Are there societal guidelines for bagging a patient or using other noninvasive ventilation methods, such as Bi-level Positive Airway Pressure (BiPAP), after induction for Rapid Sequence Intubation (RSI), particularly in patients with underlying respiratory conditions like Chronic Obstructive Pulmonary Disease (COPD) or pneumonia?

Bag-Mask Ventilation After Induction for RSI: Guideline Recommendations

Bag-mask ventilation may be used to assist ventilation and prevent hypoxia after induction for RSI when indicated, despite traditional teaching to avoid it. 1

Current Guideline Position on Post-Induction Ventilation

The most recent consensus guidelines from the Difficult Airway Society, Association of Anaesthetists, Intensive Care Society, Faculty of Intensive Care Medicine, and Royal College of Anaesthetists (2020) explicitly address this question and represent a significant evolution from traditional RSI dogma. 1

Primary Recommendation: Gentle CPAP First, BMV When Needed

After reliable loss of consciousness, gentle continuous positive airway pressure (CPAP) may be applied if the seal is good, to minimize the need for mask ventilation. 1 This represents the preferred initial approach to maintain oxygenation while minimizing aspiration risk.

However, bag-mask ventilation may be used to assist ventilation and prevent hypoxia if indicated. 1 The guidelines are clear that preventing hypoxia takes priority over the theoretical aspiration risk from positive pressure ventilation.

Technical Specifications for BMV During RSI

When bag-mask ventilation is applied after induction, specific techniques must be followed: 1

• Use minimal oxygen flows and airway pressures consistent with preventing hypoxia 1
• Insert a Guedel airway to maintain airway patency 1
• Use the 2-handed, 2-person technique with VE-grip to improve seal, particularly in obese patients 1
• Ensure full neuromuscular blockade before attempting ventilation (wait 1 minute or use peripheral nerve stimulator) 1

Alternative: Supraglottic Airway Device

A second-generation supraglottic airway (SGA) may be inserted after loss of consciousness and before tracheal intubation to replace the role of bag-mask ventilation or if BMV is difficult. 1 This provides an alternative ventilation strategy that may offer better seal and control than face mask.

What About BiPAP/NIPPV After Induction?

The guidelines specifically state that non-invasive ventilation should be avoided during the RSI sequence itself. 1 However, this recommendation applies to the period after induction and paralysis have occurred.

NIPPV Has a Role Before Induction

Noninvasive positive pressure ventilation (NIPPV) is recommended for preoxygenation in patients with severe hypoxemia (PaO2/FiO2 < 150). 2, 3 This occurs before administering sedative-hypnotic and neuromuscular blocking agents, not after.

High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging as an apneic oxygenation strategy. 2, 3 Again, this is initiated during preoxygenation and may continue during the apneic period.

Clinical Algorithm for Post-Induction Ventilation Strategy

Step 1: Ensure Adequate Preoxygenation

• Standard patients: 3-5 minutes with well-fitting mask 1
• Severe hypoxemia: Use NIPPV for preoxygenation 2, 3
• Anticipated difficult laryngoscopy: Consider HFNO 2, 3
• Agitated/uncooperative: Use medication-assisted preoxygenation (delayed sequence intubation with ketamine) 2, 3

Step 2: After Induction and Full Paralysis

• First choice: Apply gentle CPAP with good mask seal 1
• If hypoxia develops: Initiate bag-mask ventilation using 2-person VE-grip technique with minimal pressures 1
• If BMV difficult: Insert second-generation SGA 1

Step 3: Proceed to Intubation

• Use videolaryngoscope when available 1
• Aim for first-pass success 1

Special Population Considerations

Patients with COPD or Pneumonia

While the evidence shows that COPD patients have increased risk of ventilator-associated pneumonia and that pneumonia increases mortality in hospitalized COPD patients 4, 5, these concerns relate to prolonged mechanical ventilation, not brief bag-mask ventilation during RSI.

The same guidelines apply regardless of underlying respiratory condition—preventing hypoxia takes priority. 1 The brief period of positive pressure ventilation during RSI does not significantly increase aspiration risk compared to the catastrophic consequences of severe hypoxemia.

Patients with Duchenne Muscular Dystrophy

The American College of Chest Physicians specifically recommends that DMD patients with FVC <50% predicted should be considered for assisted or controlled ventilation during induction and recovery from anesthesia. 1 This represents a population where post-induction ventilatory support is explicitly endorsed.

Critical Pitfalls to Avoid

Pitfall 1: Dogmatic Avoidance of BMV Leading to Hypoxia

Traditional RSI teaching emphasized "no bagging" to prevent aspiration. Modern guidelines prioritize preventing hypoxia over theoretical aspiration risk. 1 Severe desaturation causes immediate harm; aspiration risk during brief, gentle BMV is theoretical and manageable.

Pitfall 2: Using Excessive Pressures During BMV

When BMV is necessary, use minimal pressures consistent with preventing hypoxia. 1 High pressures increase gastric insufflation and aspiration risk.

Pitfall 3: Poor Mask Seal Technique

Single-handed C-grip technique should be avoided. 1 Always use 2-person, 2-handed VE-grip technique for optimal seal and minimal leak. 1

Pitfall 4: Attempting BMV Before Full Paralysis

Ensure complete neuromuscular blockade before ventilation attempts to prevent coughing and laryngospasm. 1 Wait 1 minute after rocuronium or use peripheral nerve stimulator. 1

Pitfall 5: Inadequate Preoxygenation

The incidence of oxygen desaturation during RSI can be as high as 35.9% when preparation is inadequate. 6 Meticulous preoxygenation for 3-5 minutes is essential to maximize safe apnea time. 1

Context-Specific Nuances

COVID-19 and Aerosol-Generating Procedures

The 2020 guidelines were developed specifically for COVID-19 airway management, where aerosol generation is a major concern. 1 Even in this high-risk aerosol context, the guidelines explicitly permit BMV when needed to prevent hypoxia, emphasizing that it should be done with proper technique and minimal pressures. 1 This represents the most conservative scenario; in non-aerosol-generating contexts, the threshold for using BMV would be even lower.

Equipment Preparation

A closed circuit system is optimal (anesthetic circle breathing circuit), and a rebreathing circuit is preferable to standard bag-mask which expels exhaled gas. 1 Place an HME filter between catheter mount and circuit. 1