Face-mask ventilation is an important skill for emergent airway management and can be difficult to perform correctly and effectively [1]. Proper positioning of the head and neck, manual opening of the airway, placement of a nasopharyngeal or oropharyngeal airway device, and achievement of a tight face mask seal are essential to successful face-mask ventilation [1]. There are two main techniques for hand positioning during face-mask ventilation: the one-handed technique and the two-handed technique [1].

One-handed mask ventilation requires the mask to be secured with the index finger securing the mask near the chin and the thumb holding the mask near the bridge of the nose [1]. In the two-handed technique, the thumbs are placed on both sides of the mask [2]. Index finger placement varies depending on the two-handed method being utilized [2]. With the two-handed C-E technique, the thumb and index finger of both hands form a “C” while providing anterior pressure over the mask, while the remaining fingers form an “E” to lift the jaw [1]. In the two-handed V-E technique, the thumbs are held parallel adjacent to the mask connector to apply pressure on each side of the mask [1]. The second through fifth digits wrap around and elevate the mandible to draw it anteriorly into the mask, establishing a jaw thrust maneuver when appropriate [1]. Two-handed mask ventilation requires an assistant to provide ventilation if the patient is not spontaneously breathing [2].

Traditionally, two-handed mask ventilation was performed when attempts at single-handed mask ventilation have failed [2]. However, today it is generally accepted that two-handed face-mask ventilation is superior to one-handed face-mask ventilation in both routine and difficult airway cases [1]. A 2020 study evaluating if two-handed mask ventilation was superior to one-handed mask ventilation during inhalational induction of anesthesia in children found that the two-handed technique provided superior airway patency that was not influenced by the anesthetic depth [3]. Both minute ventilation and tidal volume were lower when a one-handed technique was performed [3].

Recent literature on airway management has focused on comparing the different two-handed methods [1]. A 2021 study sought to compare the effectiveness of mask ventilation between the two-handed techniques in obese unconscious apneic adults [4]. 81 adults received mask ventilation after induction using either the C-E technique or the V-E technique in a randomized crossover manner [4]. The primary outcome that was analyzed was expired tidal volume [4]. The results of the study revealed a higher failure rate for mask ventilation using the C-E technique (44%) versus the V-E technique (0%) [4]. Tidal volume was also significantly lower for those who were in the C-E group than those in the V-E group [4]. The researchers suggested that mask ventilation using the two-handed V-E technique is more effective than with the C-E technique, but additional research is still needed [4].

A two-handed mask ventilation technique is recommended because it provides a better mask-to-face seal and produces greater tidal volumes [4]. It can be used as a rescue measure for difficult intubation situations before surgical intervention is used [4]. Anesthesia providers can improve their skills by learning and practicing the two-handed techniques, which will likely improve the quality of ventilation and downstream outcomes [4].

References

1. Hart, D., Reardon, R., Ward, C., & Miner, J. (2013). Face mask ventilation: a comparison of three techniques. The Journal of Emergency Medicine, 44(5), 1028-1033. doi:10.1016/j.jemermed.2012.11.005
2. Daily, W. (2013). Mask Ventilation. The Difficult Airway: A Practical Guide, 35.
3. Choudhry, D., Brenn, B., Sacks, K. et al. (2021). Comparative evaluation of one‐handed versus two‐handed mask holding techniques in children during inhalational induction of anesthesia: A randomized crossover study. Pediatric Anesthesia, 31(3), 338-345. doi:10.1111/pan.14111
4. Fei, M., Blair, J., Rice, M. et al. (2017). Comparison of effectiveness of two commonly used two-handed mask ventilation techniques on unconscious apnoeic obese adults. BJA: British Journal of Anaesthesia, 118(4), 618-624. doi:10.1093/bja/aex035