What is the C and E technique for anesthesia? A comprehensive guide

October 11, 2025 •

6 min read

First described as a vital airway management skill, the C and E technique for anesthesia is a fundamental method used to provide manual bag-mask ventilation. This critical skill involves a specific hand position to secure a tight mask seal and maintain an open airway, ensuring adequate oxygenation for a patient during the induction of anesthesia or a medical emergency.

Quick Summary

This guide explains the C and E technique for anesthesia, a manual ventilation method using specific hand positioning to secure a tight mask seal and maintain an open airway during medical procedures and emergencies.

Key Points

Basic Airway Skill: The C and E technique is a fundamental method for manual bag-mask ventilation used during anesthesia and resuscitation.
Hand Position: It involves forming a 'C' with the thumb and index finger to create a tight mask seal and an 'E' with the other three fingers to lift the mandible and open the airway.
Single-Handed Method: A single provider can use this technique, but it may be less effective for patients with difficult airway anatomy or obese patients.
Two-Handed Method: The two-handed C-E technique provides a superior mask seal and ventilation, especially in challenging cases.
Comparison to V-E: Studies show the V-E technique, which uses the thumbs to press the mask and four fingers to lift the jaw, can be more effective than C-E in obese patients.
Clinical Application: The technique is crucial during the induction of anesthesia, airway emergencies, and as a rescue measure for failed intubations.
Training is Key: Proper training and experience are necessary to effectively perform the C and E technique and recognize when an alternative method is required.

The C and E technique is a foundational skill in anesthesiology and critical care, primarily used for bag-mask ventilation (BMV). It refers to a specific hand position for the provider to deliver breaths to a patient who is not breathing adequately or at all. The 'C' shape formed by the thumb and index finger ensures a tight seal on the mask, while the 'E' shape, formed by the remaining three fingers, lifts the jaw to maintain airway patency.

The Hand Position: Breaking Down the 'C' and 'E'

The C and E technique is a manual skill that requires precision and practice to master. The specific hand placement directly addresses two primary challenges of manual ventilation: creating a leak-proof mask seal and preventing the tongue from obstructing the airway. A failure in either of these areas can compromise a patient's oxygenation.

The 'C' Grip: This part of the technique focuses on the mask seal. The provider's thumb and index finger form a 'C' shape around the face mask's cuff. The thumb typically applies pressure on the nasal bridge area, while the index finger presses on the lower part of the mask, just above the chin. The goal is to create even, consistent pressure around the edges of the mask to prevent air from leaking out during ventilation. This ensures that the air being delivered from the bag goes into the patient's lungs and not into the surrounding atmosphere.
The 'E' Grip: This component addresses the airway obstruction issue. The remaining three fingers (middle, ring, and little finger) are used to lift the patient's jaw and create a patent airway. The fingers are placed on the bony part of the mandible, with the little finger ideally at the angle of the jaw. The provider lifts the jaw forward towards the mask, aligning the oral, pharyngeal, and laryngeal axes to open the airway. It is crucial to lift the bony parts of the jaw and not press on the soft tissue under the chin, which could inadvertently worsen the obstruction.

Step-by-Step Procedure for Single-Handed C-E Technique

When performed by a single provider, the C-E technique is a rapid and essential method for short-term ventilation. While often sufficient, it can be less effective than the two-handed method, especially in patients with anticipated difficult airways.

Position the Patient: Ensure the patient is in the correct position for airway management, typically supine with the head in a neutral position or slightly extended using a "head tilt-chin lift" maneuver, if no cervical spine injury is suspected.
Select and Place the Mask: Choose an appropriately sized face mask that fits snugly over the patient's nose and mouth without overlapping the eyes or chin. The mask should be placed with the narrow end over the bridge of the nose.
Form the 'E-C Clamp': Use your non-dominant hand to form the 'E-C clamp'. The index finger and thumb form the 'C' around the mask, and the remaining three fingers form the 'E' by lifting the mandible towards the mask. For optimal effect, lift the face toward the mask, rather than pushing the mask down onto the face.
Ventilate: Use your dominant hand to squeeze the bag of the bag-valve-mask (BVM) device, delivering breaths at the appropriate rate and volume while observing for adequate chest rise.

Single-Handed vs. Two-Handed Techniques

The choice between a one-handed and two-handed technique for C-E ventilation depends on the clinical situation, the patient's characteristics, and the availability of personnel. The two-handed approach is generally considered more effective and is often reserved for difficult ventilation scenarios.

One-Handed (EC-Clamp) Technique

Method: One provider uses one hand to form the 'C' and 'E' grips while the other hand squeezes the bag.
Advantages: Efficient for a single rescuer, quicker to initiate in certain situations.
Disadvantages: Can be less effective at providing a tight seal, especially in patients with difficult airway anatomy, leading to air leaks and potential gastric insufflation. It also provides less force to lift the jaw and relieve obstruction.

