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Basic airway management in adults

Author: Kathleen A Wittels, MD
Section Editor: Ron M Walls, MD, FRCPC, FAAEM
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2023. | This topic last updated: Jan 21, 2022.

INTRODUCTION

Bag-mask ventilation is the cornerstone of basic airway management and is not a

skill easily mastered [1]. This procedure is most often needed because of inadequate
ventilation, which can result from impaired respiratory effort or airway obstruction.
Basic airway interventions may also be needed to manage the patient with
inadequate oxygenation and during cardiopulmonary resuscitation.

This topic will review the essential techniques involved in basic airway management
in adults. Airway management of children is discussed separately (see "Emergency
endotracheal intubation in children"). Issues related to endotracheal intubation in
adults and other advanced airway management techniques are discussed
elsewhere.

CAUSES OF INADEQUATE VENTILATION

Respiratory effort — Inadequate respiratory effort can result from intrinsic (eg,

intracranial hemorrhage) or extrinsic (eg, opioid overdose) factors. Poor respiratory
effort causing inadequate ventilation can be difficult to discern: it is often silent, and
detection depends on close observation of chest wall movement. Thorough
evaluation requires that the patient be undressed and the clinician observe the rate,
pattern, and depth of breathing, use of accessory muscles, abnormal sounds, and
signs of injury. Both laymen and health care professionals often fail to accurately
determine the adequacy of respiratory effort [2,3].

Airway obstruction — Soft tissue airway obstruction in the unconscious patient can

occur by several mechanisms. These include prolapse of the tongue into the
posterior pharynx and loss of muscular tone in the soft palate [4,5]. Simple airway
maneuvers, such as the head-tilt chin-lift or jaw-thrust with or without a head tilt,
often ameliorate this problem quickly (see 'Airway maneuvers' below). Obstruction
by foreign bodies, injured tissue, blood, and secretions can also occur.

Noises produced by the obstructed upper airway often make such obstruction
easier to detect than poor respiratory effort. As an example, snoring or gurgling
noises may be heard when the upper airway becomes partially obstructed by soft
tissue or liquid (eg, blood, emesis). Complete airway obstruction is silent but may
manifest transiently as retractions of the accessory muscles of respiration
(suprasternal, supraclavicular, intercostal, subcostal) or as cyanosis, until frank
respiratory arrest supervenes.

If the patient is making respiratory effort, but not adequately ventilating because of
airway obstruction, the clinician must immediately attempt to determine the cause
of the obstruction while taking measures to alleviate it. In a conscious adult, there
are data supporting the efficacy of chest thrusts, back blows or slaps, and
abdominal thrusts in relieving complete foreign body airway obstruction (FBAO) [6-
8]. The chance of relieving an FBAO may be highest when using a combination of
these techniques. One study showed that 50 percent of airway obstruction episodes
were not relieved by a single technique [9].

The 2015 update to the American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care recommends no changes from
the 2010 guidelines with regards to the management of FBAO [10]. Rapid-sequence
abdominal thrusts followed by chest thrusts if unsuccessful should be performed for
the patient with a severe airway obstruction. Chest thrusts are the initial
recommended technique if one is unable to encircle the abdomen of the patient or
if the patient is late in pregnancy [11]. There have been several case reports of
injuries (eg, gastric rupture) from abdominal thrusts, so a quick physical assessment
after thrusts are performed is reasonable [12-14].

Unresponsive patients with presumed FBAO should receive cardiopulmonary

resuscitation (CPR), as chest thrusts in these patients may produce higher airway
pressures when compared with abdominal thrusts [15]. The 2010 American Heart
Association (AHA) guidelines recommend that a blind finger sweep not be used in
the unconscious patient with an obstructed airway unless during the course of CPR,
solid material becomes visible in the airway [11]. When the airway is opened during
CPR, if solid material becomes visible, it should be removed.

The 2020 AHA guidelines confirm prior protocols for lay responders with an
additional recommendation that it is reasonable for appropriately skilled health care
providers to use Magill forceps to remove a FBAO in patients with out-of-hospital
cardiac arrest [16]. The guidelines recommend against the routine use of suction-
based airway clearance devices.

