hi everyone this is lahiri from abc's anesthesia and today i'm going to go through
bagma ventilation technique and all the ways to optimize it make sure you're doing a really
good job tips and tricks and the overall approach and strategy so let's get started
so it's really important that you only do these techniques if you're trained in performing these
techniques and again this video will be a small part of the process you're learning
and how to effectively bag my spend plate now the first disclaimer is that this is a really high-end
technique even though bagmas ventilation seems non-invasive just remember that most of the time
you'll be doing this on patients who are hypoxemic and quite unwell and that means that from the very
start it's so important that you need a call for help if this is something that you need help for
now as always i really like to teach something in isolation as you know from all my other
videos i try to make sure that everything has a structure and a framework so you know where
it fits in the overall plan so these resources are the difficult airway society and also the
vortex approach and i'll put some links uh to those resources in the story notes below
the aim of all of these techniques whether it's lma ventilation intubation or bagmas ventilation
is that you may have a patient who's not ventilating appropriately or not oxygenating
and so you need to create flow of air and oxygen through the mouth down through the pharyngeal and
oropharyngeal structures down into the trachea to raise the chest so you're really trying to give
positive pressure ventilation when a patient isn't able to do negative pressure ventilation
on their own or effectively enough with their diaphragm as you can see with bag mask ventilation
i've got this inflatable soft mask and that just gets placed onto the face this mask has
to create a good seal so that no air escapes that way i can generate a positive pressure which then
forces air through the mouth around that corner and therefore you're kind
of getting air flow through the oral axis pharyngeal excentric heel axis
therefore inflating the lungs and in this position you can see that this rise and fall of the chest
now one of the important things is how do we get a good seal now each face mask is slightly different
but i want to give you the principles therefore you'll know how to fit a mask no matter what style
it is the first thing you'll notice about this mask is that it's in kind of a triangle style
structure just know that the pointy end goes on top of the bridge of the nose and the flatter
part the bottom of this triangle goes just in the um groove above the mental prominence as you can
see there's a couple of valleys here so the one is just the bridge of the nose and the other is this
point over here and that way you know that the mask fits now if the mask was too large you might
see this hanging over the edge therefore you get a leak there if the mask is too small you might find
that it doesn't even cover the mouth properly that way you know you're vent you're not going
to be able to get a good seal therefore you're not going to be able to positive pressure ventilate so
your mask should fit at the bridge of the nose and through that groove there just above the mental
prominence just below the lip that we've got a good seal now the next thing that we often learn
when we're doing bagmas ventilation is the grip on the mask you notice that we talk about a c and
e grip so when i'm demonstrating the ce grip the c is this shape over here and you'll notice that
i put my thumb at the top near the bridge of the nose and then my pointer finger just there that
way that can create a bit of pressure across the mask through the top and the bottom of the mask
now my e-grip goes here so i've got my little finger just at the angle of the jaw
and then i've got this ring finger just along the side of the bone and then finally the middle
finger at the chin one important thing to note is that these fingers aren't pushing into the soft
tissue they're really just around the bone now once you've got the ce grip one of the
really important things to note is that really you want to try and lift the face towards the mask so
you're not pushing down because that obstructs all the structures so you really want to see a lifting
up of the face towards the mask rather than pushing the mask down if you just look at that
lifting up opens up the airway and tries to align those three axes whereas pushing down on the face
really doesn't help it makes the angle more acute therefore magmas ventilation will be a problem
so here we go that's the ce grip sometimes your mask is just going to be a little bit different
you might have a mask which doesn't have this really nice soft inflatable plastic or you may
have a face shape that's a bit different so often elderly faces have less structure to
them someone who doesn't have dentures might have the face falling away in this case you've got to
do everything you can to make sure that this mask creates a seal so that's where you'll see people
adopting a different grip for example the most common thing is to do a two-handed grip
as you can see here i've got this double ce grip i've got a c shape here a c shape here e shape
along the jawline there and another e shape along the jawline just mirroring the other side again
i'm lifting the face and i'm not pushing down lifting the face opens the airway pushing down
obstructs the airway now you might be wondering how am i going to ventilate this patient you get
someone to help you out and that way you can have someone else ventilating while you're doing this
so you won't have another hand to help you so you'll need to get your assistant there
to ventilate the bag while you're creating this really strong seal with the mask now often i
get asked this question what happens if i've got really small hands or if i'm just not as strong
with my hands and they're fatiguing one of the really good things you can do is
use your palms and then you've got all four fingers to lift up the jaw and that way i've
got all the strength of my intrinsic muscle the hand not just my fingers so again i'm lifting
