This session covers:

• General overview
• C-E hold
• Ensuring proper ventilation and oxygen delivery
• Oro-pharyngeal airways
• Naso-pharyngeal airways

A. Overview

Indications:

• Respiratory failure:
  • Inadequate respiratory effort (apnea,hypoventilation)
  • Ineffective breathing or severe respiratory distress
• Hypoxia unresponsive to supplemental oxygen
• Severe airway obstruction(as a temporizing measure)
• During resuscitation: Cardiopulmonary arrest or peri-arrest states
• Preparation for intubation: Preoxygenation or rescue ventilation during failed airway attempts
• Transport of unstable patients: To maintain oxygenation/ventilation

Contraindications:

• Complete upper airway obstruction (unless attempting to ventilate whilepreparing for definitive airway)
• Facial trauma/deformity or poor mask seal (use alternative airway management like supraglottic airway or intubation)
• High risk of aspiration with ineffective airway protection (consider early definitive airway)
  1. Note:There are no absolute contraindications if BVM is the only option to oxygenate a patient in extremis

Complications:

• Gastric insufflation: Risk of vomiting and aspiration
• Barotrauma: Pneumothorax or pneumomediastinum from excessive pressure
• Hypoventilation or hyperventilation: Leading to hypoxia or respiratory alkalosis
• Poor mask seal: Leading to inadequate ventilation and oxygenation
• Increased intracranial pressure (ICP): If hyperventilated in head injury patients
• Provider fatigue: In prolonged resuscitation efforts

B. Procedure for bag-valve mask ventilation:

Steps to Perform the C-E Hold:

1. Position yourself at the patient’s head and adjust the height of the bed–
2. Use your thumb and index finger (forming the “C”)to create a seal around the mask apex and sides.
3. Apply gentle downward pressure to maintain the seal.
4. Place your middle, ring, and pinky fingers (forming the “E”)along the bonymandible:
5. Apply an upward lifting force to perform a jaw thrust.
6. Avoid pressing on soft tissues of the neck to prevent airway obstruction.
7. Ventilate using the bag with your other hand.

Key Tips:

• ✅ Maintain neck in sniffing position if no C-spine concern.
• ✅ Avoid excessive pressure that could occlude the airway.
• ✅ Ensure visible chest rise with each breath.
• ✅ If unable to get a good seal—consider two-person technique.

Video Demonstration:

Watch a Pediatric BVM Ventilation with C-E Hold (Video: Proper BVM technique, including C-E hold and jaw thrust demonstration)

C. Ensuring Proper Ventilation with BVM

How to Confirm Adequate Ventilation:

• Observe visible chest rise and fall with each ventilation.
• Monitor oxygen saturation (SpO₂) and heart rate—improvements suggest effective ventilation.
• Listen for bilateral breath sounds over lung fields.
• Avoid over-ventilation—deliver gentle, controlled breaths (~6-8 mL/kg tidal volume).
• Watch for gastric distention, which suggests air entering the stomach instead of the lungs.
  1. Tip: In small infants, use a manometer if availableto prevent high pressures (>20-25cm H₂O) that risk barotrauma.

⚠️ Pitfalls in Oxygen Delivery with a BVM (Ambu Bag):

• BVM does not provide passive oxygenation.
  • Why? The self-inflating bag only delivers oxygen during active squeezing.
  • Passive flow through the maskcannot occurbecause the bag’s valve preventsoxygen flow unless squeezed.
• If a patient is apneic but breathing is expected to resume, BVM alone is inadequate for apneic oxygenation—use high-flow nasal cannula or non-rebreather mask for passive oxygen delivery.
• Reservoir bag attachment is essential for delivering high FiO₂ (close to 100%).Without it, FiO₂ drops significantly.
• Mask leaks reduce effective ventilation and oxygenation.

✅ Take-Home Points:

• Chest rise is the most reliable signof effective ventilation.
• Self-inflating BVMs do not provide oxygen passively—oxygen is delivered only when the bag is squeezed.
• Always check equipment setup:
  • Oxygen tubing connected and running at10-15 L/min
  • Reservoir bag attached and filled
  • Proper mask size and seal

Airway Adjuncts

D. Oropharyngeal Airway (OPA):

Indications:

• Unconscious patient without a gag reflex
• Airway obstruction from tongue or soft tissue collapse
• To facilitate effective BVM ventilation

Contraindications:

• Concious or semi-conscious patients (intact gag reflex -> risk of vomiting/aspiration)
• Oral trauma or mandibular fracture

Sizing and Insertion:

• Measure: From the corner of the mouth to the angle of the mandible.
• Insertion:
  • Option 1 (older children): Insert upside down, then rotate 180° once past the tongue.
  • Option 2 (infants/small children): Insert right-side up using a tongue depressor to avoid trauma.
• Ensure the flange rests against the lips and airway is patent.

Video: OPA Insertion Demo (Pediatric) Watch Here

E. Nasopharyngeal Airway (NPA):

Indications:

• Semi-conscious patients or those with intact gag reflex needing airway support
• BVM ventilation where OPA is contraindicated
• Oral trauma, clenched teeth, or seizure activity
• Sizing and Insertion:1.Measure:From thetip of the nose to the tragus of the ear.2.Insertion:a.Lubricate the airway with water-based gel.b.Insertbevel toward the septumalong the floor of the nostril.c.Advance gently until the flangerests against the nostril.3.If resistance is met, try the other nostril.

Contraindications:

• Basilar skull fracture or facial trauma(risk of intracranial placement)
• Coagulopathy or nasal obstruction

Sizing and Insertion:

1. Measure:From the tip of the nose to the tragus of the ear.
2. Insertion:
   • Lubricate the airway with water-based gel.
   • Insert bevel toward the septum along the floor of the nostril.
   • Advance gently until the flange rests against the nostril.
     • If resistance is met, try the other nostril.

Video: NPA Insertion Demo – Watch Here

⚠️ Pro Tips:

• Choose the largest size that fits comfortably to minimize airway resistance.
• Reassess airway patency and chest rise after placement.
• Both adjuncts do not replace definitive airway management if needed.