AIRWAY MANEUVERS

Two positioning maneuvers can be performed to improve airflow in the patient

receiving basic airway management: head-tilt chin-lift and jaw-thrust.

Head-tilt chin-lift — The head-tilt chin-lift is the primary maneuver used in any

patient in whom cervical spine injury is NOT a concern. In this technique, the
clinician uses two hands to extend the patient's neck and open the airway. While
one hand applies downward pressure to the patient's forehead, the tips of the index
and middle finger of the second hand lift the mandible at the mentum, which lifts
the tongue from the posterior pharynx ( picture 1). This technique has been
shown in multiple studies to improve airway patency [17].

Jaw-thrust maneuver — The jaw-thrust maneuver is an effective airway technique,

particularly in the patient in whom cervical spine injury is a concern. This maneuver
moves the tongue anteriorly with the mandible, minimizing the tongue's ability to
obstruct the airway [18]. With the patient supine and the clinician standing at the
head of the bed, the technique is performed by placing the heels of both hands on
the parieto-occipital areas on each side of the patient's head, then grasping the
angles of the mandible with the index and long fingers, and displacing the jaw
anteriorly ( picture 2). The jaw thrust is the safest first approach to opening the
airway of a casualty with a suspected neck injury because if properly performed, it
can generally be accomplished without extending the neck.

Cervical spine immobilization — Most airway maneuvers are associated with some

movement of the cervical spine (c-spine) [19,20]. Regardless of the maneuver
chosen, the clinician must stabilize the c-spine in order to minimize head and neck
movement in any patient with a possible c-spine injury. Failure to do so is associated
with a 7 to 10-fold increase in neurologic injury among patients with c-spine trauma
[21]. If sufficient personnel are present, manual in-line stabilization, rather than
mechanical restraints, should be used to ensure c-spine stabilization. Cervical collars
can interfere with airway maneuvers and have been shown to cause increased
intracranial pressure (ICP) from partial obstruction of venous outflow [22,23]. Collars
may be removed, provided manual in-line stabilization is maintained continuously,
while basic airway management is performed. If the collar is left in place, clinicians
should either open or remove the front half to permit basic airway management.

AIRWAY ADJUNCTS

Once an open airway has been established, it must be maintained. Oropharyngeal

and nasopharyngeal airway devices are important adjuncts in achieving this goal.
Both will prevent the tongue from occluding the airway and provide an open conduit
for air to pass. Unless bag-mask ventilation is expected to be needed only
transiently (eg, while naloxone takes effect), we suggest an oropharyngeal airway
(OPA) be placed whenever bag-mask ventilation is required. The OPA may be
supplemented by one or even two nasopharyngeal airways. Neither of these airway
devices will protect the trachea from aspiration of secretions or gastric contents. An
endotracheal tube should be inserted as soon as possible in any patient unable to
protect his or her airway.

Oropharyngeal airway — Oropharyngeal airways (OPAs) should only be used in a

deeply unresponsive patient who is unable to maintain his or her airway [24]. In
responsive patients, they can cause vomiting and aspiration. The OPA is a curved,
firm, hollow tube, with a rectangular aperture that is used to maintain a conduit
between the mouth and the glottis to prevent obstruction by the patient's tongue
and other soft tissue. OPAs have a flange that when properly inserted, rests against
the patient's lips to prevent inadvertent inward migration of the OPA. This flange
does not interfere with forming an adequate seal from a face mask.

OPAs come in multiple sizes ( picture 3). A line between the posterior angles of
the mandible approximates the plane of the posterior oropharynx. Therefore, a
rough method for choosing the correct OPA size is to hold the airway beside the
patient's mandible, orienting it with the flange at the patient's mouth and the tip
directed toward the angle of the mandible. The tip of an appropriately sized OPA
should just reach the angle of the patient's mandible ( picture 4).

