How Should You Deliver Breaths When Using A Bag Mask

Delivering effective breaths with a bag-mask ventilation (BMV) device is a critical skill for healthcare professionals, first responders, and anyone trained in basic or advanced life support. Proper technique ensures adequate oxygenation and ventilation for patients who are unable to breathe effectively on their own. Mastering this skill requires a thorough understanding of the equipment, correct hand placement, appropriate ventilation rates, and potential complications.

Understanding Bag-Mask Ventilation (BMV)

Bag-mask ventilation, sometimes referred to as manual ventilation, is a technique used to provide breaths to a patient who is not breathing adequately or not breathing at all. This can occur in various medical emergencies, including cardiac arrest, respiratory failure, drug overdose, or trauma. The goal of BMV is to deliver oxygen-rich air into the patient's lungs, allowing for gas exchange and preventing hypoxia.

The equipment used in BMV consists of three main components:

• The Bag: This is a self-inflating bag, typically made of silicone or rubber, that holds a volume of air or oxygen. Bag sizes vary, with adult bags typically holding 1500-2000 ml, and pediatric bags holding smaller volumes.
• The Mask: This is a soft, pliable mask that is placed over the patient's nose and mouth to create a seal. Masks come in different sizes to fit various facial structures, ensuring a tight seal and preventing air leaks.
• The Connector: This connects the bag to the mask, allowing the flow of air or oxygen from the bag to the patient. It often includes a one-way valve to prevent exhaled air from flowing back into the bag.

Indications for Bag-Mask Ventilation

Bag-mask ventilation is indicated in any situation where a patient's breathing is inadequate to maintain sufficient oxygenation and ventilation. Common indications include:

• Apnea: Complete cessation of breathing.
• Respiratory Arrest: The patient has stopped breathing.
• Respiratory Failure: The patient is breathing, but not effectively enough to maintain adequate oxygen and carbon dioxide levels in the blood.
• Bradypnea: Abnormally slow breathing.
• Tachypnea: Abnormally fast breathing with inadequate tidal volume.
• Decreased Level of Consciousness: When the patient's level of consciousness impairs their ability to protect their airway or breathe effectively.

Contraindications for Bag-Mask Ventilation

While BMV is a life-saving technique, there are some situations where it may be contraindicated or require special consideration:

• Facial Trauma: Severe facial injuries or deformities may make it difficult to achieve an adequate mask seal.
• Upper Airway Obstruction: A foreign body or other obstruction in the upper airway may prevent effective ventilation.
• Active Vomiting: BMV may increase the risk of aspiration. Suction equipment should be readily available.
• Laryngospasm: Spasm of the vocal cords may prevent effective ventilation.

Preparing for Bag-Mask Ventilation

Proper preparation is crucial for successful bag-mask ventilation. This includes assembling the equipment, positioning the patient, and selecting the appropriate mask size.

1. Gather Equipment: Ensure you have the following equipment readily available:
   • Bag-mask device with appropriate size mask.
   • Oxygen source with regulator and tubing.
   • Suction equipment.
   • Oral and nasal airways (if needed).
   • Gloves and personal protective equipment (PPE).
2. Check Equipment: Inspect the bag-mask device for any damage or leaks. Ensure the one-way valve is functioning properly. Connect the bag to an oxygen source and set the flow rate to 10-15 liters per minute.
3. Position the Patient: Place the patient in a supine position on a firm, flat surface. The head should be in a neutral or slightly extended position, unless contraindicated due to suspected spinal injury. If spinal injury is suspected, use the jaw-thrust maneuver to open the airway.
4. Open the Airway: Use the head-tilt/chin-lift maneuver to open the airway, unless contraindicated. Place one hand on the patient's forehead and gently tilt the head back while lifting the chin with the fingers of your other hand. Be careful not to compress the soft tissues under the chin.
5. Select Mask Size: Choose a mask that is the correct size for the patient's face. The mask should cover the nose and mouth without pressing on the eyes. A good fit is essential for creating a tight seal and preventing air leaks.
6. Insert Airway Adjuncts (if necessary): If the patient is unconscious and does not have a gag reflex, consider inserting an oral or nasal airway to help maintain an open airway. An oropharyngeal airway (OPA) is inserted into the mouth to keep the tongue from blocking the airway. A nasopharyngeal airway (NPA) is inserted into the nose and is generally better tolerated in patients with a gag reflex.

Delivering Breaths with a Bag-Mask

The technique for delivering breaths with a bag-mask involves creating a tight seal between the mask and the patient's face while squeezing the bag to deliver air into the lungs. This can be performed by one or two rescuers, with the two-rescuer technique generally considered more effective.

One-Rescuer Technique

The one-rescuer technique requires the rescuer to use one hand to hold the mask in place while using the other hand to squeeze the bag. This can be challenging, as it can be difficult to maintain a tight seal and deliver adequate ventilation at the same time.

1. Position Yourself: Position yourself at the patient's head.
2. Form a "C-E" Seal: Place the mask on the patient's face, ensuring it covers the nose and mouth. Use your thumb and index finger to form a "C" around the mask, pressing down to create a tight seal. Use your remaining three fingers to lift the jaw, forming an "E" shape with your fingers along the bony part of the jaw.
3. Squeeze the Bag: Use your other hand to squeeze the bag, delivering a breath over 1 second. Watch for chest rise to ensure adequate ventilation. Avoid squeezing the bag too forcefully, as this can cause gastric distension.
4. Ventilation Rate: Deliver breaths at a rate of 10-12 breaths per minute for adults (one breath every 5-6 seconds) and 12-20 breaths per minute for children and infants (one breath every 3-5 seconds).
5. Monitor: Continuously monitor the patient's chest rise, skin color, and vital signs to assess the effectiveness of ventilation.

