Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer

BVM Ventilation

Today I want to talk about proper ventilation with a Bag-Valve-Mask, aka the BVM. I am joined by my friend Reuben Strayer, MD of EM Updates. You’ll see Reub’s talk from this year’s EMCrit ED Critical Care Conference and hear some of my thoughts as well.

After Reuben’s lecture, I made a few points of my own:

  • Anesthesiologists can’t do one hand BVM as well as they think, at least according to this article: (Anesthesiology 2010; 113:873-9)
  • How about the best article on how to manipulate the jaw for optimal BVMing
  • Here is a link to an article where I discuss Vent as a Bag and here is the video as well.

need an audio-only version, (right click here and choose save-as), otherwise


Please use the Ultimate BVM



  1. Pressure Gauge
  2. One-Way Exhalation Port
  3. PEEP Valve
  4. ETCO2

Or Consider the Oxylator

And now to the Vodcast…


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  1. Minh Le Cong says

    Reuben, Scott, great podcast as always! insightful and entertaining. its so true that a lot of emergency airway management has to be relearned and retaught.I like the herd analogy..I watched a video of Al Sachetti talking on RSI and saying a lot of the problems with it are that we practice it like sheep..we do things because thats what everyone else does, not what might be sensible…or even evidence based. take cricoid pressure as an example.
    EMcrit has already proven it can teach life saving stuff to the masses and at least two patients owe their lives to your podcasts on surgical airway. I am sure even more patients will owe their lives to this podcast on resilient BVM technique!

  2. Steven Moore says

    Awesome show! On an anesthesia rotation as of present and was told at one point that “oral and nasal airways are for CRNAs not Anesthesiologists”. I think the attending was implying that it’s cheating to use those things, but when it comes to saving a life optimization is the name of the game not pride. Also thank you for confirming my suspicion that everyone sucks at CE ventilation, my hand were so worn out using the CE method it made it tough to properly maneuver the laryngoscope for intubation.

  3. says

    Scott, do you know of any studies supporting the use of multiple simultaneous basic airways (OPA/NPAs)? It seems to work well for most of us, but I haven’t come across anything in the literature — everyone just seems to have come up with it on their own.

    • says

      First time I came across the concept was Ron Walls’ airway course, but I don’t think those folks came up with the idea. I think it was in Benumof’s original textbook as well; I don’t think that was the origin either. Anyone know?

      • Jason N. Cook says

        Brandon.. I’m part of the west coast faculty of the Difficult Airway for EMS course & a flight paramedic/ground medic in Utah. The recommendation of using multiple airways is about maximizing the airway using all resources available to properly, efficiently, and safely ventilate our patients. When we first began teaching the concept, especially the recommendation of two NPA’s, we were met with quizzical glances and a lot of head scratching.

        Using a properly sized OPA & two properly sized NPA’s simultaneously, along with proper patient/airway positioning, provides us the most unobstructed, efficient delivery of oxygen via BVM. Couple this with GREAT (not good) BVM techniques of proper rate, VT, ventilation pressures, & application of PEEP, & you have succeeded in what I refer to as “sexy bagging”. I STRONGLY believe that if we as providers & educators really care about airway education & application, we HAVE to make bagging (w/all that that includes) the SINGLE MOST IMPORTANT technique we improve. Time to make bagging as “sexy” and as important as all of the ‘other’ advanced stuff that we do. Doing so improves pre-intubation oxygenation, lessens the chance of hypoxia during intubation, and most importantly… gives us ‘time’ to plan, prepare, and perform our airway ‘event’, rather than making hasty attempts at intubation.

        I believe we were taught, and have until recently, continued to practice & teach BVM ventilation wrong. I have so much respect for Ruben, Scott, Minh, Cliff, Walls, Murphy, Braude & others that are helping us all to realize & believe that there is a better approach to peri-intubation ventilation/oxygenation, intubation, RSI, video laryngoscopy, and a teamwork/checklist approach to airway encounters.

