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Face Mask Ventilation: A Comparison of Three Techniques

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Abstract

Background

There are multiple techniques for face-mask (FM) ventilation. To our knowledge, the one-handed vs. two-handed C-E technique has been compared in children and adults, but no studies have compared the various two-handed methods.

Objective

To compare the effectiveness of mask seal using three different FM techniques on a model intended to simulate difficult FM ventilation and measure ventilation performance.

Methods

This was a prospective randomized study of health care providers. A standard airway-training mannequin was modified to produce variable airway resistance and allow measurements of ventilation volume and pressure. Each subject performed FM ventilation for 3 min per technique (30 breaths) in a randomized order. Median exhaled tidal volume and proximal peak flow pressure were determined and compared.

Results

Seventy subjects were enrolled. Both two-handed ventilation techniques were more effective than the one-handed technique by both volume and pressure measurements. The one-handed C-E technique yielded a median volume of 428.4 mL, vs. the two-handed C-E technique with 550.8 mL, and the two-handed V-E technique with 538 mL (p < 0.001). Peak pressure measurements revealed a median of 54.6 cm H2O for the one-handed C-E technique, 66 cm H2O for the two-handed C-E technique, and 66.6 cm H2O for the two-handed V-E technique (p < 0.001). There was not a difference between the various two-handed techniques.

Conclusions

This model for FM ventilation is able to differentiate the efficacy of FM techniques. Both two-handed ventilation methods were superior to one-handed ventilation, both of which should perhaps be included in airway training for health care providers.

Introduction

Face-mask (FM), or bag-valve-mask, ventilation is the single most important skill for emergent airway management. Although the FM method of ventilation seems to be simple, it can be difficult to perform correctly and effectively. Proper position of the head and neck, manually opening the airway with a jaw thrust maneuver, placing a nasopharyngeal or oropharyngeal airway device, and achieving a tight face mask seal are the keys to successful FM ventilation 1, 2, 3.

There are multiple techniques for hand positioning during FM ventilation, including the one-handed C-E technique (Figure 1), the two-handed C-E technique (Figure 2), and the alternative technique, which we will refer to as the V-E technique (Figure 3). Despite the importance of this skill, there have only been a few studies comparing the efficacy of these techniques in adults. To our knowledge, there are no studies comparing the various two-handed methods, which include the two-handed C-E technique and the V-E technique, which is taught in a few airway courses (1).

The double C-E technique is the only two-handed method taught in the American Heart Association Courses (Basic Life Support, and Advanced Cardiac Life Support) and cited in major anesthesia textbooks for FM ventilation 2, 3, 4, 5. Some practitioners prefer the alternative V-E technique. Our aim is to compare the efficacy of FM ventilation using these three techniques on a difficult airway model.

Section snippets

Study Design

Institutional review board approval was obtained for this prospective randomized study of health care providers.

Setting

This study took place in an Emergency Department (ED) in a large Level I trauma center.

Selection of Participants

Eligible subjects were health care providers in the ED, including Emergency Medicine (EM) attending physicians, residents (EM residents and residents from other programs rotating in the ED), physician assistants, nurses, paramedics, and respiratory therapists. Exclusion criteria were subjects who

Results

Seventy subjects were enrolled in the study. One subject did not complete measurements, leaving 69 for analysis. All 69 did three techniques; 6280 breaths were measured; mean volume and pressure for each subject at each technique were determined for analysis. The median was 30 breaths per subject per technique, range 26–38 (each technique was done for 3 min). There were 13 EM attending physicians, 20 EM residents, six residents of other specialties, seven physician assistants, 13 nurses, three

Discussion

Although it is generally accepted that two-handed FM ventilation is superior to one-handed FM ventilation, our study is the first to compare the two-handed C-E technique with the two-handed V-E technique. There are a number of studies that have compared the one-handed C-E technique (Figure 1) to the two-handed C-E technique (Figure 2), all of which found that the two-handed C-E technique was more effective 6, 11, 12, 13, 14, 15. Some of these studies compared various one-handed techniques to

Conclusion

Two-handed FM ventilation is more effective than one-handed FM ventilation, in both routine and difficult airway situations. We found no significant difference between the two-handed C-E technique and the two-handed V-E technique in this study. However, each health care provider had variable success with each technique. Therefore, it seems that teaching both techniques for airway training may be optimal.

Article Summary

1. Why is this topic important?

  1. Face-mask ventilation is the most important airway skill.

2. What does this study attempt to show?
  1. This study compares the traditional

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