A. Introduction to BVM Ventilation

This lesson provides a comprehensive overview of Bag-Valve-Mask (BVM) ventilation, a critical skill in emergency medical care. We will cover the principles, techniques, and safety considerations for effective BVM ventilation.

B. Understanding BVM Ventilation

BVM ventilation is a method of providing positive pressure ventilation to patients who are unable to breathe adequately on their own. It is a temporary measure used until a more definitive airway management technique, such as intubation, can be established, or when the patient resumes spontaneous breathing.

• Purpose: To deliver oxygen-enriched air to the patient’s lungs, supporting gas exchange.
• Key Components:
  • Mask: Creates a seal over the patient’s nose and mouth.
  • Bag: A self-inflating bag that is squeezed to deliver air.
  • Oxygen Reservoir: Enhances the concentration of delivered oxygen.

C. Indications and Contraindications

Understanding when and when not to use BVM ventilation is crucial for patient safety.

Indications:

• Apnea (absence of breathing).
• Respiratory Failure (inadequate breathing):
  • Bradypnea (slow breathing).
  • Tachypnea (rapid breathing) with inadequate tidal volume.
  • Hypoxia (low oxygen levels) despite supplemental oxygen.
  • Increased work of breathing.
• Pre-oxygenation prior to intubation or other advanced airway procedures.
• Assisting a patient with inadequate spontaneous breaths.

Contraindications:

• There is generally only one absolute contraindication:
  • Complete upper airway obstruction that cannot be relieved. If the obstruction is relieved, BVM ventilation can be performed.
• Relative Contraindications (Proceed with caution and preparation):
  • Facial trauma: May make it difficult to obtain an adequate mask seal. Use alternative techniques if possible.
  • Significant vomiting: Increases the risk of aspiration. Suctioning equipment must be readily available.

D. Equipment Preparation

Ensuring the BVM unit is ready for use is essential. Check the following:

• BVM Unit:
  • Integrity: Inspect the bag for any tears or leaks.
  • Valve Function: Ensure valves are functioning correctly (no air leaks, proper direction of flow).
  • Oxygen Connection: Verify a secure connection to the oxygen source.
• Mask Selection: Choose the appropriate mask size to create a tight seal over the patient’s nose and mouth. Common sizes include infant, child, and adult.
• Oxygen Source:
  • Flow Rate: Set the oxygen flow rate to 10-15 liters per minute (LPM) for adults, and higher flow rates for reservoir bags.
  • Connection: Confirm the oxygen tubing is securely connected to both the oxygen source and the BVM unit.
• Suction Equipment: Ensure suction equipment is readily available and functioning to clear any secretions or vomit that may obstruct the airway.
• Adjuncts: Consider using airway adjuncts (oral or nasal airways) to help maintain airway patency, especially in unconscious patients.

E. BVM Ventilation Technique

The following steps outline the proper technique for performing BVM ventilation:

• Patient Positioning:
  • Supine: Position the patient on their back.
  • Airway Maneuvers: Use the head-tilt/chin-lift maneuver (unless contraindicated by suspected spinal injury, in which case use the jaw-thrust maneuver) to open the airway.
  • Consider adjuncts: Insert an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) if tolerated, to maintain airway patency.
• Mask Placement:
  • Seal: Place the mask over the patient’s nose and mouth, creating a tight seal.
  • Hand Position: Use the “C-E” technique:
    • “C”: Use your thumb and index finger to form a “C” over the top of the mask, pressing down to seal it.
    • “E”: Use your middle, ring, and little fingers to form an “E” under the patient’s jaw, lifting it upwards.
• Ventilation:
  • Rate: Deliver breaths at the appropriate rate:
    • Adults: 1 breath every 5-6 seconds (10-12 breaths per minute).
    • Children/Infants: 1 breath every 2-3 seconds (20-30 breaths per minute).
  • Volume: Deliver an adequate tidal volume to produce visible chest rise. Avoid excessive volume, which can lead to gastric distention.
  • Observation: Observe for chest rise and fall with each breath.
  • Avoid hyperventilation: Do not breathe too fast or too forcefully.
• Two-Person BVM: If available, use a two-person technique:
  • One provider maintains the mask seal with both hands.
  • The second provider squeezes the bag.
  • This technique generally provides better mask seal and ventilation.

F. Monitoring and Assessment

Continuously monitor the patient’s response to BVM ventilation:

• Chest Rise and Fall: Ensure visible and symmetrical chest movement with each breath.
• Auscultation: Listen for bilateral breath sounds.
• Vital Signs: Monitor heart rate, blood pressure, and oxygen saturation (SpO2). Improvement in heart rate and SpO2 are good signs.
• Skin Color: Observe for improvement in skin color (from cyanotic to pink).
• Capnography (if available): Monitor end-tidal carbon dioxide (EtCO2) to assess the effectiveness of ventilation.
• Patient Condition: Assess the patient’s overall condition, including level of consciousness.

G. Potential Complications

Be aware of potential complications associated with BVM ventilation:

• Gastric Distention: Inflation of the stomach with air, which can lead to vomiting and aspiration. Prevent by:
  • Proper head position.
  • Slow, gentle ventilations.
  • Avoiding excessive tidal volumes.
  • Consider using a nasogastric tube (if available and appropriate) to decompress the stomach.
• Aspiration: The inhalation of gastric contents into the lungs. Prevent by:
  • Suctioning: Have suction equipment readily available.
  • Positioning: Place the patient in the recovery position if vomiting occurs, if possible and if no contraindication.
• Inadequate Ventilation: Failure to provide sufficient oxygen and carbon dioxide removal. Ensure:
  • Proper mask seal.
  • Adequate tidal volume.
  • Correct ventilation rate.
• Barotrauma: Lung injury caused by excessive pressure. Avoid by:
  • Gentle ventilation.
  • Observing for just enough chest rise.

H. Special Considerations

Certain patient populations or situations require special attention during BVM ventilation:

• Infants and Children:
  • Use appropriately sized masks and bags.
  • Deliver smaller tidal volumes and faster respiratory rates.
  • Be gentle with ventilation pressure.
• Patients with Facial Trauma:
  • May be difficult to obtain a good mask seal.
  • Consider using alternative airway techniques (e.g., laryngeal mask airway, intubation) if BVM is ineffective.
• Patients with Stomas:
  • Ventilate through the stoma if the patient has a tracheostomy or laryngectomy.
  • Seal the mouth and nose if ventilating through the stoma.

I. Documentation

Accurate and timely documentation of BVM ventilation is essential. Include the following:

• Date and time of BVM initiation.
• Patient’s condition and indication for BVM.
• Mask size and type.
• Oxygen flow rate.
• Ventilation rate and tidal volume.
• Patient’s response to ventilation (chest rise, breath sounds, vital signs, SpO2, EtCO2).
• Any complications encountered.
• Personnel involved.
• Changes in patient condition.

J. Hands-on Skills Practice

Practice BVM ventilation techniques using mannequins in various scenarios. Focus on:

• Proper mask seal.
• Effective ventilation rate and volume.
• Two-person BVM technique.
• Airway adjunct use.

K. Question and Answer Session

Review key concepts and address any questions from participants.

L. Assessment and Evaluation

Evaluate participants’ understanding and proficiency in BVM ventilation through practical skills assessment and/or written quizzes.