ACUTE

RESPIRATORY
INSUFFICIENCY
(ARI)

Ivano-Frankivsk National Medical University

Department of Anesthesiology and Intensive Care
IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITET
Department Anesthesiology and Intensive
Care

The general principles

of anesthesiological
manamgement

Ivan Titov, PhD

 ACUTE RESPIRATORY
INSUFFICIENCY
– acute respiratory
insufficiency (ARI) is a condition
when the respiratory system fails
to provide a normal gas content of
the blood.
Etiological and pathogenic factors of ARI
• acute respiratory obstruction of the respiratory
tract;
• restriction of the respiratory surface of the lungs by
pneumothorax, exudative pleurisy, tumor;
• diffuse disorder of gases through the alveolar-
capillary membrane due to the development of
pulmonary edema;
• chest injury;
• functional disorders of the respiratory centre in case
of exogenic and endogen intoxications, cerebral
traumas, circulatory disorders in the stem of the
brain;
• neuro-muscular disorders of impulse transportation
(tetanus, polyneuritis, myasthenia, poisoning with
phosphoric organic compounds)
• Pulmonary embolism of branches of the pulmonary
artery.
 MAIN STEPS

timely diagnosis
emergency first aid
intensive therapy
 Pathogenesis
1. Disorders of permeability of the
respiratory tract;
2. Disorders of respiratory
biomechanics;
3. Disorders of gas diffusion;
4. Disorders of the pulmonary
circulation;
5. Correlation changes of ventilation
and perfusion.
What is а respiratory failure?
Classification
What is a respiratory insufficiency
 Pathogenetic forms
 bronchopulmonary;
 thoracoabdominal;
 centrogenic;
 nervous-muscular;
 cardiac-vascular;
 mixed;
 Diagnostic criteria

1.Clinical signs;
2.Results of laboratory
examinations;
3.X-ray signs;
4.Other examinations;
The main syndromes of
ARI
Hypercapnia;
Hypoxemia;
 Hypoxia.
 HYPOXIA

Hypoxia stages Hypoxia stages concerning

concerning changes changes of respiration and
of the CNS cardio-vascular activity

Euphoria Analeptic

Apathy Toxic

Hypoxic coma Terminal (agonic)

 Postoperative respiratory
insufficiency
As reasons to consider
 (1) the obstruction of respiratory tracts
above all things, bronchial obstruction,
pneumothorax;
 (2) then – pneumonia;
 (3) then is pain, high intra-abdominal
pressure
 Postoperative respiratory insufficiency
(emergency and ethiotropic treatment)

 1. Hypoxia and hypercapnia improvement on

general rules
 2. Correction of airway obstruction (upper
respiratory tract, bronchi)
 3. Correction of the restrictive disorders of
breathing (pain, intra-abdominal and intrathoracic
high-pressure)
 3. Correction of water-electrolyte disorders
 4. Therapy for infectious complications
 Prophylaxis of complications
1.Adequate anesthesia
2. Early physical activity
3. Using of nasogastric probe only on strict
indication
4. Depending on a specific clinical situation
to consider application (1) of the deep
breathing exercises, (2) stimulating
spirometery, (3) stimulation of cough, (3)
postural drainage, (4) percussion and
vibrating massage, (3) apparatus
procedures (periods of breathing under
positive pressure, permanent positive
pressure in respiratory tracts)
 Bronchial asthma
 A patient is excited or stressed, dyspnea at
rest, he can only sitting, talks separate words,
respiratory rate is 30 per min, additional
muscles take part in the breathing, there are
loud wheezes during inspiration and
expiration, pulse rate more than 120 per min,
paradoxical pulse (during inspiration APsys >
25 mm Hg), FEV1 or PEF < 40% from a due
or the best, PaO2 < 60 mm Hg, cyanosys is
possible, PaCO2 > 42 mm Hg, SaO2 < 90%
 Diagnostics of lifethreatening
asthma
 A patient is languid or in the entangled
consciousness, respiratory rate is not a model,
thoracoabdominal dissociation, rales are quiet or
not heard, bradycardia, the absent of paradoxical
pulse confirms the fatigue of respiratory muscles,
FEV1 or PEF < 25% from a due or the best, deep
hypoxemia and hypercapnia
Emergency of severe bronchial asthma attack
 Most comfortable position for breathing (fully to execute
the patient wishes).
 Inhalation of oxygen-air mixtures with FiO2 0,35-0,4.
 1A. If a patient can take a deep breath, inhalation b-2-
adrenomimetic by the dosed inhaler (for example,
Salbutamol).
 1B. If a patient can not take a deep breath – parenterally
adrenalin for 0,3-0,5 ml 0,1% solution each 20 mines to 3
doses hypodermic (for the children - 0,01 mg/kg,
maximum for 0,3-0,5 mg in the same mode) or
terbutaline 0,25 mg each 20 mins to 3 doses hypodermic
(for the children – for 0,01 mg/kg in the same mode), but
it already indicate to the necessity of intubation and
mechanical ventilation.
 1C. If the therapy by inhalation of b-2- adrenomimetic
was uneffective in a previous 5-6 hours or there is the
overdose (HR > / = 130 per min – pass to the step of 3B-
3C (depending on the severity of state).
 Lifethreatening asthma
emergency

