Optimization of Face-Mask-Ventilation – and every other lifeline for that matter – begins the same way every time: fundamental airway manipulation.

There are 2 core manipulation techniques that instantly open the airway in an unresponsive, apneic patient. These maneuvers reposition the patient and make anatomy work for you, not against you. You should perform them in every patient who is hypoxic, even before reaching for any of the three lifelines. They are:

• Jaw Thrust
• Head-Tilt, Chin-Lift

Jaw Thrust

The jaw thrust maneuver involves placing your thumbs and thenar eminences over the patient’s cheekbones and using the other eight fingers to reach behind the angle of the mandible to displace the entire jaw forward (creating an underbite).

Yes, just like the vice grip, but without the face mask.

This lifts all the structures of the anterior airway (tongue, epiglottis, muscles, fat) away from the posterior oropharynx, creating an unobstructed airway.

Check out this brief video from the NEJM that shows just how dramatic an impact the jaw thrust maneuver has.

Fun Tip: forcing the mandible forward with your hands can be quite painful (try it on yourself). While this wouldn’t be very nice to an awake patient, performing a jaw thrust in a patient who is unexpectedly found to be unresponsive kills three birds with one stone: 1) it opens the airway, and 2) allows you to assess the patient’s level of responsiveness to pain, and 3) triggers the patient to wake up and take a breath. This can be very helpful in a patient who is intoxicated with a CNS depressant (opioid, EtOH).

Head-Tilt, Chin-Lift

Just like the jaw thrust, this maneuver works by displacing the structures of the anterior airway away from the posterior oropharynx. Just by tilting your head back and lifting your chin, the airway becomes more patent. Try it on yourself: touch your chin to your chest and take a breath, then tilt your head back and take a breath. Can you see the difference?

This quick video shows you how to perform the head-tilt, chin-lift maneuver:

This is key to face mask ventilation. Whether you’re performing the one-person or the two-person technique, the head-tilt, chin-lift maneuver will significantly improve your ventilation.

Caution: Avoid the head-tilt, chin-lift maneuver if you suspect that your patient may have a C-spine injury!! In this case, the jaw thrust maneuver is preferred. This will usually require more than one pair of hands: someone to hold the c-spine, someone to hold the mask & jaw thrust (vice grip), and someone to bag.

No two patients are the same. Facial hair, dentures, facial structure, age-related changes, and prior surgery can all influence the effectiveness of face-mask ventilation. Providing high-quality, equitable care requires recognizing these normal variations and understanding how to adjust your technique accordingly. Let’s take a moment to review two common clinical presentations you are almost guaranteed to encounter and the specific modifications that optimize mask seal and ventilation.

Dentures

If you never thought about what you would do if you were bagging a patient with dentures, and if you never made a plan for this specific scenario, your instinct might be to treat dentures as a foreign body and remove them immediately.

And you’d be correct for 2 out of 3 airway lifelines. Unfortunately, not for FMV.

While removing all obstacles is preferred for endotracheal intubation or supraglottic airway placement, an effective mask seal depends on the structural fullness of the face. Dentures help maintain facial contour and provide a stable surface for the mask cushion to seat. When dentures are removed, the loss of support can lead to inward collapse of the cheeks and lips, increasing air leak and making ventilation more difficult. Hence the mnemonic:

“BAG IN, TUBE OUT”

Bag refers to BVM, and tube refers to ETT (or SGA).

Beard

Facial hair disrupts the contact between the mask cushion and the skin, allowing air to escape and making it harder to generate adequate tidal volumes. Unlike dentures, this is not about structural support. It is about seal integrity.

To compensate, you must improve the seal. Strategies include applying a water-soluble gel to the beard to reduce air leak, or using a large piece of occlusive transparent dressing (e.g., Tegaderm ®) to cover the facial hair and cutting/poking a hole for ventilation.

Perhaps more than any other lifeline, face-mask ventilation can be significantly improved with three very simple, yet very powerful adjuncts:

In a nutshell, the first two help bypass or displace upper airway anatomy, thereby decreasing airflow resistance. The third adds resistance at the exhalation port of the BVM, and thus increases the pressure against which the patient exhales (PEEP), allowing the alveoli to remain filled and oxygenated.

