Bag-Mask Ventilation

Positive pressure ventilation

Ventilation of the lungs
single most important and most
effective step in cardiopulmonary
resuscitation of the compromised
newborn

INDICATIONS
To ventilate and oxygenate a patient.
A ventilation face mask may be used
with an oropharyngeal or
nasopharyngeal airway during
spontaneous, assisted, or controlled
ventilation.

CONTRAINDICATIONS
In patients with full stomach, cricoid
pressure must be maintained to
avoid vomiting and aspiration.
Risks
vomiting and aspiration.

EQUIPMENT
Ventilation bags (manual resuscitator) come in 2
types: self-inflating bag and flow-inflating bag.
Ventilation bags used for resuscitation should be self
inflating.
Ventilation bags come in different sizes: infant, child,
and adult.
Face masks come in many sizes.
A ventilation mask consists of a rubber or plastic
body, a standard connecting port, and a rim or face
seal.
Supplemental oxygen can be attached to ventilation
bags to provide oxygen to the patient.

A good resuscitation bag

Size 200-750 ml
Capable of avoiding excessive
pressure
A pressure pop-off valve and/or a
pressure gauge manometer

Capable of giving 100% oxygen

Appropriate sized mask

Resuscitation bags
Two types
Flow inflating bag (anesthesia bag)
Self inflating bag

Flow inflating bag

Flow inflating bag

Fill only when oxygen from a
compressed source flows into them
Depend on a compressed gas source
Must have a tight face-mask seal to
inflate
Use a flow-control valve to regulate
pressure-inflation

Flow inflating bag will not

work if
The mask is not properly sealed over
the newborns nose and mouth
There is a tear in the bag
The flow-control valve is open too
wide.
The pressure gauge is missing

Flow inflating bag

Advantages

Delivers 100% oxygen at all times

Easy to determine the adequacy of
seal
Stiffness of lungs can be felt
Can be used to deliver 100% free
flow oxygen

Flow inflating bag

Disadvantages

Requires a tight seal to remain

inflated
Requires a gas source to inflate
No safety pop-off valve
Requires more experience

Self inflating bag

Self inflating 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; user must be certain
the bag is connected to an oxygen source for the
purpose of neonatal resuscitation
Require attachment of an oxygen reservoir to
deliver 100% oxygen

Without Reservoir

With Reservoir

Self inflating bag

Advantages

Does not need a gas source to inflate

Pressure release valve
Easier to use

Self inflating bag

Disadvantages

Will inflate even without adequate

seal
Requires a reservoir to deliver 100%
oxygen
Can not be used to deliver 100% free
flow oxygen

Masks
Cushioned/Non-cushioned
Round/Anatomical shaped
Size 0 or 1

Correct position of mask

Testing the self-inflating bag

Squeeze against your palm
Pressure felt
Pressure release valve
Pressure manometer
Re-inflation

Sizes:
Bag
Adult------1600 ml.
Child-------500 ml.
Infant-------500 ml.
Mask
Adult------Size 4
Child------Size 2
Infant------Size 1
Reservoir
Adult------suitable for 1600 ml. bag
Child / Infant---Suitable for 500 ml. bag
Tubing
Having suitable connectors at both
ends for easy and safe connections.

 Bag-mask ventilation gives the clinician time to

prepare for more definitive airway management.
Good technique involves preserving good maskface seal, inflating the chest with minimal
required pressure, and maintaining the optimal
patency of the upper airway through
manipulation of the mandible and cervical spine.
The mask should extend from the bridge of the
nose to the cleft of the chin, enveloping the nose
and mouth but avoiding compression of the eyes.
The mask should provide an airtight seal.
The goal of ventilation with a bag and mask
should be to approximate normal ventilation.

PATIENT PREPARATION
Sedation may be required before
beginning.

PATIENT POSITIONING
A neutral sniffing position without
hyperextension of the neck is usually
appropriate for infants and toddlers.
Avoid extreme hyperextension in
infants because it may produce airway
obstruction.
In patients with head or neck injuries,
the neck must be maintained in a
neutral position.

ANATOMY REVIEW
The upper airway consists of the oropharynx, the
nasopharynx, and supraglottic structures.
The cricoid cartilage is the first tracheal ring,
located by palpating the prominent horizontal
band inferior to the thyroid cartilage and
cricothyroid membrane.
Cricoid pressure occludes the proximal esophagus
by displacing the cricoid cartilage posteriorly. The
esophagus is compressed between the rigid cricoid
ring and the cervical spine.

PROCEDURE

Sequence
Open the airway via chin lift/jaw thrust maneuver.
Seal the mask to the face.
Deliver a tidal volume that makes the chest rise.

 E-C Clamp Technique

Tilt the head back and place a towel beneath the
head.
If head or neck injury is suspected, open the
airway with the jaw thrust technique without
tilting the head.
If a second person is present, have that person
immobilize the spine.

Apply the mask to the face.

Lift the jaw using the third, fourth, and fifth fingers
from the left hand under the angle of the mandible;
this forms the E
The thumb and forefinger form a C shape to tightly
seal the mask onto the face while the remaining
fingers of the same hand form an E shape to lift the
jaw, pulling the face toward the mask.

 When lifting the jaw, the tongue is also lifted

away from the posterior pharynx.
Do not put pressure on the soft tissues under the
jaw because this may compress the airway.

Place the thumb and forefinger of the left

hand in a C shape over the mask and exert
downward pressure
Create a tight seal between the mask and the
patients face using the left hand and lifting the
jaw.
Compress the ventilation bag with the right hand.
Be sure the chest rises visibly with each breath.

 If 2 people are present, then 1 person

can hold the mask to the face while
the other person ventilates with the
bag.
One person uses both hands to open the
airway and maintain a tight mask-to-face
seal
The second person compresses the
ventilation bag.

 If 2 or 3 people are present, someone can

apply pressure to the cricoid cartilage
(termed Sellick maneuver) to limit
gastric distention in unconscious patients
The Sellick maneuver may also prevent
regurgitation and aspiration of gastric
contents.
Avoid excessive cricoid pressure because it
may produce tracheal compression and
obstruction or distortion of the upper airway
anatomy.

To relieve gastric distention, a nasogastric

tube can be placed (if not
contraindicated).

MONITORING
Use pulse oximetry to measure
oxygen saturation levels
continuously.
Measure heart rate continuously.
Check blood pressure using a
noninvasive device.
Ensure the chest rises visibly.

COMPLICATIONS
Reduction in cardiac output.
Vomiting and aspiration.
Air trapping, barotrauma, air leak,
and reduced cardiac output can be
caused by excessive tidal volume
and rate in patients with small airway
obstruction (eg, asthma and
bronchiolitis).