When inserting an OPA, the clinician must avoid pushing the tongue into the
posterior pharynx. This can be accomplished by starting with the curve of the OPA
inverted (ie, directed cephalad) and then rotating it 180 degrees as its tip reaches
the posterior pharynx ( figure 1). Alternatively, a tongue depressor can be used to
move the tongue out of the way as the airway device is passed, or care can be taken
not to push the tongue posteriorly with the tip of the OPA.

Whichever technique is chosen, the clinician should be certain that the OPA is
correctly positioned. If there are problems ventilating the patient after insertion, the
OPA should be removed and reinserted. If ventilation problems persist, the clinician
should verify the size of the OPA (often a larger OPA will succeed where a smaller
one fails), and insert at least one nasopharyngeal airway. (See 'Nasopharyngeal
airway' below.)

Potential hazards of using the OPA include:

● Pushing the tongue posteriorly, thereby exacerbating the airway obstruction

● Using an incorrectly-sized device: too small a device is ineffective and can be

lost in the oropharynx, possibly causing obstruction; too large a device can
press against the epiglottis and obstruct the larynx

● Catching the tongue or lips (usually the lower lip) between the airway and the
teeth, thereby traumatizing the soft tissue

● Using the device in a patient with intact airway reflexes, possibly inducing
vomiting. The OPA must be removed if protective reflexes are present.
Nasopharyngeal airway — The nasopharyngeal airway (NPA) is a soft rubber or
plastic hollow tube that is passed through the nose into the posterior pharynx.
Patients tolerate NPAs more easily than OPAs, so NPAs can be used when using an
OPA is difficult, such as when the patient's jaw is clenched or the patient is
semiconscious and cannot tolerate an OPA.

Also known as nasal trumpets, NPAs come in sizes based on their internal diameter.
The larger the internal diameter, the longer the tube. A length of 8.0 to 9.0 cm is
used for a large adult, 7.0 to 8.0 cm for a medium sized adult, and 6.0 to 7.0 cm for a
small adult ( picture 5). Selecting NPAs based on length, rather than diameter,
improves accuracy [25]. A rough method for choosing the correct NPA size is to hold
the airway beside the patient's mandible, orienting it with the flared end at the tip of
the patient's nose and the distal tip directed toward the angle of the mandible. The
tip of an appropriately sized NPA should just reach the angle of the patient's
mandible.

Prior to insertion, the NPA should be coated with water-soluble lubricant or

anesthetic jelly. Contact time is insufficient for anesthetic jelly to make insertion
more comfortable, but may improve tolerance of the device after it is placed. The
device is then inserted along the floor of the naris into the posterior pharynx behind
the tongue ( picture 6). Clinicians should note that the floor of the naris inclines in
a caudad orientation approximately 15 degrees. The tube can be rotated slightly if
resistance is encountered.

Although there are two case reports of intracranial NPA placement in patients with
basilar skull fractures, such extreme complications are rare and can only occur with
devastating disruption of the basal skull, improper insertion technique (angling the
NPA cephalad in the naris, instead of following the floor of the naris), or both [25].
More common potential hazards of using the NPA include:

● Using an airway that is too long: this may cause the tip to enter the esophagus,
increasing gastric distention and decreasing ventilation during rescue efforts.

● Injury to the nasal mucosa causing bleeding: this occurs in 30 percent of

insertions and can lead to aspiration of blood or clots [26].
BAG-MASK VENTILATION

Bag-mask ventilation is a crucial airway management skill and one of the most
difficult to perform correctly. The clinician performing bag-mask ventilation must
carefully monitor the adequacy of his or her technique at all times. Properly
performed bag-mask ventilation enables clinicians to provide adequate ventilation
and oxygenation to a patient requiring airway support. This in turn gives the
clinician sufficient time to pursue a controlled, well-planned approach to definitive
airway management, such as endotracheal (ET) intubation.

Successful bag-mask ventilation depends on three things: a patent airway, an

adequate mask seal, and proper ventilation (ie, proper volume, rate, and cadence).
Airway patency is obtained using airway maneuvers and adjuncts. Whenever
possible, a two-handed technique is preferred for bag-mask ventilation. (See 'Airway
maneuvers' above and 'Airway adjuncts' above.)

