The ‘four hands CPR technique’

As many of you know, providing adequate ventilations with a bag-valve-mask (BVM) during cardiopulmonary resuscitation (CPR) is challenging. It is difficult to create a good seal with the mask, the operator of the BVM often has other tasks at the same time like coordinating the scene during the first minutes of the arrest and the communication between the operator of the BVM and the person providing the chest compressions is often suboptimal due to the stressfull setting. As a result, it is difficult to provide high performance basic life support with adequate ventilations and optimal synchronization of compressions and ventilations, escpecially in the first minutes of the resuscitation attempt.

This is why I often teach resuscitation team members to apply the facemask with two hands and let the person who provides the chest compressions squeeze the BVM for two times. I call this the ‘four hands CPR technique’, although this is also referred to as the ‘modified 2-rescuers CPR technique’.

This has the following advantages:
√ Optimal seal of the facemask by using two hands
√ Optimal jaw thrust technique
√ You do not need an extra person to squeeze the bag for you
√ No simultaneous ventilation and compression, preventing gastric insufflation
√ Short pause in compressions (3 seconds in this video)
√ No need to communicate on the timing of the pause in compressions, creating more calm in the room
√ The provider who is giving ventilations gets feedback on the insufflations because you can feel the chest rising with the hand which remains on the chest
√ The person applying the facemask, when an adequate seal is achieved, can maintain this and is better able to delegate tasks to bystanders or other team members. This is especially useful in the case of a paramedic who is first on the scene or a resident attending an in-hospital cardiac arrest during a nightshift who arrives first.

Does it have disadvantages? Yes, a few things to keep in mind are:
– Continue to evaluate the adequacy of the ventilations. If the provider who is providing the chest compressions notices that the ventilations are not correct, he/she needs to prompt the provider who is holding the facemask to recheck the seal and jaw thrust (or consider using a oropharyngeal airway).
– You can’t squeeze the bag yourself, so instruct the person squeezing the bag not to overinflate. A pratical way to achieve this is asking them to squeeze the bag with two fingers. An other alternative is to use a smaller bag, like a pediatric bag.
– If you are the code team leader as well, delegate these hands-on tasks as soon as you can when others arrive who can take over.

That said, I think it is a very useful trick to improve your resuscitation performance. Certainly in that very difficult phase of the first stressful minutes when you simply have to run the code and the only person competent to provide airway maneuvers and BVM ventilation. And, like with everything else, I would strongly encourage you to train with this technique. When all team members are familiar with this technique, and train accordingly, you will optimize your performance. And hopefully that will benefit your patients.


Update June 2020:

This technique has been studied in 2 simulation studies, both showing an improvement in ventilation performance while maintaining chest compression quality. Check out:

Root CW, Deutsch BC, Lakha S, Shah A, Lin HM, Hyman JB. Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation. The Journal of emergency medicine. 2019;57:51-8.

Shim HW, Park SO, Lee YH, Yoo YB, Hong DY, Baek KJ, et al. Effectiveness of a modified 2-rescuer cardiopulmonary resuscitation technique using a bag-mask for less experienced health care providers: A randomised controlled simulation study. Hong Kong Journal of Emergency Medicine. 2015;22:23-30.


Furthermore, this technique is now recommended by the International Liaison Committee on Resuscitation (ILCOR), in their practical recommendations in response to the COVID-19 pandemic.



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8 Responses to The ‘four hands CPR technique’

  1. Matt says:

    Very thought provoking. Cool idea. Thank you for sharing.


    • Thanks Matt, hope it will be useful for your practice! Let me know when you have used it and what you think of it.


      • Matt says:

        I completed a small cross-over of conventional versus 4-hand methods with Laerdal QCPR manikin. Much better ventilations, slightly worse chest compressions (but barely so). If anyone else can enroll, lets start a multi-site cross-over simulation trial.

        Liked by 1 person

  2. Wim says:

    I have also teached this technic in mine lessons. Good technic and indeed better ventilation. However it is difficult to convince our doctors to use this technic.


  3. Jürgen Kramer says:

    If you have to fix the Mask with both Hands and the other team member providing the Heartmassage, how do you handele the rest, for example AED-Pads, prep for IV, Intubation, getting the Adrenalin or Amiodaron ready etc. If you don’t have to ventilate because of the Heartmassage you can get this things ready but in this case I don’t understand how you can manage this kind of things.


    • Matt says:

      I’d say it’s applicability is for 2 rescuer scenarios, with no advanced life support until additional personnel available. The 3+ people begin the less effective interventions i.e. adrenalin, amio, intubation.


  4. merteko says:

    Is a standard procedure 112 Belgium.


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