Because of how powerful these three adjuncts are, they will be covered in depth in the next three stations of the FMV section.

Choosing the right mask size and optimizing its fit on the face can dramatically improve your ability to oxygenate. A properly sized mask will rest on the patient’s nasal bridge superiorly, cover the nose and the entire mouth, and rest in the crease just above the mental prominence inferiorly.

A mask that is too small will fail to cover the lips properly, and allow the air to leak inferiorly:

Conversely, a mask that is too big will either extend below the chin causing a leak inferiorly, or it will sit over the orbits/eyes and lose seal superiorly:

You are never truly prepared to manage an airway without oxygen and suction! They are the first two things you reach for as a critical patient arrives.

In fact, if there is only one thing you take home from today’s lesson, let it be this:

YOU SHALL NEVER MANAGE AN AIRWAY WITHOUT OXYGEN OR WITHOUT SUCTION.

Oxygen

You can’t deliver oxygen with a BVM if it isn’t connected to an oxygen source. Making sure oxygen is actually flowing is critical. It seems obvious in a calm environment or on a manikin. But during a real resuscitation, under stress and adrenaline, simple things get missed. Building oxygen checks into the Vortex Approach as part of optimization creates a powerful, lifesaving cognitive safeguard.

Suction

Blood? Saliva? Emesis? The type of contamination is irrelevant. What is relevant, however, is that it will prevent you from properly oxygenating your patient. What can you do? Suction! Suction early. Suction aggressively. Suction frequently. A clear, decontaminated airway = increased success with every single lifeline.

As the final category of optimization strategies recommended by the Vortex Approach, “Muscle Tone” is consistent and relevant across all three lifelines, not just FMV.

It refers to pharmacologic sedation & paralysis, used in general anesthesia and rapid sequence induction.

While the process of RSI and the pharmacology of sedatives and paralytics are beyond the scope of this installation, the bottom line is this: the more awake, tense, and agitated your patient is, the more difficult it will be to ventilate them.

Sedation reduces protective reflexes, and neuromuscular blockade (paralysis) eliminates active airway resistance and muscle opposition. Jaw tension resolves, vocal cords relax, and chest wall compliance improves. Without competing spontaneous effort, positive-pressure ventilation becomes more controlled and efficient. The goal is to work for the patient, not against them.

If you want to dive deeper into RSI and airway pharmacology, click the buttons below to visit our dedicated learning spaces and purchase full access to our content.

“A simple tool that turns obstruction into oxygenation.”

The Essentials

Overview

The oropharyngeal airway (OPA) is a rigid, curved adjunct designed to keep the upper airway patent by preventing posterior displacement of the tongue and soft tissues against the posterior pharyngeal wall. It is a basic, fast, low-cost intervention used to facilitate oxygenation and ventilation, most commonly during bag-mask ventilation (BMV) and resuscitation.

Description

An OPA is typically made of hard plastic and consists of:

• Flange (bite block): Rests on the lips/teeth and limits depth of insertion, can reduce occlusion from biting.
• Curved body: Conforms to oral and pharyngeal anatomy.
• Distal tip: Sits above the epiglottis in the oropharynx when properly positioned.

OPAs come in multiple sizes (often color-coded by manufacturer). Proper sizing and correct insertion technique determine success and reduce complications.

Indications

Use an OPA when you need airway patency in a patient who cannot reliably maintain their own airway.

Common indications:

• Unconscious patient with absent or markedly blunted gag reflex
• Airway obstruction from tongue/soft tissue collapse (snoring respirations, poor air entry with BMV)
• To facilitate effective BMV (improves seal and reduces obstruction)
• During resuscitation (CPR, peri-intubation optimization, post-intubation bite protection in select settings)

Clinical goal: improve alveolar ventilation/oxygen delivery by reducing upper airway obstruction.

Contraindications

Absolute (practical)

• Intact gag reflex / awake or semiawake patient
  • High likelihood of gagging, vomiting, and laryngospasm.

Relative

• Significant oral trauma (unstable teeth, severe mucosal injury)
• Recent oral surgery or known friable oral tissues
• Severe trismus or inability to open the mouth adequately
• Ongoing active vomiting (risk of aspiration, consider alternative strategy)

If an OPA is not tolerated or triggers gagging, move to alternatives (positioning, jaw thrust, NPA if appropriate, two-person BMV optimization).

