

However, proper execution of this maneuver requires manipulation of the head, which moves the patient’s neck. If a neck injury is present, the head tilt/chin lift maneuver could worsen the injury. For this reason, EMTs and paramedics suspecting the presence of spinal injury should use an alternative manual airway maneuver, such as the jaw thrust.

Although manual airway maneuvers are effective at establishing a patent airway, rescuers often find them difficult to maintain for prolonged periods. Many find it useful to add the assistance of some type of mechanical airway maneuver, or airway adjunct to maintain airway patency. These include oropharyngeal and nasopharyngeal airways.

Bag-valve mask ventilation

One critical skill all EMS providers must master is effective bag-valve mask ventilation (BVM). Unfortunately, BVM ventilation by out-of-hospital (OOH) care providers often results in inadequate ventilation and may be potentially dangerous for both intubated and non-intubated patients.

Manikin studies demonstrate that EMTs using a standard BVM deliver mean tidal volumes significantly lower than those recommended by the American Heart Association[1]). In the same study, EMTs achieved recommended ventilation volumes in only 27 percent of the ventilation attempts[2].

One problem associated with ineffective ventilation is the inability of EMS personnel to provide effective mask seal on the BVM[3,4] (The American Heart Association (AHA) recommends use of EC clamp as a technique for sealing the face mask to the patient’s face during assisted ventilation[5]. However, attempting to provide an effective BVM seal using a single-hand EC clamp often tilts the mask to the left and allows air leakage from under the right side of the air-cushion[6].

Some argue that replacing the EC clamp with a rotated mask hold may provide a more effective seal[7]. This hold combined with a “chin lift grip” and a newly designed ergonomic face mask may help improve mask seal when performed by a single rescuer[8].

Two-person BVM technique

Side by side comparisons demonstrate that a BVM technique that utilizes two rescuers instead of one provides consistently more effective ventilation than a single person technique[9,10,11,12]. In this two-person technique, one rescuer can deliver the recommended tidal volume by squeezing the bag while the second rescuer can use both hands to provide an effective mask seal on the patient’s face. For the rescuer holding the seal, replacing the two-handed EC clamp with the thenar eminence grip improves ventilation efficacy[13].

The thenar eminence grip is achieved by using muscles at the base of the thumb to place downward pressure on the mask while using the other four fingers of each hand to pull the jaw into the mask. However, given the personnel restrictions that often accompany EMS responses, two person BVM techniques are not always feasible.

Avoiding gastric insufflation

During BVM-assisted ventilation, rescuers must use caution to avoid generating high airway pressures. In general, inspiratory pressures greater than 20 cm H2O in the adult patient increases the risk of forcing air through the esophagus and into the stomach, a condition known as gastric insufflation[14]. Gastric insufflation increases the risk of regurgitation and subsequent aspiration of stomach contents.

Although a number of factors contribute to high airway pressures, EMS personnel who ventilate patients slowly, deliver smaller tidal volumes, and reduce the inspiratory period decrease the risk of gastric insufflation. In addition, ventilation using a bag-valve device equipped with a pressure-responsive, flow-limiting valve reduces mean airway pressure and the likelihood of gastric insufflation compared to using a standard BVM[15]. An inspiratory pressure of 15 cm H2O provides the reasonable balance between effective ventilation and the risk of gastric insufflation[16].

Use of pressure manometers and filters

One simple tool to monitor inspiratory pressure is a manometer, which EMS personnel can place within the breathing circuit between the BVM and the patient. Pressure manometers allow the EMS provider to see exactly how much pressure is being created in the patient’s airway with each ventilation attempt. EMTs and paramedics can then adjust ventilation techniques to avoid unwanted pressures. The use of an in-line manometer during BVM ventilation of a simulated infant has been shown to decrease peak inspiratory pressure[17].

Some BVM devices have an option to install an inline bacterial/viral filter to reduce pathogen introduction into the patient’s airway and contamination of the healthcare provider by the patient’s exhaled breath. The filters are small but do introduce an increase in dead space volume by about 25 to 50 mL, not thought to be clinically relevant. The devices have a filtering efficiency greater than 99.99 percent and are effective against a number of pathogens including viruses that cause hepatitis, influenza, and SARS[18,19].

It is important to note however, that filtering efficiency is highly dependent upon how the device is tested. Viruses and bacteria are smaller than water droplets. Any testing method that utilizes pathogens nebulized in an aqueous medium will likely appear more efficient than they really are[20]. This is because the filter is actually trapping water droplets that contain the pathogens.

It is possible a testing method that utilized dry air as the transport medium for the pathogen would yield different results. Pathogen transmission is still possible even when utilizing these filters. EMTs and paramedics must take additional protective measures such as the use of personal protective equipment that include taking droplet precautions.

In some cases, paramedics may need to begin inhaled drug therapy while simultaneously providing assisted ventilation, especially following endotracheal intubation. Unfortunately, the efficiency of drug delivery via nebulizer during mechanical ventilation varies from 0 to 42 percent[21]. Case reports in an adult[22] and two infants[23] suffering from bronchoconstriction refractory to nebulized beta-agonists report almost immediate improvement in aeration and lung compliance following the endotracheal instillation of undiluted bronchodilators.

For acute exacerbations of asthma requiring endotracheal intubation, the AHA recommends endotracheal administration of undiluted beta-agonists as soon as tube placement is confirmed rather than continued use of nebulizers[24].


