Manual ventilation and risk of barotrauma: primum non nocere.

Optimizing bag ventilation during cardiopulmonary resuscitation or ventilation of an unprotected airway1 is mandatory to minimize the risk of pulmonary complications and the occurrence of gastric inflation due to excessive airway pressure.2 Numerous studies have underlined the difficulty of providing safe and effective bag ventilation in these situations, and new devices have been marketed to help clinicians ensure adequate ventilation.3,4 During bag ventilation of an intubated patient, the risk of excessive airway pressure is even greater, because of the absence of air leak. Several case reports have told of complications associated with bag ventilation, including lung hyperinflation resulting in electromechanical dissociation5 and severe pulmonary barotrauma.6–8 It appears that some of these incidents were due to the malfunction or misuse of the bag-valve device, whereas in other instances the pattern of ventilation was clearly responsible for the incident. Little is known about the risk of barotrauma during bag ventilation of intubated patients, although situations that require bag ventilation are frequent (eg, manual ventilation after tracheal intubation before connecting the patient to the ventilator, during intrahospital transport, or sometimes because of persistent desaturation despite having increased the fraction of inspired oxygen [FIO2] during acute respiratory failure).