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MAXIM: Patients will not die if they are not intubated; they will die if their lungs are not ventilated and their blood is not oxygenated.


The goal for airway management in any patient must be to maintain adequate ventilation and oxygenation. This does not necessarily mean intubation. Correct bag-valve-mask (BVM) ventilation/oxygenation technique is an underrated skill that will buy you time in the patient with a difficult airway. Proper steps for optimal two-person BVM ventilation include the following:

  1. Positioning—ear-to-sternal notch alignment (when clinical scenario permits). Neck slightly flexed and head slightly extended. (See Fig. 22.15.)

  2. Jaw thrust—displace mandible anteriorly with pressure from long, ring, and small fingers on mandible, not soft tissues.

  3. Mask compression—thumb and index fingers should apply firm pressure to face and nasal bridge. (See Figs. 22.16 and 22.17.)

  4. Oral/nasal airways—may help maintain airway patency during BVM ventilation. (See Fig. 22.18.)

  5. Use 7 mg/kg tidal volume, over 1 to 2 seconds at 12 breaths/min.

FIGURE 22.15

Optimal Ear-to-Sternal Notch Alignment. Optimal position for ventilation and laryngoscopy occurs when the external auditory canal and the sternal notch are aligned in the horizontal plane (B) and the face is parallel to the ceiling (C). This position optimizes airway patency and ventilation mechanics. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.16

Bag-Valve-Mask Ventilation. Correct positioning and forces during BVM ventilation are demonstrated for the one- and two-person (thumbs) techniques. Upward force on the mandible, not soft tissue, is key to effective jaw-thrust technique. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.17

Bag-Valve-Mask Ventilation. Incorrect (A) and correct (B) positioning and forces during BVM ventilation are demonstrated for the two-person techniques. Lack of jaw thrust during BVM will allow the tongue to block air passage. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.18

Nasal and Oral Airways. Appropriately sized and placed nasal and oral airways maximize upper airway patency during BVM ventilation. (Photo contributor: Lawrence B. Stack, MD.)


  1. Be an expert at BMV ventilation.

  2. Ear-to-sternal notch positioning is most beneficial in obese patients and those with obstructive sleep apnea.

  3. Keeping dentures in place facilitates BVM, whereas removing them facilitates orotracheal intubation.

  4. Mid-face and mandibular disfiguration from whatever cause will interfere with optimal BVM ventilation.

  5. Consider laryngeal mask airway (LMA), King LT, or Air-Q if unable to intubate or obtain adequate seal for BVM ventilation.

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