Mask placement — Prior to placing the mask on a patient's face, the airway should
be opened using the airway maneuvers and devices discussed above. (See 'Airway
maneuvers' above and 'Airway adjuncts' above.)

Once the airway is open, the next step is to correctly position the mask on the
patient's face. The bag is detached from the mask prior to mask positioning. Having
a large, heavy bag pulling on one end of the mask is a common error that
unnecessarily complicates proper placement. The nasal portion of the mask should
be spread slightly and placed on the bridge of the patient's nose. The body of the
mask is then placed onto the patient's face covering the nose and mouth. The three
facial landmarks that must be covered by the mask are the bridge of the nose, the
two malar eminences, and the mandibular alveolar ridge [27]. Neither the provider's
wrists nor the mask cushion should rest on the patient's eyes during bag-mask
ventilation as this can cause a vagal response or damage to the eyes.

There are two methods for holding the mask in place: the single-hand (one hand,
one person) mask hold and the two-hand (two hand, two person) mask hold.
Although the two-hand mask hold is most effective, it requires a second clinician.
Therefore, it is important to be comfortable with both techniques. When ventilation
using a one hand, one person technique is unsuccessful, despite oral and nasal
airway placement, a two hand, two person technique should be used.

Single-hand technique for bag-mask ventilation — One hand is placed on the

mask with the web space between the thumb and index finger resting against the
mask connector. The web space is placed in the center of the mask, allowing for a
more even application of pressure ( picture 7). Force should not be exerted via the
palm of the hand because it is off center and more likely to produce an air leak.

The other three fingers (ie, middle, ring, and little) are placed along the mandible
and pull the mandible up into the mask in a chin-lift maneuver, allowing the airway
to open further. Those with larger hands can place the little finger posterior to the
angle of the mandible and perform a jaw-thrust, although this is tiring to the hand.
The correct technique is to lift the mandible up into the mask with the middle, ring,
and little fingers while holding the mask tightly against the patient's face with the
thumb and index finger ( picture 7). Clinicians should take care to pull up only on
the bony parts of the mandible: pressure to the soft tissues of the neck may occlude
the airway.

Two-hand technique for bag-mask ventilation — The two-hand mask hold

requires two providers, but it is the most effective method of opening the patient's
airway while maintaining an adequate mask seal and minimizing provider fatigue.
With this technique, one provider's sole responsibility is to use both hands to create
a good mask seal and to maintain an open airway. Another provider squeezes the
bag to ventilate the patient. Proper placement and holding of the mask are essential
for a good seal and are the most difficult aspects of bag-mask ventilation. The most
experienced airway manager available should therefore control the mask.

There are two ways to position the hands. In the more traditional method, both
thumbs and index fingers hold pressure along the inferior and superior ridges of
the mask ( picture 8). The other three fingers on each hand hold the mandible, in
a fashion similar to the one-handed mask hold, and perform a simultaneous chin-lift
and jaw-thrust maneuver. This position may not be comfortable to maintain for long
periods of time.

We recommend another method of two-handed mask technique that uses the

stronger thenar eminences to hold the mask in place. The thenar eminences are
positioned parallel to each other along the long axis of each side of the mask,
allowing the four remaining fingers to provide chin-lift and jaw-thrust maneuvers
( picture 8). This technique is easier to perform, allows stronger hand muscles to
maintain a proper seal, minimizes provider fatigue, and enables four fingers to
perform the chin-lift and jaw-thrust [28].

In a crossover randomized trial of 42 elective surgery patients, two-handed bag-

mask ventilation provided greater minute ventilation and tidal volumes and fewer
episodes of inadequate ventilation compared to a one-handed technique [29].

Trouble-shooting problems with bag-mask ventilation — When obstruction to air

flow exists or the chest does not rise, the clinician should first consider the most
common causes:

● Inadequate mask seal: Patients with facial hair may need KY jelly or water
applied to improve the seal; edentulous patients should have their false teeth
reinserted [30] or their cheeks may be expanded with 4 x 4 gauze.