Sizing

Correct size matters. Too small can push the tongue backward or fail to relieve obstruction, too large can cause trauma or worsen obstruction.

Standard sizing method:

• Measure from the corner of the mouth to the angle of the mandible.

Quick clinical check:

• The flange should rest on the lips, and the distal tip should reach the oropharynx without “bottoming out” or riding shallow.

When in doubt between two sizes, it’s often safer to start with the size that matches the corner-of-mouth-to-angle-of-mandible measurement, then adjust based on effectiveness and tolerance.

Technique for Placement

Preparation

1. Position: Place the patient in a sniffing or neutral position appropriate to the context; use head tilt–chin lift or jaw thrust as needed (jaw thrust if trauma concerns).
2. Suction: Clear blood, secretions, or vomitus as feasible.

Insertion (Adult)

Two common approaches are used; choose the one that minimizes trauma and maximizes control.

Method A: 180° rotation (classic adult technique)

1. Open the mouth using a scissor technique or jaw thrust.
2. Insert the OPA upside down (concavity facing up) along the tongue.
3. Advance until the distal tip approaches the soft palate.
4. Rotate 180° so the concavity faces down, following the curve of the tongue.
5. Seat the flange on the lips/teeth.

Method B: Tongue depressor / direct insertion

1. Use a tongue depressor (or laryngoscope blade if appropriate) to move the tongue forward.
2. Insert the OPA in its final orientation (concavity down) without rotation.
3. Advance gently until the flange rests on the lips.

Method B can reduce the risk of pushing the tongue posteriorly and may reduce mucosal injury in some hands, but it requires more deliberate control.

Confirmation of Effect

• Improved ease of BMV (less resistance, better chest rise)
• Reduced “snoring” or obstructive sounds
• Improved ventilation parameters if monitored (capnography waveform during BMV, oxygenation trends)

Troubleshooting and Removal

• Gagging/vomiting: remove immediately, suction, reposition, consider an alternative adjunct.
• Worsened obstruction: suspect incorrect size or malposition; remove and re-size, optimize head position, and jaw thrust.
• Remove when the patient regains airway reflexes or can maintain their airway, unless it is serving a specific role under close monitoring.

Complications (worth knowing)

• Dental or soft tissue trauma, bleeding
• Gagging, vomiting, aspiration
• Laryngospasm (especially if not deeply unconscious)
• Worsened obstruction from incorrect sizing or placement

🎧 Deep Cuts

The essentials give you the foundation.
This is where we sharpen it.

“A patent airway without opening the mouth.”

The Essentials

Overview

The nasopharyngeal airway (NPA) is a soft, flexible airway adjunct inserted through the nostril to maintain upper airway patency by bypassing obstruction at the level of the tongue and soft palate. It is especially useful when the mouth cannot be opened, when an oropharyngeal airway is not tolerated, or when you need an adjunct in a patient who is not deeply unconscious.

Description

An NPA is typically made of soft rubber or flexible plastic and consists of:

• Flange: Rests at the naris and limits depth of insertion.
• Flexible tube: Traverses the nasal passage into the nasopharynx.
• Beveled distal tip: Helps guide insertion and reduce trauma.

NPAs come in multiple diameters and lengths (often manufacturer color-coding). Correct sizing and lubrication are key to safe, effective use.

Indications

Use an NPA when you need to improve airway patency and the patient may not tolerate an OPA, or oral access is limited.

Common indications:

• Upper airway obstruction from tongue/soft tissue collapse (snoring respirations, poor air entry with BMV)
• Facilitation of bag-mask ventilation (particularly when an OPA triggers gagging)
• Patients with intact or partially intact gag reflex who still need an adjunct
• Trismus, clenched jaw, or limited mouth opening
• Adjunct during suctioning/airway toileting when appropriate

Clinical goal: reduce upper airway resistance and improve effective ventilation/oxygen delivery.

Contraindications

Absolute (practical)

• Known or suspected basilar skull fracture or severe midface trauma (classic “don’t” scenario)
• CSF rhinorrhea or clear signs of anterior skull base injury

Relative

• Significant nasal trauma or suspected nasal bone/cribriform injury
• Severe coagulopathy/anticoagulation (higher epistaxis risk)
• Nasal obstruction (polyps, severe septal deviation), prior nasal surgery
• Active epistaxis

If facial trauma is present, decide deliberately. When concern for skull base injury is high, avoid NPA and use other airway strategies.

