2. Introduction
• Bag and mask ventilation is a life-saving technique
• Used to provide oxygen and remove carbon dioxide
from the lungs of infants and children who are not
breathing or are breathing inadequately.
3. • Basic airway management technique that allows for
oxygenation and ventilation of patients until a more
definitive airway can be established.
• Also used in cases where endotracheal intubation or other
definitive control of the airway is not possible.
• Always the first response to inadequate oxygenation and
ventilation
• The first "bail-out" maneuver to a failed intubation attempt
• Attenuates the urgency to intubate
4.
5. TYPES OF BAG USED
1.Flow inflating bag (Anaesthesia Bag)
• Fills only when oxygen from a compressed source flows
into it
• Depend on a compressed gas source
• Must have a tight face-mask seal to inflate
• Use a flow-control valve to regulate pressure-inflation
6.
7. 2.Self inflating bag (AMBU Bag)
• Fill spontaneously after they are squeezed, pulling
oxygen or air into the bag
• Remain inflated at all times
• Can deliver positive-pressure ventilation without a
compressed gas source.
• Require attachment of an oxygen reservoir to
deliver 100% oxygen
8. PROCEDURE
One hand to
• maintain face seal
• position head
• maintain patency
Other hand for ventilation
Requires practice to master
9.
10. Indications
• Respiratory failure
• Failure of ventilation
• Failure of oxygenation
• Failed intubation
• Elective ventilation in the operating room
11. Contra Indications
• Complete upper airway obstruction.
• BVM ventilation is relatively contraindicated after paralysis and
induction (because of the increased risk of aspiration).
• Caution is advised in patients with severe facial trauma and eye
injuries.
• In addition, foreign material (e.g. gastric contents) in the airway
may lead to aspiration pneumonitis.
In these circumstances, alternative approaches, including
endotracheal intubation, may be necessary.
12. TECHNIQUE
• "Sniffing"position if C-spine OK
• Thumb + index finger to maintain face seal
• Middle finger under mandibular symphysis
• Ring and little finger under the angle of
mandible
13. 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
14. 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
15. 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
16. Predictors of a Difficult Airway : Bag-
Valve-Mask Ventilation
• Upper airway obstruction
• Lack of dentures
• Midfacial smash
• facial burns, dressings, scarring
• poor lung mechanics( resistance or compliance )
17. 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
18. 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
19. 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
20. 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
21. 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
23. 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
24. Complications
• Related to over-inflating or over-pressurizing the patient, which can cause:
• Hypoventilation/ Hyperventilation
• Inflated air in the stomach (called gastric insufflation)
• Lung injury from over-stretching (called volutrauma)
• Lung injury from over-pressurization (called barotrauma).
• Aspiration
• Undesirable CV effects such as hypotension, secondary to caval
compression.
25. 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