Lower lip placement, in which the caudad end of the face mask is positioned
between the lower lip and the alveolar ridge, may improve ventilation in
edentulous patients ( picture 9) [31]. In one observational study of 49
edentulous patients with a substantial air leak during two-handed bag-mask
ventilation performed in the operating room, use of the lower lip technique
reduced the median air leak by 95 percent.

Another alternative to reinserting false teeth or expanding the cheeks in

edentulous patients is a modification of the two-handed thenar eminence
method in which the index fingers lift the soft tissue of the cheeks against the
rim of the facemask, while the remaining three fingers pull the jaw upward
( picture 10) [32]. Further study is needed before this technique can be
widely recommended for edentulous patients.

● Improper mask size: Ensure that the corners of the mouth and all airway
adjuncts are inside the body of the mask, not creating a leak by interfering
with mask seal.

● Lack of airway adjuncts (ie, nasopharyngeal and oropharyngeal airways):

 Verify that airway adjuncts are being utilized and in proper position.

● Inadequate airway maneuvers: Ensure the jaw-thrust and other maneuvers

are being done effectively in order to open the airway.

● Inexperienced personnel: Determine if a more experienced clinician needs to

be recruited to help provide optimal bag-mask technique, particularly mask
seal [27].

Factors associated with difficult bag mask ventilation are discussed separately. (See
"Approach to the difficult airway in adults for emergency medicine and critical care",
section on 'Difficult bag-mask ventilation'.)

Ventilation volumes, rates, and cadence — Once an open airway and a good

mask seal are present, the clinician connects the bag to the mask and ventilates the
patient. Three critical errors should be avoided:

● Giving excessive tidal volumes

● Forcing air too quickly
● Ventilating too rapidly

A volume just large enough to cause chest rise (no more than 8 to 10 cc/kg) should
be used, as overinflation of the lungs can lead to barotrauma. During
cardiopulmonary resuscitation (CPR), even smaller tidal volumes are adequate (5 to
6 cc/kg) due to the reduced cardiac output of such patients [33]. The bag should not
be squeezed explosively. It should be squeezed steadily over approximately one full
second. This technique, in addition to producing smaller tidal volumes, reduces the
likelihood of creating sufficient pressure to open the gastroesophageal sphincter,
which leads to gastric inflation. A potential complication of gastric insufflation is
vomiting, which can lead to aspiration of gastric contents.

During CPR, the compression to ventilation ratio delivered by bag-mask ventilation

should be 30:2 which corresponds to approximately eight breaths per minute. The
ventilatory rate should not exceed 10 to 12 breaths per minute. (See "Adult basic life
support (BLS) for health care providers", section on 'Ventilations'.)

These important concepts are based on multiple randomized controlled studies in

animals and observational studies in humans showing that the use of larger tidal
volumes and ventilation rates is associated with increased intrathoracic pressures,
which compromise both coronary and cerebral perfusion pressures [34-38].

Cricoid pressure (Sellicks maneuver) — Sellicks maneuver (ie, firm cricoid

pressure) may reduce gastric insufflation during bag-mask ventilation, and it is
reasonable to apply it during BMV if adequate personnel are available. The
technique and its role in rapid sequence intubation are controversial and discussed
in detail separately. (See "Rapid sequence intubation for adults outside the
operating room", section on 'Positioning'.)

NOVEL DEVICES

Novel intraoral masks for ventilation are in development [39]. Well-performed trials
in humans are needed to determine their effectiveness and possible limitations.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links:
Airway management in adults".)

SUMMARY AND RECOMMENDATIONS

● Causes of inadequate ventilation – Poor respiratory effort causing

inadequate ventilation can be difficult to discern: it is often silent and requires
close observation of chest wall movement. The most common cause of airway
occlusion in an unconscious patient is prolapse of the tongue into the
posterior pharynx. This problem can often be corrected quickly using simple
airway maneuvers such as the head-tilt chin-lift or jaw-thrust with or without a
head-tilt. (See 'Causes of inadequate ventilation' above.)

● Airway positioning maneuvers – Positioning maneuvers, including head-tilt

chin-lift ( picture 1) and jaw-thrust ( picture 2), can be performed to
improve airflow in the patient receiving basic airway management. (See 'Airway
 maneuvers' above.)

