Ventilating a patient with a BVM is an easy skill; you open the airway, use adjuncts, get a good seal, squeeze the bag and voila! Intubation and supraglottic airways are awesome and way more important. That's what I thought early on in my EMS career as an EMT. Wrong! When you listen to the airway gurus/masters: Scott Weingart, Jim Ducanto, Reuben Strayer, Rich Levitan, and many others...you see that they mastered ventilating a patient with a BVM before they became highly skilled/successful at laryngoscopy and intubation. You can be an airway master too with a few key points and correcting some bad habits:
Prepare Equipment. Have appropriately sized OPA or NPA, BVM, nasal cannula, suction, and some sheets/blankets nearby. Out of all this equipment what is most often forgotten is the suction! Have your suction turned on and set up, that way when old faithful blows you're ready.
Position Patient. Originally most of us were taught to "put the patient in the sniffing position," this was to open the airway and allow for adequate ventilation. This is the most misunderstood and incorrectly taught skill. In order to do this correctly we must understand what "sniffing position" is and why this position is the most beneficial. Sniffing position is NOT a head tilt chin lift; sniffing position means you elevate the head toward the ceiling by placing pillows, sheets, or blankets behind the patient's upper back and head. Once the patient's ear hole is at or above to sternum the patient is in the "true sniffing position."
Why is the position preferred? It protects the airway from aspiration, it flattens the curve (picture B) improving laryngoscopy and intubation views, and truly opens the airway allowing improved flow of oxygen into the lungs.
Use Airway Adjuncts. It happens a lot for some reason, but in the heat of the moment we ventilate our patient with no airway adjuncts being utilized. Use them! Mix and match if you want, put one in each nostril, or an OPA with an NPA. More is better!
Good Mask Seal. Two person BVM is ideal and the best way to achieve a good seal. But today your short-handed and the E-C clamp is failing you...why you ask? Because the E-C clamp is the wrong technique in the emergency setting, we should have never taught it this way. For a good seal use the two thumbs down technique with a jaw thrust, then you stick that BVM bag under your chicken wing and ventilate the patient. I have done this several times with great success and you will get a great mask seal!
We Suck at Ventilating. Yes, it is true and has been proven over and over. We squeeze the bag to forcefully, with too much volume, and too frequently. In the heat of the moment we lose our focus, it happens and we must refocus our attention. When you squeeze the bag do it in a controlled fashion and squeeze only until you see chest rise then stop. Then count out loud or in your head to ensure we are not ventilating at too high a rate. Once every 5-6 seconds for adults, once every 3 for pediatrics, once every 1-2 seconds for neonatal resuscitation, and once every 6-8 seconds for cardiac arrest. I know, the AHA disagrees and PALS has changed for cardiac arrest ventilation rates.........but that's another discussion for another day. Also be aware that depending on what is going on with your patient you may want to ventilate at a higher rate and use ETCO2 as your guide; but we will save that for another day as well.
Apply Nasal Cannula. This is one of those pro tips, place a nasal cannula on the patient under your mask. We do this for a couple reasons: 1) you can hook up the nasal cannula to a second oxygen source and maximize oxygenation when the BVM and PEEP valve is not getting the job done, 2) attach the nasal cannula to oxygen and set at 10-15 lpm before you intubate (apneic oxygenation), this proven technique will provide some oxygenation of the patient and buy time before the SpO2 begins to drop.
Trauma Patient Considerations: The main change with our trauma patient is to keep patient in neutral position and protect the spine. We can still place some padding to get patient in sniffing position, but not to the same degree as our medical patients.
Pediatric Considerations: Not much changes here either. Select the proper size equipment for the patient. Position the patient the same, yes even little infants; the towel/blanket will need to go below their shoulders as well as the head. With small children and infants use the "eagle claw" to seal the mask. With the eagle claw you are pulling the face "up into" the mask.
That's all folk's, as always reach out to us with any questions or comment below. Check the references for some awesome videos and more tips from the airway gurus! For a summary of what we discussed watch the video below:
References:
Life In The Fast Lane. (November 3, 2020). Own the Airway. Retrieved from https://litfl.com/own-the-airway/#:~:text=%20Own%20the%20Airway%21%20%201%20Preoxygenation.%20First%2C,oxygen.%20Racine%20SX%2C%20et%20al%20%282010%29.%20More%20
Pediatric Emergency Playbook. (February 1, 2018). Airway Master Moves. Retrieved from https://pemplaybook.org/podcast/airway-master-moves/
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