Chapter 7

Providing effective ventilation and oxygenation using a bag-mask is probably the single most important aspect of airway management. Bag-mask-ventilation (BMV) refers to the use of a bag-valve-mask (BVM) system/device to deliver gas rich in oxygen either passively or actively by manually ventilating the patient using a face-mask interface. Manual noninvasive ventilation also accurately describes the use of a BMV device to provide positive pressure ventilation (PPV). This should be differentiated from mechanical noninvasive ventilation which also uses a face-mask interface but provides respiratory effort assistance (PPV) delivered by specialized ventilator.

### 7.1.1 Is There Still a Role for Bag-Mask-Ventilation in This Advanced World of Difficult Airway Devices?

Definitive airway management has traditionally been defined as the placement of an endotracheal tube in the trachea. Although few would argue that there has been a philosophical and evidence-based shift away from defining airway management by the method of gas exchange to focus on the goals of resuscitation namely, maintaining patient oxygenation and ventilation while preserving hemodynamic status. In other words, endotracheal tubes do not save lives; providing adequate perfusion and gas exchange does. Oxygenation and ventilation may be provided using endotracheal tubes, extraglottic devices, BMV devices, and surgical methods. Which method is most appropriately employed will depend on patient characteristics, the clinical situation, and practitioner's skill.

Bag-mask-ventilation particularly in the prehospital setting has been shown to be no less effective than endotracheal intubation (ETI) or extraglottic device (EGD) use.1-3 With mounting evidence that prehospital ETI is of questionable benefit and in certain scenarios potentially harmful, alternative methods of maintaining oxygenation and ventilation, including BMV are being reaffirmed as an essential airway management skill.4-10

Bag-mask-ventilation has been compared to other ventilatory strategies in the prehospital, operating room, and simulation settings.11-22 Extraglottic devices, such as the laryngeal mask airway (LMA) and Combitube™, have become accepted intermediate alternatives to BMV and go to options in failed intubation and failed BMV (or "can't intubate, can't ventilate") scenarios.

There is a theoretical advantage in using EGDs in patients suffering a of cardiac arrest where chest compressions can continue uninterrupted. In general, however, ventilation has been deemphasized in the early phase of adult nonasphyxia-related resuscitation, where oxygen delivery is more dependent on blood flow than on arterial oxygen content.

This is in keeping with the recent American Heart Association recommendation in which ventilation is de-emphasized in the early phase of adult non-asphyxia related resuscitation because oxygen delivery has been shown to be more dependent on blood flow than arterial oxygen content. Ultimately, however, the American Heart Association guidelines recommend BMV as an equivalent option compared to other advanced life support (ALS) options (ETI, LMA, or Combitube) stating that "there is no evidence that advanced airway measures improve survival rates in the setting of prehospital cardiac arrest."11

Bag-mask-ventilation is a challenging skill to learn and perform effectively.23-25 Despite the advent ...

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