Bag and mask Ventilation Presented by Sakun Rasaily, (Pediatric Nurse, Pediatric ward , B.P. Koirala Institute of Health Science Dharan, Sunsari (Nepal)

1. BAG and MASK VENTILATION
(BMV)
Sakun Rasaily, Staff Nurse
Pediatric –I
B.P. Koirala Institute of Health Science
Dharan, Sunsari (Nepal)

2. PRESENTATION OUTLINE
• INTRODUCTION OF BMV
• EQUIPMENT & PARTS
• TYPES / ADVANTAGES/ DISADVANTAGES OF BAG
• INDICATIONS
• PROCEDURE
• TECHNIQUE
• CONTRAINDICATIONS
• COMPLICATIONS
• NURSING MANAGEMENT.

3. INTRODUCTION
BAG and MASK VENTILATION:
• This is the most important airway skill.
• A basic airway management technique that allows for
oxygenation and ventilation of patients until a more
definitive airway can be established.
• Also used in cases where endotracheal intubation or
other definitive control of the airway is not possible.

4. Contd...
• In the pediatric population, BMV may be the
best option for prehospital airway support.
BMV ventilation is also appropriate for elective
ventilation in the operation theatre when
intubation is not required, but it is now often
substituted by the laryngeal mask airway

5. EQUIPMENT & PARTS OF BMV

6. PARTS OF BMV
The BMV consists of
1. The bag : a flexible air chamber , attached to a face mask via
a shutter valve which is squeezed to expel air to the patient.
2. Mask: a flexible mask to seal over the patients face,
3. Filter and valve : a filter & valve prevent backflow into the
bag itself (prevents patient deprivation and bag
contamination)
4. Oxygen Reservoir:
5. Pressure Gauge
6. Oxygen Connecting tube

7. Contd…..
• Provide a volume of 6-7 mL/kg per breath (approximately
500 mL for an average adult).
• For a patient with a perfusing rhythm, ventilate at a rate of 10-
12 breaths per minute.
• Adult size: 2 litres, Paediatric size:500 ml

8. TYPES OF BAG USED
1.Flow inflating bag (Anaesthesia Bag)
• Fills only when oxygen from a
compressed source flows into it
• Depend on a compressed gas source
• Must have a tight face-mask
seal to inflate
• Use a flow-control valve to
regulate pressure-inflation

9. 2.Self inflating bag (AMBU Bag)
• Fill spontaneously after they
are squeezed, pulling oxygen or
air into the bag
• Remain inflated at all times
• Can deliver positive-pressure
ventilation without a compressed
gas source.
• Require attachment of an oxygen reservoir to deliver 100%
oxygen

10. Advantages and disadvantages of types of bags
Advantages Disadvantages
Flow Inflating
Bag
•Delivers 100% oxygen at all times
•Easy to determine the adequacy
of seal
•Stiffness of lungs can be felt
•Can deliver PEEP or CPAP
•Requires a tight seal to remain
inflated
•Requires a gas source to
inflate
•No safety pop-off valve
•Requires more experience
Self Inflating
Bag
•Does not need a gas source to
inflate
•Pressure release valve/ Pop – off
valve set at 30 – 40 cm H20
•Easier to use
•Will inflate even without
adequate seal
•Requires a reservoir to deliver
100% oxygen
•Can not be used to deliver
100% free flow oxygen

11. THE THREE PILLARS OF AIRWAY
MANAGEMENT
:1Patency of Upper Airway : ( airflow integrity )
2Protection against aspiration
3Assurance of oxygenation and ventilation

12. INDICATION
• Respiratory failure
Failure of ventilation
Failure of oxygenation
• Failed intubation
• Elective ventilation in the operating room

13. PROCUDURE
• One hand to
• maintain face seal
• position head
• maintain patency
• Other hand for ventilation

14. BMV TECHNIQUE
• “Sniffing”position if C-spine OK
• Thumb + index finger to maintain face seal
• Middle finger under mandibular symphysis
• Ring and little finger under the angle of mandible

15. Bag and mask ventilation
Yes
No
Check for inadequate seal; reapply face mask
Chest Rise
No
Chest RiseYes
Check for blocked airway.
Reposition head, remove secretions, mouth slightly open
Chest RiseYes
No
Consider insufficient pressure. Increase pressure; consider intubation

16. Ventilate for 30 seconds
Rate 40-60 bpm
Increasing HR, visible rise and fall of chest
Check heart rate with stethoscope or umbilical palpation for 6 seconds
Less than 6 beats
(< 60bpm)
6-10 beats
(60-100bpm)
More than 10 beats
(>100 bpm)
•Continue ventilation
•Initiate chest compression
•Consider intubation
•Continue ventilation
•Consider intubation
•Check for
spontaneous
breathing
No Yes
•Continue positive pressure ventilation
•Consider intubation
•Consider OG tube insertion
•Need of post-resuscitation care
•Gradually discontinue
positive pressure ventilation
•Provide tactile stimulation
•Provide free flow oxygen
•Need of post-resuscitation care

17. WHY SNIFFING POSITION?
• Sniffing position allows for greater occipito-atlanto-
axial angulation.
• No exact definition has been established.
• However, 35 degrees neck flexion and 15 degrees
head extension is generally considered worldwide.
• Sniffing position prevents falling of tongue thus
preventing obstruction of the upper airway.