Insert tracheal tube and start

mechanical ventilation (oxygen-air
mixture, low volumes, low
frequency, large time of
expiration)
Drug therapy parenterally and by
nebulizer in a breathing circuit as
for the bronchial asthma severe
exacerbation
 Interstitial and alveolar
pulmonary edema
 Anxiety, weakness, general sweating
 Dyspnea, the SpO2 is normal at the outset
 Increase central venous pressure and/or
pulmonary blood pressure
 Interstitial: rough breath sounds and dry rales
 Alveolar: fine moist rales, foamy rose sputum (it
is too late)
 On the frontal thorax X-ray film (there are roots
of lungs enlargement, lung pattern enlarged and
there are infiltrative shadows.
 Pulmonary edema emergency for high AP
and CVP

1.To give the patient comfort position in the bed to ease

breathing
2.Oxygen therapy with FiO2 = 1,0, and then depending on
success of SpO2 maintenance - oxygen therapy with FiO2
</= 0,5 and spontaneous breathing under permanent
positive pressure or mechanical ventilation with the same
FiO2 level.
3.Morphine 3-5 mg i.v. slowly, if necessary to repeat through
15 min (general dose 10 mg).
4.To determine and treat of causes
5.For eliminate of foaming (alcohol 33% 10-20 ml i.v. slowly,
inhalation of dry oxygen, through an alcohol in place of
water)
6. Hemodynamics correction: nitroglycerine 0,25-1,0
mcg/kg/min or Isosorbidedinitrate 1-10 mg/hour i.v. by the
dropper, and/or furosemide to 1 mg/kg i.v.
 Pulmonary edema emergency for low AP
(independently from CVP)