Two-Rescuer Technique

The two-rescuer technique is generally considered more effective, as one rescuer can focus on maintaining a tight mask seal while the other rescuer focuses on delivering breaths.

1. Position Yourselves: One rescuer positions themselves at the patient's head to hold the mask, while the other rescuer positions themselves at the side to squeeze the bag.
2. Maintain a Two-Handed Seal: The rescuer holding the mask uses both hands to maintain a tight seal. Place both thumbs along the top of the mask and the remaining fingers along the bony part of the jaw, lifting the jaw upwards to create a tight seal.
3. Squeeze the Bag: The second rescuer squeezes the bag, delivering a breath over 1 second. Watch for chest rise to ensure adequate ventilation. Avoid squeezing the bag too forcefully.
4. Ventilation Rate: Deliver breaths at a rate of 10-12 breaths per minute for adults (one breath every 5-6 seconds) and 12-20 breaths per minute for children and infants (one breath every 3-5 seconds).
5. Coordinate: The two rescuers should coordinate their efforts to ensure effective ventilation. The rescuer squeezing the bag should watch for chest rise and communicate with the rescuer holding the mask to adjust the seal if necessary.

Key Considerations for Effective Ventilation

Delivering effective breaths with a bag-mask requires attention to detail and a focus on proper technique. Here are some key considerations to keep in mind:

• Mask Seal: Maintaining a tight mask seal is essential for preventing air leaks and ensuring adequate ventilation. Use the "C-E" technique or the two-handed technique to create a tight seal. If necessary, ask for assistance to help maintain the seal.
• Airway Positioning: Proper airway positioning is crucial for ensuring that air can flow freely into the lungs. Use the head-tilt/chin-lift maneuver or the jaw-thrust maneuver to open the airway. Consider using an oral or nasal airway to help maintain an open airway.
• Ventilation Rate: Deliver breaths at the appropriate rate for the patient's age and condition. Avoid hyperventilation, as this can lead to decreased cardiac output and cerebral vasoconstriction.
• Ventilation Volume: Deliver breaths with sufficient volume to produce visible chest rise. Avoid over-inflation, as this can cause gastric distension and increase the risk of aspiration.
• Oxygenation: Connect the bag-mask device to an oxygen source and set the flow rate to 10-15 liters per minute to deliver high-flow oxygen.
• Monitoring: Continuously monitor the patient's chest rise, skin color, and vital signs to assess the effectiveness of ventilation. Use a pulse oximeter to monitor oxygen saturation.
• Gastric Distension: Be aware of the risk of gastric distension, which can occur when air is forced into the stomach instead of the lungs. Avoid over-ventilation and use gentle ventilation techniques. If gastric distension occurs, consider applying gentle pressure to the abdomen to help relieve the distension.
• Aspiration: Be aware of the risk of aspiration, which can occur when stomach contents are regurgitated into the lungs. Have suction equipment readily available and be prepared to suction the airway if necessary.
• Fatigue: Bag-mask ventilation can be physically demanding, especially during prolonged resuscitation efforts. Rotate rescuers to prevent fatigue and maintain effective ventilation.

Troubleshooting Common Problems

Despite best efforts, problems can sometimes arise during bag-mask ventilation. Here are some common problems and how to troubleshoot them:

• Difficulty Maintaining a Seal:
  • Ensure the mask is the correct size for the patient's face.
  • Reposition the mask and try a different technique for holding the mask (e.g., "C-E" technique, two-handed technique).
  • Consider using a beard to create a better seal (if applicable).
  • Ask for assistance to help maintain the seal.
• No Chest Rise:
  • Check the airway for obstruction. Suction the airway if necessary.
  • Ensure the head is properly positioned.
  • Increase the ventilation volume.
  • Ensure the bag-mask device is functioning properly.
  • Consider using an oral or nasal airway.
• Gastric Distension:
  • Avoid over-ventilation.
  • Use gentle ventilation techniques.
  • Consider applying gentle pressure to the abdomen.
• Decreasing Oxygen Saturation:
  • Ensure the bag-mask device is connected to an oxygen source.
  • Increase the oxygen flow rate.
  • Ensure a tight mask seal.
  • Consider advanced airway management techniques (e.g., endotracheal intubation).

Advanced Airway Management

In some cases, bag-mask ventilation may not be sufficient to provide adequate oxygenation and ventilation. In these situations, advanced airway management techniques, such as endotracheal intubation or the use of a supraglottic airway device, may be necessary. These procedures should only be performed by trained healthcare professionals.

• Endotracheal Intubation: Involves inserting a tube into the trachea to secure the airway and allow for mechanical ventilation.
• Supraglottic Airway Devices: Devices such as the laryngeal mask airway (LMA) or the esophageal-tracheal Combitube are inserted into the pharynx to provide an airway without entering the trachea.

Conclusion

Delivering effective breaths with a bag-mask is a fundamental skill in emergency medicine. Proper technique, including maintaining a tight mask seal, ensuring proper airway positioning, delivering breaths at the appropriate rate and volume, and continuous monitoring, is essential for providing adequate oxygenation and ventilation to patients in respiratory distress. Regular practice and ongoing training are crucial for maintaining proficiency in this life-saving skill. By understanding the principles of bag-mask ventilation and mastering the techniques involved, healthcare professionals and first responders can be better prepared to manage respiratory emergencies and improve patient outcomes.