18. BMV DURING CPR
• During cardiopulmonary resuscitation (CPR), give 2 breaths
after each series of 30 chest compressions until an advanced
airway is placed. Then ventilate at a rate of 8-10 breaths per
minute.
• Give each breath over 1 second.
• If the patient has intrinsic respiratory drive, assist the
patient’s breaths. In a patient with tachypnea, assist every
few breaths.
• Ventilate with low pressure and low volume to decrease
gastric distension.

19. CRICOID PRESSURE
• Cricoid pressure consistencycy should be maintained not in all but in
emergency cases while appling BVM .
• It is the backward Pressure on cricoid cartilage with a force of 30-40
newtons
• This pressure is meant to compress the esophagus and reduce the risk
of aspiration.
• However, it does not completely protect against regurgitation,
especially in cases of prolonged ventilation or poor technique.
• Care must be taken to avoid excessive pressure, which can result in
compression of the trachea.

20. BMV VENTILATION: ASSESSMENT OF ADEQUACY
• Observe the chest rise and fall
• Good bilateral air entry
• Improving color
• Lack of air entering the stomach
• Feeling the bag
• Pulse oximetry (oxygen saturation)

21. CONTRAINDICATIONS
• In the case of complete upper airway obstruction.
• BVM ventilation is relatively contraindicated after paralysis
and induction (because of the increased risk of aspiration).
• Caution is advised in patients with severe facial trauma and
eye injuries.
• In addition, foreign material (e.g. gastric contents) in the
airway may lead to aspiration pneumonitis. In these
circumstances, alternative approaches, including endotracheal
intubation, may be necessary.

22. PREDICTORS OF A DIFFICULT
AIRWAY : BMV
• Upper airway obstruction
• Edentulous patients
• Beard
• H/O Snoring
• Obese
• Elderly >70 years
• Facial burns, dressings, scarring
• Poor lung mechanics
• resistance or compliance

23. DIFFICULT AIRWAY ADAGE
• The first response to failure of bag-mask ventilation is always
“better” bag-mask ventilation
• optimize airway position, triple airway maneuvre (head tilt,
chin lift, jaw thrust)
• place Oropharyngeal and Nasopharyngeal airways
• two-handed technique
• try lifting head off pillow to open airway
• Generate as much positive pressure as possible
without inflating the stomach

24. Contd...
If bag and mask still fails:
1. Intubate
2. If Cant ventilate, cant intubate
*Larngeal mask airway
*Cricothyroidotomy
*Needle Cricothyroidotomy and Transtracheal Jet
Ventilation

25. COMPLICATIONS OF BMV
Related to over-inflating or over-pressurizing the
patient, which can cause:
• Hypoventilation/ Hyperventilation
• Inflated air in the stomach (called gastric insufflation)
• Lung injury from over-stretching (called volutrauma)
• Lung injury from over-pressurization (called barotrauma)
• Lung aspiration
• Air Embolism

26. NURSING MANAGEMENT:
1. Promote respiratory function.
2. Monitor for complications
3. Prevent infections.
4. Provide adequate nutrition.
5. Monitor GI bleeding.

27. PROMOTE RESPIRATORY FUNCTION
1. Auscultate lungs frequently to assess for abnormal sounds.
2. Suction as needed.V/S recording and reporting.
3. Turn and reposition every 2 hours.
4. Secure ETT properly.
5. Monitor ABG value and pulse oximetry.

28. Suction of an Artificial Airway
1. To maintain a patent airway
2. To improve gas exchange.
3. To obtain tracheal aspirate specimen.
4. To prevent effect of retained secretions.
( Its important to OXYGENATE before and
after suctioning)

29. MONITOR FOR COMPLICATIONS
1. Assess for possible early complications
Rapid electrolyte changes.
Severe alkalosis.
Hypotension secondary to change in
Cardiac output.
2. Monitor for signs of respiratory distress:
Restlessness
Apprehension
Irritability and increase HR.

30. CONTD………
3. Assess for signs and symptoms of barotrauma(rupture of
the lungs)
Increasing dyspnea
Agitation
Decrease or absent breath sounds.
Tracheal deviation away from affected side.
Decreasing PaO2 level .
1. Assess for cardiovascular depression:
Hypotension
Tachy. and Bradycardia
Dysrhythmias.

31. • PREVENT INFECTION
1. Maintain sterile technique when suctioning.
2. Monitor color, amount and consistency of sputum.
• PROVIDE ADEQUATE NUTRITION
1. Begin tube feeding as soon as it is evident the patient will remain on the
ventilator for a long time.
2. Weigh daily.
3. Monitor I&O .
MONITOR FOR GI BLEEDING
1. Monitor bowel sounds.
2. Monitor gastric PH and hematest gastric secretions every shift.

32. • INTRODUCTION OF BVM
• EQUIPMENT & PARTS OF BVM
• TYPES / ADVANTAGES/ DISADVANTAGES OF BAG
• INDICATIONS
• PROCEDURE
• TECHNIQUE
• CONTRAINDICATIONS
• COMPLICATIONS
• NURSING MANAGEMENT.

33. ANY Questions PLZ!!!

34. REFERENCES
• http://emedicine.medscape.com/article/80184-overview
• www.proceduresconsult.com/.../bag-mask-ventilation-
EM-082-procedures
• https://en.wikipedia.org/wiki/Bag_valve_mask
• https://meds.queensu.ca/central/assets/modules/basic-
airway-management/bagmask_ventilation.html
• www.ncbi.nlm.nih.gov/pubmed/14717873
• www.slideshare.net