up and i'm pushing down and that provides really good access to give a good jaw thrust
as well as you know using your whole palm pushing down as your fingers are lifting up now there's a
few other things that can cause a problem with the seal generally this is elderly patients who
have the face shape drooping away and that makes it difficult to make a seal but also patients
who have a beard really hard to get a seal with that if i really need someone to be optimized
because they've got really bad other indicators of airway problems what i'm going to do is i'm just
going to ask them to shave their beard because it's potentially a life and death thing so in
that circumstance where i've got a patient who's a difficult intubation and a difficult lma
and they're sick in another way maybe they've got hemodynamic compromise or they're hypoxemic i'm
just going to ask them to shave their beard because i really want to make everything
absolutely optimal now when i'm teaching airway specialists like nsaid registrars i try to teach
an overall approach with all of these different techniques whether it's bag mask ventilation lma
or intubation and ventilation so first of all most of the ways you can optimize these things
are change the size and the type as well as positioning and paralysis when i think about that
every patient when you're trying to ventilate them the positioning is far better if there's
a sniffing in the morning a position so you've got lower c-spine flexion and atlanta occipital
extension and that means that really i want the tragus of the ear to be lined up with
external angle and i've got a video on the optimal positioning of the patient as well on the channel
headlight occipital extension again just helps to align the ac3 axes the oral axis for energy lexus
and the tracheal axis so that's positioning but giving paralysis is a pretty risky thing to do so
only do so if you're comfortable with knowing the way of giving it and managing the potential risks
of that but overall the ways i can optimize things in general are changing the size of something
changing the type of it positioning and paralysis now the specifics with bag mask ventilation
include maneuvers and adjuncts now the three maneuvers that are commonly talked about are
jaw thrust chin lift and head tilt and again all of these things are really trying to align those
three axes to give you that context let's just go through the jaw thrust this is probably the most
common technique i use because often with the jaw thrust i do get that head tilt as well so a jaw
thrust is getting your fingers behind the angle of the jaw now it's a really good cheat here that the
angle of the jaw is right near where the ear is it's as far back as you can go along the jawline
when i'm at that point i then lift up and you can see that the jaw is moving that means
the jaw is attached really to the tongue and now the soft tissue of the tongue and other structures
are lifted off the oropharynx and that means that the passage of air can now flow more
easily now this mannequin is quite hard to do jaw thrust but the most difficult patients will also
feel difficult so just know that sometimes you need your strongest fingers to do this i use my
pointer finger and my middle finger and sometimes i put my you know my palm on the cheeks and that
allows me to get an even bigger jaw thrust so especially in the most difficult patients
this is pre-optimal and just showing that again i've got my two strongest fingers my point on my
middle finger at this very posterior angle of the jaw there's a plateau there i then lift up and you
can see how much your thrust i can get now just to give you a bit of context so imagine i've got this
here that's that's exactly where the tongue is but now you can see a cutaway to see exactly how air
flows now sometimes the tongue and soft tissues are so pronounced that they're blocking the airway
so there's no passage of air possible if i do a jaw thrust i'm simply lifting those features up
and that allows a nice aperture and opening into the airway allows the flow of gas and flow of
oxygen now the head tilt is again a really useful technique i often use this when i'm inserting an
lma as well as doing during laryngoscopy and what this does it is again tries to line up those three
axes so by tilting the atlanta occipital joint i'm now opening up the airway or trying to align the
oral axis with the pharyngeal and tracheal axis so all i'm doing is moving the head like this
but also i open the mouth so i can guide a laryngoscope in and that makes that easier
and otherwise i can use my left hand to do a head tilt because i'm going to use a
right-handed technique to put in the lma which again we'll show in another video so again
often the head tilt creates a less of a sharp angle i'm able to put the lma in and that way
it falls in easier so final maneuver the chin lift and really this is putting your fingers
just at the chin or the mental prominence and then lifting up to me it is like a combination
where when i do a jaw thrust i can often then hold the jaw thrust in place with a chin lift
so this is more active and then holding that chin there is much easier so that was
jaw thrust head tilt and chin lift again these are common maneuvers that are really really useful
and if you ever have a patient who's obstructed on the ward high bmi patient maybe they've been a bit
narcotized and they're snoring you'll find that simply giving a jaw thrust or a head tilt will be
a simple technique and simple way of relieving that obstruction so those are the maneuvers
the next phase is really trying to show you the adjuncts and how we use the adjuncts so really
there's just two adjuncts which are simple pretty simple to use and these include the oropharyngeal
airway called the godels airway and the nasopharyngeal airway now the godels so they come
in a range of sizes green is the smallest one for adults yellow is the middle size and red is quite
large now the whey size is quite straightforward now i'm going to give you an example here the aim
of the gideon is to unobstruct the airway because you've got all these soft tissues that potentially
cause obstruction a goodell sits just behind the tongue just sitting above the epiglottis
