Effective bag-valve-mask ventilation saves lives Simple techniques help you ensure proper ventilation of patients in respiratory distress or respiratory arrest.

By Huy Vo, MSN, CRNA; Matthew Park, MSN, CRNA; and Simson Wang, MSN, CRNA

your patient piratory distress can progress to ROBERT WALKER *, in the postanesthesia care unit, is respiratory arrest. recovering from laparoscopic chole - cystectomy. The anesthesia provider When you need BVM tells you that the patient’s history is You should use BVM ventilation in unremarkable and surgery went or res - the following situations: well. When you speak to Mr. Walker, piratory ar - • a patient whose breathing is he’s lethargic but awake and fol - rest using bag- bradypneic, tachypneic, shallow, lowing commands. His vital signs valve-mask (BVM) ventilation. or weak are normal, and he’s receiving oxy - Ap plying these tips can help you • a patient who has a decreased gen by face mask. He complains of save precious time. level of consciousness with or moderate abdominal pain, and the without decreased oxygen satu - anesthesiologist prescribes I.V. hy - What can go wrong ration dromorphone. Fifteen minutes later, The respiratory system acts as a • a patient who is not breathing. you notice that Mr. Walker’s breath - conduit for exchanging oxygen and These indications are part of the ing is slow and shallow. He doesn’t carbon dioxide and fueling cells. ABCs of resuscitation, which start respond to verbal commands but (See Airway A & P primer .) When after you call for help when you awakens with vigorous tactile stim - gas exchange is interrupted, respi - find a patient in respiratory distress. ulation. His pulse oximetry reading ratory distress may occur. This dis - • Airway. Is the airway open? If drops from 99% to 90%. What tress may be associated with an up - the patient is unconscious, open should you do? per-airway obstruction, such as the airway using the head Your knowledge and skill in ba - pharyngeal edema, laryngeal ede - tilt/chin lift (or jaw thrust if you sic airway management can mean ma, trauma, or a foreign body suspect a cervical spine injury). the difference between life and lodged in the airway. But the most • Breathing. Is the patient breath - death for your patient. This article common cause of an upper-airway ing? If so, how effective are the offers simple, helpful tips for man - obstruction is the tongue. (See breaths? In Mr. Walker’s case, his aging patients in respiratory distress Tongue trouble .) Left untreated, res - respiratory distress presents as

American Nurse Today Volume 12, Number 2 AmericanNurseToday.com 6 Airway A & P primer The anatomy of the respiratory system can you’re providing ventilation, watch be divided into two parts: the upper and for the rise and fall of your pa - lower airway. The upper airway, which is in - tient’s chest, listen for clear breath volved with ventilation , includes the nose, sounds on auscultation, and check pharynx, and larynx. Patients undergoing for improved oxygen saturation and general anesthesia are intubated with an skin color. endotracheal tube, which is inserted past Applying techniques you learned the larynx and into the trachea, for the dura - in basic life support help you man - tion of surgery. age the patient’s airway and ensure The lower airway, which includes the tra - effective BVM ventilation. chea, bronchi, and lungs, plays a part in oxygenation . Ventilation and oxygenation are often Using the head-tilt /chin-lift used interchangeably, but they have two maneuver distinct definitions. Ventilation moves air Use the head-tilt/chin-lift maneuver in and out of the lungs, while oxygenation to open a patient’s airway, unless is the process by which gas exchange of you suspect cervical spine injury, in oxygen occurs. Think of ventilation as the which case, you should use a mod - physical act of breathing involving the up - ified jaw thrust. Position the mask per-airway structures (nose, pharynx, and so it covers the patient’s nose and larynx) and oxygenation as the physiologi - mouth. If the mask sits over the pa - cal act of breathing involving the lower-airway structures (trachea, bronchi, and tient’s chin, you may have to read - lungs). just it so it sits near the edge of the chin, or get a smaller mask. slow, shallow breaths and a tient’s breathing by gently and falling pulse oximetry reading. slowly squeezing the BVM to pro - Inserting an oral or nasal airway He needs your help with BVM. vide assistive ventilation. If you can’t provide adequate venti - • Circulation. Does the patient Be aware that hyperventilation lation, the patient’s tongue may be have a pulse? If not, start chest and overinflation forces air into the obstructing the upper airway. Use compressions. Fortunately, Mr. stomach, which can lead to gastric an oral or nasal airway to displace Walker has a pulse. distention and place the patient at the tongue forward. You can learn Be sure a colleague gathers es - risk for aspiration. Also, the patient more about selecting and correctly sential airway management equip - won’t be adequately ventilated. As placing oral and nasal airways at ment, using the S.O.A.P. mnemonic to ensure everything necessary is brought to the bedside: S—Suction Tongue trouble O—Oxygen The illustration on the left shows the patient’s tongue obstructing the upper airway. In A—Airway (BVM, oral and nasal the illustration on the right, the patient’s head has been properly positioned to move airways, endotracheal tube, the tongue forward, so air can flow into the lungs. laryngoscope blade, and airway crash cart) P—Pharmacy (advanced cardiac life support drugs that are found on many crash carts).

