Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351

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Seminars in Fetal & Neonatal Medicine

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Review

Face mask ventilation e the dos and don’ts

Fiona E. Wood a, *, Colin J. Morley b
a
Department of Neonatal Medicine, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK
b
University of Cambridge, Department of Obstetrics and Gynaecology, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK

s u m m a r y
Keywords: Face mask ventilation provides respiratory support to newly born or sick infants. It is a challenging
Continuous positive airway pressure technique and difficult to ensure that an appropriate tidal volume is delivered because large and variable
Infant
leaks occur between the mask and face; airway obstruction may also occur. Technique is more important
Masks
Positive end-expiratory pressure
than the mask shape although the size must appropriately fit the face. The essence of the technique is to
Positive pressure ventilation roll the mask on to the face from the chin while avoiding the eyes, with a finger and thumb apply a strong
Resuscitation even downward pressure to the top of the mask, away from the stem and sloped sides or skirt of the
mask, place the other fingers under the jaw and apply a similar upward pressure. Preterm infants require
continuous end-expiratory pressure to facilitate lung aeration and maintain lung volume. This is best
done with a T-piece device, not a self-inflating or flow-inflating bag.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction 2. Face masks

Face mask ventilation is the most important technique in the There are many shapes of mask. Most are round with a cush-
initial resuscitation and stabilisation of newly born infants, and is ioned rim. Some are triangular, called ‘anatomically’ shaped. Older
taught in all neonatal resuscitation courses. designs have a flat, uncushioned rim.
Face mask ventilation aims: Several things need to be known before using face masks:

to provide positive pressure ventilation (PPV) for newly born
The mask must be the right size. It must extend from the chin
infants who are apnoeic or have inadequate breathing; tip and not encroach on the eyes. Therefore, one size will not fit

to facilitate the clearance of lung fluid, aerate the lungs, all babies [5].
establish and maintain a functional residual capacity (FRC) and
There is little evidence that different shaped masks are better than
thereby ensure oxygenation as soon as possible after birth. others at forming a seal on the face [6]. However, a soft and
flexible edge does help form a seal. A firm top that does not indent
Mask ventilation is a difficult technique to master and ensure when held on the face is preferable. The Rendell-Baker mask has a
appropriate tidal volume delivery. The problems [1e4] are as firm edge, reportedly making it difficult to get a good seal [7].
follows.
More important than the shape is how it is used [5,6,8].

Mask leak is very common and varies a lot during resuscitation.

Masks are difficult to hold on the face in a way that ensures a 2.1. Gas leak between the mask and face
leak-free seal.

With a very large leak the tidal volume delivered may be too We investigated mask leak with different masks and staff of
small. varying experience. We made the Laerdal Resusci Baby manikin

If there is little or no leak the tidal volumes may be dangerously leak-free by replacing the original ‘lung’ with a 50 ml Dräger test
large. lung connected by non-distensible tubing to the mouth by an

Pushing the mask too hard with poor technique may obstruct airtight seal [9].
gas flow. Mask leak was measured with a flow sensor between the
resuscitation device and mask to measure flow going through the
mask into the manikin and then back through the mask. Flow was
* Corresponding author. Tel.: þ44 (0) 1642 854874; fax: þ44 (0) 1642 854874. integrated to give tidal volume. The difference between the infla-
E-mail address: fi[email protected] (F.E. Wood). tion flow and expiration flow was mask leak [6,9].

1744-165X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.siny.2013.08.009
 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351 345

We found that mask leak often exceeded 50% with some par-
Check that the mask is positioned evenly on the face when
ticipants having 100% leak and not ventilating the manikin, viewed from above and side, being upright and not tilted.
whereas others had almost no leak. It was similarly high and var-
For masks with a solid top, downward pressure must be
iable with different masks and between professional categories applied evenly using an index finger and thumb, not touching
(Fig. 1) [5,6]. More recent work corroborates these findings across a the stem and not encroaching on the side of the mask. The
broader range of modern and preterm designs [10,11]. index finger should be on the chin side. This is the ‘two-point
top-hold’. The finger and thumb should apply a firm pressure
2.2. Techniques of positioning and holding a mask on the face on the mask to ensure that it is sealed on the face.

