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Training Day: Practice proper bag-valve mask ventilation techniques

Train for different BLS and ALS techniques so you can deliver an adequate breath to every patient, every time


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“Kneel with your patient’s head secured between your knees and secure the face mask with one hand while squeezing the bag against your opposite thigh.”

That’s the way I was taught to efficiently ventilate a patient when on the scene of a respiratory arrest.

That’s even how I initially taught new EMTs and EMRs early in my career as an instructor. I was simply teaching them what I had been told – until I realized that what I was being told was bad practice.

Whether you’re ventilating via bag-valve face mask, supraglottic airway or endotracheal tube, proper airway maintenance begins in the classroom. (image/Bound Tree Medical)
Whether you’re ventilating via bag-valve face mask, supraglottic airway or endotracheal tube, proper airway maintenance begins in the classroom. (image/Bound Tree Medical)

So I changed my philosophy, actions and teaching habits, and adopted a better (safer) way of ventilating my patients.

It all started with my initial training. I had been set up for poor practice on this. Yes, it worked, but the potential to do patient harm also existed, and that doesn’t rest easy with me. I wanted to do no harm. I wanted to deliver an adequate breath every time.

Know your ventilation rate

If you’re an EMS instructor, I encourage you to time your students. No, don’t see how many ventilations they’re capable of providing within a minute’s time. Rather, see how many they’re actually delivering when they count to three, when they count to six or when they’re tasked with rescue or asynchronous breathing during continuous chest compressions.

Environment has a lot to do with it, so change the environment for your students when you evaluate ventilation. Start in a controlled environment, right at the beginning of the skills portion of their class, then monitor them for one or two minutes. Have the room quiet, put them at the head of their manikin with nothing but a bag-valve with a mask and have them ventilate.

I would anticipate that their rate would be spot on, with once every three seconds (for pediatrics) or six seconds (for adults).

Now change the environment. Have them complete a chapter test, and then move directly into a BVM evolution, or have them perform two minutes of continuous chest compressions and then have them deliver proper BVM ventilations.

Do you notice a difference? Do you anticipate a difference? I do.

Focus on proper volumes

In the equation of providing ventilations at an adequate rate, adequate volume is an important factor. Just as hyperventilating is bad for the patient, so is hyperinflating.

Basic ventilations provided through a face mask require a different volume of air than through an endotracheal tube (due to the elimination of dead space). As such, we need to practice with both, with all advanced airways. Not only should we be monitoring the patient for chest rise, we should also be monitoring them for (the absence) of gastric inflation, which is likely due to hyperventilation or hyperinflation.

Delivering adequate ventilation

I encourage all my EMS students to modify how they ventilate their patients – at least, with how many fingers they utilize to perform this vital skill. Three fingers – that’s it – for ventilating an adult patient. Two fingers if you’re ventilating a child or infant, in which case, infants only get a two-finger puff of air.

Using only three fingers will set you up to better control your rate, because it will become cumbersome to ventilate rapidly with this method, as well as your volume and pressure. Nice and easy – that’s how you’ll see these ventilations being performed, with a good volume and pressure in the process, the way they’re supposed to be delivered.

Whether you’re ventilating via face mask, supraglottic airway or endotracheal tube, remember that proper airway maintenance begins in the classroom. It’s also instilled in the classroom, reinforced in the classroom and perfected in the classroom.

Not too fast, not too much, nice and easy – it’s a delicate skill. So delicate, in fact, that patients can die as a result of it being performed improperly, or as a result of it being performed without a focus on being delivered adequately, every time.

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