How to Master BVM Ventilation

Bag mask ventilation, also known as bag-valve-mask (BVM) ventilation, is an important airway management technique used by trained healthcare professionals to provide ventilatory support during certain respiratory emergencies and cardiac arrest situations. BVM ventilation provides positive-pressure breaths to support ventilation and oxygenation when a patient is not breathing adequately.

This article covers BVM ventilation techniques, recommended ventilation rates, common mistakes, signs of effective ventilation, and considerations for advanced airway management. We’ll also discuss pediatric airway management and ventilation rates, which are important concepts covered in PALS training.

Table of Contents

• What Is Bag Mask Ventilation?
• When is Bag Mask Ventilation Used?
• How to Perform Bag Valve Mask Ventilation
• One-Person vs. Two-Person BVM Ventilation
• Bag Mask Ventilation Rates
• Common Bag Mask Ventilation Mistakes
• How to Know if Bag Mask Ventilation is Working
• When Should You Use an Advanced Airway?
• Improve Your Airway Management Skills

What Is Bag Mask Ventilation?

Bag mask ventilation, also known as bag-valve-mask (BVM) ventilation, is a manual ventilation treatment utilizing a bag and face mask to provide oxygen and ventilation to patients requiring airway support. Manual positive-pressure ventilation is a broader term used to denote breaths delivered using a manual device (often a BVM).

The equipment involved with a BVM includes the following:

• Bag: A self-inflating bag which is squeezed by the provider to provide breaths to the patient via a one-way valve.
• Mask: Available in typically infant, pediatric and adult sizes to cover the nose and mouth for an airtight seal to prevent air leakage during ventilation.
• Oxygen Reservoir: With self-inflating bags, this is used to maintain higher oxygen concentrations with delivered breaths.
• Oxygen Source: Often an oxygen tank or oxygen supply outlet on the wall in the patient’s room.

BVM ventilation is appropriate when patients present with an inadequate spontaneous respiratory rate or effort and require immediate ventilatory support. BVM ventilation acts as a bridge to other forms of definitive positive pressure ventilation (e.g. BiPAP, intubation) or potential reversal of causes of the respiratory event (e.g. bronchodilators, Narcan, etc.).

When Is Bag Mask Ventilation Used?

BVM ventilation is used to provide immediate oxygenation and ventilation to patients with indications of respiratory compromise. Some common indications for BVM ventilation include:

• Inadequate Ventilation: Think about patients with bradypnea (opioid overdose) who have an inadequate rate and depth of respirations.
• Cardiac Arrest: For pulseless patients, BVM ventilation is critical to maximize oxygen supply to the tissues and minimize acidosis via the expulsion of CO2. BVM is often used as a bridge to intubation in this setting.
• Peri-Intubation Support: BVM is used to pre-oxygenate the patient for rapid sequence intubation (RSI) or anesthesia induction.
• Altered Mental Status: Depressed level of consciousness with lack of airway protection may require BVM as a bridge to advanced airway.

As discussed in the above examples, BVM can act as a bridge for patients requiring an advanced airway which includes tracheal intubation with an endotracheal tube (ETT). This type of airway allows for longer-term airway protection and ventilation. Alternatively, supraglottic/extraglottic airway devices can be used which are temporary rescue devices that provide oxygenation, ventilation and airway protection without entering the trachea.

How to Perform Bag Valve Mask Ventilation

Now that we’ve discussed the indications, what is the most effective way to deliver bag mask ventilation? Here are the following steps for learning this critical skill taught in BLS certification training.

Position the Airway

Proper airway positioning is crucial for optimizing airflow during BVM ventilation. The following airway positioning techniques are used to achieve this goal:

• Head-Tilt Chin-Lift: This is the most common maneuver used whenever cervical spine injury is not a concern. One hand applies downward pressure on the forehead while the index and middle fingers of the other hand lift the mandible (chin) to elevate the tongue from the posterior pharynx.
• Jaw-Thrust: This is the preferred maneuver when cervical spine injury is a concern. The heels of both hands are placed on the parieto-occipital areas while the index and long fingers grasp the mandibular angles to displace the jaw anteriorly, moving the tongue forward with the mandible.
• Sniffing Position: When intubation with an endotracheal tube (ETT) is required, the sniffing position provides oral, pharyngeal and laryngeal alignment to facilitate the procedure.
• Airway Adjuncts: In some cases, airway adjuncts are required to maintain the airway for BVM ventilation. These include oropharyngeal airways and/or nasopharyngeal airways.

Create a Proper Mask Seal

Without a proper mask seal, the pressurized air leaks around the mask and you end up ventilating the outside air more than the patient who desperately needs it! See the following factors which are critical for maintaining a good mask seal:

• Mask Sizing: A properly fitting mask covers the area between the nasal bridge and the crease of the chin. The wrong size mask will cause air to leak around the sides of the mask and produce insufficient tidal volume for the patient.
• CE Technique: This mask-seal technique is often taught where the thumb and index finger form a “C” shape to secure the mask to the patient’s mouth and nose while the rest of the fingers pull the jaw toward the mask. This technique requires care to prevent uneven pressure distribution and fatigue with prolonged usage.
• Preventing air leaks: Common causes of air leaks, apart from fatigue and difficult hand placement, include facial hair and interfering substances such as vomit, saliva or bleeding.

