Skill 14-16

Using a Manual Resuscitation Bag and Mask

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a bag and mask may be used to deliver oxygen and assist with ventilation until the patient is resuscitated or can be intubated with an endotracheal tube. Bag and mask devices may be referred to as Ambu bags (air mask bag units) or BVMs (bag-valve masks). The bags come in infant, pediatric, and adult sizes. The bag consists of an oxygen reservoir, oxygen tubing, the bag itself, a one-way valve to prevent secretions from entering the bag, an exhalation port, an elbow so that the bag can lie across the patient's chest, and a mask. When the bag is compressed, the nonrebreathing valve directs gas from the bag through the mask and to the patient; when the bag is released, the exhaled gas exits through the exhalation port, and the bag simultaneously reinflates (Hess et al., 2021). The mask is removed to fit onto an endotracheal or tracheostomy tube.

Delegation Considerations

The use of a BVM may be delegated to assistive personnel (AP) in an emergency situation. The use of a BVM may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Handheld resuscitation device with a mask
Oxygen source
Disposable gloves
Face shield or goggles and mask
Additional PPE, as indicated

Assessment

Assess the patient's respiratory effort and drive. If the patient is breathing less than 10 breaths/min, is breathing too shallowly, or is not breathing at all, assistance with a BVM may be needed. Assess the oxygen saturation level. Patients who have decreased respiratory effort and drive may also have a decreased oxygen saturation level. Assess the heart rate and rhythm. Bradycardia may occur with a decreased oxygen saturation level, leading to a cardiac dysrhythmia. Many times, a BVM is used in a crisis situation. Manual ventilation may also be used during airway suctioning.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered breathing pattern
Impaired gas exchange

Outcome Identification and Planning

The expected outcome to achieve is that the patient will exhibit signs and symptoms of adequate respirations and oxygenation. Other outcomes that may be appropriate include that the patient will receive adequate volume of respirations with the BVM, and the patient will maintain oxygen saturation within acceptable parameters.

Implementation

Action	Rationale
1. If this is not a crisis situation, perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
2. Put on PPE, as indicated.	PPE prevents the spread of microorganisms. PPE is required based on transmission precautions.
3. If this is not a crisis situation, identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.	Explanation alleviates fears. Even if the patient appears unconscious, the nurse should explain what is happening.
5. Put on disposable gloves. Put on a face shield or goggles and a mask.	Using gloves deters the spread of microorganisms. PPE protects the nurse from pathogens.
6. Connect the mask to the bag device (Figure 1) and connect the oxygen tubing to the oxygen source (Figure 2). Turn on the oxygen to a flow rate of 10 to 15 L/min (Hess et al., 2021). This may be done by visualizing or by listening to the open end of the reservoir or tail: if air is heard flowing, the oxygen tubing is attached and on.	The expected results might not be accomplished if the oxygen tubing is not attached and on.
7. Initiate cardiopulmonary resuscitation (CPR), if indicated. Refer to Skill 15-1.	Start CPR in any situation in which either breathing alone or breathing and a heartbeat are absent. The brain is sensitive to hypoxia and will sustain irreversible damage after 4 to 6 minutes of no oxygen. The faster CPR is initiated, the greater the chance of survival.
8. Position yourself at the patient's head. If possible, get behind the head of the bed and remove the headboard. Tilt the patient's head back and lift their jaw forward.	Standing at the head of the bed makes positioning easier when obtaining a seal of the mask to the face. Hyperextending the neck opens the airway.
9. Place the mask over the patient's face with the opening over their oral cavity. If the mask is teardrop shaped, the narrow portion should be placed over the bridge of the patient's nose.	This helps ensure an adequate seal so that oxygen can be forced into the lungs.
10. Use the thumb and index finger of one of your hands to make a “C” on the side of the mask, pressing the edges of the mask to the patient's face to form a seal. Use the remaining three fingers on the same hand to lift the angles of the patient's jaw to open the airway and press the mask to the face (Hess et al., 2021).	This helps ensure that an adequate seal is formed so that oxygen can be forced into the lungs.
11. Using your other hand, squeeze the bag to give a breath over 1 second (Figure 3), watching the chest for symmetric rise.	The volume of air needed is based on patient's size. Enough has been delivered if their chest is rising. If air is introduced rapidly, it may enter the stomach.
12. Deliver the breaths with the patient's own inspiratory effort, if present. Avoid delivering breaths when the patient exhales. Deliver one breath every 6 seconds (about 10 breaths/min, adults) (American Heart Association [AHA], 2020b), if the patient's own respiratory drive is absent. Continue delivering breaths until the patient's drive returns or until the patient is intubated and attached to mechanical ventilation.	If a patient has spontaneous inspiratory effort, breaths delivered to them must be timed to coincide with the spontaneous breaths to avoid the discomfort of dyssynchronous breathing, anxiety, and resistance to ventilation (Morton & Fontaine, 2018). Once the patient's airway has been stabilized or the patient is breathing on their own, bag-mask delivery can be stopped.
13. When use of the manual resuscitation bag and mask is no longer required, dispose of equipment appropriately.	This reduces the risk for transmission of microorganisms and contamination of other items.
14. Remove the face shield or goggles and mask. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has exhibited signs and symptoms of adequate respirations and oxygenation, has received an adequate volume of respirations with the BVM, and has maintained oxygen saturation within acceptable parameters.