1.Oxygen therapy with FiO2 = 1,0, and then depending on

success of SpO2 maintenance – oxygen therapy with FiO2 </=
0,5, and spontaneous breathing under permanent positive
pressure or mechanical ventilation with the same FiO2 level.
3.Morphine 3-5 mg i.v. slowly, if necessary to repeat through
15 min (general dose 10 mg).
4.To determine and treat of causes
5.For eliminate of foaming (alcohol 33% 10-20 ml i.v. slowly,
inhalation of dry oxygen, through an alcohol in place of water)
6.Hemodynamics correction inotropic support: Dobutaminum
2-3 mcg/kg/min or dopamine 2-5 mcg/kg/min, their
combination is possible
Diagnostics of drowning
1.(a) Breathing – from dyspnea and cough to acute respiratory
insufficiency with a severe hypoxia and hypercapnia;
bronchospasm is possible;
(b) Neurologic – from excitation and agitation to the coma and
convulsion;
(c) Circulation – heart rate disturbance, elevated or lowered AP,
may be cardiac arrest
2. “Wet drowning” - cyanosis, rose large-meshed foam at the mouth
3. «Dry drowning » - cyanosis, white close-meshed foam at the
mouth
4.Syncopal drowning (reflex cardiac arrest) – skin pallor, foam at
the mouth is absent.
5. Fresh water drowning - rapid absorption water from respiratory
tracts with the gradual development of noncardiac pulmonary
edema
6. Sea water drowning persistent foaming in alveoli and respiratory
tracts, and alveolar pulmonary edema from the onset
 Emergency for drowning
 1. Depends not on the type of drowning, but on the
severity of state:
 (а) Cardiac arrest – start CPR immediately
 (б) unconsciousness, breathing disorder or absent, stable
circulation and lateral position, oxygen therapy with
maximal FiO2, intravenous access in the «opened line»
mode or symptomatic correction of hemodynamics
 (в) consciousness, breathing and circulation without the
expressed disturbances - a prophylaxis of further
careless conduct as a result of excitation, warming and
oxygen therapy with FiO2 0,4-0,5.
 2. Hospitalization is obligatory in all of cases
 Pulmonary embolism
diagnostics
 Acute massive occlusion - acute system hypotension with or without
a fainting, severe refractory hypoxia
 The pulmonary infarction (1) early signs: shortness of breath,
tachycardia, coronal pain, periodic collapses; (2) late signs:
fervescence, pleura pain; (3) late rare sign: haemoptysis.
 Pulmonary embolism without infarction - dyspnea, tachypnea,
tachycardia
 Classic X-ray signs (Appendix 2)
 Classic ECG-signs (Appendix 3)
 Diagnosis verification - pulmonary arteries spiral CT scan or
pulmonary angiography
 Diagnosis rejection: if the D- dimers content less than 500 ng/l and
there are not pulmonary embolism X-ray.
Air embolism can be produced during inspiration if negative
intrathoracic pressure draws air into an open vein, an event most
likely to happen during a neurosurgical or ear, nose, and throat
procedure in which the patient sits upright and the operative wound
is above the level of the heart. Air bubbles become trapped in
pulmonary arteries and right ventricle where they mechanically
impede blood flow. Reactions at the gas-fluid interface trigger blood
clotting and the accumulation and activation of neutrophils. Small
fibrin and platelet thrombi are found in pulmonary arteries. The
physiologic consequences include transient airway constriction and
vasoconstriction with great increases in pulmonary vascular
resistance and pulmonary artery pressure. With large emboli
pulmonary edema, hypoxemia, systemic hypotension and
myocardial ischemia are seen. Fatalities have been reported with
embolism of 100 ml of air.
Amniotic fluid emboli are a rare complication of
pregnancy. Infusion of amniotic fluid occurs during
tumultuous uterine contractions when the head is in
the birth canal. The amniotic fluid is forced through a
rupture in the chorion into the maternal veins,
precipitating severe dyspnea, tachypnea, and
hypotension. Disseminated intravascular coagulation
is a common consequence. At autopsy the lungs are
hemorrhagic. Squamous cells are lodged in the
arterioles. Amniotic debris also contains lipid and
mucin, which can be identified with appropriate stains.
Reportedly, the clinical diagnosis can be confirmed by
the demonstration of squamous cells in blood
withdrawn by pulmonary artery catheter.
• Fat embolism is the result of abrupt pressure changes in
the long bones, which rupture thin walled venous sinuses and
force marrow fat into them. It embolizes to the lung. In addition,
levels of plasma triglycerides, free fatty acids, and lipase rise
as part of the stress response. Endothelial damage is caused
by fatty acids released from embolized fat and by mediators
released during associated blood coagulation. Fat emboli can
be recognized by ordinary histopathologic sections as sharply
delimited, empty-appearing capillary loops or arterioles, but
frozen sections stained for fat are required for confirmation.

• Bone marrow emboli commonly follow vigorous

cardiopulmonary resuscitation. Like thrombotic emboli they
become adherent, endothelialized, and eventually organized.
• Foreign-body embolism can result from introduction of foreign
material into the veins during medical procedures but is also common among
intravenous narcotic users. Particles of insoluble material added as “fillers” to
drugs intended for oral use embolizes to the lung and impact in arterioles and
small muscular arteries where they cause thrombosis and proliferation of intimal
cells. Often they migrate into the perivascular space or interstitium where they
give rise to foreign-body granulomas composed of macrophages, multinucleated
giant cells, and a few lymphocytes. The process of migration appears to involve
the production of granulomatous response in the vascular wall with disintegration
of muscle and elastic tissue. In cases where lesions are not numerous, their
detection is aided by the use of polarizing filters, since cornstarch and talc, two of
the materials commonly used as fillers, are strongly birefringent. When the
vascular thrombosis is widespread, pulmonary hypertension results. Lesions may
resemble those of primary pulmonary hypertension, particularly in view of the
cellular proliferation induced by the foreign material. Extensive interstitial
granulomas can produce roentgenographic nodularity and a restrictive ventilatory
defect.