Sizing

You need the right diameter and length.

Diameter (French size)

• Choose a size that approximates the patient’s small finger or nostril diameter.
• Typical adult sizes often used: 7.0–8.0 mm internal diameter (varies by manufacturer), smaller for petite adults.

Length

• Measure from the tip of the nose to the tragus of the ear (or angle of mandible, depending on local teaching).
• Too short fails to bypass obstruction, too long can irritate the larynx and provoke coughing or laryngospasm.

When in doubt, prioritize adequate length to reach the nasopharynx while ensuring gentle insertion and patient tolerance.

Technique for Placement

Preparation

1. Position: Neutral or sniffing as appropriate. Use jaw thrust if needed.
2. Select nostril: Ask about prior fractures, obstruction, or “better side” if awake. Inspect quickly for patency if time allows.
3. Lubricate generously: Water-soluble lubricant reduces trauma and epistaxis risk.
4. Consider topical vasoconstrictor if available and clinically appropriate (institution-dependent), especially if bleeding risk is a concern.

Insertion

1. Hold the NPA with the bevel toward the septum (common approach to reduce turbinate trauma).
2. Insert into the nostril along the floor of the nose (straight back, not up).
3. Advance gently with steady pressure. If resistance is met:
   • Stop, withdraw slightly, adjust angle, rotate subtly, and re-advance.
   • If still resistant, try the other nostril or a smaller size.
4. Advance until the flange rests on the naris.

Avoid force. Force creates bleeding, swelling, and a worse airway.

Confirmation of Effect

• Improved ease of BMV, better chest rise
• Decreased obstructive sounds (less snoring/stridor from soft tissue collapse)
• Improved ventilation monitoring if available (capnography waveform during assisted ventilation)

Troubleshooting and Removal

• Epistaxis: remove if significant, apply pressure, suction, switch nostril/size, or use alternative adjunct.
• Coughing/gagging: may indicate the tube is too long, too large, or patient is too reactive. Remove and reassess.
• No improvement: suspect incorrect size, malposition, or a different primary problem (seal, severe obstruction below the pharynx, laryngospasm, bronchospasm).

Remove when no longer needed or if complications occur.

Complications (worth knowing)

• Epistaxis and nasal mucosal trauma
• Turbinate injury, rare ulceration with prolonged use
• Gagging/coughing, laryngospasm in reactive patients
• Misplacement (rare but catastrophic in high-risk facial trauma scenarios)
• Increased airway resistance if diameter is too small

If you want, I can also add a tight “NPA vs OPA” comparison box for your textbook chapter, including: who tolerates what, quick sizing rules, and failure patterns (bleeding, too short, too long, wrong angle).

When the chest rises, but oxygen saturation remains low, it may be time to add PEEP. During bag-valve-mask (BVM) ventilation, one of the most overlooked yet critical optimization techniques is the use of a Positive End-Expiratory Pressure (PEEP) valve. By preventing alveolar collapse and improving alveolar recruitment, PEEP can significantly enhance oxygenation when ventilation alone is insufficient.

PEEP helps keep the alveoli open at the end of exhalation, preventing atelectasis and improving oxygenation. Without it, lung units can collapse with each breath, reducing the effectiveness of ventilation and increasing the risk of hypoxia. This is especially important in patients with respiratory failure, peri-intubation hypoxia, or conditions like pulmonary edema.

Adding a PEEP valve to your BVM can enhance oxygenation and improve overall ventilation efficiency. Dialing in the right amount—typically 5-10 cm H₂O—can make a huge difference in your patient’s outcome.

💡 Pro Tip: If your patient’s oxygen saturation remains low despite good mask seal and tidal volumes, check if you’re using adequate PEEP. It might be the missing piece in your BVM optimization toolkit!

How To Attach A PEEP Valve

Demonstration of the Power of PEEP

Anatomy lab with PAC’s Dr. Chris Root, MD

What does this look like in human lungs? Watch this short demonstration in the anatomy lab from one of our annual PAC conferences.