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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:

  1. Positioning—ear to sternal notch alignment (when clinical scenario permits). Neck slightly flexed, head slightly extended.

  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.

  4. Oral/nasal airways—may help maintain airway patency during BVM ventilation.

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

Figure 22.1.

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. This position optimizes airway patency and ventilation mechanics. (Photo contributor: Lawrence B. Stack, MD.)

Figure 22.2.

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

Figure 22.3.

Nasal and Oral Airways. Appropriate sized and placed nasal and oral airways maximize upper airway patency during bag-valve-mask 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 while removing them facilitates orotracheal intubation.

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

  5. Consider LMA, Combitube, Air-Q if unable to intubate or obtain adequate seal for BVM ventilation.

MAXIM: Patients with airway problems should be positioned for their comfort, not ours.


If physically able and mentation is normal, a patient with airway difficulty will assume a position which optimizes their airway patency and gas exchange, usually sitting up and leaning forward. Such patients include those with incomplete airway obstruction, flash pulmonary edema, and massive airway bleeding from oropharyngeal trauma. Unfortunately, during preparation for intubation, such patients often are placed supine prematurely, increasing the patient's respiratory distress and anxiety, increasing the likelihood of spontaneous emesis and aspiration, and decreasing his ability to handle oropharyngeal bleeding or secretions. In these clinical situations, we should rethink ...

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