If the mask has a flexible top, then holding this with the index
While investigating how to minimise mask leak [12] we found finger and thumb encircling the top outside edge of the mask
that holding the mask stem between the index finger and thumb helps stabilize the top and apply an even downward pressure
was least effective, as it was difficult to achieve a balanced down- [5]. This is the ‘OK rim hold’.
ward pressure and jaw lift. With a Laerdal mask, the ‘two-point top-
Fingers should not push on the skirt of the mask because this
hold’, with good jaw lift, was most effective. The ‘OK rim hold’ was distorts it.
most effective with the 60 mm Fisher and Paykel mask because this
The other fingers of the hand holding the mask should be
stabilised the pliable top (Figs. 2 and 3). placed under the jaw on that side to apply jaw lift; drawing the
Of the mask techniques tested we have found that the two-point face upwards into the mask with a pressure equal to the
top-hold is the single resuscitator technique that most reliably re- downward force being applied.
duces mask leak (watch http://www.youtube.com/watch?v¼_THh-
S26OsA). 2.3. Two-handed technique

Roll the mask on to the face rather than placing it straight There are several other techniques to apply a mask. However,
down. This is done by positioning a finger on the baby’s chin tip the only one that reliably minimises leak is the two-handed
to align the mask edge [12] ensuring that it is not extended technique [8,10,13]. This is similar to the two-point top-hold,
beyond the chin, then gently rolling it upwards on to the face with equal downward pressure on the top of the mask from the
ensuring it is not encroaching on the eyes. A mask over the index fingers and thumbs with good jaw lift, but two hands are
orbits will not seal well and may damage the eyes. used.

Fig. 1. The percentage leak at the face mask for two face masks: Laerdal size 0/1 (dark shading) and Fisher and Paykel 60 mm (light shading). Box plots show median values (solid
lines), interquartile range of data and outliers (circles). From Wood et al [5].
346 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351

Fig. 2. Percentage leak at the face mask for two face masks: Laerdal size 0/1 (dark shading) and Fisher and Paykel 60 mm (light shading) and three hold type. Box plots show median
values (solid lines), interquartile range (margins of box), range of data, outliers (circles) and extreme values (asterisk). From Wood et al [12].

2.4. Self-assessment of mask leak 3. Ventilation devices

During manikin studies, participants were asked to assess the 3.1. Self-inflating bags (SIBs)
amount of mask leak as: very small or nil, small, moderate, large, or
very large. In the first three categories there was wide variation
These are bags of 240, 300, 450, or 500 ml capacity that refill
from <20% to 90%. However, in the large category the leak varied quickly by recoil. The mask fits to one end and an oxygen
from 60% to 100%. For one mask no-one claimed to have a very large supply and reservoir can be fitted to the other. They entrain
leak despite many exceeding 80%. No-one who claimed to have a room air and do not need compressed gas, so can be used in any
very small or no leak had a leak <20% [5]. Resuscitators estimates setting. The bag refills even with a large mask leak. They have a
of leak were similarly inaccurate in infant studies (Fig. 4). blow-off valve that releases pressure if it rises above a preset

Fig. 3. Photographs of the three mask holds demonstrated on the Laerdal round neonatal mask size 0/1. From Wood et al [12].
 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351 347

Fig. 4. Face mask leak for each inflation as a percentage of the inspired tidal volume for each of 20 infants during 30 s of positive pressure ventilation. Box plots show median (solid
bar), interquartile range (margins of the box) and 95% confidence interval. The resuscitators’ estimates of their median face mask leak are shown as short horizontal bars next to the
leak for each infant. Adapted from Schmölzer et al [17].

level that varies by manufacturer (35e40 cmH2O). Some have a
It requires experience and skill to maintain an end-expiratory
pressure manometer attached. pressure. There has to be little or no mask leak, which is

The tidal volume should be w5e8 ml/kg. We have seen that to difficult to achieve; the flow control at the back of the bag has
deliver these volumes, when there is a good mask seal, the bag to be carefully modulated to maintain an appropriate PEEP
should be gently squeezed between a thumb and just one or during expiration. This may cause the PEEP to rise too high or
two fingers. A 500 ml bag could deliver too much volume, and fall too low, particularly as leak changes.
so a 240 ml bag may be more appropriate.
If the expiratory valve is closed too much the pressure can rise

If the operator needs to empty the bag fully, this suggests a very very high. Many have a built-in pressure blow-off valve to limit
large mask leak. this. A manometer must be used.

The bag should be squeezed slowly to provide an inflation time
It is possible, in skilled hands, to deliver a prolonged inflation of
aiming to match a spontaneous inspiratory time. 10 s but the pressure is variable.

