What is the best bag valve mask (BVM) technique?

Best Bag Valve Mask (BVM) Technique

The two-person bag valve mask technique is superior to single-person technique and should be used whenever possible, with one rescuer maintaining a two-handed mask seal while the second rescuer compresses the ventilation bag. 1

Proper BVM Equipment Selection

• BVM devices should include a non-jam inlet valve, either no pressure relief valve or one that can be bypassed, standard 15-mm/22-mm fittings, an oxygen reservoir, and a non-rebreathing outlet valve 1
• Masks should be transparent to allow detection of regurgitation, create a tight seal on the face, and have an oxygen inlet with standard connector 1
• For adults, use a 1-2 L bag to deliver approximately 600 mL tidal volume, which is usually sufficient to produce visible chest rise 1
• For pediatric patients, select appropriately sized masks and bags to deliver age-appropriate tidal volumes 1

Two-Person BVM Technique (Preferred Method)

• One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal while the second rescuer compresses the bag 1
• The EC-clamp technique is effective for maintaining the mask seal: three fingers lift the jaw (forming an "E") while the thumb and index finger hold the mask to the face (making a "C") 1
• Both rescuers should observe the chest to ensure adequate rise 1
• This technique is particularly important when there is significant airway obstruction, poor lung compliance, or difficulty creating a tight seal 1, 2
• Research shows that two-rescuer BVM ventilation delivers significantly higher tidal volumes (mean 480 mL vs. 260-270 mL for single-rescuer techniques) 3, 4

Single-Person BVM Technique (When Second Rescuer Unavailable)

• BVM ventilation is challenging for a lone rescuer and is not recommended during CPR for a lone provider 1
• If absolutely necessary, the Thenar Eminence (non-dominant hand) - E-C (dominant hand) technique has been shown to be most effective for novice providers 5
• For lone rescuers during CPR, mouth-to-barrier device techniques are preferred over BVM 1

Proper Ventilation Technique

• Deliver each breath over approximately 1 second 1
• Use only enough force to make the chest visibly rise 1
• For adults with spontaneous circulation requiring ventilatory support, deliver breaths at a rate of 10-12 breaths per minute (1 breath every 5-6 seconds) 1
• If the chest doesn't rise, reopen the airway, verify the mask-to-face seal, and reattempt ventilation 1
• When using supplemental oxygen, maintain a flow of 10-15 L/min into a reservoir attached to a pediatric bag and at least 15 L/min for an adult bag 1

Avoiding Common Pitfalls

Preventing Excessive Ventilation

• Healthcare providers often deliver excessive ventilation during CPR, which is harmful 1
• Excessive ventilation increases intrathoracic pressure, impeding venous return and decreasing cardiac output, cerebral blood flow, and coronary perfusion 1
• It can cause air trapping and barotrauma in patients with small-airway obstruction 1
• It increases the risk of regurgitation and aspiration in patients without an advanced airway 1

Managing Airway Resistance and Bronchospasms

• Patients with airway obstruction or poor lung compliance may require higher inspiratory pressures 1
• Ensure your BVM device allows bypassing the pressure-relief valve if necessary to achieve visible chest expansion 1, 2
• For patients with bronchospasms, the two-person technique is strongly recommended to overcome increased resistance 2
• Use only enough force to achieve visible chest rise, even when dealing with increased resistance 2

Minimizing Gastric Inflation

• Deliver each breath over approximately 1 second to avoid excessive peak inspiratory pressures 1
• Cricoid pressure may be considered in unresponsive patients if an additional healthcare provider is available, but avoid excessive pressure that could obstruct the trachea 1

Oxygen Administration

• When available, use supplementary oxygen (concentration >40%, flow rate of 10-12 L/min minimum) 1
• An oxygen reservoir attached to the BVM allows delivery of higher oxygen concentrations (60-95%) 1
• Once circulation is restored, it may be reasonable to titrate oxygen to maintain oxyhemoglobin saturation ≥94% 1