Performing BVM ventilation In patients like Mr. Walker who are experiencing respiratory distress but still breathing, use BVM ventilation to provide assistive breaths. Attach the BVM to an oxygen flow meter at greater than 10 L/min. Place the mask over the patient’s mouth and nose with one hand and, using Wikimedia commons, Vassia Atanassova (Spiritia) your other hand, follow the pa -

AmericanNurseToday.com February 2017 American Nurse Today 7 Proper finger placement during BVM ventilation the American Red Cross website: . Getting and maintaining a tight seal on the bag-valve-mask (BVM) requires proper https://goo.gl/ONBzDT technique. These photos illustrate what to do and what not to do. Maintaining a tight seal To ensure oxygen is delivered to the lungs, you need an airtight seal over the patient’s mouth. To main - tain that seal, use the E-C tech - nique to hold the BVM: First, cre - ate a C-shape with your thumb and index finger over the top of the mask and apply gentle downward Correct: With the middle, ring, and pinkie Incorrect: In this photo, the middle, ring, and pressure. Then hook your pinkie, fingers placed along the mandibular bone, pinkie fingers are on the soft tissue under ring, and middle fingers around the the mandible is pulled up into the mask. the chin, which will worsen airway obstruc - patient’s mandible and lift it up to - The index and thumb are used to create a tion by pulling the tongue farther into the tight seal around the mouth and nose. posterior pharynx. Also, the mask is pushed ward the mask, creating an E. into the patient’s face. Another option is the E-O tech - nique. In this method, you use the web between your thumb and in - dex finger to encircle the neck of Troubleshooting BVM problems the mask, while you lift the chin The following table, organized using the MOANS acronym, lists difficulties you might with your other fingers to provide encounter when using a bag-valve-mask (BVM), along with potential solutions. chin lift. If you have difficulty with the Difficulty Solutions one-handed E-C or E-O techniques and another provider is with you, Mask seal Difficulty maintaining mask Use water-soluble lubricant over facial switch to the two-handed, two- seal on patients with facial hair to seal contact between mask hair, large facial structures, or and face. Use oral airway if having person technique. Using both no teeth difficulty obtaining adequate seal hands, grasp each side of the pa - with facial hair or no teeth. Consider tient’s face using the E-C tech - two-hand, two-person ventilation. nique. Then pull the mandible up into the mask to provide an air - Obese Difficulty maintaining mask Use oral or nasal airway to displace seal and providing adequate redundant tissue and open airway. tight seal. While you maintain the breaths due to increased re- Place patient in reverse Trendelenburg seal, the other provider ventilates dundant tissue (such as a large position with a roll under patient’s the patient. tongue, thick neck, or excess head when attempting to use BVM. adipose tissue around face or This displaces excess abdominal and Clinical pearls neck) around upper airway, chest tissue weight, allowing im- Using correct BVM technique, you which can lead to obstruction proved chest expansion with ventila- can ensure proper ventilation of a tion. Goal is to achieve horizontal patient in respiratory distress or line from external auditory meatus to sternal notch. In morbidly obese respiratory arrest. Positioning your patients, two-person technique hands correctly on the mask and works best. assessing for potential challenges increase your chance of success. Age > 55 Difficulty maintaining mask seal Use oral airway to open patient’s with older patients airway. Leave dentures in place to improve mask seal. Pull, don’t push A common mistake when perform - No teeth Difficulty maintaining mask seal Use oral airway to improve mask seal. ing BVM ventilation is to push the on patients with poor dentition Leave dentures in place to improve or no teeth mask seal. mask onto the patient’s face while delivering breaths. This pushes the Stiff Difficulty providing adequate Use albuterol or ipratropium to tongue farther into the posterior breaths to patients with asthma, bronchodilate lungs; use PEEP valve, pharynx, exacerbating the upper- COPD, ARDS, or pregnancy if available. airway obstruction. To provide ade - BVM: bag valve mask; COPD: chronic obstructive pulmonary disease; ARDS: acute respiratory distress quate ventilation, use the “E” fin - syndrome; PEEP: positive end-expiratory pressure gers (pinkie, ring, and middle)

American Nurse Today Volume 12, Number 2 AmericanNurseToday.com 8 Airway from the E-C technique to pull the discharged home without further patient’s mandible into the mask, management problems. while at the same time using your is the single most thumb and index fingers to hold important skill Huy Vo, Matthew Park, and Simson Wang are the mask in place. certified registered nurse anesthetists at the University of California at Los Angeles. Grasp bone, not soft tissue needed to save a life. Another common mistake is using *Names in clinical scenarios are fictitious. the fingers to grasp the soft tissue beneath the mandible. Like push - Airway management saves lives Selected references ing on the mask, grasping the soft Regardless of your patient’s comor - Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the tissue can push the tongue into bidities, using the simple tech - difficult airway: an updated report by the the posterior pharynx, worsening niques described in this article pro - American Society of Anesthesiologists Task the obstruction. Use the E-C or E- vides you with the tools you need Force on Management of the Difficult Air - O techniques to avoid this error. to react quickly and appropriately way. Anesthesiology . 2013;118(2):251-70. (See Proper finger placement dur - when your patient suffers respirato - Brown EN, Solt K, Purdon PL, et al. Monitor - ing BVM ventilation .) ry distress or respiratory arrest. Re - ing brain state during general anesthesia. In: Miller RD, ed. Miller’s Anesthesia . 8th ed. member, airway management is the Philadelphia, PA: Elsevier Saunders; 2015: MOANS single most important skill needed 1524-40. The MOANS mnemonic—mask to save a life. Butterworth JF, Mackey DC, Wasnick JD. Air - seal, obese, age over 55, no teeth, way management. In: Morgan & Mikhail’s and stiff—helps for problems you Fortunately, your prompt inter - Clinical Anesthesiology . 5th edition. New may encounter with the mask. vention with a BVM to assist Mr. York, NY: McGraw Hill; 2013: 309-42. These challenges can be overcome Walker’s breathing sustains him Umesh G, Krishna R, Chaudhuri S, et al. E-O when you have the necessary ma - until he receives naloxone to re - technique is superior to E-C technique in manikins during single person bag mask terials and equipment nearby. (See duce the sedative effect of hydro - ventilation performed by novices. J Clin Troubleshooting BVM problems .) morphone. He does well and is Monit Comput . 2014;28(3):269-73.

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