Checking mask ventilation

[nimbus]

The only reason to check mask ventilation is to give an opportunity for the trainee/practitioner to practice mask ventilation. It does nothing for the patient and potentially increases time to intubation. I give NMB together with the induction agent and almost never mask ventilate.

Another Nail in the Coffin of the Practice of Checking Mask ... : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

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[kidthor]

Same here... I give NMB on induction prior to mask ventilation.

Weird/creepy of the journal author to put the phrase "another nail in the coffin" when discussing something related to patient care, though.

 

[facted]

I paralyze right away but always ventilate. I'd like to see how easy/hard it is as it may change my outlook on extubating deep.

 

[coffeebythelake]

Same here... I give NMB on induction prior to mask ventilation.

Weird/creepy of the journal author to put the phrase "another nail in the coffin" when discussing something related to patient care, though.

German humor?

 

[nimbus]

German humor?

I also noticed the letter was replying to a study that was conducted in Korea. Those results may not be generalizable to Wisconsin.

 

[IMGASMD]

I also noticed the letter was replying to a study that was conducted in Korea. Those results may not be generalizable to Wisconsin.

“super obese” patient BMI, 32
I kid I kid. Didn’t read the primary article.

 

[coffeebythelake]

I also noticed the letter was replying to a study that was conducted in Korea. Those results may not be generalizable to Wisconsin.

I agree patient population matters.
Now I'm not sure how the average pt looks in Korea or Germany, but in America we do supersize. And we probably end up inducing general anesthesia in thse patients when the anesthesiologists in these other countries would opt for awake fiberoptic.

I believe they specifically mentioned some exclusion criteria.

 

[T-burglar]

Almost anyone regardless of BMI can be mask ventilated unless there are a handful of specific airway pathologies present

 

[Mman]

as was taught to me in residency...

If you induce them and can't ventilate, you are going to give the succinylcholine anyway. Just give it right away and it will wear off even quicker if you need it to.

Now with Roc and Suggamadex? What's the harm in pushing them both back to back? You will be able to reverse the Roc before the propofol is gone. And if I'm really worried I either do awake FOI (probably about 1/5000 cases or so) or induce them still spontaneously breathing and take a peek with glidescope.

 

[coffeebythelake]

Well I think the ultimate question is when an anesthesiologist draws the line between induction vs awake approach. We are taught you shouldnt induce a patient if you think they might be difficult to intubate. But sometimes we push the boundaries of this. Is there a difference?

 

[Mman]

Well I think the ultimate question is when an anesthesiologist draws the line between induction vs awake approach. We are taught you shouldnt induce a patient if you think they might be difficult to intubate. But sometimes we push the boundaries of this. Is there a difference?

You shouldn't induce apnea in a patient if you think they will be impossible to both intubate and ventilate. If you are confident that you can do either, go for it.

 

[coffeebythelake]

You shouldn't induce apnea in a patient if you think they will be impossible to both intubate and ventilate. If you are confident that you can do either, go for it.

I am speaking in reference to the generalizability of data from Korea.

 

[deleted697127]

The only reason to check mask ventilation is to give an opportunity for the trainee/practitioner to practice mask ventilation. It does nothing for the patient and potentially increases time to intubation. I give NMB together with the induction agent and almost never mask ventilate.

Another Nail in the Coffin of the Practice of Checking Mask ... : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

Just curious, is your strategy for improving throughput or because you think it’s better in general. I feel like we all develop our own way of doing things in residency and eventually people stop giving you tips on the basics if what you’re doing works... but i assume most people in my program mask for a minute for the roc to kick in. Does your group keep track of time until induction is complete? kinda hard to get excited about saving 2 minutes on induction when the surgery resident takes half an hour to remember how to suture as soon as their attending walks out of the room.

 

[nimbus]

Just curious, is your strategy for improving throughput or because you think it’s better in general. I feel like we all develop our own way of doing things in residency and eventually people stop giving you tips on the basics if what you’re doing works... but i assume most people in my program mask for a minute for the roc to kick in. Does your group keep track of time until induction is complete? kinda hard to get excited about saving 2 minutes on induction when the surgery resident takes half an hour to remember how to suture as soon as their attending walks out of the room.

