The Edge: Is There a Better Grip for Face Mask Ventilation?

The Edge is a new monthly column from FlightBridgeED that features top EMS medical directors sharing current trends in critical care and prehospital medicine. In this installment FlightBridgeED's associate medical director, James DuCanto, MD, looks at face mask ventilation. 

Several years ago I was asked, along with friend and colleague Adrian Matioc, MD, professor of anesthesiology at the University of Wisconsin, to revise a chapter in a major textbook on airway management. This textbook, Benumof and Hagberg’s Airway Management, spans a thousand pages and serves as a reference for healthcare professionals of all levels. 

When I contributed to the creation of this chapter, I had 20 years of private practice in anesthesiology—in other words, I thought I knew everything I needed to know about face mask ventilation. But what I discovered upon “deep-diving” the topic was that a large proportion of its knowledge and techniques were not rooted in peer-reviewed quality improvement but instead passed along as “tradition,” using antiquated concepts and methods. 

Matioc single-handedly opened my eyes to this topic through his four-part series of articles in the journal Anesthesiology that detailed the history of airway management from the preanesthetic era to the modern day.^1–4 Matioc taught me that the suboptimal techniques we have inherited stem from the method and posture required to hold an ether mask and simultaneously palpate the facial artery pulse, carotid pulse, and pharyngeal area (to detect swallowing).

The idea here is if the pulse fades or becomes absent, remove the ether mask and allow the patient to expel the ether (to   avoid cardiac arrest). If the caregiver feels the patient engaging in swallowing motions, add more ether. The genesis of what we accept as the “CE” mask grip is inherently flawed for the purpose of modern basic life support mask ventilation resuscitation.

At the turn of the 20th century, the German company Draeger introduced an important mechanical resuscitation system known as the Pulmotor. The Pulmotor was a compressed gas-powered pressure-cycled resuscitator created in 1907 to treat victims of toxic gas inhalation, chiefly from mining and industrial accidents. Its technique required a tight seal with mask straps, supplemented with the “Esmarch-Heiberg maneuver,” which is the technique of bimandibular jaw thrust from behind the angle of the jaw, producing prognathism of the lower jaw (i.e., the lower teeth slide anterior to the upper teeth). 

The Pulmotor remained the state of the art in resuscitation equipment for many years, as it permitted two-handed face mask ventilation with a superior method of airway control, but was ultimately phased out in deference to simpler, manually operated resuscitators. The Kreiselman Resuscitator, introduced in the U.S. circa 1943 (a full 12 years prior to invention of the Ambu resuscitator), was an example. Although manually operated resuscitators offered multiple advantages over compressed gas-powered versions (e.g., reduced size, complexity, and cost), they required a one-hand mask ventilation technique—thus the CE mask grip was pushed into the mainstream. 

Modern face mask ventilation requires an update of the CE technique—a technique that provides a more ergonomic method to hold the mask that allows validated airway maneuvers to open the upper airway while simultaneously improving the symmetry of the mask seal. Put plainly, modern face mask ventilation requires that we study, practice, and adopt the “chin lift” grip.

Chin Up

The chin lift grip requires the clinician to use a method of airway management familiar to many of us who received CPR training in the days before compression-only CPR, namely the “chin lift with head extension” maneuver to position the patient for mouth-to-mouth resuscitation. 

The technique begins with the right hand on the patient’s forehead (to facilitate the neck extension) and the fingers of the left hand below the tip of the chin, probing inward to contact the bone of the jaw (where the left and right portions of the mandible join in the midline). Upward rotation in the sagittal plane produces mandibular advancement (chin lift) with simultaneous neck extension (when appropriate, of course; omitted in cases of suspected cervical spine injury), which will advance the tongue and epiglottis anteriorly off the posterior pharyngeal wall, providing a remedy to upper airway obstruction. The face mask is applied with the left hand in such a manner that the fingers drape over the bottom portion of the mask to maintain the chin lift and neck extension. 

Now let’s talk about how we’ll hold the mask to make this work. In contrast to the CE grip (in which the mask is physically held only on the left portion, with the left hand), the face mask is held chiefly in the web of the hand between the thumb and forefinger of the left hand, allowing the rescuer to utilize a pronated hand position with the ability to achieve a symmetric seal (Figure 1). The CE grip provides an asymmetric mask seal stronger on the left side, often requiring the rescuer to compensate by applying downward pressure with the bag-valve device to complete the seal on the right. 

In contrast to the hand and forearm position of the CE grip, the left arm and hand are in a relaxed pronated posture, whereas the CE grip requires a posture akin to a “stress” position. According to the Canadian Centre for Occupational Health and Safety, “When the hand holds and uses a tool in an awkward position, it has less strength and is consequently more susceptible to soreness and eventual injury.”⁵ Due to its awkward angle and the static forces required, we need to recognize the CE grip forces the caregiver into a technique that’s suboptimal and cannot be maintained for any great length of time without repeated adjustments and loss of upper airway patency. 

A relaxed posture with the left hand grasping and applying a symmetric mask seal, along with validated airway maneuvers applied to the bony structures of the upper airway (lower mandible at the mentum along with neck extension), represents the best upgrade to modern face mask ventilation we can immediately implement. I recommend practicing these techniques on a BLS airway training manikin prior to clinical use and that your service’s medical director be involved in the decision to implement them.  

References

1. Matioc AA. An Anesthesiologist’s Perspective on the History of Basic Airway Management: The “Preanesthetic” Era—1700 to 1846. Anesthesiology, 2016 Feb; 124(2): 301–11.

2. Matioc AA. An Anesthesiologist’s Perspective on the History of Basic Airway Management: The “Preanesthetic” Era—1846 to 1904. Anesthesiology, 2017 Mar; 126(3): 394–408.

3. Matioc AA. An Anesthesiologist’s Perspective on the History of Basic Airway Management: The “Preanesthetic” Era—1904 to 1960. Anesthesiology, 2018 Feb; 128(2): 254–71.

4. Matioc AA. An Anesthesiologist’s Perspective on the History of Basic Airway Management: The “Preanesthetic” Era—1960 to Present. Anesthesiology, 2019 May; 130(5): 686–711.

5. Canadian Centre for Occupational Health and Safety. OSH Answers Fact Sheets, www.ccohs.ca/oshanswers/ergonomics/handtools/hazards.html.

James “Jim” DuCanto, MD, is the associate medical director of airway and ventilation for FlightBridgeED, LLC.