Dr. Arthur Slutsky is a world-renowned physician-scientist whose career bridges biomedical engineering, critical care medicine, and mechanical ventilation research.
- Positions: Professor Emeritus, University of Toronto; Former VP of Research, St. Michael’s Hospital.
- Achievements: Hundreds of peer-reviewed articles, major contributions to ventilator-induced lung injury (VILI) prevention, Canadian Medical Hall of Fame inductee (2025).
- Impact: His research has shaped how clinicians worldwide manage acute respiratory failure in ICU and prehospital settings.
Quick Summary / Key Takeaways
If you remember only five things from Dr. Slutsky’s perspective, make it these:
- BVM ventilation is simple in theory, difficult in practice — quality depends heavily on provider skill.
- Both under- and overventilation can cause harm; poor mask seal and excessive volume/pressure are common issues.
- Overventilation worsens outcomes in TBI, cardiac arrest, and other critical conditions by causing hypotension, hypocapnia, and barotrauma.
- Smaller “small adult” BVMs are not safer — they can worsen clinical outcomes.
- Training and feedback devices are essential — real-time measurement of tidal volume, rate, and pressure can improve the quality of manual ventilation.
Key Evidence & Guidelines
- Tidal Volume Targets: 400–600 mL for the avg american adult male; many standard BVMs deliver >1000 mL if fully compressed.
- EPIC TBI Findings: Avoiding hypoxia, hypotension, and hyperventilation improves outcomes.
- Snyder 2025 / Justice 2024: Small adult BVMs deliver volumes far below target; worse outcomes than standard bags.
- Idris 2023: Poor-quality ventilation in OHCA linked to worse survival.
- Wang 2018 (JAMA): No survival difference between early intubation and supraglottic airway (often BVM), but quality of ventilation is key.
Overventilation & Its Effects
Physiologic Consequences:
- ↑ Intrathoracic pressure → ↓ venous return → hypotension, reduced cardiac output.
- VILI→ pneumothorax, alveolar rupture, barotrauma.
- Hypocapnia → cerebral vasoconstriction → worsened TBI outcomes.
Training Recommendations
- Hands-on, high-frequency practice — quarterly, not just at certification.
- Real-time feedback devices — measure tidal volume, rate, pressure.
- Scenario-based drills — mask leaks, stiff lungs, obstructed airway.
- Two-person BVM technique for optimal seal.
Table of Contents
SECTION 1: Foundations of BVM Ventilation
1. What is bag-valve-mask ventilation, and why is it critical in emergency care?
2. When have you seen the BVM succeed or fail?
3. When should a BVM be used instead of mechanical ventilation?
SECTION 2: Common Errors & Consequences
4. What are the most common errors in BVM ventilation?
5. What are the consequences of over-pressurization and hyperventilation?
6. How much volume does a standard adult BVM deliver compared to what’s actually needed?
7. Are smaller (“small adult” or pediatric) BVMs safer for adult use?
SECTION 3: BVM vs Mechanical Ventilation
8. How does manual BVM ventilation compare to mechanical ventilation?
SECTION 4: Skill Variability & Training
9. Why is there so much variability in BVM technique, even among trained providers?
10. How should BVM training evolve to reduce preventable harm?
SECTION 5: Tools & Innovations
11. What tools or innovations help improve BVM safety and effectiveness?
SECTION 1: Foundations of BVM Ventilation
FAQ 1: What is bag-valve-mask ventilation, and why is it critical in emergency care?
Bag-valve-mask (BVM) ventilation is a manual method of delivering breaths to patients who are not breathing adequately. It’s vital in prehospital care and the first minutes of resuscitation, often the only way to oxygenate a patient before intubation or mechanical ventilation. Proper use buys time and can dramatically improve outcomes.
Real Results: During the 1952 polio epidemic in Copenhagen, BVM-like manual ventilation saved hundreds of lives when mechanical ventilators were unavailable (Lassen 1953; Wunsch 2023).
Takeaway: BVM is a fast, accessible bridge to definitive airway support, but its success depends on skilled execution.
FAQ 2: When have you seen the BVM succeed or fail?
BVM ventilation has saved lives in overdose, trauma, and cardiac arrest, but failure can occur due to poor technique, equipment issues, or late intervention. Poor mask seal, overventilation, or underventilation can worsen hypoxia and CO₂ retention, compounding injury.
Real Results: In traumatic brain injury cases, poor BVM technique has been linked to worse neurological recovery due to uncontrolled ventilation rates and volumes.
Takeaway: Technique quality is the main factor separating BVM success stories from preventable failures.
FAQ 3: When should a BVM be used instead of mechanical ventilation?
BVMs are crucial when mechanical ventilation isn’t immediately available—cardiac arrest, trauma, patient transfers in-hospital, or mechanical ventilator troubleshooting. They’re also used in-hospital to assess whether issues are machine-related or patient-related.
Real Results: During COVID-19 ventilator shortages, BVM ventilation allowed temporary ventilation/oxygenation until ventilators became available, preventing deterioration in critical patients.
Takeaway: BVM is both a bridge in emergencies and a diagnostic tool when mechanical ventilation issues arise.
SECTION 2: Common Errors & Consequences
FAQ 4: What are the most common errors in BVM ventilation?
Underventilation, largely from poor seal, and overventilation from excessive rate or volume are the most common mistakes. Both can cause significant harm, from hypoxia to hemodynamic compromise to VILI.
Real Results: Simulation studies show even trained providers often deviate from recommended ventilation parameters without real-time feedback.
Takeaway: Consistent, correct BVM technique is rare without feedback and practice.
FAQ 5: What are the consequences of over-pressurization and hyperventilation?
Over-pressurization raises intrathoracic pressure, lowering venous return and cardiac output—especially dangerous during cardiac arrest. Hyperventilation with associated hypocapnia reduces cerebral blood flow, especially harmful in TBI.
Real Results: The EPIC TBI studies found that avoiding hypoxia, hypotension, and hyperventilation significantly improved survival and neurological outcomes.
Takeaway: Small adjustments in ventilation rate, volume, and seal can dramatically improve patient survival and recovery.
FAQ 6: How much volume does a standard adult BVM deliver compared to what’s needed?
An average American adult male typically requires 400–600 mL per breath, but most adult BVMs can deliver over 1,000 mL if fully squeezed—raising the risk of overventilation.
Real Results: Field studies show many providers exceed target volumes under stress, increasing barotrauma risk.
Takeaway: Controlling bag compression is essential to avoid excessive tidal volumes.
FAQ 7: Are smaller (“small adult” or pediatric) BVMs safer for adult use?
No—small adult BVMs often underdeliver volumes, leading to hypoventilation and CO₂ retention. Pediatric BVMs should not be used in adults.
Real Results: Snyder et al. (2025) found worse outcomes in adults ventilated with small adult bags compared to standard adult BVMs.
Takeaway: Use standard adult BVMs with proper technique and feedback tools for best results.
SECTION 3: BVM vs Mechanical Ventilation
FAQ 8: How does manual BVM ventilation compare to mechanical ventilation?
Mechanical ventilation delivers consistent volume, pressure, and rate, while manual BVM is highly variable and operator-dependent.
Real Results: Wang et al. (2018, JAMA) found no difference in survival between early intubation and supraglottic airway (often BVM) in OHCA—but ventilation quality was key.
Takeaway: Both methods can work; quality of execution matters more than the device.
SECTION 4: Skill Variability & Training
FAQ 9: Why is there so much variability in BVM technique, even among trained providers?
Lack of real-time feedback and infrequent use mean skills deteriorate quickly. Different patient lung mechanics further complicate consistency.
Real Results: EMS providers may perform BVM only a few times per year, often in high-stress situations, reducing technique reliability.
Takeaway: Skill decay and patient variability make ongoing, feedback-based training essential.
FAQ 10: How should BVM training evolve to reduce preventable harm?
Regular, feedback-driven, scenario-based training should be mandatory. Providers must learn to manage leaks, stiff lungs, and airway obstruction.
Real Results: Studies show real-time volume rate, and flow feedback improves ventilation accuracy and adherence to guidelines.
References:
Berge, N., Smith, J., & Voinea, A. (2025, August 8). A mixed methods study on the effectiveness and usability of real-time ventilation feedback devices in EMS [Conference poster]. National Association of EMS Educators (NAEMSE) Annual Symposium, Orlando, FL.
Culbreth RE, Gardenhire DS. Manual bag valve mask ventilation performance among respiratory therapists. Heart Lung. 2021 May-Jun;50(3):471-475. doi: 10.1016/j.hrtlng.2020.10.012. Epub 2020 Nov 1. PMID: 33138977; PMCID: PMC7604178.Brady MF, Weber NK, Walker, III R, et alFeasibility of manual ventilation replacing mechanical ventilationBMJ Innovations 2021;7:297-301.
Takeaway: High-frequency, feedback-based practice is the best safeguard against preventable errors.
SECTION 5: Tools & Innovations
FAQ 11: What tools or innovations help improve BVM safety and effectiveness?
Flow-limiting devices, pressure relief valves, real-time tidal volume displays, and capnography can reduce user error and improve consistency.
Real Results: SMART bag systems and other flow-limiting devices have been shown to prevent excessive flow rates and improve ventilation uniformity in EMS simulations.
Takeaway: Pairing skilled technique with modern feedback tools transforms BVM from guesswork to precision.