● Basic airway devices – Oropharyngeal airway (OPA) ( picture 3 and

figure 1) and nasopharyngeal airway (NPA) ( picture 5 and picture 6)
devices are important adjuncts for maintaining an open airway. Unlike a cuffed
endotracheal (ET) tube, neither one protects the trachea from aspiration of
secretions or gastric contents. An ET tube should be inserted as soon as
possible in any patient unable to protect their airway. Proper insertion
technique and appropriately sized devices are essential to the successful use of
OPAs and NPAs. (See 'Oropharyngeal airway' above and 'Nasopharyngeal
airway' above.)

● Bag-mask ventilation – Bag-mask ventilation is a crucial airway management

skill and difficult to perform correctly. The clinician performing bag-mask
ventilation must carefully monitor the adequacy of his or her technique at all
times. Proper technique enables clinicians to provide adequate ventilation and
oxygenation to a patient requiring airway support and is described above. (See
'Bag-mask ventilation' above.)

Successful bag-mask ventilation depends on three things: a patent airway, an

adequate mask seal, and proper ventilation (ie, proper volumes, rates, and
cadence). Airway patency is obtained using airway maneuvers and adjuncts.
(See 'Airway maneuvers' above and 'Airway adjuncts' above.)

Proper placement and holding of the mask is essential for a good seal.
Whenever possible, clinicians should use the two-hand technique ( picture 8)
that makes use of the thenar eminences to hold the mask in place. (See 'Two-
hand technique for bag-mask ventilation' above.)

● Common difficulties with bag-mask ventilation – Problems commonly

encountered during bag-mask ventilation include: inadequate mask seal,
improper mask size, lack of airway adjuncts (ie, nasopharyngeal and
oropharyngeal airways), and inadequate airway maneuvers. (See 'Trouble-
shooting problems with bag-mask ventilation' above.)

When performing bag-mask ventilation, clinicians must avoid three critical

errors: giving excessive tidal volumes, forcing air too quickly, and ventilating
 too rapidly. (See 'Ventilation volumes, rates, and cadence' above.)

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2004; 32:S345.
38. Yannopoulos D, Tang W, Roussos C, et al. Reducing ventilation frequency during
cardiopulmonary resuscitation in a porcine model of cardiac arrest. Respir Care
2005; 50:628.
39. Amack AJ, Barber GA, Ng PC, et al. Comparison of Ventilation With One-Handed
Mask Seal With an Intraoral Mask Versus Conventional Cuffed Face Mask in
a Cadaver Model: A Randomized Crossover Trial. Ann Emerg Med 2017; 69:12.
Topic 267 Version 21.0
GRAPHICS

Head-tilt/chin-lift maneuver

To relieve upper airway obstruction, the clinician uses two hands to extend the
patient's neck. While one hand applies downward pressure to the patient's
forehead, the tips of the index and middle fingers of the second hand lift the
mandible at the chin, which lifts the tongue from the posterior pharynx. The
head-tilt/chin-lift maneuver may be used in any patient in whom cervical spine
injury is NOT a concern.

Graphic 70710 Version 7.0

Jaw-thrust maneuver

The jaw-thrust maneuver is used to relieve upper airway obstruction

by moving the tongue anteriorly with the mandible, minimizing the
tongue's ability to obstruct the airway. With the patient supine and
the clinician standing at the head of the bed, the technique is
performed by placing the heels of both hands on the parieto-
occipital areas on each side of the patient's head, then grasping the
angles of the mandible with the index and long fingers, and
displacing the jaw anteriorly. The jaw-thrust maneuver may be used
in the patient in whom cervical spine injury is a concern.

Graphic 51547 Version 6.0

Oropharyngeal airways

Graphic 50230 Version 2.0

Oropharyngeal airway sizing

A rough method for choosing the correct oropharyngeal airway (OPA)

size is to hold the airway beside the patient's mandible, orienting it with
the flange at the patient's mouth and the tip directed toward the angle
of the mandible. The tip of an appropriately sized OPA should just reach
the angle of the patient's mandible.

