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Be Great at Face Mask Ventilation

How many pairs of underwear you buy in your career depends mostly on how good you are at ventilation (BVM)

– Reuben Strayer

The Letter – Why you should make the BVM your best friend


Most people think they’re familiar enough with how to use the bag valve mask (BVM) that is hanging on the side of that crash cart, but it’s amazing how unbelievably bad the face mask ventilation (FMV) technique of most providers is when those skills are put to the test in an emergency. Don’t be one of those. The BVM is one of three important upper airway lifelines for managing the airway of critically ill patients, and in the time of COVID19, proper technique is even more essential to keep yourself and your team members safe.

In fact, it’s perhaps the most important airway tool in your arsenal. As Reuben Strayer @emupdates argues in the video below: you can be an average intubator with good BVM skills and stay out of trouble. By contrast, you can be an excellent intubator and find yourself in some scary situations if you have poor BVM skills.

There is no one in the FOAMed world who has highlighted the need for mastery of the BVM with more laconic humor and no nonsense practicality than Dr Reuben Strayer @emupdates Take the 11 minutes needed to watch this great video and you will understand the paramount importance of having skill with a BVM.

Bottom line if you’re grabbing that BVM it means you need to know how to use it. Many don’t, and what’s worse, is that once it’s clear they’re not succeeding in adequately oxygenating with the BVM, many providers also fail to adjust their technique: continuing to deliver poor oxygenation for prolonged periods of time, or rushing headlong into attempt(s) at intubation. Usually, this only makes things worse: increasing the likelihood you will fail at your first intubation attempt due to increased stress and urgency, and putting your patient at risk of prolonged hypoxia, and peri-intubation arrest. Successful oxygenation with a BVM gives you the invaluable gift of time: time to breath, to plan your next move, and to gather your team and resources for an orderly attempt at a definitive airway. .

apply the twin concepts of optimization & best effort to your fmv strategy

We also cover these twin concepts at the Protected Airway Course. Take a moment to watch this introductory video.


  1. Start with 2 person, Two Thumbs Down technique
  2. No good? Then check your mask seal, optimize your jaw thrust, and try again.
  3. Good seal & good jaw thrust but resistance?  Check for FB or need for suction
  4. No FB obstruction? Place oral and nasal airway(s)
  5. Good ventilation but still hypoxic?
  6. Check O2 flow
  7. Attach PEEP valve
  8. Still hypoxic? MOVE ON

BVM skills are even more important in the time of COVID19. Proper technique with a good seal, a viral filter, and a PEEP valve will help protect your patient, you, and your team in an airway emergency

This whole process should happen rapidly over the course of 2-3 minutes.

Still nothing?  Take time to optimize but don’t over-analyze. If you’ve achieved your best effort with FMV accept that it’s time to move on to another oxygenation strategy! The power in knowing how to optimize your FMV technique is that it will give you the confidence to know when you’ve definitively achieved your best effort and move your team forward with another upper airway lifeline like a laryngeal mask airway while you prep for a surgical solution should it become necessary..

Remember the Importance of PEEP

Even if you get everything right and you feel that you’re ventilating your patient well, they may remain hypoxic due to the underlying cause of their respiratory failure. Alveoli filled with fluid will create areas of dead space and reduce the efficiency of ventilation.

Fortunately, there’s a simple tool available that will improve this situation. The bad new? It’s not standard on most BVMs. So don’t forget to place that simple PEEP valve on your BVM. Here’s a demonstration of how to do it.

A demonstration of why it’s important to use a PEEP valve for better lung recruitment.

Thanks to my friend Chris Root @gueromedico for demonstrating this at the Protected Airway course in 2016.