Mask Ventilation: Avoiding Hand Fatigue

Hand fatigue during mask ventilation can cause  loss of the ability to maintain a good mask seal. Those of us who mask ventilate patients have all been there. We’ve been mask 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.

With mask ventilation, it’s important to know how to open the 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 Mask Ventilation With A Good Seal With The Mask

With mask ventilation, if you get a good mask seal to start, maintaining that mask seal is easier.

Pull the head into extension and open the airway.

Illustration showing opening the airway by extending the head

The first step to a good mask seal is opening the airway. (All illustrations from Anyone Can Intubate 5th Ed., C. written MD)

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.

Illustration of applying the top of the mask to the bridge of the nose to obtain a good mask seal while make ventilating a patient

Apply the top of the mask to the bridge of the nose, where leaks often occur.

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.

Illustration showing pulling the face into the mask, using the cheek tissue on either side to help make the seal while makes ventilating a patient

Pull the face into the mask, using the cheek tissue on either side to help make the seal.

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.

Illustration showing final mask position with the lower lip and mouth inside the mask while makes ventilating a patient

Seat the mask over the chin, making sure the lower lip is inside 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.

Illustration of the final positions of the finger positions. Thumb and forefinger press mask against the face and form a "C" shape. Remaining fingers grip mandible and form an "E".

Note the finger positions. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”.

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.

Illustration showing need to pull the patient's face into the mask t seal, not push the mask down over the face while makes ventilating patient

Don’t just push the mask down, pull the patient’s face into the mask t seal.

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.

Start Mask Ventilation

UIllustration Use the weight of the bag to help make the seal on the right side of the mask as you mask ventilate.

Use the weight of the bag to help make the seal on the right side of the mask as you ventilate.

To mask 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. For the importance of allowing the patient to exhale click here. 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

Illustration of using your helper to assist in sealing the mask.

A helping hand can often help seal a leak if adjusting the weight the mask fails.

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

Illustration showing Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

Using both your hand to seal a mask is very efficient in long difficult ventilations. You must communicate carefully with the assistant squeezing the bag to ensure good ventilation.

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).


Illustration showing Helpful tips for avoiding hand fatigue while effectively ventilating

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.

For additional information on how to provide assisted mask ventilation go to


May The Force Be With You

Christine Whitten MD, author Anyone Can Intubate 5th Edition
Pediatric Airway Management: A Step By Step Guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten     Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

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8 thoughts on “Mask Ventilation: Avoiding Hand Fatigue”

  1. Hi,
    As always, excellent tips. Good points about resting the arms to ease the shoulders and back.

    If in a fairly stable situation (not acutely resuscitating), try to have an elevating stool so as to sit to maintain that braced and rested position (but not giving up a good view of the chest, abdomen, and action). Cumulative fatigue of your different parts adds up to problems with your grip, and your mind will be stressed, too.

    Head-straps for the mask do not take away the responsibility and care in assuring a good seal, but they can ease the fatigue; never leave the patient alone –straps must be released instantly if there is emesis; suction until clear.

    Weight of the bag and squeeze-fatigue can be eased by rotating to the mask-holding forearm, then squeezed against the arm. If an extension tube can be interposed between the bag and valve, the bag can be squeezed against the bed.

    If one is competent with a flow-filling anesthesia bag, it is inherently less fatiguing than a self-refilling bag which has more weight and substance. Additionally, adjusting flow can give nice low-pressure breaths by simply occluding the tail or port for the incoming fresh gas flow to inflate the lungs.

    Thank you for all the fine work that you do.

    Tom Trimble, RN

  2. “Don’t push the mask down on the face, pull the face up into the mask” is the same rule I teach all students I try to teach airway management. Such a simple sentence, yet it makes one think about keeping the airway open first and foremost, then secondly getting the mask zeal, rather than focusing all on mask zeal in the beginning and closing the airway, then having to reopening it.

    Another smart little tip I learned from one of my attendings. When mask-ventilating during induction, why not let the “real expert” take over the actual ventilations? Set the anesthesia machine in pressure-controlled mode, for example 15/0 x 12. Frees up one hand, the mental task of “dosing every breath” and gives you precise control of peak pressure delivered at the optimum I:E of 1:2. I find myself increasingly using this on edentulous and obese patients, works like a charm!

    Another great article, thanks a lot!

    Tor P

    1. While you can use the ventilator in a pinch to assist your ventilation, just be careful because you will lose all of the feedback that you receive by squeezing the bag yourself. While the machine might alarm if compliance changes or if you develop a leak, there is no guarantee it will do so if the changes are small. And sometimes it’s those small changes that alert you to the big changes that are coming – or help you prevent those big changes. I view induction of anesthesia like takeoff and landing an airplane. Sure you can use your instruments to control the plane, but if your plane sucks a bird into the engine I think you will want your own hands on the controls.
      Chris Whitten

  3. Dear Christine,

    This article is excellent, and the illustrations very effective. I would love to seek your permission to use the C and E grip diagram in a short video for a free e-learning course. The course is hosted by the UK paediatric royal college for the ETAT+ course for low resource settings and available at with free registration. Can we discuss via e-mail?

    Many thanks,


  4. Great Article!


    May I ask for permission to use those illustrations(C grip and Summary) for our clinical station session?

    Many Thanks,

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