Squeezing a bag hard and fast activates the blow-off valve, and
With FIBs it is not possible to sense the compliance or changing
much of the gas is lost rather than going to the baby. compliance of the lung and accordingly adjust the pressure

SIBs do not deliver positive end-expiratory pressure (PEEP) and required to ventilate a baby [16].
so are not ideal for helping to form and maintain the FRC in a
very preterm baby. A PEEP valve can be fitted but the pressure 3.3. T-piece resuscitator
is not constant [14]. PEEP can only be provided if the bag is
squeezed at least 40 times/min, but the level will vary with the
It consists of a system to regulate and display the peak inflating
rate. pressure (PIP) and pressure release valves. It needs compressed

SIBs with a PEEP valve cannot deliver continuous positive air- gas. The gas leaves the system via flexible tubing to a T-piece
ways pressure (CPAP) [14]. that directs the gas into the mask. The T-piece has a variable

It is difficult with SIBs to give a prolonged inflation of screw valve to control the PEEP/CPAP level. Inflation is gener-
10 s [15]. ated by transiently occluding this valve with a finger. The
duration of the occlusion determines the inflation time. It can
be used to provide a sustained inflation [17].
3.2. Flow inflating bag (FIB)
Before resuscitation the gas flow, PIP and PEEP are set [18].

Delivered pressures are more stable and accurate than with SIB

These are w500 ml floppy bags with the mask fitted at one end or FIB.
and a small open tube or valve at the other end. They have no
As it is pressurised throughout ventilation, any leak will be
in-built recoil and need a flow of gas into the bag to keep it higher than with SIB.
inflated.
A T-piece is the only resuscitation device that can provide a

They rely on a good mask seal to maintain bag pressure during consistent CPAP.
expiration. The bag pressure is controlled by the tube at the far
Operators need to be aware: (1) if the infant is not responding
end being variably compressed by the little finger curled round the PIP may need to be increased. This is not as intuitive as
it, or the valve adjusted. squeezing a bag harder. (2) Once set, the flow must not be
348 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351

changed during a resuscitation because PIP and PEEP will pressure and tidal volume is weak and highly variable for several
change. reasons [4] see Fig. 6:

4. Mask leak and tidal volumes during neonatal resuscitation
Some volume is lost from the mask before it enters the baby.

Lung compliance and resistance varies so it is not possible for
Studies with manikins have been criticised as having limited one PIP to deliver the optimal tidal volume for all babies.
clinical applicability or relevance. However, several studies,
At birth the lung is full of fluid. Water has a much higher
measuring mask leak and tidal volumes, during resuscitations of resistance through the airways than gas, so higher pressures
preterm babies have shown almost exactly the same large and very may be required for the initial inflations but not subsequently.
variable leak (Fig. 4) [1,19].
Many babies breathe during resuscitation and contribute to the
With very variable leaks, the tidal volumes can vary from a tidal volume.
damaging 30 ml/kg to so little that the lungs are not being inflated
Airway obstruction occurs during resuscitation and the PIP
(Fig. 5) [20]. may not overcome this.
Reducing variation in mask leak enables more consistent
ventilation, improving effectiveness and minimizing potential 6. What is the appropriate tidal volume?
harm [17,20].
The appropriate tidal volume during resuscitation is not known
5. Pressure or tidal volume during ventilation? accurately and so we have to extrapolate from experience with
spontaneously breathing babies at birth, ventilated babies after
During resuscitations tidal volume is not measured. Ventilation birth, and animal studies.
is guided by clinical assessment. However, this is inaccurate and For ventilated babies, with aerated lungs, a tidal volume of
hypocarbia may occur in about a quarter of preterm infants [3]. w5 ml/kg, at a rate of 40e60/min, should provide adequate control
Lung injury has been demonstrated in preterm animals after only a of the partial pressure of CO2 [22].
few large tidal volume inflations [21]. During the first inflations, where the fluid is moved out of the
Traditionally, pressure has been targeted but not tidal volume. airways and an FRC is forming, tidal volumes may need to be larger.
Neonatal intensive care ventilators measure the tidal volume and Studies of exhaled CO2, at this time, have shown that no CO2 was
may deliver a set tidal volume (usually 4e6 ml/kg). This ‘volume- detected if the tidal volume was <5 ml/kg [24].
targeted’ approach has benefits compared to pressure-limited Studies of breathing preterm babies, immediately after birth,
ventilation and could assist resuscitations [22]. showed a mean tidal volume of about 6 (SD: 4) ml/kg [25,26]. In
Resuscitation guidelines suggest that inflations use a PIP of ventilated very preterm infants it is about 5 (SD 0.6) ml/kg [27,28].
w20e30 cmH2O, with limited supporting data. Term newborns Many resuscitated babies are overventilated and have a low
can generate much higher negative pressures when aerating their partial pressure of arterial CO2 when admitted to the neonatal
lungs [23]. Achievement of a set PIP cannot be taken as proof of intensive care [3]. These babies received tidal volumes w9 ml/kg.
adequate tidal volume; however, failure to achieve a set pressure Preterm lamb studies have shown that a few inflations with
is proof of inadequate volume delivery. The relationship between tidal volumes of >15 ml/kg damaged the lungs with a systemic