I do it for my own ease and convenience. If I have the xylo/roc/propofol combined in the same syringe, I can hold the mask with one hand and push all the drugs together without swapping syringes. By the time they stop breathing, they’re ready to intubate.

 

[PieOHmy]

Almost anyone regardless of BMI can be mask ventilated unless there are a handful of specific airway pathologies present

Do you know who is NOT included in the almost anyone category?

 

[deleted875186]

I do it for my own ease and convenience. If I have the xylo/roc/propofol combined in the same syringe, I can hold the mask with one hand and push all the drugs together without swapping syringes. By the time they stop breathing, they’re ready to intubate.

The roc hurts going in the IV. Also, are you worried people will feel weak from the roc before asleep?

 

[Echo33]

I was originally taught to check before giving muscle muscle relaxant and quickly learned how pointless and potentially harmful it is. Should the case and cardiovascular system allow it, my inductions are RSI without cricoid, no breaths whatsoever.

 

[OB1🤙]

I honestly can't remember the last time I mask ventilated someone.

For real.

 

[ScarfTheVerb]

I still mask on occasion, but my standard induction is: lido, 1/2 the prop, 50 of roc, the other half of the prop, wait about 10 seconds and then put the tube in. Only rarely does anyone move with laryngoscopy and certainly no one has complained of being weak. I have a drawer full of suggamadex readily available.

 

[coffeebythelake]

I still mask on occasion, but my standard induction is: lido, 1/2 the prop, 50 of roc, the other half of the prop, wait about 10 seconds and then put the tube in. Only rarely does anyone move with laryngoscopy and certainly no one has complained of being weak. I have a drawer full of suggamadex readily available.

You must have some damn good roc

 

[DM27]

I rarely mask ventilate between induction and administration of paralysis/intubating. My stance is it prolongs time to intubation and adds the risk of insufflating the stomach. The only scenarios where I typically will attempt to mask ventilate is when I am either a) Considering a deep extubation or b) I am teaching a trainee how to mask ventilate.

The point about "you're going to give sux anyways" is a valid one. If you induce someone, and find yourself unable to ventilate, but haven't tried to intubate, you have entered a unique no man's land scenario of "can't ventilate, haven't tried to intubate" so what's next? Anything but trying to intubate is basically wasting time.

 

[coffeebythelake]

I rarely mask ventilate between induction and administration of paralysis/intubating. My stance is it prolongs time to intubation and adds the risk of insufflating the stomach. The only scenarios where I typically will attempt to mask ventilate is when I am either a) Considering a deep extubation or b) I am teaching a trainee how to mask ventilate.

The point about "you're going to give sux anyways" is a valid one. If you induce someone, and find yourself unable to ventilate, but haven't tried to intubate, you have entered a unique no man's land scenario of "can't ventilate, haven't tried to intubate" so what's next? Anything but trying to intubate is basically wasting time.

Well I think mask ventilation provides some information. If unable to ventilate you might opt to give suxx or a bigger dose of rocuronium than the standard. Your goal is to optimize intubating conditions and adequate muscle relaxant is a large part of that.

 

[nimbus]

I still mask on occasion, but my standard induction is: lido, 1/2 the prop, 50 of roc, the other half of the prop, wait about 10 seconds and then put the tube in. Only rarely does anyone move with laryngoscopy and certainly no one has complained of being weak. I have a drawer full of suggamadex readily available.

You must have some damn good roc

I just give everything together and my roc is good too.

 

[deleted162650]

I just give everything together and my roc is good too.

You do this on cardiac cases too? I would think you would want the ability to titrate your induction meds a little more than the master blaster technique allows?

 

[dannyboy1]

Excluding airway or mediastinal mass has anyone had a situation where you can’t ventilate? I find that no matter how obese the patient is 2 hand mask + oral airway always works.....

 

[ScarfTheVerb]

Just the occasional ZZ Top beard

 

[nimbus]

You do this on cardiac cases too? I would think you would want the ability to titrate your induction meds a little more than the master blaster technique allows?

Yes but those patients are usually pretty snowed from versed/fentanyl prior to actual induction so the propofol dose is greatly reduced....typically 50-100mg.

