Bag and mask ventilation (BMV) is positive pressure ventilation delivered using a self-inflating bag and face mask. The bag reinflates without an external gas source and is attached to oxygen and air sources. BMV is started if the baby is not breathing, has gasping respirations, or has a heart rate below 100 bpm. For term babies, room air is recommended initially and oxygen is only used if saturation does not improve within 90 seconds. Preterm babies are given intermediate oxygen concentrations of 21-30%. Proper technique is needed to ensure an open airway and adequate seal with appropriate mask size. Ventilation rate is 40-60 breaths per minute and pressure is adjusted based on response.

1. Bag and Mask Ventilation

2. • Positive Pressure Ventilation (PPV)
• PPV is usually given by using a self-inflating bag and face
• mask (bag and mask ventilation or BMV). The selfinflating
• bag is easy to use as it reinflates completely
• without any external compressed source of gas.
• The resuscitation bag should have a capacity
• of 240 to 750 mL. The bag is attached to sources of oxygen
• and air and a blender which provides a desired
• concentration of supplemental oxygen.

3. Bag and mask equipment
• Neonatal resuscitation bags (self-inflating)
• Face-masks (for both term and preterm babies)
• Oxygen with flow meter and tubing
Self inflating bags in children
Flow inflating bags in hospital which need oxygen flow
Preterm neonates – neonatal bags 250ml
Term neonates and children<8yrs – 400 - 500 ml
Adequate amout of tidal volume – visible chest rise

4. Start PPV
• if the baby is not breathing (apnea)
• if the baby has gasping respirations.
• if the baby appears to be breathing, but the heart rate is below
100 bpm
• Both too little and too much of oxygen are bad for the baby.
• Studies have shown that term babies resuscitated with room air
compared to 100% oxygen have better survival and long-term
outcomes.

5. • It is therefore recommended that term babies should be initiated on
room air resuscitation.
• Ideally, oxygen saturation should be monitored by pulse oximetry
and
• Oxygen delivery should be titrated to maintain the oxygen saturation
in targeted range.
• In absence of pulse oximetry, room air should be substitute by
100% oxygen, if the baby fails to improve (improvement in HR and
breathing) by 90 seconds. .
• PPV in preterm babies (<35 weeks) is recommended using
intermediate concentration of oxygen (21 to 30%)

6. Excessive expansion compromise cardiac output increase
regurgitation and air leak
In head injury or cardiac arrest excess ventilation affect neurological
outcome
Self inflating bag can supply room air or oxygen
• Paediatric bag valve device
• Without reservoir – connected to oxygen inflow of 10ml/min
delivers 30 – 80% oxygen
• With reservoir – oxygen inflow 15ml/min delivers 60 – 95% oxygen

7. Procedure
• The infant's neck should be slightly extended to ensure
an open airway. The care provider should be positioned
at head end or at the side of baby so as to have an
unobstructed view of infant's chest and abdomen.
• Select an appropriate sized face mask that covers the mouth and
nose, but not eyes of the infant. The face mask
should be held firmly on face to obtain a good seal.
• The bag should be compressed using fingers and not by hands.
• PPV is the single most effective step in babies who fail to
breath at birth.

8. • If the baby is not responding to PPV by prompt increase
in HR, ventilation corrective steps are taken.
Observe for an appropriate rise of the chest and auscultate
for breath sounds.

9. • Action
• Inadequate seal Re-apply mask
• Blocked airway
• Blocked airway
• Blocked airway
• Inadequate pressure
• Consider alternate airway
condition
• Reposition the Infant's head
• Clear secretions by suction
• Ventilate with mouth slightly
open
• Increase pressure slightly
• Blocked airway(endotracheal
tube)

10. • When normal rise of the chest is observed, one should
begin ventilating. Ventilation should be carried out at a
rate of 40 to 60 breaths per minute, following a 'squeeze,
two, three' sequence
• Usual pressure required for the first breath is 30-40 cmH20. For
subsequent breaths, pressure of 15-20 cm H20 is
adequate.
After the infant has received 30 seconds of PPV, evaluate the HR and.
take n follow-up action

11. • Improvement in the infant's condition is judged by
• increasing HR, spontaneous respiration and improving color.
• If the infant fails to improve, check adequacy of ventilation in form of
visible chest rise
• PPV may cause abdominal distension as the gas escapes into the
stomach via esophagus.
• Distended stomach presses on the diaphragm and. compromises the
ventilation.
• Therefore, if ventilation is continued for more than two minutes, an
orogastric tube (feeding tube size 6-8 Fr) should be inserted and left
open to decompressthe abdomen.