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Providing effective oxygenation and ventilation using a facemask is probably the single most important component of airway management. The ability to oxygenate and ventilate immediately, in almost any environment and potentially stabilize a critically ill patient makes face-mask ventilation (FMV) one of the cornerstone interventions with which all practitioners in the operating room, emergency department (ED), and prehospital environment must be proficient. FMV refers to the use of a bag-mask unit, most of which but not all have valves (in which case they are referred to as Bag-Valve-Mask units or BVMs) system/device to deliver gas rich in oxygen either passively or actively by manually ventilating the patient using a facemask interface. Examples of non-valved bag-mask devices include Mapleson E (Jackson Rees Modification of Ayres T-piece) and other t-piece occluding systems. Manual noninvasive ventilation also accurately describes the use of an FMV device to provide positive pressure ventilation (PPV). This should be differentiated from mechanical noninvasive ventilation, which also uses a facemask interface but provides respiratory effort assistance (PPV) delivered by specialized ventilator.

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

Definitive airway management has traditionally been defined as the secure placement of an endotracheal tube (ETT) in the trachea. 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’s oxygenation and ventilation while preserving hemodynamic status. In other words, ETT doesn’t save lives, whereas providing adequate perfusion and gas exchange does. Optimal oxygenation and ventilation may be provided using ETTs, extraglottic devices (EGDs), FMV devices, and surgical methods. Which method is most appropriately employed will depend on patient characteristics, the clinical situation, and practitioner’s skill.

Face-mask ventilation, particularly in the prehospital setting, has been shown to be no less effective than endotracheal intubation (ETI) or EGD use.1–4 In a large prospective population-based study of out-of-hospital cardiac arrest (OHCA) patients, survivors who received FMV had more favorable neurologic outcomes compared to those who had their airway managed by ETI or EGD.5 With increasing controversy regarding the value of prehospital ETI, other means of maintaining oxygenation and ventilation including FMV are being reaffirmed as an airway management priority.6–12

For OHCA, 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. There is consensus that advanced airway management should not be considered a priority over CPR/defibrillation and has the potential of causing harm by interrupting CPR, from complications of airway management, impairing cerebral perfusion, and perhaps inadvertent hyperventilation.11 The use of EGDs in the context of cardiac arrest may theoretically provide benefit as they do not require an interruption in chest compressions for placement and use.


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