The Pitfalls of Using Pop-Off Valves in Adult Emergency Airway

Although common in pediatric airway equipment, positive-pressure relief ("pop-off") valves are also present on some adult resuscitator bags. These valves are designed to decrease barotrauma but, in doing so, limit the airway pressure provided during manual bag-assisted ventilation. In critically ill adult patients with high airway pressures, these valves can be detrimental and result in hypoventilation and subsequent hypoxemia.

In the 7 days after an unannounced introduction of new resuscitator bags with pop-off valves in the emergency department, there were 3 adult patients for whom an open pop-off valve resulted in hypoventilation and hypoxemia. These cases involved both medical and traumatic pathologies. In each case, there was a delay in discovering the change to a resuscitator bag equipped with a pop-off valve. Once the emergency physicians noticed the pop-off valve and closed them, there was significant improvement in ventilation and oxygenation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hand-operated resuscitator bags are an essential tool for airway management. These cases represent two main lessons: changing airway equipment without notifying staff is dangerous, and an open pop-off valve will result in inadequate ventilation when patients have high airway pressures, without the tactile feedback of difficult bagging. Emergency physicians should be aware of equipment changes and know to disable the pop-off valve on resuscitator bags if they find them in their departments.