Documentation

Guidelines

Document the incident, including the patient's respiratory effort before initiation of bag-mask breaths, lung sounds, oxygen saturation, chest symmetry, and resolution of the incident (e.g., intubation or patient's respiratory drive returns).

Sample Documentation

9/1/25

2015 Patient arrived to emergency department with respiratory rate of 4 breaths/min; respirations shallow; pulse 58; manual breaths delivered using adult bag with mask and 100% oxygen, oxygen saturation increased from 78% to 100% after eight breaths delivered; Dr. Alsup at bedside; patient sedated with 5 mg midazolam before intubation with 7.5-mm oral endotracheal tube, taped 10 cm at lips; lung sounds clear and equal in all lobes; see graphics for ventilator settings. Nasogastric tube placed via R naris to low intermittent suction, small amount of dark green drainage noted, chest x-ray obtained.

—C. Bausler, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Chest is not rising when breaths are delivered, and resistance is felt: Reposition the head or perform the jaw-thrust maneuver. If the chest is not rising at all and resistance is being met, the tongue or another object may be obstructing the airway. If repositioning does not resolve the effort, consider performing the Heimlich maneuver.
Chest is rising asymmetrically: Instruct the assistant to listen to lung sounds bilaterally. The patient may need a chest tube placed due to pneumothorax. Anticipate the need for chest tube placement.
Oxygen saturation decreases from 100% to 80%: Assess whether the chest is rising. If the chest is rising asymmetrically, the patient may have a pneumothorax. Anticipate the need for a chest tube. Check the oxygen tubing. Someone may have stepped on the tubing, either kinking the tubing or pulling the tubing from the oxygen device.
Seal cannot be formed around the patient's face, and a large amount of air is escaping around mask: Assess the patient's face and mask. Is the mask the correct size for the patient? If the mask size is correct, reposition your fingers, or have a second person hold the mask while you compress the bag.

Special Considerations

General Considerations

If a patient has spontaneous inspiratory effort, breaths delivered to the patient must be timed to coincide with their spontaneous breaths to avoid the discomfort of dyssynchronous breathing, anxiety, and resistance to ventilation (Morton & Fontaine, 2018).
If three or more rescuers are present, two rescuers can provide more effective bag-mask ventilation than one rescuer (AHA, 2020b; Hess et al., 2021). One rescuer maintains a seal on the mask and an open airway with two hands using the technique described above, while the other squeezes the bag to deliver the ventilation and oxygenation.
Have equipment to suction airway readily available when using a BVM. Air can be forced into the stomach during manual ventilation with a mask, causing abdominal distention. This distention can cause vomiting and possible aspiration. Be alert for vomiting; watch through the mask. If the patient starts to vomit, stop ventilating immediately, remove the mask, wipe and suction vomitus as needed, then resume ventilation.

Infant and Child Considerations

Deliver breaths at a rate of 20 to 30 breaths/min for infants and children who have a pulse but absent or inadequate respiratory effort (AHA, 2020b).

EVIDENCE FOR PRACTICE

Cardiopulmonary Resuscitation and Emergency Cardiac Care

Related Guideline

The American Heart Association provides guidelines for cardiopulmonary resuscitation and emergency cardiac care and has incorporated these guidelines into the Basic Life Support and Advanced Life Support education for health care providers who respond to respiratory and cardiovascular emergencies.

American Heart Association (AHA). (2020). 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Parts 1-7. Circulation, 142(16 Suppl 2). https://www.ahajournals.org/toc/circ/142/16_suppl_2

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Skill 14-16

EVIDENCE FOR PRACTICE