Those of us who ventilate patients have all been there. We’ve been ventilating a patient with a bag-valve-mask device during a prolonged and difficult intubation process and our hand holding the mask starts to cramp.
As an anesthesia provider I often ventilate patients with bag-valve-mask devices. Of course we need to know how to manage the airway during emergency situations in the ICU or emergency room. When we administer general anesthesia, we mask ventilate both at the beginning and at the end of a case.
For some surgical procedures we may even allow the patient to breathe anesthetic gas spontaneously through a mask during the entire surgical procedure, requiring us to hold the airway open, assist ventilation as needed, and stay out of the surgeon’s way. Laryngeal mask airways are often used these days for such cases, but in the old days the choice was either mask ventilation or intubation.
When ventilating a patient with a mask, it’s important to know how to open and airway and provide positive pressure breaths. However, it’s also important to know how to do so in a way that conserves your grip strength. Ventilating with a mask can be very tiring to your hand. Prolonged “masking” can tire your hand to the extent that you lose grip strength and coordination — making maintenance of an open airway harder to sustain over time. When I’m working with a new student, and when appropriate to the case, I often have them hold the mask during the entire anesthesia because it helps them improve their skills. So how do you effectively and efficiently ventilate while minimizing hand fatigue? Let’s look at the steps to follow.
Start With A Good Seal With The Mask
If you get a good seal to start, maintaining that seal is easier.
Pull the head into extension and open the airway.
All masks are roughly triangular in shape. Always seat the apex of the mask over the very top of the bridge of the nose first and press firmly . One of the most common mistakes providers make is to place the apex of the mask over the center of the nose. When you do this, there is no way to seal the gap at the top of the mask and the top of the nose. Always place the apex at the top of the bridge of the nose where it meets the forehead.
Reach down with your free index and middle fingers and pull the loose cheek tissue forward to bunch on either side of the mouth. Pull the face into the mask. As you lower the mask over the cheeks, allow the edges of the mask to grab the bunched cheek tissue. Make sure the lower lip is inside the mask.
Place your remaining fingers on the jawbone and pull upward. This action also holds the head in extension and holds the airway open while you position the mask.
Note the final finger position. Thumb and forefinger press the mask against the face and form a “C” shape. The remaining fingers grip the boney mandible and pull upward, forming an “E”. The mask seal is created by the opposing force of thumb and index fingers pushing down, against the force of the last three fingers pulling the mandible up.
Don’t just push the mask down onto the face. You are basically sandwiching the patient’s face between the mask and your fingers pulling up on the jawbone. Think of it as pulling the patient’s face into the mask. If you press the palm of your hand against the patient’s cheek, you will transfer most of the force of maintaining the seal to your shoulders and upper arm rather than your hand. This is very helpful in maintaining a seal over time.
Take your right hand off the mask while you maintain your seal and jaw lift with the left hand Your right hand will now squeeze the bag.
To ventilate, obtain a good seal with the mask with one hand and then squeeze the bag with the other. The chest should rise with each breath. Pay attention to the resistance you feel as the lungs inflate. Obstruction makes squeezing the bag difficult. A leak in the ventilation system makes squeezing the bag very easy. In both these cases however the chest won’t rise. When in doubt, have a helper listen to both sides of the chest for breath sounds. The absence of breath sounds means inadequate ventilation until proven otherwise. You should see evidence of exhaled CO2 if an end-tidal CO2 device monitors the patient.
Use The Weight Of The Bag To Help The Seal
Shift the weight of bag to help you make the mask seal on the right side of the face. You can tilt your hand and bag as well as rotate the bag on the adapter if needed.
Optimize Patient Position
Optimize patient head position. Place an oral or nasal airway. Tilt the head into extension. If the patient is morbidly obese and blood pressure permits consider putting the back of the bed up slightly to relieve pressure on the diaphragm and improve chest wall compliance. Anything that opens the airway will make prolonged ventilation easier to maintain.
Use The Least Force Needed To Inflate Lungs
Always use the least force required to effectively inflate the lungs. Slow, steady inflation is more effective than rapid, jerky puffs because the gas is more likely to expand the chest and less likely to distend the stomach. Stomach distention pushes the diaphragm up into the chest cavity, impairing lung inflation and increasing the risk of vomiting and aspiration.