Fig. 5. Expired tidal volume for each inflation for each of 20 infants during 30 s of positive pressure ventilation. Box plots show median (solid bar), interquartile range (margins of
the box) and 95% confidence interval. The resuscitators’ estimates of their median expired tidal volume are shown as short horizontal bars next to the leak for each infant. Adapted
from Schmölzer et al [17].
 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351 349

Fig. 6. Comparison of delivered expired tidal volume in ml/kg and peak inflation pressure during resuscitation of preterm infants. From O’Donnell [4].

inflammatory response [29]. This may be a problem for very pre-
the jaw being pushed backwards or neck flexion from the
term infants. pressure on the mask.
Currently it is not easy to measure, monitor and control tidal
volume during resuscitation. However, this is now standard prac- The four practical responses to airway obstruction are:
tice during neonatal ventilation and will almost certainly be used in
the future to guide resuscitation.
ensure that the neck is in a position to ‘open the airway’;

check the mask size, position and hold;

increase the inflating pressure;
7. Observing chest movement to assess ventilation

use an expired CO2 detector to assess effectiveness of
ventilation;
Resuscitators guide their inflations by observing chest wall

pass an endotracheal tube.
movement. The ability of resuscitators to assess this accurately, and
particularly the tidal volumes delivered, has been assessed and
9. Colorimetric CO2 devices with mask ventilation
measured [30]. The chest moved with most inflations but the
resuscitation team could not accurately assess the tidal volume
A colorimetric CO2 detector is recommended during endotra-
being delivered.
cheal intubation to detect whether the endotracheal tube is in the
trachea and ventilation is being achieved, by the detection of CO2 in
8. Airway obstruction the exhaled gas. It detects expired CO2 within about six inflations
by a colour change from purple to yellow. These can be useful
There are times when little or no gas flows into the lungs. This during mask ventilation to detect airway patency, obstruction or
may be because of inadequate PIP and stiff lungs, or obstruction to inadequate ventilation [32,33].
the gas flow.
The reasons for airway obstruction are not known. It has been 10. Laryngeal mask airways (LMAs)
speculated that it might be due to an unsatisfactory chin and neck
position. The ‘neutral head position’ and ‘sniffing’ position using An LMA is an alternative device for delivering pressure to the
mild extension of the neck are taught; although there is little evi- airways for a short time. It is a small inflatable silicone mask that
dence for this during mask ventilation some neck extension is often fits over the larynx, with a connecting tube. It is passed through the
needed if a baby needs intubating [31]. mouth without the need for a laryngoscope. Once inserted, a
The possible causes of airway obstruction are: cushioned rim is inflated to achieve a low-pressure seal around the
laryngeal inlet. Like face masks they are not leak-free, especially at

the tongue obstructing the pharynx; inflating pressures used during neonatal resuscitation. They are

laryngeal adduction; easier to place correctly than an endotracheal tube, even by inex-

excess pressure from the mask blocking the nose and mouth; perienced operators. The use of LMAs has been reported in case
350 F.E. Wood, C.J. Morley / Seminars in Fetal & Neonatal Medicine 18 (2013) 344e351

series of term infants [34] and in small numbers of moderately

preterm infants [35]. The smallest-sized LMA is too large to be used Research directions
in very preterm infants. Successful use of LMAs in infants with
upper airway anomalies has been reported [36].
Investigate how to squeeze a self-inflating bag.

Does applied force during mask ventilation have phys-
11. Nasal tubes or face masks? iological consequences?

Investigate the causes of airway obstruction.

Evaluate training improvements for effective face mask
It has been suggested that a nasal tube, or tubes, may be more
ventilation.
effective for resuscitating neonates than a face mask. If a single tube
Evaluate the use of a resuscitation monitor in training
is used in one nostril, after the nasopharynx has been cleared of and clinical practice.
secretions, the other nostril and mouth must be held closed to
prevent gas leaking. A large randomized controlled trial comparing
face mask with a nasal prong during neonatal resuscitation has Conflict of interest statement
recently been completed [37]. There were no significant differences
in any clinical outcome. Fiona wood is contributing to the development of the Resusci-
tation Council (UK) ARNI course and associated training system.
12. PEEP and CPAP during resuscitation Colin Morley is a consultant to Fisher and Paykel Healthcare and
Laerdal Global Health. He has received payment for lectures from
It has been shown both in animal experiments [38,39] and Dräger Medical and Chiesi Pharmaceuticals. He has served on the
randomized controlled trials [40e43] that PEEP or CPAP facilitate neonatal group of the International Liaison Committee on
the formation of an FRC and improve oxygenation. It therefore Resuscitation.
seems logical to resuscitate preterm infants with a device that
delivers known levels of PEEP or CPAP if available. Funding sources

13. Which gas flows should be used? None.

There is little research about the appropriate gas flow. Flows of References
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