Graphic 77645 Version 3.0

Oropharyngeal airway insertion

When inserting an oropharyngeal airway (OPA), the clinician must avoid pushing
the tongue into the posterior pharynx. This can be accomplished by starting with
the curve of the OPA inverted (ie, directed cephalad) and then rotating it 180
degrees as its tip reaches the posterior pharynx.

Graphic 62820 Version 3.0

Nasopharyngeal airways without an adjustable
flange

For an NPA without an adjustable flange, the correct size is more

accurately determined by the length rather than bore of the adjunct.
The distance from the nostril to the tragus has been shown to
correlate well with the length from the nostril to the vocal cords in
normal infants and children and is our preferred method for sizing.
Alternatively, the distance from the nostril to the mandible may be
used. However, the accuracy of this method has not been studied.

Graphic 69419 Version 3.0

Nasopharyngeal airway insertion

The nasopharyngeal airway (NPA) should be coated with water-soluble lubricant or

anesthetic jelly. The device is then inserted along the floor of the naris into the
posterior pharynx behind the tongue. Clinicians should note that the floor of the
naris inclines in a caudad orientation approximately 15 degrees. The tube can be
rotated slightly if resistance is encountered.

Graphic 79849 Version 4.0

One-hand bag mask ventilation technique

To perform this technique, one hand is placed on the mask, with the web space between
the thumb and index finger resting against the mask connector. The web space is placed
in the center of the mask, allowing for a more even application of pressure. The correct
technique is to lift the mandible up into the mask with the middle, ring, and little fingers,
while holding the mask tightly against the patient's face with the thumb and index finger.
Clinicians should take care to pull up only on the bony parts of the mandible; pressure to
the soft tissues of the neck may occlude the airway.

Courtesy of Kathleen Wittels, MD.

Graphic 80091 Version 2.0

Two-handed bag mask ventilation techniques

There are two ways to perform the two-handed technique. In the traditional
method (picture A), both thumbs and index fingers hold pressure along the
inferior and superior ridges of the mask. The other three fingers on each hand
hold the mandible, in a fashion similar to the one-handed mask hold, and perform
a simultaneous chin-lift and jaw-thrust maneuver. This position may not be
comfortable to maintain for long periods of time. We recommend another method
that uses the stronger thenar eminences to hold the mask in place (picture B). The
thenar eminences are positioned parallel to each other along the long axis of each
side of the mask, allowing the four remaining fingers to provide chin-lift and jaw-
thrust maneuvers.

Graphic 82048 Version 4.0

Bag mask technique for edentulous patient

In edentulous adults, placing the caudad end of the mask between the lower lip and
the alveolar ridge may improve ventilation.

Courtesy of Kathleen Wittels, MD.

Graphic 87227 Version 1.0

Modified 2-hand airway technique for edentulous patient

The photographs above show the classic C-E (picture A) and the modified V-E (picture B) techniques for
ventilation. With the V-E method, the index fingers lift the soft tissue of the cheeks against the rim of th
facemask, while the remaining three fingers pull the jaw upward. This technique may allow for a better
when ventilating edentulous patients.

From: Jain D, Sahni N, Goel N, et al. The C-E versus modified V-E hand positions for holding a face mask when ventilating an ede
patient: A randomised crossover trial. Eur J Anaesthesiol 2021; 38:1194. DOI: 10.1097/EJA.0000000000001479. Copyright © 202
European Society of Anaesthesiology and Intensive Care. Reproduced with permission from Wolters Kluwer Health. Unauthorize
reproduction of this material is prohibited.

Graphic 134635 Version 1.0

Contributor Disclosures
Kathleen A Wittels, MD No relevant financial relationship(s) with ineligible companies to
disclose. Ron M Walls, MD, FRCPC, FAAEM Other Financial Interest: Airway Management
Education Center [Health care provider education and resources]; First Airway [Health care
provider education and resources]. All of the relevant financial relationships listed have been
mitigated. Jonathan Grayzel, MD, FAAEM No relevant financial relationship(s) with ineligible
companies to disclose.

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