 

[jwk]

Just a different train of thought - intubation skills are already decreasing due to the widespread use of video laryngoscopy. Mask-only anesthetics are essentially a lost art, and I think mask skills will deteriorate as well.

 

[deleted171991]

You must have some damn good roc

Fresh from the fridge, not just lying around in the drawer?

 

[deleted171991]

Excluding airway or mediastinal mass has anyone had a situation where you can’t ventilate? I find that no matter how obese the patient is 2 hand mask + oral airway always works.....

No matter how obese?

 

[dannyboy1]

No matter how obese?

I have big hands ......

 

[IMGASMD]

I have big hands ......

You know people say about people who have big hands.......

They need big gloves......
Ba dum tssss

 

[T-burglar]

You do this on cardiac cases too? I would think you would want the ability to titrate your induction meds a little more than the master blaster technique allows?

Only academics "titrate induction" for typical cardiac cases.

In private practice you realize that similar to testing ventilation before paralyzing, slowly inducing is pointless.

Even in cardiac, It's prop roc tube, or start NE infusion then prop roc tube.

There are exceptions of course like trying not to blowout an acute aortic syndrome, but for typical cases its pointless.

 

[MoMoGesiologist]

Only academics "titrate induction" for typical cardiac cases.

In private practice you realize that similar to testing ventilation before paralyzing, slowly inducing is pointless.

Even in cardiac, It's prop roc tube, or start NE infusion then prop roc tube.

There are exceptions of course like trying not to blowout an acute aortic syndrome, but for typical cases its pointless.

Really? My residency always did cardiac cases with a slow midaz and fent induction. You just give prop like a general case?

 

[Dantrolene FC]

Just a different train of thought - intubation skills are already decreasing due to the widespread use of video laryngoscopy. Mask-only anesthetics are essentially a lost art, and I think mask skills will deteriorate as well.

I totally agree with this premise. As a medical student who can intubate with ease, it ticks me off when the attendings make me start with video laryngoscopy because the patient “looks” difficult because they’re BMI is 35. How will I attain intubation skills if I only practice on easy patients? And the freaking resident is behind me and can take over if I fail.

I don’t understand why almost all the CRNA’s where I’m at exclusively use the Miller blade. I was preparing to intubate a patient who required 3 attempts to intubate the week before with a Miller blade. The SRNA failed with one attempt, and it took the attending two attempts to successfully intubate.

I saw this in the note, so I prepared to intubate with a Mac. The CRNA tried to make me use a Miller “because it’s been shown to be most successful with difficult intubations”. I politely declined and he said “Ok, I’ll have the Miller on standby to take over”. I intubated with the Mac in 1 attempt in 10 seconds with a grade 1 view.

I’m not sure why I told this story, but I guess it goes to show that not only are people relying on video laryngoscopy a lot, but they also work with only 1 blade.

 

[deleted171991]

Really? My residency always did cardiac cases with a slow midaz and fent induction. You just give prop like a general case?

Why not? Just think about it.

 

[nimbus]

I’m not sure why I told this story, but I guess it goes to show that not only are people relying on video laryngoscopy a lot, but they also work with only 1 blade.

That’s me. Mac4 and glidescope are what work for me. Don’t plan to change unless something better comes along.

 

[deleted171991]

I totally agree with this premise. As a medical student who can intubate with ease, it ticks me off when the attendings make me start with video laryngoscopy because the patient “looks” difficult because they’re BMI is 35. How will I attain intubation skills if I only practice on easy patients? And the freaking resident is behind me and can take over if I fail.

I don’t understand why almost all the CRNA’s where I’m at exclusively use the Miller blade. I was preparing to intubate a patient who required 3 attempts to intubate the week before with a Miller blade. The SRNA failed with one attempt, and it took the attending two attempts to successfully intubate.

I saw this in the note, so I prepared to intubate with a Mac. The CRNA tried to make me use a Miller “because it’s been shown to be most successful with difficult intubations”. I politely declined and he said “Ok, I’ll have the Miller on standby to take over”. I intubated with the Mac in 1 attempt in 10 seconds with a grade 1 view.

I’m not sure why I told this story, but I guess it goes to show that not only are people relying on video laryngoscopy a lot, but they also work with only 1 blade.

