II. Indications: Positive Pressure Ventilation

III. Contraindications: Relative (Exercise caution)

  1. Severe facial Trauma
  2. Open eye injuries
  3. Oral cavity with foreign body

V. Device: Flow-inflating bag (Anesthesia Bag)

  1. Mechanism
    1. Requires compressed oxygen source to fill
  2. Advantages
    1. Preferred for Newborn Resuscitation
    2. Lung compliance can be felt on squeezing bag
    3. Can deliver free-flow 100% oxygen
  3. Disadvantages
    1. Requires a tight facial seal
    2. Higher risk of over-inflating lung (use manometer)
    3. Technically more difficult to learn to use
  4. Technique
    1. Set oxygen supply flowmeter to 5-10 L/min
    2. Adjust bag volume with flow-control valve

VI. Device: Self-inflating bag (Bag-valve mask or Ambu Bag)

  1. Aduncts
    1. PEEP Valves
      1. Put PEEP Valve on every bag-valve-mask
      2. However does increase risk in Hypotension of decreasing venous return (by increasing intrathoracic pressure)
      3. PEEP valves dramatically improve Oxygen Delivery with bag-valve-mask by keeping alveoli open
      4. Levitan (2013) Practical Emergency Airway Management Course
    2. Impedance Threshold Device (e.g. ResQPOD)
      1. May be indicated in CPR (but variable evidence)
      2. Attaches inline between positive pressure device (e.g. ambubag) and mask or ET Tube
      3. Assists in maintaining negative intrathoracic pressure which in turn increases venous return
      4. Associated with increased rate of Return of Spontaneous Circulation
        1. Aufderheide (2005) Crit Care Med 33(4): 734-40 [PubMed]
      5. However more recent studies showed no benefit
        1. Aufderheide (2011) N Engl J Med 365(9): 798-806 [PubMed]
  2. Mechanism
    1. Bag fills spontaneously after being squeezed
  3. Advantages
    1. Does not require an oxygen source
    2. Easier to learn to use
  4. Disadvantages
    1. Can not deliver free flow oxygen
  5. Oxygen Delivery with ventilation (Bag-Valve Mask)
    1. No Oxygen Source
      1. Delivers 21% Oxygen (Room air)
    2. Without Oxygen Reservoir
      1. Delivers 30-80% Oxygen at 10 LPM flow
    3. With Oxygen Reservoir (required for high oxygen flow)
      1. Delivers 60-95% Oxygen at 10-15 LPM flow
      2. Delivers oxygen if reservoir fills
  6. Pop-Off Valves (Bag Valve Mask)
    1. Usually set at 30-45 cm H2O
    2. Pop-off should be easily occluded on bags
      1. Higher pressures are needed during CPR
    3. Occlusion of the pop off valve
      1. Depress valve with finger during ventilation or
      2. Twist the pop-off valve into closed position
  7. Images
    1. Neonatal Ambu-Bag
      1. lungAmbuPeds250.png

VII. Device: Noninvasive Positive Pressure Ventilation (NIPPV)

VIII. Precautions

  1. Do not use Bag Valve Mask to deliver free flow oxygen
    1. Oxygen only flows when squeezing bag
  2. Position patient for best ventilation (Oops Mnemonic, Levitan)
    1. Oxygen On
    2. Apply 15 lpm by Nasal Cannula under mask for Apneic Oxygenation
    3. Pull Mandible forward (Jaw Thrust maneuver)
    4. Sit patient up (to 20 degrees)
  3. Anticipate difficult mask ventilation (Mnemonic: MOANS)
    1. Mask seal (e.g. beard)
    2. Obstruction
    3. Older Age
    4. No teeth (replace dentures for Bag Valve Mask Ventilation)
    5. Stiff lungs requiring increased Ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
  4. References
    1. Difficult Airway Course
      1. http://www.theairwaysite.com

IX. Technique

  1. Tidal Volume
    1. Term Newborns
      1. Administer 5-8 ml/kg (15 to 25 ml per ventilation)
      2. Bag volume: 200 to 750 ml (usually >450 ml)
    2. Adults and older children
      1. Administer 10-15 ml/kg
  2. Hold mask over face with one hand
    1. Mask should fit snugly
      1. Covers mouth, nose and chin
      2. Should not cover eyes
    2. Thumb over nose
    3. Support jaw with middle or ring finger
    4. Avoid submental pressure (risk of airway obstruction)
    5. Employ assistant when unable to obtain adequate seal with one hand
      1. Obese patients
      2. Patients with dentures (consider leaving dentures in for better mask fit)
      3. Facial hair
      4. Clinician with small hands or inadequate strength
  3. Head Tilt - chin lift (Avoid if Trauma!)
    1. Use Jaw Thrust maneuver in Trauma or suspected spine injury
    2. Infants/Toddlers
      1. Neutral sniffing position without hyperextension
    3. Children >2yo
      1. Anterior displacement of c-spine
      2. Folded towel under neck and head
  4. Observe for adequate ventilation
    1. Adequate chest rise
    2. No signs of gastric insufflation

