Feel The Seal
One handed face-mask EC seal SUCKS! Two handed EC seal is okay, but you’re better off to "Feel the Seal" and provide thumbs down face-mask seal to deliver appropriate ventilations to your apneic patients.
Don’t be a monkey, be a seal
BVM ventilation is a basic skill, mastered by few, and most likely to be delegated to the least experienced provider. We expect providers to deliver an adequate tidal volume to achieve an appropriate minute ventilation to allow for proper gas exchange and oxygenation. We want to allow the air to go in and out, one of the most fundamental and necessary requirements to sustain life. Yet we’re not provided appropriate feedback on creating an effective face-mask seal or how to deliver an adequate amount of tidal volume.The standard response we try is to attempt one handed EC seal, which without an airway adjunct in place, results in closing the mouth. Not really helping us out.
Actually, one handed bagging sucks, big time, regardless if you're an RT, doc, or paramedic! Expired tidal volumes are pretty low for one handed bagging ranging from 186 mL in a simulation environment to 371 mL in obese patients (which is probably why they make BVM's with such large volumes). The two handed technique was better, but isn’t the best. Especially considering that many of our patients requiring ventilation have facial hair, dentures or vomit all over the airway making it even more difficult to get an effective seal. Or maybe they’re big and you’re small so it’s very difficult and tiresome to use the EC seal.
(Reference notes: The studies used a ventilator to deliver a consistent tidal volume and measured expired tidal volume. They’re also cross over studies so providers provided multiple techniques for getting a face-mask seal in both simulation and the OR.)
But wait! You said they’re using a ventilator, we use a BVM which means I can just squeeze more if I don’t get a great seal… We already over ventilate and squeeze the bag too much. We don’t need to keep doing something that’s hurting our patients.
To get an effective seal and deliver and appropriate tidal volume we can utilize the thumbs down technique, VE, modified 2-handed etc, do what it takes to Feel the Seal!
See the seal, become the seal, feel the seal! Place the mask on the face, point your thumbs toward their feet, take your thenar eminence (the big fatty part of your thumb) and place it on the mask without displacing the jaw down, wrap your thumbs around the posterior part of the mandible and lift up performing the jaw thrust. Have your partner provide the appropriate rate and tidal volume. Use your hands to Feel the Seal and adjust for any changes.
Thumbs down technique inherently lifts the lower mandible and tongue to provide a clear path for the ventilations whereas the EC seal posteriorly displaces the lower mandible and can more easily enter the stomach. Be careful not to just smoosh the mask down on the face but instead lift the face into the mask. Get your PEEP Valve, your favorite BVM, your sexiest manikin*, and practice!
Feel the Seal, go thumbs down to get a thumbs up!
*Make sure your manikin has appropriately sized lungs so you’re practicing giving the appropriate tidal volume.
Fei, M., et al. “Comparison of Effectiveness of Two Commonly Used Two-Handed Mask Ventilation Techniques on Unconscious Apnoeic Obese Adults.” British Journal of Anaesthesia, vol. 118, no. 4, Apr. 2017, pp. 618–24. ScienceDirect, doi:10.1093/bja/aex035.
Hart, Danielle, et al. “Face Mask Ventilation: A Comparison of Three Techniques.” The Journal of Emergency Medicine, vol. 44, no. 5, May 2013, pp. 1028–33. PubMed, doi:10.1016/j.jemermed.2012.11.005.
Joffe, Aaron M., et al. “A Two-Handed Jaw-Thrust Technique Is Superior to the One-Handed ‘EC-Clamp’ Technique for Mask Ventilation in the Apneic Unconscious Person.” Anesthesiology, vol. 113, no. 4, Oct. 2010, pp. 873–79. PubMed, doi:10.1097/ALN.0b013e3181ec6414.
“National Registry of EMTs.” National Registry of EMTs, http://www.nremt.org/rwd/public/. Accessed 24 June 2019.
Otten, David, et al. “Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model.” Annals of Emergency Medicine, vol. 63, no. 1, Jan. 2014, p. 6–12.e3. PubMed Central, doi:10.1016/j.annemergmed.2013.07.014.