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Low-Quality Bag-Mask Ventilation Is Associated With Adverse Airway Outcomes

Tuesday, January 23, 2024
10:30 AM – 10:40 AM MT
Location: Connections Central - Star Research Theater
Introduction: Self-reported bag-mask ventilation (BMV) difficulty has been associated with adverse patient outcomes, but objective quality is rarely measured. We hypothesized that low quality BMV is associated with adverse airway outcomes (AAOs).


Methods: Single-center, prospective observational study. In critically ill children receiving BMV prior to tracheal intubation (TI), we used a respiratory function monitor to record flow (mL/s) and pressure (cmH2O) to calculate inspiratory and exhaled tidal volume (mL) and leak (%). Low quality breaths were prospectively defined as: 1) exhaled tidal volume (VTe) < 4mL/kg or >12mL/kg of ideal body weight calculated based on the median BMI (for age and gender) and height; 2) excessive peak inspiratory pressure (PIP), defined as PIP >25cmH2O with excessive VTe (>12mL/kg); 3) leak >40%; or 4) failure to relieve upper airway obstruction (UAO), defined as VTe < 4mL/kg, PIP >30cmH2O and leak >80%. An AAO was defined as a TI associated event (standard National Emergency Airway Registry for Children definition) and/or the presence of hypoxemia (SpO2 < 80%). Respiratory pathology was defined as respiratory tract disease or anatomy that would affect resistance or compliance. Analysis with Chi-2 test and logistic regression with generalized estimating equations to account for clustering by patient.


Results: There were 8,446 BMV breaths observed among 85 subjects with 32 (38%) with a respiratory condition. AAOs occurred in 14 (16.5%) TIs (10 hypoxemia, 8 TIAE). Children with AAOs had a higher proportion of low quality BMV breaths (86% vs. 75%; p< 0.001), inadequate or excessive VTe (59% vs. 54%; p< 0.001), excessive PIP (22% vs. 13%; p< 0.001), and leak >40% (59% vs. 41%; p< 0.001). There was no difference in the proportion of UAO breaths among patients with and without AAOs (3% vs. 3%; p=0.91). After controlling for respiratory pathology, low quality BMV by any criteria was associated with an increased odds of AAO (aOR 2.8; 95% CI: 1.2, 6.2; p=0.01).


Conclusions: Using advanced respiratory function monitor technology during BMV in critically ill children immediately prior to intubation, we identified 3 aspects of low quality BMV (VTe, PIP, leak) associated with increased adverse airway outcomes, even after accounting for respiratory pathology.