Two-Handed (Double C-E) Technique

Method: Two providers are involved. One provider uses both hands to form the 'C' and 'E' grips, and the second provider squeezes the bag. Alternatively, one provider can use both hands, forming a 'C' with the thumbs and an 'E' with the other fingers on both sides of the jaw.
Advantages: Significantly better mask seal and greater jaw thrust, leading to larger tidal volumes and lower failure rates, particularly in obese patients.
Disadvantages: Requires either a second person or a modified technique, which may not always be feasible.

Comparison of C-E Technique vs. Other Techniques

Anesthesiologists and medical providers have a range of options for manual ventilation. The C-E technique is just one of several approaches. Other notable manual techniques include the V-E clamp and jaw thrust maneuvers.


Feature	C-E Technique	V-E Technique	Two-Handed Jaw Thrust
Hand Position	Thumb and index form 'C' on mask; remaining fingers form 'E' on mandible.	Thumbs and thenar eminences on mask; remaining fingers lift jaw.	Fingers along angle and ramus of mandible; thumbs press on mask.
Primary Goal	Secure mask seal and lift chin.	Provide superior mask seal and jaw thrust.	Maximize jaw elevation to overcome obstruction.
Effectiveness	Standard effectiveness; can be improved with two hands.	Often more effective than C-E, especially in obese patients.	High effectiveness, particularly for difficult airway or c-spine immobilization.
Best Used For	Routine mask ventilation, particularly one-handed when a good seal is easily achieved.	Obese patients or those with difficult-to-ventilate airways.	Patients with suspected c-spine injury, as it doesn't require neck movement.

Advantages and Disadvantages of the C-E Technique

Advantages

Fundamental Skill: The C-E technique is a core competency taught to all healthcare providers involved in airway management.
Widely Applicable: It can be used in a variety of clinical scenarios, including the operating room, emergency department, and prehospital settings.
Quick to Initiate: A single provider can rapidly initiate the one-handed version, which is crucial in emergencies.

Disadvantages and Limitations

Risk of Gastric Insufflation: If the seal is poor and high pressure is used, air may enter the stomach, increasing the risk of aspiration.
Variable Effectiveness: The success of the technique can vary based on patient anatomy (e.g., facial hair, edentulousness) and the provider's experience.
Less Effective than Alternatives in Difficult Airways: For obese patients or those with other anatomical challenges, the V-E or two-handed jaw thrust techniques have shown higher success rates and better tidal volumes.

Clinical Applications in Anesthesiology

The C and E technique is not a standalone solution but a tool within the broader context of airway management. Its most common application is during the induction of general anesthesia, where the patient's own breathing is suppressed, and manual ventilation is necessary before a definitive airway (e.g., endotracheal tube) is secured.

Induction of Anesthesia: During this phase, the patient becomes apneic (stops breathing). The anesthesiologist uses the C-E technique with a bag-valve-mask to deliver oxygen and volatile anesthetic gases until the airway is secured.
Airway Emergencies: In scenarios where a patient suddenly loses the ability to breathe, the C-E technique is a rapid, lifesaving maneuver to provide immediate oxygenation and ventilation.
Failed Intubation: If an anesthesiologist is unable to intubate the trachea, the C-E technique can be used as a rescue maneuver to continue ventilating the patient while a different strategy is planned.

For more detailed information and visual aids on performing bag-mask ventilation, medical professionals can consult authoritative resources such as the NCBI Bookshelf section on Bag-Valve-Mask Ventilation.

Conclusion

The C and E technique for anesthesia is a cornerstone of airway management, providing a standardized approach to manual bag-mask ventilation. While the fundamental principles of creating a tight mask seal and opening the airway remain constant, its application can be adapted to various clinical situations and patient needs. The effectiveness of the technique can vary, and providers must be trained to recognize when a different approach, such as the two-handed V-E or jaw thrust, may be necessary. By understanding the proper execution, advantages, and limitations of the C and E technique, healthcare providers can ensure effective oxygenation and ventilation, contributing to better patient outcomes during anesthesia and critical care.

Frequently Asked Questions

The 'C' in the C and E technique represents the 'C' shape made with the thumb and index finger to create a tight seal on the patient's face mask.

The 'E' in the C and E technique refers to the 'E' shape formed by the middle, ring, and little fingers, which are used to lift the mandible (jaw) and open the patient's airway.

A two-handed technique is often preferred because it allows for a more secure mask seal and a stronger jaw lift, resulting in more effective ventilation, especially in difficult airway situations or with obese patients.

While the C and E technique is widely applicable, its effectiveness can be limited in certain patients, such as those who are obese or have difficult facial anatomy. In such cases, alternative techniques like the V-E or two-handed jaw thrust may be more effective.

The primary difference lies in the hand position for holding the mask. In the C-E technique, the thumb and index finger form a 'C' on the mask. In contrast, the V-E technique uses the thumbs and thenar eminence on both sides of the mask to create a seal, which often provides a better seal and greater tidal volume.

In pediatric anesthesia, the C and E technique is used similarly to adults for bag-mask ventilation, with the crucial consideration of selecting an appropriately sized mask that fits the child's smaller face without covering the eyes.

Incorrect performance of the C-E technique, particularly with a poor mask seal, can lead to air leaks, inadequate oxygenation, and gastric insufflation (forcing air into the stomach), which increases the risk of aspiration.