  4. Bill Hinckley says

    I’m interested in folks’ thoughts on the risk/benefit ratio of performing Sellick cricoid cartilage pressure during BMV to minimize gastric insufflation leading to puke in the airway. I believe Sellick during BMV was removed from the latest ACLS recommendations. I realize that if you’re bagging correctly, slow with low pressure, that you shouldn’t need it. However, I’ve seen very few folks of any discipline able to remain calm and cool enough in these situations to truly bag with low enough pressure to avoid insufflating the stomach. I also realize that there’s no guarantee that Sellick = an occluded esophagus. It just seems to me like, if there’s an extra hand available (not mine; I’m maintaining the both-thumbs-down mask seal) that it’s worth a shot to minimize the chance of the “game over”, puke-in-the-airway scenario. As long as you’re putting pressure on the correct cartilage (cricoid), it’s a complete ring and should not impede ventilation.

    • says

      We review all of the evidence against cricoid in this article (Ann Emerg Med. 2011 Nov 1. [Epub ahead of print] Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Weingart SD, Levitan RM.)

      It can be deleterious to your ventilations by obstructing the trachea. We have abandoned it entirely.

    • 50William says

      Flight medic here, I have personally caused a failed intubation (two man HEMS crew) which resulted in placement of a KING rescue airway due to my own overzealous use of poorly done sellick’s maneuver. I have also had the glidescope in the patient’s mouth when my partner added a slight amount of force to his poorly applied sellick’s maneuver and went from a grade 1 view to “nothing but meat.” I think the risk of potential missed intubation with resultant desat is much higher than the benefit of using sellick’s maneuver (assuming it prevents aspiration at all.) We have basically abandoned the practice. I am however, forcing the two-person two-hand mask ventilation technique as well as OPA+NPAx2 on all of my partners, even if they think it is overkill!

      Thanks for the great site

  5. Minh Le Cong says

    The problem with Sellick manoeuvre or cricoid pressure is that it its poorly taught and performed in a non standardised manner. We know from research that often it is applied in the wrong place and very often applied too lightly or with excessive pressure. It unfortunately has become standard of RSI care in many parts of the world and will likely remain so due to medico legal concerns. Attempts to conduct proper trials of its efficacy are unlikely to due to the fact its viewed as standard RSI care and ethics approval will be likely rejected.
    My proposal for such a controlled trial, at a major anaesthetic conference last year in Australia was met with the above comments.
    In my practice I have essentially abandoned its routine use but not completely. The research suggests that with proper training and practice, cricoid pressure applied in a standard manner should occlude the upper oesophagus with minimal effects on the trachea. Therefore in high aspiration risk cases I still apply cricoid pressure but ensure I show my assistant where to push, how hard and when to release it. So for upper GIT bleeders, intoxicated overdoses who have taken a bucket of pills orally, people at high risk of vomiting/regurgitation such as heavily pregnant women, trauma patients with a oral bleeding.

    If the patient is crashing and I don’t have the time to show my assistant proper cricoid pressure then I do not bother. You have to individualise your airway plan.

    Emergency airway management can be divided into life sustaining manoeuvres and non life sustaining stuff. Cricoid pressure is nice to do if done correctly, THEORETICALLY, but not life sustaining stuff in my view.

    and then RSA came along with second generation supraglottic devices ( game changer..get an airway in quickly, drain the stomach , don’t worry about cricoid)…and know this. The research does suggest that cricoid pressure, even when applied by experienced assistants, increases the difficulty of correct placement of a LMA and ventilation via a LMA.

  6. Monica Wachnik says

    I’m a relatively new practicing PA in ED & Critical care that just yesterday had problems ventilating a patient with a BVM that I RSI’d which my attending stepped in and used the 2-hand technique. It was impressively successful. I’m going to apply this to all my future resp failure/pre-intubation patients. I’ll have to ask her if she listened to your podcast.

    On another note, we all know the unfortunate statistical failures of prehospital intubations/ventilation and found your lecture phenomenal and truly believe that extending this info to the ems community can have vast improvements in respiratory maintenance. I just started to give lectures to paramedics and I hope you don’t mind that I extend your tips to them.

    • says

      As a practicing Paramedic: “Amen”. We’re universally taught poor airway management and are afforded few opportunities to learn the techniques in a controlled manner. The vast majority of our training is On the Job Training based on the Tradition of Care.

      Keep up the good work!

  7. says

    Soren Rudolph writes with this comment:
    Hi Scott
    Just heard Ruebens talk and it made me think of this little handy technique my friend Michael Seltz developed:

    Acta Anaesthesiol Scand. 2005 Feb;49(2):252-6.
    Tube tip in pharynx (TTIP) ventilation: simple establishment of ventilation in case of failed mask ventilation.

    Kristensen MS.

    Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. msk@rh.dk

    Mask ventilation occasionally fails. Alternative readily available and simple methods to establish ventilation in these cases are needed.

    Retrospective description of cases in which a new technique, tube tip in pharynx (TTIP) ventilation, was employed for restoring ventilation in case of failed facemask ventilation during induction of anaesthesia. The technique involves a standard endotracheal tube and can be performed single-handed: A standard endotracheal tube was placed via the mouth with the tip in the pharynx and the cuff was inflated. By placing the fourth and fifth fingers below the ramus of the mandible, the third finger below the lower lip, the second finger above the upper lip and on one side of the nose and the first finger on the other side of the nose, an open airway is restored. Chin lift is inherent in the grip, thus contributing to opening of the airway.

    In all four cases of failed mask ventilation the anaesthetist could establish an open airway and subsequent ventilation without the need for an assistant. There were no indications of gastric insufflation.

    The TTIP technique established ventilation in all four patients after abandoned facemask ventilation. The technique only involves one person and an endotracheal tube and warrants to be included in the armamentarium of anaesthetists. Further prospective studies are needed to refine the technique and delimit its indications.

    • Minh Le Cong says

      great idea. nice and simple with no need for fancy new gear. thinking outside the box..love it. The benefit of ventilation without an assistant as Reuben points out is questionable. No airway death should occur unless your best mask ventilation attempt is performed = 4 hands, two brains, minimum.

    • Anand Senthi says

      interesting idea but perhaps just inserting an LMA and ventilating through that would be simpler and more effective?

  8. says

    And the Strayer himself writes in with this comment:

    If I understood you correctly, you seem to recommend connecting the vent to the mask as a substitute for using an LMA straightaway. I don’t totally follow this, it seems like a separate issue. whenever you attempt bag mask ventilation you are probably better off using the vent, but what does this have to do with the decision of whether to use a mask or an LMA?

    Let me ask you this: do you agree that placing an LMA is easier than performing proper BVM? do you agree that an LMA is likely to be more effective than BVM for ventilation on the first try? If you agree with both of these statements, how can you not conclude that we should replace BVM ventilation with LMA ventilation? the only reason I can think of is that our BVM skill would erode. but our BVM skill sucks so bad anyway, I’m not sure this is a real concern.

    The answer is I don’t agree with either of those statements. BVM fails for three reasons in almost all patients–Poor Mask seal b/c of one hand BVM, too rapid a rate b/c of adrenaline, or the mouth being forced shut b/c there is no oral airway.

    2-hand mask seal, an oral airway, and using vent as a bag solves all three of these in almost all patients. In patients in whom this fails (who can be recognized immediately by no ETCO2 with ventilations), then pop in an LMA.

    In most patients the BVM will be much quicker, easier, and at least as effective. It should be a small consideration, but we must consider the cost of the LMAs as well if they could have been avoided easily.

    • Minh Le Cong says

      Reuben, I love your logical style ! I disagree though that placing a LMA is easier than proper BVM. As you teach ,proper BVM with two people, 4hands and two brains is not difficult. LMA placement whilst usually straightforward does have some nuances and can fail. If you assume our BVM skills suck, why assume our LMA skills are any better?
      Why are anaesthesiologists so formidable experts at airway management in general? Because they get to hone their BVM skills and LMA skills and ETI skills, hundreds of times per annum. It becomes automatic . which is paradoxically their greatest weakness in emergency airway crises.
      My point is there is a learning curve to LMA skills, more so than BVM skills. Ask any anaesthesiologist. In fact the greatest benefit I believe in OR airway training is in BVM and LMA skill development. The problem is the CE BVM technique is de rigeur in the OR. this teaches a less resilient technique for emergencies. Which is why your podcast is so important to emergency providers.

  9. says

    I certainly agree that if you use optimal bag mask ventilation technique, success rate will be very high, but will success rate be higher than an LMA?

    All the head to head studies favor LMA, but these studies don’t stipulate that BMV be performed using optimal technique, so I don’t think we know the answer to this question. But, because LMA delivers air directly to the glottis, I suspect that it is superior to even optimal BVM in terms of effective ventilation on the first attempt.

    Using optimal BMV technique is not difficult, but I think it’s hard to argue that optimal BMV technique is not more difficult than jamming in an LMA, which can be done with almost no training whatsoever.

    It is based on these two premises that I suggest LMA-first ventilation. In most environments, the cost of LMA in an intubated patient going to the ICU is trivial.

    But LMA-first ventilation is a cutting edge notion; I don’t feel strongly about it. The important message is optimal bag mask ventilation technique.

    • says

      I have to concur with Minh on this one (big surprise there), LMA is not a gimme in terms of insertion. Even after gaining experience with one version, it is not directly transferable to others. I had been trained on the Laerdal products with the method devised by Brain; it was only after hanging out with Dan Cook that I found much better ways of inserting the AirQ ILA (which Cook had invented).

      There are circumstances that I would go LMA first and not even try BVM vent–for instance UGI Bleeds.

    • Minh Le Cong says

      Ludwigs angina, whats going to be more successful. LMA or BVM? You decide.
      If they were breathing before you RSI, you can BVM them. Not so sure about LMA though! But should you RSI a Ludwigs?

      • Anand Senthi says

        good call on Ludwigs angina – BVM preferable. But on your 2nd comment- plenty of working airways have been lost after sedation/paralytics pushed. BVM not always possible … hence the traditional RSI CICV scenario and LMA is of course your bail out clause there.

  10. says

    All right you two jokers. I am not an anesthesiologist and haven’t placed hundreds of LMAs, but I routinely give LMAs to my residents who will, without ever having tried it, place it successfully, and once an LMA is seated properly, effective ventilation is extremely likely. I’m sure you _can_ screw it up, but it is pretty tough to screw up LMA insertion, especially compared to bag mask ventilation, which, as we all have witnessed, is easy to do poorly. There is literature to support this assertion.


    Another advantage to an LMA-first technique is that emergency providers gain experience placing LMAs, a skill I think you’ll agree is of great utility. In the end, however, your skill in bag mask ventilation will always be your safety net.

    • says

      If we believe that excellent LMA SR, then we would conclude that LMA led to more gastric insufflation than Mask, which seems to lack face validity.

      I think we agree that excellent BVM or LMA first are both good initial techniques and in a teaching program we should probably encourage the residents to learn both.

      • Anand Senthi says

        I have to agree with Reuben’s cutting edge LMA-first idea. This concept that we can only use one or the other technique and be trained in both is clearly incorrect.
        We should be trained in both but I can’t see any reason having thought about the pro’s/con’s that LMA-first technique is not a winner. Super quick and easy to place/remove, more effective ventilation, far better airway protection and presumably less gastric insufflation (though perplexed by Scott’s comment – have you got a reference I could check out?)
        Also agree that LMA is hard to screw up while BVM vent is easy to screw up.
        At the very least LMA-first should probably be taught as an equally viable alternative to BVM in any pretty much any situation post failed intubation. At the most it should probably be considered first line.
        Agree also that whether you use a ventilator or a bag on the end of the LMA/mask is a totally separate argument.

          • Anand Senthi says

            and sorry I just found the link Scott was referring to … odd finding re gastric insufflation and agree hard to believe

  11. Jason Garcia says

    I am a current Respiratory Care student and I would like to say this podcast had been very informative to airway management! I recently attended a conference in San Diego and this was a topic for emergency departments in the use of the new thumbs down technique, I think they called it the “shark hook” technique. I appreciate the lecture and then keep them coming!


      • Jason says

        The shark hook technique is when you grap the mandible and pull straight up and open the airway, facilitating the insertion of the laryngyscope blade without striking the teeth. Simultaneuosly pulling the tongue forward is and added trick, all accomplished without compromising spinal motion restriction. The two thumps UP technique, is the two handed mask seal, but the emphasis that we push here in San Diego is maximizing the 3rd and 4th fingers at the angle of the jaw, which provides the best chance for a good mask seal, especially in pts with obesity, facial hair, secretions etc…This is the core of our Airway training with the Flight Program I’m with, which Dr. Davis at UCSD is also our Medical Director. This technique is so effective, it can not be over emphasized. I have had countless success stories with this technique, and Im a Nurse, so ANYONE can do it right, doing it THIS WAY. Our Program has had amazing improvements directly related to extreme diligent efforts at pre-oxygenation, with this technique over the last 10 years. I have used the ventilator technique in-flight as well, I find it works well. Excellent topic, maybe the best one yet on EMCRIT.

        • says

          great description! i’m still trying to understand where the shark analogy comes in; is this some how analagous to the dorsal fin or is it related to a gaff used for sharks?

  12. Jason Garcia says

    @ Emcrit,

    I went to a conference in San Diego and the Attening ED for University of California San Diego did a persentation on Emergancy ventilation and coined the term “shark hook” to explain the same theory behind the two thumbs down ventilation. I’m assuming because of the hooks you use to do a jaw thrust behind the mandibles. Same technique just a different way of he said it. Thank you again and I will be looking forward to future podcast!


  13. Charles says

    LMA, LMA, LMA !

    How is the LTA Standing in all of this ? (King Airway)
    At least you can rapidly decompress the stomach
    And allow both the Pt And the intubator more time to better stabilise and prepare
    For definite Airway Control

    • says

      King LT-D is a fantastic device, especially perfect for prehospital airway management. The reason I want an LMA is that I can intubate straight through it and not need to take it out. Reuben likes the idea of LMA in, bag, lma out, intubate. I find this unwieldy–I want to try BVM, if it fails, immediate LMA, reoxygenate and then slide the bonfils fiberoptic scope down and tube with an 8-0.

  14. Jonathan Henglein says

    Hey Scott. Great topic. Real meat of resus. After this lecture, I reviewed your sedation podcasts and metabolic acidosis podcast. If I listened correctly, in all of them, you do not recommend a rate greater than 10-12 during bvm. I find this interesting. Would you consider a slight faster rate for the above scenarios or another scenario?

  15. Andre D says

    Hi Scott,
    Excellent as always. The replacement of the bag by the ventilator is an interesting idea. Using the patient as a test lung is one benefit. I wonder if you incorporate this into your idea of NIV for preoxygenation.

  16. Andre D says

    I was a bit confused thinking you used the ventilator to gently bag during the apnoeic period if a patient is high risk of desaturating ie NIV to preoxygenate, give drugs, set a mandatory back up resp rate to gently ventilate patient until drugs have taken effect. Hence the test lung comment, (more of a joke it was) since you can see the ventilator is working. After watching your other videos I realised you use it just to reoxygenate. I must admit, whilst being taught to not bag during the apnoeic period, I like to give a gentle puff just to see if I would be able to bag the patient if there’s a problem.

  17. Sarah says

    I like how you mentioned you hook up the ventilator to the bvm to free up your hands. I am working towards my PA and hoping to either go emergency or surgical. I work in the lab and do EMS work for experience. I am learning from your podcasts and hope to pick up more tips such as these. I also like how you break the information down, or during an interveiw you do a little time out just to explain to listeners. This is beneficial.

  18. Anthony says

    Hi I found the above video cast like many of the others on this website really usefull and interesting. As some one who does not regularly use a BVM i was shown the 2 handed technique during a placement in theatres and have found it invaluable in ensuring good ventilation. I can also confirm, like asking for help or using an LMA getting some one to squeeze the bag has not affected the size of my manhood!

    Thanks for all these great lectures.


  19. says

    Occasionally, you encounter new information and immediately recognize the value as a platform for a new paradigm. I teach BLS and ACLS within the California Prison System where, for security reasons, they have very little internet access. With your permission, I would like to burn a copy of your VODcast so I may share it with the nurses and physicians inside the prisons.


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