The Bag Valve Mask

The Essentials for Mastering This Upper Airway Lifeline

fmvicontext-2The bag valves mask (BVM) is an important upper airway lifeline for managing critically ill patients who are apneic and hypoxic. It is arguably the most important airway skill you will learn. As Reuben Strayer @emupdates argues in the video below, you can be an average intubator with good BVM skills and stay out of trouble. By contrast, you can be an excellent incubator and find yourself in some scary situations if you are poor at ventilation with the BVM. Put another way:

How many pairs of underwear you buy in your career depends mostly on how good you are at ventilation (BVM) – Reuben Strayer

Bottom line if your grabbing that BVM it means you need to know how to use it. Unfortunately most clinicians use the BVM badly. Even worse, once it’s clear they are getting poor oxygenation with the BVM they also fail to adjust their technique and instead rush on to attempt(s) at intubation or other more invasive rescue techniques.

Usually this only makes things worse: increasing the likelihood you will fail at your first intubation attempt due to increased stress and urgency, and putting your patient at risk of prolonged hypoxia, and peri-intubation arrest.

There is no one who has highlighted the need for mastery of the BVM with more laconic humor or no nonsense practicality than Dr Reuben Strayer @emupdates So watch his video:

The No Nonsense BVM Optimization Plan
  1. Start with best attempt at the Two Thumbs Down technique
  2. No good? Then check your mask seal and try again.
  3. Good seal but resistance?  Look for foreign body or need for suction
  4. No FB obstruction? Place oral and nasal airway(s)
  5. Good ventilation but still hypoxic?
  6. Check O2 flow
  7. Attach PEEP valve
  8. Still hypoxic? MOVE ON

This whole process should happen rapidly over the course of 2-3 minutes.

Still nothing?  Take time to optimize but don’t over-analyze. If you’ve done your best accept that it’s time to move on and start reaching for that LMA while you prep for a surgical airway.

Before Moving On – Optimize Your Lifeline for a “Best Effort”
  • The Vortex Approach


In the Vortex Approach the BVM is just one of  three upper airway lifelines for staying in the green zone.  For each lifeline their optimization strategy that has five categories for things that can be considered. The beauty of this system is that the five categories work across all three lifelines which allows the clinician a slightly more structured framework. Here is their list for the BVM.



Additional Mastery Tips for the BVM
Lose the Beard

As someone who regularly fails his respiratory fit test I can tell you getting a good mask seal on a patient with a beard is tough. Here is one way to deal with it.


The importance of PEEP

Even if you get everything right and feel that you are ventilating your patient well they may remain hypoxic due to the underlying cause of their respiratory failure. Most BVMs in clinical areas do not come with PEEP valves. Here is why it’s important and why you should put one on your BVM.

Thanks to my friend Chris Root @gueromedico for demonstrating this at the Protected Airway course 2016.

Flipping the Airway  – The Vortex Approach
Bundled resources and perspectives on this topic from all corners of the FOAM universe




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