•Tumour embolism: Tumour emboli are occasionally seen in the lung

and are thought to be the source of the lymphangitic form of carcinoma.
 Classic ECG signs of pulmonary
embolism
The S1-Q3-T3 syndrome - a deep S wave in I
lead and deep Q wave in the III standard
lead, and the T wave in the III lead becomes
negative (to 15% cases of PE)
Suddenly onset of right heart overload -
dextrogram, ECG-signs of right ventricle
hypertrophy, right bundle-branch block
Suddenly onset of supraventricular
arrhythmia – atrial fibrillation, ciliary
arrhythmia, paroxysmal tachycardia,
extrasystole.
 Classic X-ray signs of
pulmonary embolism

Classic X-ray signs of pulmonary embolism

Fleishner lines - linear veins (areas of flat
atelectasis), spreading parallell cupula of
diaphragm
The Westermarck’s symptom - the area of relatively
hypoperfusioned pulmonary tissue
The Hampton’s hill - the wedge with basis, turned to
the pleura, occur by the pulmonary infarct (in 12-36
hours after embolism onset)
Pal’s symptom - an increase of right descending
artery
 Pulmonary embolism
emergency

•CPR – if indicated
•Oxygen (since FiO2 1,0), spontaneous
breathings or mechanical ventilation, standard
indications
•Narcotic analgetic (Morphine 5-10 mg i.v. or
Promedol 20 mg subcutaneous)
•Hemodynamics management
•Unfractionated heparin bolus 80 U/kg i.v.
 Hemodynamics management for
pulmonary embolism

 an ephedrine is 5-10 mg or epinephrine of 0,05-0,5 mcg/kg/min

(intravenously by dropper, also diminish bronchospasm, but can
increase pulmonary arterial pressure and tachycardia) or selective
bronchodilatation (short action b-agonists: salbutamol by the
dosed inhaler or nebulizer, doses and tactic see “Status
asthmaticus”) +
 selective hemodynamics support (Dobutamine 5-10 mg/kg/min);
the second line preparations - Dopamine 5-15 mcg/kg/min or
Norepinepfrine 0,2-1,0 mcg/kg/min intravenously by dropper
+
 pulmonary circulation unload (Nitroglycerine from 10-20
mcg/min or Isosorbide dinitrate from a 1 mg/h to 10 mg/h
intravenously by the dropper with a carefulness – the system AP
reduces) as decreased central venous pressure – to increase the
infusion therapy volume on polyionic solutions (under CVP and
 Diagnostics of aspiration

• Cough, stridor
• Breathing disorders, apnea or
tachypnea, wheezes
• Hyperthermia
• Visible in a pharynx castric content (or
blood or pus)
• Bronchospasm
• Abundant tracheary secretion
 Aspiration emergency
• To make patient in Trendelenburg's position, if it
possible – with right side elevated
• To aspirate the content of mouth, throat, and
respiratory tracts
• Oxygen inhalation with FiO2 1,0 + mechanical
ventilation (on general indications)
• Symptomatic correction of hemodynamics
disturbances
• Periodically to repeat a suction from trachea and
bronchi
 – agonists for persistent bronchospasm
• Antibiotics only for the intestinal content aspiration
• Bronchoscopy only for the hard fragments aspiration
 Diagnostics of airway foreign body
obstruction

• Sudden worsening
• Games, shallow objects meal, bad mastication
• Cough, pant.
• Mild aspiration - clear consciousness, vertical
position, ringing voice, loud cough, inhalations
between the fits of coughing
• Moderate aspiration - clear consciousness,
vertical position, unsounding voice, soundless
cough, inhalation between the fits of coughing is
not succeeded
• Severe aspiration - the mental confusion, can not
save vertical position, a cough and breathing go
out or went out.
Emergency for airway foreign body obstruction

Mild aspiration – to encourage a cough, sedative

conversation, supervision to complete eliminated
of obstruction.
Moderate aspiration – postural massage. If
progression to the severe obstruction – to change
tactic as described below.
Severe aspiration - (1) simple manoeuvres of airway
support (2) to examine the mouth cavity and delete
all visible foreign objects and liquids (3) to give 2
rescue breath, (4) to give 30 chest compressions
as during CPR (5) repeat if necessary from a step
(1). Chest compressions execute, even if a
carotids pulse is yet determined! Tactic is changing
as changing the obstruction severity.
 Intensive care aspiration syndrome
algorithm

 Breath correction on general rules.

Prophylaxis and treatment of noncardiogenic
pulmonary edema, aspiration pneumonia,
atelectasis

 Circulation correction on general rules.