X. Protocol: Troubleshooting

  1. No chest rise:
    1. Reposition head
    2. Ensure mask is snug
    3. Lift the jaw
    4. Consider suctioning airway
    5. Consider equipment failure (always test before use)
      1. Test bag with hand occluding patient outlet
      2. Check for bag leak
      3. Check flow-control valve
      4. Check that oxygen line is connected
    6. Consider airway adjuncts
      1. Nasal Airway
      2. Oral Airway
  2. Avoid Stomach insufflation and gastric distention
    1. Apply cricoid pressure (Sellick maneuver)
      1. In unconscious infant or child
    2. Consider NG suction
  3. Sudden decrease in lung compliance
    1. Right main Bronchus intubation
    2. Obstructed Endotracheal Tube
    3. Pneumothorax

XI. Resources

  1. Bag-Valve-Mask Demonstration Video (NEJM)
    1. http://www.youtube.com/watch?v=08pxEGmBCGM

XII. References

  1. Mason and Levitan in Herbert (2018) EM:Rap 18(1):14

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Intermittent Positive-Pressure Ventilation (C0021778)

Definition (MSH) Application of positive pressure to the inspiratory phase when the patient has an artificial airway in place and is connected to a ventilator.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D007385
SnomedCT 182685002, 150946007, 150949000, 182687005
English Inspiratory Positive Pressure Ventilation, Inspiratory Positive-Pressure Ventilation, Intermittent Positive Pressure Ventilation, IPPV, Positive-Pressure Ventilation, Inspiratory, Positive-Pressure Ventilation, Intermittent, Ventilation, Inspiratory Positive-Pressure, Ventilation, Intermittent Positive Pressure, Ventilation, Intermittent Positive-Pressure, IPPV - Int pos pres ventilat, Intermit pos press ventilation, Intermittent Positive-Pressure Ventilation, PPV - Positive press ventilatn, intermittent positive pressure ventilation, positive pressure ventilation, ventilation pressure positive, ippv, Intermit.pos.pres.vent., IPPV - Intermittent positive pressure ventilation, Intermittent positive pressure ventilation, PPV - Positive pressure ventilation, Positive pressure ventilation, Intermittent positive pressure ventilation (procedure)
Swedish Intermittent övertrycksventilation
Czech ventilace umělá s přerušovaným přetlakem
Finnish IPPV
Spanish VIPP, Ventilación a Presión Positiva Intermitente, Ventilación con Presión Positiva Inspiratoria, ventilación con presión positiva intermitente (procedimiento), ventilación con presión positiva intermitente, Ventilación con Presión Positiva Intermitente
French VPPI, Ventilation sous pression positive intermittente, Ventilation en pression positive intermittente
Italian IPPV, Ventilazione a pressione positiva inspiratoria, Ventilazione a pressione positiva intermittente
Portuguese Ventilação com Pressão Positiva Inspiratória, Ventilação Inspiratória com Pressão Positiva, IPPV, Ventilação com Pressão Positiva Intermitente
Polish Wentylacja ciśnieniami dodatnimi przerywanymi, IPPV
Japanese 間欠的陽圧換気, 換気-間欠性陽圧, 吸気性陽圧換気, 間欠性陽圧換気, 間欠的陽圧換気法, 換気-間欠的陽圧
Norwegian Intermitterende overtrykksventilasjon, IPPV, Intermitterende overtrykksresventilasjon
German IPPV, Inspiratorische Überdruckventilation, Intermittierende Überdruckventilation, Ventilation, intermittierende Überdruck-
Dutch IPPV, Intermitterende positieve-drukventilatie, Positieve-drukventilatie, inspiratoire, Positieve-drukventilatie, intermitterende, Ventilatie, intermitterende, positieve-druk-

Ontology: Ambu bag (C0221812)

Concepts Medical Device (T074)
SnomedCT 371785003
English Ambu Bags, ambu bags, ambu bag, Ambu bag (physical object), Ambu bag, Self-inflating bag
Spanish bolsa Ambu (objeto físico), bolsa Ambu, bolsa autoinflable

Ontology: Bag valve mask ventilation (C1960845)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 425447009
LNC LA17755-2
English Bag valve mask ventilation, Bag valve mask ventilation (regime/therapy), Bag valve mask ventilation (procedure), bag valve ventilation by mask, bag valve ventilation mask, bag valve ventilation by mask (treatment), Ventilation-bag valve mask
Spanish ventilación con máscara con bolsa y válvula, ventilación con máscara con bolsa y válvula (procedimiento), ventilación con máscara con bolsa y válvula (régimen/tratamiento)