In recent weeks at The Alfred ICU’s ‘Airway and Bronchoscopy’ teaching (held every Thursday morning) we emphasised the importance of effective bag-valve-mask (BVM) ventilation.
Points of emphasis:
- ensure optimal positioning
- a two-handed approach to obtaining mask seal is the most effective technique. There is evidence that the C-E technique is not as effective as the ‘two thumbs up’ approach. Even anaesthetists ventilate better with two hands holding the mask compared to when they are using just one
- ideally use airway adjuncts (oropharyngeal and nasopharyngeal airways) when using a bag-valve-mask – this will help optimise airway patency and ventilation
- if cricoid pressure is applied it may impede ventilation, remove cricoid pressure if ventilation is difficult
This superbly produced 11 minute videocast by Reuben Strayer from EM Updates is an excellent guide to BVM ventilation:
The MOANS mnemonic is a quick aid to predicting who will be difficult to ventilate:
|Mask seal||e.g. Beards, blood on the face, or facial trauma|
|Obesity / Obstruction||e.g. Obesity, pregnancy, angioedema, Ludwig’s angina, upper airway abscess, epiglottitis|
|Age||Age > 55|
|No teeth||Consider leaving dentures in place in edentulous patients|
|Sleep apnea / Stiff lungs||e.g. OSA, COPD, asthma, ARDS|
- Bag-valve-mask (BVM) ventilation (LITFL Critical Care Compendium)
- El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009 Dec;109(6):1870-80. doi: 10.1213/ANE.0b013e3181b5881c. Review. PubMed PMID: 19923516. [Free Full Text]
- Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth. 2013 May;25(3):193-7. doi: 10.1016/j.jclinane.2012.10.009. Epub 2013 Mar 21. PubMed PMID: 23523573.
- Hart D, Reardon R, Ward C, Miner J. Face mask ventilation: a comparison of three techniques. J Emerg Med. 2013 May;44(5):1028-33. doi: 10.1016/j.jemermed.2012.11.005. Epub 2013 Mar 7. PubMed PMID: 23473817.
- Joffe AM, Hetzel S, Liew EC. A two-handed jaw-thrust technique is superior to the one-handed “EC-clamp” technique for mask ventilation in the apneic unconscious person. Anesthesiology. 2010 Oct;113(4):873-9. doi: 10.1097/ALN.0b013e3181ec6414. PubMed PMID: 20808210. [Free Full Text]
Welcome to the second edition of the #FOAM Review! The idea of the FOAM review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest.
VIDEO: Critical care expert Matthew Mac Partlin gives an outstanding discussion on emergency airway access including steps to an effective cricothyroidotomy.
VIDEO: There is more than the subcostal view to echo in trauma, learn with Cartan Costello an intensivist in Sydney.
BLOG POST: The physiology behind the post lumbar puncture headache and tips to avoid this complication at RebelEM.
BLOG POST/VIDEO/DISCUSSION: Visit the ALiEM Journal club page on Clinical Decision Rule for Subarachnoid Hemorrhage to get up to date with the current evidence.
Abdomen & GI
PODCAST/BLOG: A quick review from FOAMcast on hepatic emergencies from the well known hepatic encephalopathy to the rare but deadly chylous ascites!
BLOG: Clear up some medical myths at emDocs and fight back with your consultants with evidence! Discussion includes: utility of kayexelate, stone heart, dopamine in cardiogenic shock, cross reactivity of penicillins, IVFs in DKA, troponins in SVT, the necessity of ABGs and checking coags in paracentesis!
Thoracic & Respiratory
Obstetrics & Gynecology
BLOG: You may not transport the acutely pregnant patient but you can learn a ton from the retrieval expert Minh Le Cong on physiologic considerations and specific disorders in the gravid patient.