What is the recommended breathing rate when using a Bag-Valve-Mask (BVM) during a code?

BVM Ventilation Rate During Cardiac Arrest

During a code without an advanced airway, deliver 2 breaths during a brief pause after every 30 chest compressions, with each breath given over 1 second; once an advanced airway is placed, deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are performed. 1

Without an Advanced Airway

The compression-to-ventilation ratio is 30:2 - you perform 30 chest compressions followed by a brief pause (less than 10 seconds) to deliver 2 breaths. 1

Key Technical Points:

• Each breath should be delivered over approximately 1 second 1
• Deliver approximately 500-600 mL tidal volume (6-7 mL/kg), which should produce visible chest rise 1
• The pause for ventilations should be brief - about 3-4 seconds total for both breaths 1
• Minimize interruptions in compressions - aim for a chest compression fraction of at least 60% 1

Critical Pitfall to Avoid:

Do not hyperventilate. Excessive ventilation (too many breaths or too large a volume) increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival. 1 This is a Class III recommendation (harm) - meaning you should actively avoid this. 1

With an Advanced Airway (Endotracheal Tube or Supraglottic Airway)

Once an advanced airway is placed, the paradigm changes completely. You no longer use the 30:2 ratio. 1

• Deliver 1 breath every 6 seconds (10 breaths per minute) 1
• Chest compressions continue without pauses at a rate of at least 100 per minute 1
• Ventilations are asynchronous - you don't coordinate breaths with compressions 1

The 2020 AHA Guidelines note this is a Class IIb recommendation (may be reasonable), as the optimal ventilation rate with an advanced airway remains somewhat uncertain, though 10 breaths per minute is the established standard. 1

Practical Algorithm:

1. Start CPR → 30 compressions : 2 breaths
2. Continue 30:2 ratio until advanced airway is placed
3. Once advanced airway secured → Switch to continuous compressions + 1 breath every 6 seconds
4. Monitor for visible chest rise with each breath to ensure adequate volume 1
5. Avoid excessive ventilation at all stages 1

Additional Context:

The evidence strongly supports that during the early minutes of sudden cardiac arrest (particularly VF), chest compressions are more critical than ventilations because arterial oxygen content remains adequate initially. 1 However, for prolonged arrests and asphyxial arrests (drowning, children), both compressions and ventilations are essential. 1

BVM ventilation is most effective with 2 providers - one to seal the mask and open the airway, the other to squeeze the bag. 1 For a lone rescuer, BVM is not the recommended method. 1