Bag-valve mask (BVM) ventilation is a crucial technique in emergency situations for providing manual ventilation to patients with respiratory distress. However, failures in BVM ventilation can occur due to incorrect rates, pressures, and volumes applied during the procedure. Several studies highlight the challenges faced by both experienced and inexperienced rescuers in achieving efficient BVM ventilation.
Bag-valve-mask ventilation is often ineffective during cardiopulmonary resuscitation and improving ventilation may lead to improved clinical outcomes. In one study (n=1976), lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome. (Idris, 2023)
Higher respiratory rates and/or excessive volumes during manual resuscitation result in the increased likelihood of morbidity and mortality. Studies indicate that hyperventilation is happening at alarming rates and frequencies both inside and outside of hospital settings, with significant potential complications (Culbreth 2020, O'Neill 2007).
The longer the period of incorrect rate, volume, or pressure continues, the more likely the patient is to experience significant adverse effects, such as:
- Decreased likelihood of survival.
- Cerebral hypoxia resulting in a corresponding decrease in the chances of baseline neurological outcome and increased chances of permanent neurological damage.
- Reduced cardiac output and blood pressure.
- Gastric inflation resulting in emesis, aspiration, and subsequent pneumonia.
- Lung damage.
Inexperienced rescuers may struggle with detecting the optimal head position for opening the airway during BVM ventilation, leading to inefficiencies in ventilation (Schumacher et al., 2022). Additionally, difficulties in achieving proper tidal volumes and peak inspiratory pressures have been noted, resulting in variable ventilation outcomes (Rs et al., 2021). Studies have shown that even experienced healthcare professionals encounter difficulties in correctly performing BVM ventilation, emphasizing the complexity of the procedure (Rød et al., 2022).
Furthermore, issues such as leakage around the facemask, gastric inflation, and inadequate minute ventilation volumes have been associated with BVM ventilation, underscoring the need for precise technique and skill in its application (Dörges et al., 2001). While BVM ventilation is effective when performed correctly by well-trained rescuers, it can lead to suboptimal outcomes in the hands of less experienced individuals (Paal et al., 2007).
To address these challenges, research has explored innovative approaches such as using special face masks with angle meters to optimize head positioning, employing point-of-care ultrasound to assess esophageal insufflation during ventilation, and investigating the impact of pressure-responsive flow-limiting valves on BVM ventilation (Baskin & Kimura, 2019; Busko & Blackwell, 2006). These studies aim to enhance the effectiveness and safety of BVM ventilation by improving technique and addressing common pitfalls associated with the procedure.
Currently, there are two new devices on the market, which are the only BVM devices to control for rate of ventilation, pressure of ventilation, and volume of ventilation; these are the VT Select by Pulmodyne and the Butterfly BVM by Compact Medical Inc (Merrell 2023).
In conclusion, the failure of BVM ventilation can be attributed to various factors including incorrect rates, pressures, and volumes. It is essential for healthcare providers to receive adequate training and guidance to ensure proper execution of BVM ventilation, thereby optimizing patient outcomes during emergency respiratory management.
References:
- Aufderheide, T. P. and Lurie, K. G. (2004). Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Critical Care Medicine, 32(Supplement), S345-S351.
https://doi.org/10.1097/01.ccm.0000134335.46859.09
- Baskin, P. and Kimura, B. (2019). Use of point-of-care ultrasound to assess esophageal insufflation during bag mask ventilation: a case report. Respiratory Medicine Case Reports, 28, 100928.
https://doi.org/10.1016/j.rmcr.2019.100928
- Busko, J. and Blackwell, T. (2006). Impact of a pressure-responsive flow-limiting valve on bag–valve–mask ventilation in an airway model. Canadian Journal of Emergency Medicine, 8(03), 158-163.
https://doi.org/10.1017/s148180350001366x
- Culbreth RE, Gardenhire DS. Manual bag valve mask ventilation performance among respiratory therapists. Heart Lung. 2021 May-Jun;50(3):471-475. doi: 10.1016/j.hrtlng.2020.10.012. Epub 2020 Nov 1. PMID: 33138977; PMCID: PMC7604178.
- Dörges, V., Ocker, H., Wenzel, V., Sauer, C., & Schmucker, P. (2001). Emergency airway management by non-anaesthesia house officers--a comparison of three strategies. Emergency Medicine Journal, 18(2), 90-94.
https://doi.org/10.1136/emj.18.2.90
- Idris, A. H., Aramendi Ecenarro, E., Leroux, B., Jaureguibeitia, X., Yang, B. Y., Shaver, S., … & Wang, H. E. (2023). Bag-valve-mask ventilation and survival from out-of-hospital cardiac arrest: a multicenter study. Circulation, 148(23), 1847-1856.
https://doi.org/10.1161/circulationaha.123.065561
- Merrell JG, Scott AC, Stambro R, Boukai A, Cooper DD. Improved simulated ventilation with a novel tidal volume and peak inspiratory pressure controlling bag valve mask: A pilot study. Resusc Plus. 2023 Jan 5;13:100350. doi: 10.1016/j.resplu.2022.100350. PMID: 36654722; PMCID: PMC9841173.
- O'Neill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation. 2007 Apr;73(1):82-5. doi: 10.1016/j.resuscitation.2006.09.012. Epub 2007 Feb 7. PMID: 17289248.
- Paal, P., Ellerton, J., Sumann, G., Demetz, F., Mair, P., & Brugger, H. (2007). Basic life support ventilation in mountain rescue. High Altitude Medicine & Biology, 8(2), 147-154.
https://doi.org/10.1089/ham.2007.1025
- Rs, C., Mf, B., E, M., S, N., Young, S., & Walker, R. (2021). Utility of the sotairtm device in manual ventilation of different lung compliances.
https://doi.org/10.21203/rs.3.rs-513900/v1
- Rød, I., Jørstad, A., Aagaard, H., Rønnestad, A., & Solevåg, A. (2022). Advanced clinical neonatal nursing students’ transfer of performance: from skills training with real-time feedback on ventilation to a simulated neonatal resuscitation scenario. Frontiers in Pediatrics, 10.
https://doi.org/10.3389/fped.2022.866775
- Schumacher, F., Oberhanss, N., Paal, P., Pietsch, U., Wenzel, V., & Herff, H. (2022). Developing a special face mask with angle meter to optimize the head position while performing bag valve mask ventilation – a prospective simulated proof of concept study.
https://doi.org/10.21203/rs.3.rs-1716603/v1