The airway pressures during bag-valve-mask ventilation: a randomized crossover manikin trial

Bag-valve-mask (BVM) ventilation is a lifesaving intervention, but excessive airway pressures can lead to gastric insufflation and aspiration. This randomized manikin study aimed to compare the effects of different BVM hand-grip techniques (one-hand, two-hand CE, two-hand TE) and airway scenarios on generated peak inspiratory pressures (PIP). In this randomized crossover manikin trial, 46 emergency medicine residents ventilated a manikin with three hand-grip techniques in normal and difficult airway scenarios (10 consecutive ventilations per condition). Airway pressures were continuously measured with a digital pressure sensor. To account for the repeated-measures design, continuous PIP data were analyzed with a linear mixed model (LMM). LMM analysis revealed significant main effects for both hand-grip technique and airway scenario ( p < 0.001). The one-hand technique produced significantly lower pressures compared to both bimanual techniques, while the two-hand TE technique performed no better than the standard CE technique. Individual ventilations frequently exceeded the 20 cmH₂O surrogate threshold, ranging from 55.4% (one-hand, normal airway) to 73.5% (TE, difficult airway). Extreme inter-operator variability was observed, with the absolute maximum PIP reaching 110.8 cmH₂O. Operator training level had no significant effect on pressure generation. BVM ventilation frequently produces peak inspiratory pressures that exceed the 20 cmH₂O physiological surrogate threshold, regardless of hand-grip technique or practitioner experience. These simulation findings highlight a potential mechanical risk of gastric insufflation but cannot directly predict real-world aspiration events. The results support the rationale for future clinical investigations into objective pressure-monitoring adjuncts to enhance airway management safety in vulnerable patient populations. NCT07591909 (2026-05-18).