and showing an aperture into the trick here i'm just going to give you a side view of that
now that you've seen the anatomy the sizing of the godel makes a lot more sense for example if
i'm trying to get it past the tongue so that this aperture sits just below the tongue and
just above the larynx really i want to size it from the top of the mouse or the incisor
down to the angle of the jaw and that way i'm going past the potential obstructions this green
one which is too small goes from the angle of the lip but doesn't go as far as the angle of
the jaw so this wouldn't fit as well the red one however does fit now the way this fits is it's
kind of an interesting insertion technique what i do is i put it backwards it's facing upwards when
obviously it should be sitting down and that just allows me to get past the tongue in an efficient
way so i place it in and then i rotate as i go down i'm just going to show that again from
another angle i open the mouth like this just briefly i place the goodell in i rotate once
probably when the peak curvature is at the lip i then curve it around and that point it fits right
behind the tongue in the correct position at this point now it's relieved any obstruction around the
tongue and i can use this mask on with a ce grip and ventilate the patient now the final adjunct i
can potentially use is a nasopharyngeal airway and just as the name suggests it goes from the nasal
angle down through the pharynx and again bypasses the tongue and other obstructive potential showing
this on this anatomical structure here so it will go from a higher angle and again it will bypass
the tongue and any pharyngeal obstructions to try and provide a passage of air down into the trachea
and just from that you can probably see logically how this is going to fit so just like the godel
i'm going to size it from the nose the opening of the nose down towards the angle so that's probably
a little bit small so what i want to do is get the right size there and that's probably correct again
the nasal opening down to the angle of the jaw now generally speaking what i have to practically do
the nose has certain obstructions in itself it's got turbinates and it's very prone to epistaxis
and bleeding so what i often do is i put a cophenyl cane spray which is a vasoconstrictor as
well as local anesthetic and that just means that it'll be tolerated if the patient is a bit more
awake so that means i've do a couple of sprays of cofenecin in the nostril that i think i'm going to
use that's what i do before i insert this there's a couple of things you really got to know so
because there is that risk of epistaxis and you're putting this in structures which are close to some
apertures in the cranium you really got to be careful in patients who are on anticoagulants
for someone who's on warfarin or or rivaroxaban or any of the other anti-platelets as well you
want to be really careful and potentially not do a nasopharyngeal airway now again a pretty
decent contraindication is a patient who's had a trauma or a base of skull fracture
and that could be a real problem if you place a nasopharyngeal airway through the nose it could
go through the basal skull into the brain so again any kind of trauma patient anyone who's
had surgery in that region as well please avoid using this so let's talk about the insertion so
the incision is actually quite straightforward often again i've lubricated and i've given some
vaso constrictor to the nose and then i simply push it backwards just know that the aperture
into the nose is straight back and you don't have to go upwards so it's really back posteriorly
and that's the way it should be inserted again at this point i could put my bag mask on if required
and ventilate the patient as needed now the patient is semi-conscious and just obstructed
you don't really need to put the bag mask on this patient you will have unobstructed the airway you
might provide a jaw thrust get the right position which is like a semi-recumbent 30 degree position
and the patient will hopefully be ventilating fine while you ask for assistance and help
so why don't we go through the whole scenario of a patient who's potentially obtunded and
i'm trying to maximize everything so just remember i'm thinking about my overall strategy i'm getting
assistance i'm thinking of positioning so i'll get a pillow raise them to the perfect position
where i've got the mastoid aligned with the sternal angle if i'm able to i might consider
paralysis at some point during this thing so i've got assistance positioning paralysis
patient needs some kind of ventilation let's say so i think of having the mass size correctly
and then creating good seal i might use maneuvers such as a jaw thrust and chin lift to start
ventilating the patient if these maneuvers aren't working i might need to consider adjuncts so
i'll size the ryegadel insert that godel and then ensure that i've got everything at my disposal say
my seal isn't good i'll get two hands on and get someone else to ventilate for me so as you can see
in a few seconds i've thought about the overall context of the patient i've enhanced the position
i've optimized the position i've considered paralysis if i'm able to i've got a good seal
with two hands jaw thrust chin lift and i've got a good dell in and potentially thinking about a
nasopharyngeal airway thanks everyone for watching we've gone through bag mask ventilation in the
context of airway management and showing you all the ways of optimizing bagmas ventilation a few
traps and tips and tricks to optimize it so we've gone through bagmas ventilation itself the anatomy
how to size a mask and the seal we've gone through different maneuvers jaw thrust chin lift and head
tilt we looked at some adjuncts as well which is the cadell's airway oropharyngeal airway and the
nasopharyngeal airway so we've gone through all that and then put it together in a context in how
to continually assess the patient's oxygenation and ventilation so i hope this was useful for you
share with anyone who might be interested and thanks for watching see you next time
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