Basic Airway Management in

Adults
Kristine Joy Agcaoili MD, DPBA
INTRODUCTION
• Bag-mask ventilation - cornerstone of basic airway management.

• This topic will review the essential techniques involved in basic airway
management in adults.

• Airway management of children is discussed separately.

• Issues related to endotracheal intubation in adults and other

advanced airway management techniques are discussed elsewhere.
CAUSES OF INADEQUATE VENTILATION
• Respiratory effort
• Airway obstruction
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
• Jaw-thrust maneuver

• Cervical spine immobilization

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Cervical Spine Immobilization
AIRWAY ADJUNCTS
• Once an open airway has been established, it must be maintained.

• Oropharyngeal and nasopharyngeal airway devices

• Both will prevent the tongue from occluding the airway and provide an open
conduit for air to pass.
AIRWAY ADJUNCTS
• Oropharyngeal airway
• Nasopharyngeal airway
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BAG-MASK VENTILATION
• Crucial airway management skill
• One of the most difficult to perform correctly

• Successful bag-mask ventilation depends on three things:

• a patent airway,
• an adequate mask seal,
• proper ventilation (i.e. , proper volume, rate, and cadence).

*Airway patency is obtained using airway maneuvers and adjuncts.

Mask placement
• Bag is detached
• Nasal portion of the mask is spread slightly and placed on the bridge
of the patient's nose.
• Body of the mask is 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.
• Neither the provider's wrists nor the mask cushion should rest on the
patient's eyes during bag-mask ventilation
Mask placement
• Two methods for holding the mask in place:
• single-hand (one hand, one person) mask hold
• two-hand (two hand, two person) mask hold
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Two-hand technique for bag-mask ventilation
• Most effective method of opening the patient's airway while
maintaining an adequate mask seal and minimizing provider
fatigue.
• 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
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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 ; edentulous patients

• ●Improper mask size
• ●Lack of airway adjuncts (ie, nasopharyngeal and oropharyngeal
airways)
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Trouble-shooting problems with bag-mask
ventilation
• Inadequate airway maneuvers

• ●Inexperienced personnel

• Factors associated with difficult bag mask ventilation are discussed

separately.
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

Ventilation volumes, rates, and cadence
• A volume just large enough to cause chest rise (no more than 8 to 10
cc/kg)

• During cardiopulmonary resuscitation (CPR), even smaller tidal

volumes are adequate (5 to 6 cc/kg)

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

mask ventilation should be 30:2 which corresponds to approximately
8 breaths per minute. The ventilatory rate should not exceed 10 to 12
breaths per minute.
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.
NOVEL DEVICES
• Novel intraoral masks for ventilation are in development.

• Well-performed trials in humans are needed to determine their

effectiveness and possible limitations.
SUMMARY AND RECOMMENDATIONS
• Poor respiratory effort causing inadequate ventilation can be difficult to
discern

• ●Positioning maneuvers, including head-tilt chin-lift and jaw-thrust, can be

performed to improve airflow in the patient receiving basic airway
management.

• ●Oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) devices

are important adjuncts for maintaining an open airway.

• ●Bag-mask ventilation is a crucial airway management skill and one of the

most difficult to perform correctly.
Summary and Recommendations
• ●Successful bag-mask ventilation depends on three things: a patent airway,
an adequate mask seal, and proper ventilation (ie, proper volumes, rates,
and cadence).

• ●Proper placement and holding of the mask is essential for a good seal.

• ●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.

• ●When performing bag-mask ventilation, clinicians must avoid three

critical errors: giving excessive tidal volumes, forcing air too quickly, and
ventilating too rapidly.