Patients suffering from respiratory failure, traumatic injuries, or cardiac arrest may display signs of inadequate respiration or apnea, indicating a need for oxygen and ventilatory support. In the prehospital environment rescuers turn to a basic but vital piece of equipment, the bag valve mask (BVM), to support these patients. They use a BVM to provide manual ventilation, stabilizing a patient and giving rescuers time to treat medical issues requiring immediate attention.

Although a basic tool, the BVM requires skill and practice for even the most seasoned rescuers to use successfully. Studies show that despite training and regular recertification in Basic Life Support (BLS) CPR, it's difficult for rescuers to provide BVM ventilations at the recommended breaths per minute, potentially causing significant health challenges for patients.¹

The Components of a BVM

A BVM is comprised of a nonrebreathing valve situated between a facemask and a self-inflating bag; a reservoir bag is attached to the end of the self-inflating bag and there is a connection for an oxygen source. BVMs are used to manually ventilate a patient and can be used with other advanced airway adjuncts such as endotracheal tubes, supraglottic airways, and tracheostomy tubes.

How to Manually Ventilate With a BVM

To perform BVM ventilation, also referred to as manual ventilation, the flexible mask is placed over the patient’s mouth and nose in a way that ensures a tight seal. The “C-E” grip is one way to do this: the middle, ring, and little fingers (the “E”) are placed under the jaw while the thumb and index finger (the “C”) press down on the mask. When possible, two rescuers deliver manual ventilations so that one can focus on a tight seal while the other focuses on squeezing the self-inflating bag steadily and smoothly. Doing so pushes air into the patient’s nose and mouth. The 2020 American Heart Association Guidelines recommends manually ventilating an adult patient at a rate of 10 breaths per minute until spontaneous breathing returns or advanced cardiac lifesupport (ACLS) measures are taken.²

Complications of BVM Ventilation

Skilled ventilation is largely dependent on four key elements:

• patient airway
• mask seal or properly placed patent advanced airway adjunct
• ventilation technique
• use of a positive end-expiratory pressure (PEEP) valve when applicable

Complications sometimes arise from the human component of manual ventilation. Squeezing the bag too hard or too fast can provide a patient with too much tidal volume, leading to hyperventilation and barotrauma, or to air leakage into the stomach, also known as gastric insufflation. Gastric insufflation can cause vomiting, particularly dangerous during ventilation.³ Not squeezing the bag hard or quickly enough can deprive the patient of oxygen.

One study of out-of-hospital cardiac arrests (OHCA) showed that experienced EMS responders performing manual ventilation averaged 30 breaths per minute, a rate significantly higher than the recommended 10 breaths per minute.¹ Gauging how much and how often to squeeze the self-inflating bag can be difficult in rescue situations, particularly without real-time feedback. Clinicians don’t know how well the patient is being ventilated, leaving them to guess whether their ventilations are on target.

Overcoming Manual Ventilation Challenges

Real BVM Help^® from ZOLL^® addresses rescuers’ need for real-time feedback in the field.

With Real BVM Help, a sensor and cable connected to the X Series^® Advanced monitor/defibrillator is connected in line to the BVM. During manual ventilations, the sensor — using new technology from ZOLL — collects ventilation data and displays it in real time on the X Series Advanced monitor. A Ventilation Quality Indicator (VQI) ring fills for each breath, changing color based on ventilation quality, volume, and rate — green when in target and yellow when out of target. A glance at the Real BVM Help display on the X Series Advanced monitor tells clinicians how well their patient is being ventilated and how to make adjustments to improve ventilation quality.

ZOLL is the only company that offers a monitor/defibrillator that provides real-time feedback ventilation rate and volume on its display. Regardless of the conditions in the field or a patient’s other medical challenges, with Real BVM Help on X Series Advanced, clinicians can improve the quality of manual ventilation in the field and can adjust instantly to meet a patient’s changing needs.

¹Aufderheide TP, Lurie KG. Crit Care Med. 2004 Sep;32(9 Suppl):S345–51.
²Panchal AR, et al. Circulation. 2020;142:S366–S468.
³Bucher JT, et al. Bag Mask Ventilation. StatPearls, https://www.ncbi.nlm.nih.gov/books/NBK441924/. Treasure Island (FL): StatPearls Publishing; 2021. Accessed 25 May 2021.