Can Providers Use Clinical Skills to Assess the Adequacy of Ventilation in Children During Bag-Valve Mask Ventilation?

OBJECTIVE: Bag-valve mask (BVM) ventilation requires both manual skill and clinical assessment of minute ventilation. Subjective factors can make supplying appropriate ventilation difficult. Capnography is not routinely used when ventilating nonintubated patients. Our objective was to determine if providers were able to maintain normal capnography values with BVM ventilation in pediatric patients based on clinical skills alone.

METHODS: Providers (nurses, residents, and fellows) delivered 2 minutes of BVM respiratory support to healthy children during induction of anesthesia for elective surgery. All patients had standard monitoring including capnography, but providers were blinded to capnography data. Capnography data were video recorded; values between 30 and 50 mmHg were considered indicative of normal ventilation. Any deviation from this range for greater than 10 consecutive seconds was considered an episode of inappropriate ventilation.

MAIN RESULTS: Twenty-five providers-patient pairs were enrolled. Nineteen providers were anesthesia residents. The median age of patients was 5.3 years (interquartile range, 3.3-8.5 years). Nineteen providers (76%) had at least 1 episode of abnormal ventilation with a median of 2 episodes per provider (interquartile range, 0.5-2.5). Among these providers, total mean duration of abnormal ventilation was 57 seconds (95% confidence interval, 41-72) or 47% (95% confidence interval, 34%-60%) of the 2-minute period.

CONCLUSIONS: Normal ventilation is difficult to maintain among providers delivering BVM ventilation to pediatric patients without objective feedback. Incorporation of capnography monitoring may improve BVM ventilation in children.