Relax Your Mask Holding Hand As Much As Possible
Your left hand holding the mask will tend to tire quickly if you keep it constantly tensed. Fatigue then interferes with your ability to ventilate. Learn to maintain the mask seal using the least amount of tension in your hands as possible. Don’t allow your hand to assume a “claw” shape as it goes into tetany. Instead:
- Rest the palm of your hand against the cheek.
- Use your shoulder and arm strength to help maintain the seal, not just your finger grip.
- Relax the left hand slightly as the bag refills to rest it
- Use the cheek tissue to help make the seal
- Rotate the elbow on the ventilation bag to help seal the mask
If you have a good mask seal, little or no air will escape around the mask. You can tolerate some leakage as long as you can ventilate.
Let Your Patient Exhale Between Breaths
Remember to allow your patient to exhale between breaths. Relax the mask hand for the few seconds it takes for the bag to refill. Gripping the mask too tightly can cause your hand to cramp. If your fingers spasm, you’ll lose fine motor control and may have difficulty maintaining a seal. If you have a good mask seal, little or no air will escape around the mask. You can tolerate some leak as long as you can ventilate the patient.
Try To Feel The Tidal Volume With The Ventilating Hand
Educating your hand to the correct “feel” of ventilation is valuable. If you can tell how well you are ventilating the patient without constantly looking at the chest, you free your attention for other matters. The easier it is to ventilate, the less likely you are to become excessively fatigued.
Don’t forget that difficulty in ventilation may be due to your patient’s illness and not your technique. Congestive heart failure, bronchospasm, and pneumothorax can also make airway resistance worse, breath sounds fainter, and ventilation difficult. You must prove, however, that the fault is not your own before blaming poor ventilation on the patient.
Ask For Help To Seal The Mask If Needed
In certain patients getting a good seal on the mask may not be easy. In adults this is especially true with edentulous or morbidly obese patients. Typically the leak will be on the side with the bag, opposite the hand holding the mask. You can rotate the ventilation bag attachment to change the point of maximum pressure and improve your seal. Reposition your hands if necessary. You can also ask a helper to push the cheek up against the outside of the mask at the leak sites. This seals very effectively. If you’re having trouble never hesitate to ask one of your assistants to help you create the seal by holding the mask tight against the patient’s face at the leak points.
Ask For Help Squeezing The Bag
If difficulty persists, use both your own hands to seal the mask. Have your helper squeeze the bag for you. Place your thumbs on top of the mask and your index fingers on the bottom, bunching the soft tissue of the cheeks under the mask. Pull the jaw upward with your remaining fingers by spreading them along the jaw line, underneath the angle of the mandible. Pull up forcefully, squeezing the patient’s face between the mask and your hands. Hold just the bone. Pushing on the soft tissue under the jaw can force it into the airway and worsen obstruction.
Use of both hands makes it easier to shift the mandible forward and pull the obstructing tissue up and off the larynx. Move your fingers as needed to perfect your seal. In the meantime, have your helper squeeze the bag.
When someone else is squeezing the bag, it’s especially important to verify adequate ventilation — since you can no longer feel the compliance of the bag yourself. Watch the chest rise, see the air condense on the mask (if mask is clear plastic), and have someone listen for breath sounds. Make sure your helper tells you immediately if there are any signs of obstruction or lack of seal immediately. This technique is a team effort and excellent communication.
Let Someone Else Ventilate
If your hands are giving out, don’t be afraid to ask another provider with good airway management skills to give you a break. If you can’t hold the seal you won’t be ventilating effectively. Don’t let your ego stand in the way of patient care. You can always switch back later if needed.
Consider An LMA
Assuming that you can’t intubate for any reason, a common reason for a prolonged and challenging ventilation attempt, then consider placing a Laryngeal Mask Airway,or LMA. LMAs are wonderful ventilation devices and should always be considered a potential first line rescue airway (see previous article here).
You can also consider intubation with the Fastrach LMA, a device that lets you ventilate while also intubating (see previous article here).
Ensuring a good mask fit, optimally positioning the patient, and using good personal body mechanics will prevent hand fatigue and allow effective ventilation in the most difficult circumstances. But never be afraid to ask for help.