Airway Basics: BVM Is Your First Advanced Airway

BVM Is Your First Advanced Airway

We have all felt it. The adrenaline surge on a critical call, the pressure to do something. And in airway management, that “something” often defaults to grabbing a laryngoscope. We see intubation as the definitive, heroic intervention. But what if I told you the most advanced airway in your kit is the one you learned on day one? It is the Bag-Valve-Mask (BVM).

Why We Rush Past the Basics

The rush to intubate is often driven by ego and anxiety. A tube feels final, a problem solved. But a failed intubation attempt is a disaster. It causes hypoxia, risks aspiration, and can create airway trauma that makes subsequent ventilation impossible. Meanwhile, a patient who is being effectively ventilated with a BVM is being oxygenated. That is the goal. The goal is not the tube; it is the oxygen in the lungs.

Mastering the BVM is not “settling.” It is a mark of a confident, skilled provider who prioritizes patient outcomes over procedures.

Mastering the Two-Person BVM Technique

A one-person BVM seal on a moving patient is a low-percentage play. The two-person technique should be your default for any difficult airway.

• Provider 1 (Airway): This is the expert. Their only job is the mask seal. Forget the C-E grip you were taught. Use the two-handed “thenar eminence” grip. Place both thumbs along the sides of the mask, using the fleshy part of your palms to apply downward pressure. Your fingers hook under the mandible and pull the jaw up into the mask. You are not pushing the mask down; you are lifting the face into it.
• Provider 2 (Ventilation): Their job is to squeeze the bag. Gently. One hand. Just enough to see chest rise. Deliver one breath every 5-6 seconds. Count it out loud if you have to. Over-bagging increases intrathoracic pressure, decreases preload, and risks barotrauma.

Positioning is Everything

You cannot bag what you cannot align. The “sniffing position” is non-negotiable. Get the patient’s ear canal on the same horizontal plane as their sternal notch. This aligns the oral, pharyngeal, and tracheal axes. In adults, this often means putting a folded towel or blanket under their head and shoulders. Do not forget your adjuncts! An OPA or NPA is mandatory to keep the tongue from occluding the airway.

When BVM is Better than Intubation

• Short Transports: If you are 5 minutes from the hospital, spending 3 minutes attempting to intubate a patient you can ventilate is poor time management.
• The “Cannot Intubate, Can Ventilate” Scenario: You have given it your best look, but you cannot see the cords. Do not force it. Back out, place an OPA, and go back to a perfect two-person BVM technique.
• Cardiac Arrest: Multiple studies have shown no significant survival benefit between intubation and skilled BVM ventilation in out-of-hospital cardiac arrest. Do not interrupt high-quality compressions for a low-percentage tube attempt.