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Perform the head-tilt chin-lift maneuver or the jaw thrust. In patients with suspected cervical spine injury, do not perform a head-tilt; rather, perform only a chin-lift maneuver.

Use an airway adjunct. Note the following:

Place the mask on the patient’s face before attaching the bag. [8]  Cover the nose and the mouth with the mask without extending it over the chin. Change the size of the mask, as appropriate, to create a good seal.

Various methods of mask positioning have been described. The one-hand E-C technique is shown in the images below. Using the nondominant hand, create a C-shape with the thumb and index finger over the top of the mask, and apply gentle downward pressure. Hook the remaining fingers around the mandible, and lift it upward toward the mask, creating the E.

The alternative one-hand technique shown in the image below can also be employed.

If a second person is available to provide ventilations by compressing the bag, a two-hand technique can be used (see the image below). Create two opposing semicircles with the thumb and index finger of each hand to form a ring around the mask connector, and hold the mask on the patient’s face. Then lift up on the mandible with the remaining digits.

Alternatively, place both thumbs opposing the mask connector, using the thenar eminences to hold the mask on the patient’s face, while lifting up the mandible with the fingers (see the image below).

No matter which technique is used, it is essential to avoid applying pressure on the soft tissues of the neck or on the eyes.

Place the web space of the thumb and index finger against the mask connector. Push downward with gentle pressure. Wrap the remaining fingers around the mandible and lift it upward.

The two-hand technique is preferred to the one-hand technique and should be used whenever possible. [13, 14]  The National Association of EMS Physicians (NAEMSP) has recommended that a two-person approach be followed for prehospital BVM ventilation whenever feasible. [10]

Ventilation

Provide a volume of 6-7 mL/kg per breath (~500 mL for an average adult). For a patient with a perfusing rhythm, ventilate at a rate of 10-12 breaths/min. [12]

During cardiopulmonary resuscitation (CPR), give two breaths after each series of 30 chest compressions until an advanced airway is placed. Then ventilate at a rate of 8-10 breaths/min. [12, 15]

Give each breath over 1 second. [12]  If the patient has intrinsic respiratory drive, assist the patient’s breaths. In a patient with tachypnea, assist every few breaths. [16]  Ventilate with low pressure and low volume so as to minimize gastric distention.

Maintain cricoid pressure consistently, keeping the following considerations in mind:

Assess the adequacy of ventilation, taking care to do the following:

Although the evidence is not conclusive, some have found capnography to be a feasible and potentially useful means of assessing BVM ventilation in the context of CPR, particularly in neonates. [17]

The following tips and comments may facilitate the performance of BVM ventilation: