Airway Skills 2:

Bag-Valve-Mask Use

Using a bag-valve-mask (BVM) is an important skill. Following are

guidelines for doing it well:

1. Use an oral or nasal airway to deliver oxygen beyond the

patient's tongue.
2. Obtain a good mask-face seal by forming a C with your
thumb and forefinger. Use your other fingers to grasp the
jaw, holding the mask firmly against the face.
3. In some patients, obtaining a seal may be difficult. An
assistant may use two hands to obtain the seal.
4. Be cognizant of the tidal volume being delivered. For both
adults and (PEDS) children, tidal volume should be about 10
to 15 cc/kg. A 12 kg 1-year-old child should receive a tidal
volume of 120 to 180 cc, while a 70 kg adult should receive
a tidal volume of 700 to 1050 cc. Watch for rise and fall of
the chest as an indication that the patient is being well
ventilated.
5. If possible, use a BVM with an attached pressure monitor.
These disposable devices are inexpensive and may be
adapted to most BVMs. Knowing how much pressure is being
generated helps the BVM user deliver the correct tidal

volume. These monitors measure tracheal pressure in cm of

H2O. A pressure of 20 to 30 cm H2O is usually the goal. Too
much pressure results in gastric distension.
6. PEDS: Ventilatory rate varies from 20 ventilations per
minute in small children to 12 to 15 ventilations per minute
in adults. In severe asthma, a rate of only 7 to 8 ventilations
per minute may be indicated.
7. Cricoid pressure (Sellick's maneuver) should be optional and
may not prevent gastric insufflation and regurgitation.
8. It is very useful to sense the degree of resistance felt when
the lungs are ventilated. Decreased lung compliance is an
important component of asthma and lung contusion. Under
these circumstances, it may be necessary to use unusually
large amounts of pressure.
9. A form of PEEP may be administered with a BVM by
maintaining compression of the bag for about a second at
the end of the inspiratory cycle. This is sometimes referred
to as "recruitment" because it allows delayed opening of

alveoli, recruiting more effective ventilation in the face of

atelectasis. Oxygen saturation can sometimes be improved
with this maneuver.
Reference
McGee JP, Vender JS. Nonintubation management of the airway:
mask ventilation in Airway management: principles and practice.
Benumof JL, Ed. St. Louis, 1996, Mosby; 228-254.
Edition 13-October 2011