Bag-Valve-Mask Ventilation

In recent weeks at The Alfred ICU’s ‘Airway and Bronchoscopy’ teaching (held every Thursday morning) we emphasised the importance of effective bag-valve-mask (BVM) ventilation.

Points of emphasis:

  • ensure optimal positioning
  • a two-handed approach to obtaining mask seal is the most effective technique. There is evidence that the C-E technique is not as effective as the ‘two thumbs up’ approach. Even anaesthetists ventilate better with two hands holding the mask compared to when they are using just one
  • ideally use airway adjuncts (oropharyngeal and nasopharyngeal airways) when using a bag-valve-mask – this will help optimise airway patency and ventilation
  • if cricoid pressure is applied it may impede ventilation, remove cricoid pressure if ventilation is difficult

This superbly produced 11 minute videocast by Reuben Strayer from EM Updates is an excellent guide to BVM ventilation:

The MOANS mnemonic is a quick aid to predicting who will be difficult to ventilate:

Mask seal e.g. Beards, blood on the face, or facial trauma
Obesity / Obstruction e.g. Obesity, pregnancy, angioedema, Ludwig’s angina, upper airway abscess, epiglottitis
Age Age > 55
No teeth Consider leaving dentures in place in edentulous patients
Sleep apnea / Stiff lungs e.g. OSA, COPD, asthma, ARDS


  • Bag-valve-mask (BVM) ventilation (LITFL Critical Care Compendium)
  • El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009 Dec;109(6):1870-80. doi: 10.1213/ANE.0b013e3181b5881c. Review. PubMed PMID: 19923516. [Free Full Text]
  • Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth. 2013 May;25(3):193-7. doi: 10.1016/j.jclinane.2012.10.009. Epub 2013 Mar 21. PubMed PMID: 23523573.
  • Hart D, Reardon R, Ward C, Miner J. Face mask ventilation: a comparison of three techniques. J Emerg Med. 2013 May;44(5):1028-33. doi: 10.1016/j.jemermed.2012.11.005. Epub 2013 Mar 7. PubMed PMID: 23473817.
  • Joffe AM, Hetzel S, Liew EC. A two-handed jaw-thrust technique is superior to the one-handed “EC-clamp” technique for mask ventilation in the apneic unconscious person. Anesthesiology. 2010 Oct;113(4):873-9. doi: 10.1097/ALN.0b013e3181ec6414. PubMed PMID: 20808210. [Free Full Text]

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