When ventilating a patient, an EMT must maintain a proper mask seal, deliver breaths at the correct rate for the patient’s age, watch for visible chest rise with each breath, and keep the airway open using the appropriate positioning technique. These priorities apply whether you’re using a bag-valve-mask (BVM), pocket mask, or any other ventilation device. Getting any one of them wrong can mean the patient isn’t actually receiving oxygen, even if the equipment is working perfectly.
Open the Airway First
Before delivering a single breath, you need a clear, open airway. For most patients, the head-tilt-chin-lift maneuver tilts the head back and lifts the chin forward, pulling the tongue away from the back of the throat. This alone can resolve an obstruction caused by a relaxed tongue in an unconscious patient.
If there’s any possibility of a cervical spine injury, such as after a fall, car crash, or diving accident, you must use the jaw-thrust maneuver instead. Stand at the head of the stretcher, place your palms on the patient’s temples, and use your fingers to lift the lower jaw upward without moving the neck. The goal is to push the jaw forward until the lower teeth sit higher than the upper teeth. This opens the airway while keeping the spine in a neutral position. If you hear snoring or gurgling sounds during ventilation, the airway isn’t fully open and you need to reposition.
Use Airway Adjuncts When Needed
If manual positioning alone doesn’t keep the airway clear, airway adjuncts help maintain an open passage.
An oropharyngeal airway (OPA) is appropriate only for completely unresponsive patients with no gag reflex. If the patient gags, coughs, or resists, remove it immediately. A nasopharyngeal airway (NPA) is the better choice for patients who are semiconscious or have an intact gag reflex, because it rarely triggers gagging. NPAs are also useful when a patient’s mouth is difficult to open due to swelling, a clenched jaw, or structural issues.
To size an NPA, hold it against the patient’s face with the tip pointing toward the earlobe and the other end at the nostril. The correct size just reaches the earlobe. Adult NPAs range from 6 to 9 cm: smaller sizes (6 to 7 cm) for small-framed adults, medium sizes (7 to 8 cm) for average builds, and larger sizes (8 to 9 cm) for larger individuals. Insert the NPA into the most open nostril with the bevel facing the septum (concave curve facing down), and rotate gently if you meet resistance.
Maintain a Proper Mask Seal
A leaking mask is one of the most common reasons ventilation fails in the field. The standard one-person technique is the E-C clamp: your thumb and index finger form a “C” shape pressing the mask down onto the face, while your third, fourth, and fifth fingers hook under the jaw in an “E” shape, simultaneously performing a jaw thrust. This keeps the mask sealed while lifting the airway open.
The American Heart Association recommends two-person BVM ventilation over one-person whenever possible. One rescuer uses both hands to hold the mask and maintain the seal, while the second squeezes the bag. Research confirms that experienced providers can manage all techniques equally well, but less experienced providers achieve significantly better ventilation with a two-handed mask hold. If you have a second rescuer available, use them.
Deliver Breaths at the Correct Rate
Ventilation rates differ by age and clinical situation. Giving breaths too fast is one of the most dangerous mistakes an EMT can make, because it increases pressure in the chest, reduces blood return to the heart, and can push air into the stomach.
- Adults with a pulse but not breathing normally: 1 breath every 5 to 6 seconds (10 to 12 breaths per minute). The 2025 AHA guidelines specify 1 breath every 6 seconds, or about 10 breaths per minute, as a reasonable target.
- Adults in cardiac arrest with an advanced airway: 1 breath every 6 to 8 seconds, delivered continuously without pausing compressions.
- Children and infants with a pulse: 1 breath every 3 to 5 seconds (12 to 20 breaths per minute). With an advanced airway during CPR, every 6 to 8 seconds.
- Newborns who are not breathing adequately: 40 to 60 breaths per minute using an appropriately sized mask.
Every single breath should be delivered over one full second. Squeezing the bag too quickly creates excessive pressure that forces air into the stomach rather than the lungs. A slow, steady squeeze is more effective than a forceful one.
Watch for Visible Chest Rise
The single most important sign that your ventilation is working is visible chest rise. Each breath should produce a gentle, symmetrical expansion of the chest. If you don’t see the chest rise, something is wrong: the seal is leaking, the airway isn’t open, or the tidal volume is too low.
When you do see chest rise, avoid the temptation to squeeze harder or deliver more air. You want just enough volume to make the chest visibly rise. Overinflation increases the risk of gastric distension (air filling the stomach), which can cause vomiting and aspiration.
Beyond chest rise, other signs of adequate ventilation include normal skin color returning (pink rather than blue or gray), improvement in heart rate, breath sounds that are clear and equal on both sides, and pulse oximetry readings climbing above 94% if a monitor is available. If the patient’s skin remains pale or bluish, or their oxygen levels don’t improve, reassess your technique, reposition the airway, and check your equipment.
Connect Supplemental Oxygen
A BVM without supplemental oxygen delivers only about 21% oxygen, the same concentration as room air. Connecting an oxygen source and attaching a reservoir bag dramatically increases the delivered concentration. At a flow rate of 10 to 15 liters per minute with a reservoir attached, a BVM can deliver close to 100% oxygen. At flow rates below 10 liters per minute, the oxygen concentration drops and may not meet the patient’s needs. Always ensure the reservoir bag is fully inflated before ventilating.
Wear Proper Protective Equipment
Ventilation puts you in direct contact with a patient’s airway secretions, blood, and exhaled air. At minimum, wear gloves and eye protection before managing any airway. A face mask or shield adds protection against respiratory droplets. If the patient is in any form of isolation or the situation involves significant fluid exposure, a gown should be added. Put your PPE on before making patient contact, not after you’ve already started ventilating.
Reassess Continuously
Ventilation is not a set-it-and-forget-it task. After every few breaths, confirm that chest rise is still visible and symmetrical. Listen for air leaking around the mask. Monitor the patient’s color and, when available, their oxygen saturation. If you’re ventilating during CPR, coordinate with the compressor to avoid interruptions. Count your breaths out loud or use a timing device to prevent the natural tendency to ventilate too fast under stress. Studies on real resuscitations consistently show that rescuers hyperventilate patients when they’re not actively tracking their rate.
If the patient vomits during ventilation, immediately turn them to the side (log-roll if spinal injury is suspected), suction the airway, and reposition before resuming. Aspiration of vomit into the lungs is a serious and preventable complication.