You're way too cocky for a student, dude. A videolaryngoscope is a much better device to teach intubation (especially if it has a Mac blade). And there are many other reasons why it's a bad idea to let a student play with a DL in a difficult airway.

Also, 10-15 years from now, videolaryngoscopes will be as widespread and standard of care as ultrasound machines. Already, we don't place central lines or nerve blocks without an ultrasound. Just 10 years ago, I used to do central lines without. Most good hospitals have videolaryngoscopes in the ED, ICU, OR, and at codes.

We're slowly but steadily moving towards a "monkey see monkey do" world, where any minimally-trained person can do procedures, not just highly-trained doctors. In order to get there, hospitals are investing in equipment that dumbs procedures down, such as videolaryngoscopes. That's the world you will practice in, not the DL world. Learn to use the modern tools (it's not the same technique).

 

[Mman]

my only qualm with videolaryngoscopes being standard of care is that I think you still need to know how to do it the old fashioned way. I've had too many instances of a camera going bad or the power failing or whatever for it to be the one and only way of doing things unless you have 2 videolaryngscopes ready in each room for each case which gets kinda expensive.

 

[dannyboy1]

I totally agree with this premise. As a medical student who can intubate with ease, it ticks me off when the attendings make me start with video laryngoscopy because the patient “looks” difficult because they’re BMI is 35. How will I attain intubation skills if I only practice on easy patients? And the freaking resident is behind me and can take over if I fail.

I don’t understand why almost all the CRNA’s where I’m at exclusively use the Miller blade. I was preparing to intubate a patient who required 3 attempts to intubate the week before with a Miller blade. The SRNA failed with one attempt, and it took the attending two attempts to successfully intubate.

I saw this in the note, so I prepared to intubate with a Mac. The CRNA tried to make me use a Miller “because it’s been shown to be most successful with difficult intubations”. I politely declined and he said “Ok, I’ll have the Miller on standby to take over”. I intubated with the Mac in 1 attempt in 10 seconds with a grade 1 view.

I’m not sure why I told this story, but I guess it goes to show that not only are people relying on video laryngoscopy a lot, but they also work with only 1 blade.

Umm no. Videolaryngoscopy is fantastic. I do a lot of bariatrics and I’ve lost count of the number of damn near impossible DL’s that are a chip shot with the glidescope. Also teeth are a lot less likely to be damaged with a VL than with someone really cranking a difficult VL. Maybe your attendings are also concerned about aspiration ( can happen even if the patient is NPO) and don’t want 3 attempts with intermittent mask ventilation by the medical student before the airway is finally secured, when the patient could have been easily intubated with the glide scope on the first attempt. Honestly, nobody cares how the patient is intubated. Just do it quickly and atraumaticly

 

[2Fast2Des]

I totally agree with this premise. As a medical student who can intubate with ease, it ticks me off when the attendings make me start with video laryngoscopy because the patient “looks” difficult because they’re BMI is 35. How will I attain intubation skills if I only practice on easy patients? And the freaking resident is behind me and can take over if I fail.

I don’t understand why almost all the CRNA’s where I’m at exclusively use the Miller blade. I was preparing to intubate a patient who required 3 attempts to intubate the week before with a Miller blade. The SRNA failed with one attempt, and it took the attending two attempts to successfully intubate.

I saw this in the note, so I prepared to intubate with a Mac. The CRNA tried to make me use a Miller “because it’s been shown to be most successful with difficult intubations”. I politely declined and he said “Ok, I’ll have the Miller on standby to take over”. I intubated with the Mac in 1 attempt in 10 seconds with a grade 1 view.

I’m not sure why I told this story, but I guess it goes to show that not only are people relying on video laryngoscopy a lot, but they also work with only 1 blade.

No offense, but if you think you're a hotshot just because you think you can already intubate a rock, you have much to learn. Maybe your attending doesn't want you to muck up the airway if it's a possibility in a potentially difficult patient. You learn how to perfect your technique on the easy people so when you're in over your head on a difficult airway you have the fundamentals. And even an easy looking airway can easily be a grade 3 or 4 when the blade goes in, gotta learn how to troubleshoot that before grabbing the VL as well

BTW 10 seconds is a long while to secure a chipshot view