1. Berg, R. A., Hemphill, R., Abella, B. A., Aufderheide, T. P., Cave, D. M., Hazinski, M. F., Lerner, E. B., Rea, T. D., Sayre, M. R., & Swor, R. A. (2010). Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(suppl 3), S685-S705. doi:10.1161/CIRCULATIONAHA.110.970939

2. Lee, H. Y., Jeung, K. W., Lee, B. K., Lee, S. J., Jung, Y. H., Lee, G. S., Min, Y. I., & Heo, T. (2013). The performances of standard and ResMed masks during bag-valve-mask ventilation. Prehospital Emergency Care, 17(2), 235-240. doi:10.3109/10903127.2012.729126

3. Bauman, E. B., Joffe, A. M., Lenz, L., DeVries, S. A., Hetzel, S., & Seider, S. P. (2010). An evaluation of bag-valve-mask ventilation using an ergonomically designed facemask among novice users: a simulation-based pilot study. Resuscitation, 81(9), 1161–1165. doi:10.1016/j.resuscitation.2010.05.005

4. Noordergraaf, G. J., van Dun, P. J., Kramer, B. P., Schors, M. P., Hornman, H. P., de Jong, W., & Noordergraaf, A. (2004). Airway management by first responders when using a bag-valve device and two oxygen-driven resuscitators in 104 patients. European Journal of Anaesthesiology, 21(5), 361–366.

5. Hazinski, M. F. (Ed.). (2011). BLS for healthcare provider’s student manual. Dallas, TX: American Heart Association

6. Matioc, A. A. (2009). The adult ergonomic face mask concept: Historical and theoretical perspectives. Journal of Clinical Anesthesia, 21(4), 300–304. doi:10.1016/j.jclinane.2008.08.018

7. Perel, A., Berkenstadt, H., Yusim, Y., & Ezri, T. (2009). The rotated mask hold. Journal of Clinical Anesthesia, 21(8), 617-618. doi: 10.1016/j.jclinane.2009.03.005

8. Matioc, A. A. (2012). The "rotated mask hold" and "chin lift grip" may improve the one-hand face mask ventilation airway maneuver. Journal of Clinical Anesthesia, 24(2), 167-168. doi:10.1016/j.jclinane.2010.04.002.

9. Davidovic, L., LaCovey, D., & Pitetti, R. D. (2005). Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children. Annals of Emergency Medicine, 46(1), 37–42. doi:10.1016/j.annemergmed.2005.02.005

10. Jesudian, M. C., Harrison, R. R., Keenan, R. L., & Maull, K. I. (1985). Bag-valve-mask ventilation; Two rescuers are better than one: Preliminary report. Critical Care Medicine, 13(2), 122–123.

11. Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S. (2013). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annals of Emergency Medicine, 63(1), 6-12. doi:10.1016/j.annemergmed.2013.07.014

12. Wheatley, S., Thomas, A. N., Taylor, R. J., & Brown, T. (1997). A comparison of three methods of bag valve mask ventilation. Resuscitation, 33(3), 207–210. doi:10.1016/S0300-9572(96)01024-6

13. Gerstein, N. S., Carey, M. C., Braude, D. A., Tawil, I., Petersen, T. R., Deriy, L., & Anderson, M. S. (2013). Efficacy of facemask ventilation techniques in novice providers. Journal of Clinical Anesthesia, 25(3), 193-197. doi:10.1016/j.jclinane.2012.10.009

14. Weiler, N., Heinrichs, W., & Dick, W. (1995). Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Prehospital Disaster Medicine, 10(2), 101–105.

15. von Goedecke, A., Wagner-Berger, H. G., Stadlbauer, K. H., Krismer, A. C., Jakubaszko, J., Bratschke, C., Wenzel, L., & Keller, C. (2004). Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation. Resuscitation, 63(2), 131-136. doi:10.1016/j.resuscitation.2004.04.012

16. Bouvet, L., Albert, M. L., Augris, C., Boselli, E., Ecochard, R., Rabilloud, M., Chassard, D. & Allaouchiche, B. (2014). Real-time detection of gastric insufflation related to facemask pressure-controlled ventilation using ultrasonography of the antrum and epigastric auscultation in nonparalyzed patients: A prospective, randomized, double-blind study. Anesthesiology, 120(2), 326-334. doi:10.1097/ALN.0000000000000094

17. Karsdon, J., Stijnen, T., & Berger, H. M. (1989). The effect of a manometer on the mean airway pressure during hand ventilation, an in vitro study. European Journal of Pediatrics, 148(6), 574-576.

18. Guardian EMS Products. (2013). Main flow bacterial/viral filter. Retrieved from

19. Ventlab Corporation (n.d.). Product reference guide. Retrieved from

20. Demers, R. R. (2001). Bacterial/viral filtration: let the breather beware! Chest, 120(4), 1377-1389.

21. Dhand, R., & Tobin, M. J. (1997). Inhaled bronchodilator therapy in mechanically ventilated patients. American Journal of Respiratory and Critical Care Medicine, 156(1), 3–10. doi:10/1164/ajrccm.156.1.9610025

22. Verbeek, P. R., Gareau, A. B., & Rubes, C. J. (1988). Treatment of asthma-related respiratory arrest with endotracheal albuterol. Annals of Emergency Medicine, 17(4), 358-360. doi:10.1016/S0196-0644(88)80782-0

23. Carroll, C. L., & Goodman, D. M. (2004). Endotracheal albuterol treatment of acute bronchospasm. American Journal of Emergency Medicine, 22(6), 506-507. doi:10.1016/j.ajem.2004.07.014

24. Sinz, E., Navarro, K. W., & Soderberg, E. S. (2013). ACLS for experienced providers: Manual and resource text. Dallas, TX: American Heart Association

About the Author

Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail