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
Updates:
Please use the Ultimate BVM
- Pressure Gauge
- One-Way Exhalation Port
- PEEP Valve
- ETCO2
Head Rotation for BVM
Or Consider the Oxylator
More on BVM Use
- Kovacs from AIME
- How to Grade Quality of BVM Vent
- Why to Bag during Apneic Period1
Refs
Additional New Information
More on EMCrit
- EMCrit 127 – The Oxylator with Jim DuCanto(Opens in a new browser tab)
- EMCrit 206 – ApOx, ENDAO, & PreOx Update(Opens in a new browser tab)
- Preoxygenation, Reoxygenation and Deoxygenation(Opens in a new browser tab)
- EMCrit 172 – Vent as Bag & VAPOX
- EMCrit 217 – The Ultimate “Ultimate” BVM
Additional Resources
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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… Read more »
thank you for those kind comments, my friend
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.
Have not seen literature to support the devices, if any of you find any, please post here.
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.
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?
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… Read more »
thank you, Jason
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… Read more »
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.
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… Read more »
Love it, you are totally on the right track from my perspective.
agree – definite known risks outweigh theoretical unproven benefits for cricoid pressure
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… Read more »
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… Read more »
Monica–by all means spread the word! Thanks for listening
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!
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. Source Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. msk@rh.dk Abstract BACKGROUND: Mask ventilation occasionally fails. Alternative readily available and simple methods to establish ventilation in these cases are needed. METHODS: Retrospective description of cases in which a new technique, tube tip in pharynx (TTIP)… Read more »
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.
interesting idea but perhaps just inserting an LMA and ventilating through that would be simpler and more effective?
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… Read more »
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… Read more »
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… Read more »
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.
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?
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.
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. http://www.springerlink.com/content/fpq101633l107825/ Another advantage to an LMA-first technique is that emergency providers gain experience… Read more »
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.
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… Read more »
sorry my first line should read “can’t be trained in both”
and sorry I just found the link Scott was referring to … odd finding re gastric insufflation and agree hard to believe
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
Jason, thanks for commenting. What did they mean by shark hook?
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… Read more »
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?
Finally got the answer to the naming of the shark hook technique.
See the image courtesy of Jason Lanning and Dr. Davis.
@ 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!
Jason
do they do much shark fishing in San diego?
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
Charles
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.
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?
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.
Thanks,
not sure what you mean by using your patient as a test lung
for how the vent is incorporated into preox, see these videos: EMCrit Preox Page
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… Read more »
I definitely advise bagging during apneic period in the acidotic patient and I use the ventilator to do it just as you have surmised.
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.
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.
Anthony
Paramedic
UK.
Very true my friend
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.
Thanks for the DSI talk at SMACC
Really Enjoyed
Here’s a five min video I shared with our faculty (from the NursePath and AIMEE) which I thought summed up the issues you raised with a nice Demo – https://youtu.be/PJiRABugTfg
Well, after 30 years practicing anesthesiology i didn’t think i would learn any game changing trick – Well, i just did!