Difficult or impossible face mask ventilation
Myron Yaster MD, Melissa Brooks Peterson, and Francis Veyckemans MD
Many years ago, at one of the first ASA meetings I ever attended, an oral abstract that I’ve never forgotten was presented from members of the Boston Children’s Hospital. The investigators scanned thousands of X-rays and CT scans and fed the images into a Harvard/MIT supercomputer to see if there was something, really anything, that could be used to identify patients at risk of being a difficult intubation. Unfortunately, their efforts failed and they could not find anything that would alert the anesthesia team to a potentially difficult intubation. Ok, a negative finding, so what made it so memorable (to me)? Someone in the audience asked the presenter “If this is true what do you do?” The presenter answered immediately and without any hesitation: “Oh, we just ask Dr. Charlie Nargozian, he’s always right” (Charlie was one of the airway mavens/gurus at Boston Children’s at the time). Everyone in the audience burst into knowing laughter.
“Cannot intubate, cannot ventilate” may be one of the most frightening and catastrophic things that can occur during an anesthetic. The issue of difficult airway and difficult mask ventilation in pediatrics has been the focus of research by the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Registry (PeDIR). This multi-national collaborative has published extensively on these issues and today’s PAAD adds to their findings. Indeed, today’s PAAD by Garcia-Marcinkiewicz(1) is a MUST-read by all of you and should, in my opinion, be the focus of your journal clubs, M&M conferences, and a future SPA lecture. Myron Yaster MD
Original article
Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW; PeDI Collaborative. Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth. 2023 Apr 17:S0007-0912(23)00122-8. doi: 10.1016/j.bja.2023.02.035. PMID: 37076335
Factors associated with difficult mask ventilation have been studied extensively in adults, but often the identified adult risk factors are not applicable to children.(2) In today’s PAAD, Garcia-Marcinkiewicz et al.(1) used the Pediatric Difficult Intubation Registry (PeDIR) to determine the incidence, risk factors, outcomes, and interventions performed when a difficult or impossible ventilation was encountered in a child who was also difficult to intubate (keeping in mind that the “difficult to intubate” designation is why a patient was included in the registry in the first place). A key secondary aim of the study was to determine “whether initial difficulty with mask ventilation was worsened or improved after administration of neuromuscular blocking agents and the frequency of use and efficacy of supraglottic airway devices as a ‘rescue’ ventilation technique”.(1)
OK, what did they find? Most of their findings are well known and expected. “Age less than 1 year, <5th percentile weight, increased weight, glossoptosis, and limited mouth opening were some of the physical factors associated with difficult or impossible mask ventilation in patients with difficult tracheal intubation. This adds to previous work demonstrating that children weighing <10 kg experience more airway-related complications. Pierre Robin sequence, Goldenhar syndrome, and Treacher Collins were syndromes where difficult or impossible mask ventilation was reported most frequently. After adjustment for multiple factors, Treacher Collins syndrome was independently associated with difficult mask ventilation”.(1) Failure to intubate and ventilate (really failure to oxygenate) had devastating consequences like hypoxemia (27.3%), airway trauma (2.7%) and cardiac arrest (5.7%).
Some of their findings were surprising. “Administration of opioids and inhalational induction were inversely associated with difficult mask ventilation in this population”. In simpler English, the authors found that mask induction rather than IV induction and/or the use of opioids before or during induction was associated with easier mask ventilation and was associated with a reduced the incidence of a “cannot ventilate” scenario. The use of any opioid should, however, be cautious in the case of a difficult airway. Fentanyl and its congeners like sufentanil when administered in high doses rapidly can lead to vocal cord closure and/or chest wall rigidity making ventilation all but impossible.(3)
Perhaps the most important findings of this paper: in patients with difficult or impossible mask ventilation the administration of a neuromuscular blocking agent either improved or did not affect the ease of mask ventilation the majority of the time (84-90%). This has long been an area of great controversy. The “check mask ventilation before paralyzing” principle is one of the dogmas we were all taught during our training. Indeed, the Pedi Crisis app suggests reversal of neuromuscular blockade in the presence of a difficult airway. This series, as well as a famous editorial of Markus Weiss and Tom Engelhardt “Cannot ventilate-paralyze!”— shows that paralyzing a child can indeed help in case of difficult mask ventilation provided the difficulty [in ventilation] is at least partially functional.(4) A major issue is to determine, in an emergency situation, whether there is a functional part of the obstruction, meaning: is the obstruction partially or entirely due to laryngospasm, bronchospasm, opioid-induced glottis closure or a stomach distended with insufflated gases. In each of these situations, there is a specific treatment to treat that functional obstruction that should be initiated. Moreover, there are possibly cases when paralysis compensates for a too light anesthetic.(5)
Finally, the authors found that supraglottic airways were used in fewer than half of these challenging scenarios but had a reasonable success rate when they were used in patients with difficult mask ventilation”.(1) Why supraglottic devices were seemingly under-utilized is mystifying to us. After all, it is part of the ASA difficult airway guidelines(6) , the PediCrisis app, and really should be our next best step in this crisis situation.
As we have many times in the PAAD, we commend the PeDIR and PeDI Collaborative on their continued productivity and success. Can’t wait to see what is next!
What are your thoughts? Send your responses to Myron who will post in the Friday Reader Response.
References
1. Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW. Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth 2023.
2. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009;110:891-7.
3. Bennett Joel A, Abrams Jonathan T, Van Riper Daniel F, Horrow Jan C. Difficult or Impossible Ventilation after Sufentanil-induced Anesthesia Is Caused Primarily by Vocal Cord Closure Anesthesiology 1997;87:1070-4.
4. Weiss M, Engelhardt T. Cannot ventilate--paralyze! Paediatr Anaesth 2012;22:1147-9.
5. Engelhardt T, Weiss M. A child with a difficult airway: what do I do next? Current opinion in anaesthesiology 2012;25:326-32.
6. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81.