The CPR ventilation gap: understanding and preventing hypoventilation

Cardiopulmonary resuscitation (CPR) saves lives. Yet, even this cornerstone of emergency care hides a persistent and often overlooked danger: hypoventilation during manual ventilation. In the earliest and most critical minutes of cardiac arrest—before intubation, before hospital care—ventilation is typically delivered using a bag-valve mask (BVM). A technique that looks simple on the surface but is surprisingly complex in practice....

The CPR ventilation gap: understanding and preventing hypoventilation
Selective focus of paramedics in uniform doing cardiopulmonary resuscitation to man during first aid

Cardiopulmonary resuscitation (CPR) saves lives. Yet, even this cornerstone of emergency care hides a persistent and often overlooked danger: hypoventilation during manual ventilation.

In the earliest and most critical minutes of cardiac arrest—before intubation, before hospital care—ventilation is typically delivered using a bag-valve mask (BVM). A technique that looks simple on the surface but is surprisingly complex in practice.

Let’s break down why hypoventilation matters—and how we can fix it.

What is hypoventilation?

Hypoventilation occurs when a patient doesn’t receive enough air—either because breaths are too small, too infrequent, or both.

This leads to:

  • Hypoxemia and hypoxia
  • Hypercapnia
  • Acidosis
  • Reduced survival and neurological recovery rates

In fact, an American study showed that nearly 60% of patients are hypoventilated during CPR, and that improving ventilation alone could triple survival rates.

Why is manual ventilation so challenging?

Delivering high-quality manual ventilation with a BVM is more art than science—and that’s the problem.

Mask leaks are frequent and difficult to detect without feedback.
A recent study by the Paris Fire Brigade revealed that more than 40% of the air was lost through leaks, and the average tidal volume delivered was just 280 mL—far below the 500 mL recommended for adults.

In other words: most rescuers are trying hard—but not getting enough air into the lungs.

The solution: Measure. Train. Improve.

  1. Measurement is non-negotiable.
    You can’t improve what you can’t measure. Monitoring tools that display tidal volume, detect leaks, and provide real-time feedback are essential to guide rescuers and improve ventilation quality.
  2. Train like lives depend on it—because they do.
    Hands-on simulation training at the Manual Ventilation Academy with Ventilation Feedback Devices allows providers to refine their technique, learn to identify leaks, and gain the muscle memory needed for high-stress situations.

Hypoventilation is preventable

This is not just a training issue—it’s a systems issue.
It’s time to rethink how we teach, monitor, and perform manual ventilation.

👉 Join the movement. Start training with feedback. Demand better ventilation standards. Help every breath count.

 

References

(1)  Idris, A. H., Aramendi Ecenarro, E., Leroux, B., Jaureguibeitia, X., Yang, B. Y., Shaver, S., Chang, M. P., Rea, T., Kudenchuk, P., Christenson, J., Vaillancourt, C., Callaway, C., Salcido, D., Carson, J., Blackwood, J., & Wang, H. E. (2023). Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation, 148(23), 1847–1856.

(2) Evaluation of ventilation quality of BLS Firefighter teams during OHCA : The VECARS – 1 study. F. Lemoine, D. Jost, B Tassart, A. Petermann, S. Lemoine, M. Salome, B. Frattini, S. Travers.