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Master Bag-Valve Mask Ventilation (Pediatric Edition)

NextGen Learning To Elevate Your Airway Practice

Introduction

Bag-valve-mask (BVM) ventilation is a cornerstone skill in pediatric airway management, critical for providing oxygenation and ventilation in respiratory failure, cardiopulmonary arrest, or peri-intubation scenarios. Due to children’s anatomical and physiological differences, effective face mask ventilation requires a precise technique, appropriate equipment selection, and a deep understanding of common pitfalls. This module focuses on optimizing BVM ventilation in pediatric patients through hands-on skills, troubleshooting strategies, and evidence-based best practices.

Choosing the Best Technique

In the real world, there are many variations in the approach to the bag-valve-mask (BVM). Not all of them are good. We care about doing it as effectively and consistently as possible. So should you. The two-person BVM technique, where one provider secures the mask with both hands to ensure a proper seal while the second provider delivers ventilation by squeezing the bag, has been shown to offer significant advantages over the one-person method.


Evidence Supporting Two-Person BVM Technique:

  1. Enhanced Tidal Volumes and Peak Pressures:
  • A study published in the Annals of Emergency Medicine compared one-person versus two-person BVM techniques using infant and child manikins. The findings revealed that the two-person method generated higher mean tidal volumes per weight and peak pressures than the one-person technique. Specifically, in the infant model, the two-person technique achieved a mean tidal volume of 7.2 mL/kg versus 5.9 mL/kg with the one-person method. In the child model, the two-person technique reached 8.8 mL/kg compared to 6.1 mL/kg with the one-person.

2. Improved Mask Seal and Ventilation Efficiency:

  • The two-person technique allows one provider to use both hands to create a more effective mask seal, reducing air leakage and ensuring that ventilations are more efficiently delivered. This method particularly benefits pediatric patients, where facial anatomy can make achieving a proper seal challenging. AnnEmergMed

3. Reduced Provider Fatigue:

  • By dividing the tasks between two providers—one focusing on maintaining the airway and mask seal and the other on delivering ventilations—the two-person technique can reduce individual provider fatigue, potentially leading to more consistent and effective ventilation.

The two-person BVM technique offers significant advantages in pediatric resuscitation, including improved tidal volumes, better mask seal, and reduced provider fatigue. The two-person method is recommended whenever feasible, especially in critical situations involving pediatric patients, to enhance ventilation effectiveness and patient outcomes.

I. Fundamentals of Pediatric BVM Ventilation

  • Anatomical & Physiological Considerations
  • Proper mask fit is critical, and leaks can occur easily due to small, round faces and lack of prominent facial features.
  • Prominent occiput leading to natural flexion
  • Larger tongue relative to the oral cavity
  • More compliant chest wall and increased risk of gastric insufflation
  • Higher oxygen consumption and lower functional residual capacity (FRC)

II. Equipment Selection & Setup

  • Choosing the Right Bag & Mask
  • Self-inflating vs. flow-inflating bags
  • Pediatric vs. neonatal BVM sizes (standard volumes: 250-500mL for neonates, 500-1000mL for infants and children)
  • Transparent, appropriately sized masks to ensure a proper seal
  • Adjuncts to Optimize Ventilation
  • Nasopharyngeal (NPA) and oropharyngeal airways (OPA) to maintain patency
  • Use of a PEEP valve when indicated
  • High-flow nasal cannula (HFNC) or nasal CPAP as preoxygenation tools

III. Technique for Effective BVM Ventilation

  • Proper Positioning
  • Neutral head positioning in infants, slight extension in older children
  • Shoulder roll in infants to optimize airway alignment
  • Mask Seal and Hand Techniques
  • One-person technique: “EC-clamp” method for an effective mask seal
  • Two-person technique: One provider ensures a two-handed mask seal while another delivers ventilation
  • Ventilation Strategies
  • Use of low tidal volumes (6-8 mL/kg) to prevent barotrauma
  • Slow, gentle breaths (~1 second per breath) to minimize gastric insufflation
  • Monitoring for chest rise and capnography for ventilation efficacy

Curated MedEd

This video from the University of Florida reviews the key features of a standard BVM, the one-handed and two-handed BVM techniques (you already know which one is better), and some common pitfalls.

IV. Troubleshooting & Common Pitfalls

  • Ineffective Mask Seal
  • Re-adjust the mask position and use a two-handed technique if needed
  • Consider changing the mask size
  • Obstructed Airway
  • Reposition head and neck
  • Insert OPA or NPA if obstruction persists
  • Gastric Insufflation & Risk of Aspiration
  • Minimize excessive pressures, ensure proper airway positioning
  • Consider nasogastric or orogastric tube decompression if prolonged BVM use
  • Hypoxia Despite Ventilation
  • Check oxygen source and tubing connections
  • Assess for underlying pathology such as pneumothorax or pulmonary edema

Bottom Line: Key Takeaways

  • Proper positioning, mask seal, and controlled ventilation are essential for effective BVM ventilation in pediatric patients.
  • Utilize adjuncts (OPA/NPA, PEEP valve) to optimize airway patency and oxygenation.
  • A two-person technique is preferred for superior mask seal and ventilation efficiency.
  • Avoid excessive tidal volumes and high pressures to minimize barotrauma and gastric insufflation.
  • Regular hands-on practice and team coordination improve success in high-stress scenarios.

Don’t Forget to Practice

Use this content for self-guided practice. When you’re comfortable with your initial progress, visit our expert faculty coaches for customized feedback. You can do this as many times as you like. This iterative practice and feedback process will take your skills to the next level.

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