Deliver Effective Ventilations

Several principles should be followed for ensuring optimal ventilations with BVM usage. These include:

• Visible Chest Rise: While not an objective measure, this is a helpful indicator when unable to measure tidal volume with ventilations. A good rule of thumb is to provide only enough tidal volume to observe the chest rise.
• Controlled Tidal Volume: The bag should not be squeezed to the point of total emptying, while excessive ventilatory volume should be avoided.
• Proper Ventilation Rate: For adults undergoing CPR without an advanced airway, ventilations are performed as 2 breaths after every 30 compressions. But if an advanced airway is in place, ventilations are delivered asynchronously every 6 seconds.
• Avoiding Excessive Pressure: A single ventilation should be delivered over about one second with minimum ventilatory force used to make the chest rise.

One-Person vs. Two-Person BVM Ventilation

The following table breaks down the differences in BVM ventilation capabilities when one or two providers are available.

CE Technique

The CE mask-seal technique is often taught for single rescuer BVM ventilation when no other rescuer is available to assist. Generally, the technique uses the thumb and index finger to form a “C” shape to secure the mask to the patient’s mouth and nose while the rest of the fingers pull the jaw toward the mask.

The CE mask-seal technique requires care to prevent uneven distribution of the mask seal pressure and fatigue with prolonged usage. As the provider’s hand strength decreases, the mask seal becomes compromised and air leaks occur.

Thenar Eminence (Two-Handed) Technique

In contrast to the single-provider CE technique, the two-handed Thenar Eminence Technique is recommended when there are two rescuers present. With this technique, the one rescuer squeezes the bag while the other maintains the mask seal using both hands, placing each thumb and the thenar muscles (base of thumb) on the top of each side of the mask with the other four fingers of each hand around the mandible.

This technique is preferred over the CE technique due to improved mask-seal pressure distribution with both hands creating an equal seal on around the nose and mouth, while also allowing for a more natural grip that doesn’t tax the rescuer’s hands as intensely.

Bag Mask Ventilation Rates

BVM ventilation rates are not the same across the board; rather, they vary based on age, patient status and airway modalities.

Common Bag Mask Ventilation Mistakes

Unless you’ve tried it, you may think that BVM ventilation is an easy and straightforward technique. However, there are several pitfalls and mistakes to avoid when performing this skill:

• Poor Mask Seal: As discussed above, a poor mask seal is more likely with a single rescuer utilizing the CE technique.
• Improper Positioning: Increased manual pressure shuts the patient’s mouth and worsens airway obstruction since the soft tissues and tongue are forced back.
• Excessive Ventilation Rate: Hyperventilation can cause decreased cardiac output, hypocapnia and gastric insufflation. In certain research on hyperventilation during CPR, providers were shown to vastly underestimate the rate at which they were ventilating the patient which negatively affected patient outcomes.
• Excessive Tidal Volume: Excess tidal volume additionally causes decreased cardiac output due to increased intrathoracic pressure.
• Gastric Inflation: The 2025 AHA Guidelines note that excessive ventilation can cause gastric inflation, regurgitation and aspiration. Gastric inflation, in turn, impairs bag mask ventilation.

How to Know if Bag Mask Ventilation is Working

So, how do you know if the breaths you’re administering are effective? The following are helpful signs, with some more objective than others:

• Visible chest rise: Providers often lean on this cue to confirm adequate ventilation efforts; however, this is a highly subjective measure since “adequate” chest rise is impossible to quantify.
• Breath sounds: While also helpful, this is still a deficient measure as it does not provide objective quantification of ventilation.
• Oxygen saturation: While this measure can show adequate oxygenation, it is a delayed metric and not the gold standard.
• ETCO2 monitoring: This is the gold-standard measure of adequate ventilation because is gives a real-time metric of CO2 expulsion which provides information about metabolism, perfusion and ventilation.
• Minimal Air Leakage: Mask seal is a key determinant of effective ventilation; check to make sure leakage isn’t happening, especially in the setting of excess facial hair.

When Should You Use an Advanced Airway?

At some point, BVM ventilation may no longer be sufficient for a patient in respiratory failure or cardiac arrest. If the airway cannot be opened or maintained with basic measures, providers should proceed to advanced airway management via a supraglottic or endotracheal tube intubation. ACLS training also dictates that during cardiac arrest, if ventilation is insufficient without a definitive airway, then advanced airway management should be established.

Improve Your Airway Management Skills

In conclusion, bag mask ventilation is a critical skill required for healthcare providers at all levels of patient care. It is a skill mastered through knowledge and experience which is why, at ACLS Medical Training, we offer BLS, ACLS & PALS certification courses that walk you through indications and techniques for BVM mastery as well as the knowledge of when to progress to advanced airway management. Take the next step in acquiring these lifesaving skills by registering on our site today!

References

Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004;32(9 Suppl):S345-S351. doi:10.1097/01.ccm.0000134335.46859.09

Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult basic life support: 2025 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152(16 suppl 2):S448-S478. doi:10.1161/CIR.0000000000001369