Prophylaxis and treatment of arrhythmias and
cardiac insufficiency

 Protective (drug and nondrug) cerebral

functions braking, prophylaxis and treatment
of post-hypoxic cerebral edema
Respiratory distress syndrome
in adults

Acute onset
PaO2/FiO2 < 200 mm Hg independently
of the level of end expiratory
positive pressure
Bilateral infiltration on the frontal chest
X-ray film
Pulmonary capillary wedge pressure <
18 mm Hg. or absence the signs of
left atrium hypertension
 Emergency for acute respiratory distress
syndrome

• Resuscitation on indications
• Gases exchange correction to goal level (рН no less
than 7,25, PaO2 50-70 mm Hg, PaCO2 not below 35
mm Hg). Sequence of therapy aggressiveness
increase: spontaneous breathing under permanent
positive pressure with FiO2 < 0,4  mechanical
ventilation with end expiratory positive pressure 4-5
mm Hg with same FiO2 level  step-by-step
alternating increase of end expiratory positive
pressure and FiO2.
• Continuation glucocorticoid therapy
(Dexamethasone i.v. 1mg/kg every 12 or a 24 hours)
 Intensive care adults respiratory distress
syndrome algorithm
• Treatment of underlying diseases
• Gases exchange correction of (spontaneous breathing
under permanent positive pressure with FiO2 < 0,4 
mechanical ventilation with end expiratory positive
pressure 4-5 mm Hg with same FiO2 level  step-by-step
alternating increase of end expiratory positive pressure
and FiO2.)
• Minimization of oxygen necessities (pain control, treat
convulsions, hyperthermia, hypothermia with shivering)
• Minimization of CO2 products (the same in general + diet with the
diminished amount of carbonhydratess and increased amount of fats)
• After shock completion - minimization of intravenous infusion, oral
(probe) liquid supplying
• Postural pose chance every 2 hours, during ventilators support
prone position twice per day for 4-6 hours duration.
 Obstruction of the respiratory
passages (stuck tongue)
I. Safar’s method. The patient’s position is
horizontal on the back. The 1st step. Press
your hand on the patient’s forehead and bend
his head at the atlantooccipital joint, at the
same time raise his chin by the two fingers of
another hand. The 2nd step. Fix the lower jaw
with your fingers and raise it forward and
upward: the lower teeth should be at the level
with the upper ones. If AVL must be conducted
– the 3rd step: open the patient’s mouth.
 II. Introduction of the air tube through the mouth. The
patient’s position is on the back or on one side.
1st variant. Open the mouth. Press the spatula on the
base of the tongue, move it forward from the oral
pharynx. Introduce air tube by its curved side to the
chin that its distal end does not touch the posterior
wall of the oral pharynx; the flange of the air tube
should come 1-2 cm forward from the incisors. Move
the lower jaw forward and upward, it will allow the
tongue to remove from the oral-pharyngeal wall. Press
the air tube and insert it 2 cm into the mouth that its
curve lies on the base of the tongue.
2nd variant. The air tube can be introduced into the
mouth by its curved side to the hard palate (without
spatula). When its end touches the uvula of the soft
palate, the air tube is turned to 180° and moved to the
base of the tongue.
 Prolonged obstruction of the
respiratory tract, apnea
Tracheal intubation (oral-tracheal).
While conducting intubation the preparation for anaesthesia
are used (thiopental sodium 1% 4-5mg/kg of the body
weight, ketamine 5% 2mg/kg, ethomidat 0,3 mg/kg,
diazepam 0,15-0,3 mg/kg, mydazolam 0,1-0,4 mg/kg)
and myorelaxantes (ditilin 2% 1-1,5 mg/kg). For the
patients in coma condition direct laryngoscopia and
intubation can be conducted without anaesthesia. Hold
laryngoscope in the left hand closer to the connection
with the blade. The patient’s mouth should be opened
widely by means of the thumb and pointer of the right
hand applied on the upper and lower molars. The blade
of laryngoscope is carefully inserted into the oral cavity
between the upper palate and tongue to the epiglottis,
the tongue is moved upward and to the left. While moving
the blade one should orientate to the uvula of the soft
Prolonged obstruction of the respiratory
tract, apnea
 Depending on the kind of the blade its end is placed
either under the epiglottis (Miller’s kind) or between the
epiglottis and base of the tongue (Makintosh kind). Fix
the wrists and raise the hand of the laryngoscope
upward and forward to open the glottis. Excessory
movements of the left wrist backward should be avoided
to prevent strong pressure on the upper teeth.
Intubation tube is inserted along the blade through the
glottis to the point when the cuff of the tube is lower the
vocal cords. A club-like curved conductor is inserted
into the intubation tube, its end should not advance from
the borders of the tube. Correct position of the
intubation tube is determined by the excursion of the
chest and auscultation of the lungs during AVL.
Respiratory sound should not be hear in the area of the
stomach. The cuff is blown with 5-10 ml of air and the
intubation tube is fixed.
Obstruction due to oedema, bleeding, foreign
body
Cricotomia (conicotomia).
The position of the patient is horizontal on the back, the neck is
in a neutral position.
Treat with antiseptic and apply sterile cloth on the anterior
surface of the neck (if there is some time); palpate the
cricoid’s ligament lower the thyroid cartilage on the middle
line; fix firmly the thyroid cartilage with the fingers of the
left hand and make a transversal cut 2 cm long through the
cricoids ligament; insert tracheal dilator to the side of the
lower part of the trachea and carefully open the edges of the
wound. If there is no tracheal dilator the hand of scalpel can
be inserted into the trachea transversally and turned to 90° to
widen the opening in the cricoids ligament; insert
tracheostomic tube into the trachea (or endotracheal tube),
blow the cuff and perform AVL by the sac with 100%
oxygen.
 Obstruction of the respiratory tract
with sputum

Tracheal catheterization through the skin (Seldinger’s

method).
The position of the patient is horizontal on the back,
the neck is in a neutral position. Under local anesthesia
puncture the trachea between the first and second
rings of the trachea. The needle is directed from
upward to downward obliquely. A fiber is inserted
through the needle into the trachea, the needle is
removed, catheter is inserted through the fiber 4-5 cm
deep to the side of bifurcation. The catheter is used for
high frequency AVL, tracheal instillation of moistering
means and detergents, aspiration of sputum.
 Obstruction with a foreign body on the level of
the pharynx and upper portion of the trachea.
Apnea, AVL

Heimlich method.
The position of the patient is horizontal on the
back or vertical.
Two methods are used: strong push in the
epigastric region
directed upward to the diaphragm;
press the lower portions of the chest. In some
cases a number of blows between the scapulae
are made.
 Laryngeal mask.
The position of the patient is horizontal on the back. The
head is moderately raised with simultaneous unbending
at the atlantooccipital joint (improved position). The
patient’s mouth should be opened widely by means of
the thumb and pointer of the right hand applied on the
upper and lower molars. With the thumb and pointer of
the left hand fix the air tube, and with the middle finger
press the cuff to the hard palate, insert the mask into
the oral cavity and laryngeal portion of the throat. The
cuff is blown by means of the syringe with 10-15 ml of
air (depending on the size of the mask), thus the throat
and edges of the mask are hermetically sealed.
 Apnea
Artificial ventilation of the lungs “from mouth-to-mouth”
and” from mouth-to-nose”.

The patient’s position is horizontal on the back. Permeability

of the respiratory tract is renewed by triple Safar’s method.
The mouth and nose of the patient are covered with cloth,
the mouth is closely seized by the lips of reanimator, the
nostrils of the patient are held with the fingers. Air is blown
into the mouth of the patient (into the mouth and nose in little
children) after previous inspiration. The time of blowing up to
1,5-2 sec., volume up to 1 litre. Expiration is passive. During
expiration the head of the patient is turned to the opposite
side. Efficacy of respiration is controlled by the expansion of
the chest. Frequency of respiration should be 14-16 per
minute.
 Artificial ventilation with the bag
through the oral-nasal mask.

The mask of a proper size is taken in the left hand, the thumb and
pointer press around the obturator (ring). Put the mask on the
face that a narrow part is placed on the edge of the nose and a
wide one on the alveolar process of the lower jaw. The mask is
hermetically sealed on the face. Press the mask with the thumb
and pointer, fix and push the lower jaw with the middle and
fourth fingers. At the same time the head is tilt at the
atlantooccipital joint. The small finger of the left hand is
placed at the angle to the lower jaw and pushes it forward.
Conduct respiratory movements in turn pressing and releaving
the sac with the right hand. In severe cases both hands are used
to fix the lower jaw, respiration is conducted by an assistant.