tips on masking and ventilating?

[IFNgamma]

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hi, I'm a new CA-1. Having some trouble masking and venting.

I do what I'm told, jaw thrust and have my pinky on the angle of mandible, form a "C" with index finger and thumb on the mask. Somehow I'm still not able to get a good seal, as evidenced by the wonderful smell of sevo leaking out.
And cuz I can't mask well I'm pressing down real hard w/ the mask on the patient's face, which still has leak somewhere. My left hand is like hella tired which doesn't help when I gotta do DL next.

any tips?

 

[Trisomy13]

any tips?

never say "hella" in public. ever.

 

[CalCoug]

Where I grew up, a select group of people would say "hecka" instead of hella because they weren't allowed to swear...

 

[UTSouthwestern]

For one handed masking, use your fifth and fourth digits on the mandible, second and third digits on the bottom of the mask, thumb on the top of the mask and turn the patient's head to the right while lifting the mandible and pressing down on the mask.

Alternatively, you can set your vent to a preset tidal volume or pressure, and a rate of ten, use at least 8 LPM of flow, turn on the vent and use both hands to secure the mask onto the patient's face.

Done correctly, masking a patient should utilize very little effort/strength.

 

[Arch Guillotti]

hi, I'm a new CA-1. Having some trouble masking and venting.

I do what I'm told, jaw thrust and have my pinky on the angle of mandible, form a "C" with index finger and thumb on the mask. Somehow I'm still not able to get a good seal, as evidenced by the wonderful smell of sevo leaking out.
And cuz I can't mask well I'm pressing down real hard w/ the mask on the patient's face, which still has leak somewhere. My left hand is like hella tired which doesn't help when I gotta do DL next.

any tips?

Masking looks easy to the casual observer but the reality is that it takes time and practice to become good at it. It is the one skill that you absolutely need to master in residency. I never really liked the whole idea of the "C" thing. I just grip the jaw and mask in the most comfortable way for me, making sure to stay off of the soft tissues. Good head position is helpful, as is an oral airway. I lift up the jaw MUCH more than I press down on the mask, for me this creates the tightest seal. I can't tell you how mnay times in residency I responded to a code or whatever on the floor only to find the RT with the mask smushed down on the pts. face w/horrible ineffective ventilation. THRUST the jaw up and hold the mask in place. You will get better, just takes practice. Ask to be in the ECT room😴 you will get all the masking practice you could ever want.

 

[rsgillmd]

If I get a leak, I apply the lower right headstrap. Usually that is where the leak is from.

This is all practice.

 

[loveumms]

Just like Arch said - it's all about pressing the pt to the mask, not vice versa. I have small hands which can make it a little harder and actually have to use the vent alot allowing my two hands to be free (especially on the bull neck 200kg patients). Never forget about your oral airway - it can make it 100% easier. And never be afraid to ask for help. I often will ask the nurse, or my attending to help hold up the right side of the pts face if I have a leak that I just can't get rid of.

Like everyone else has said, it's practice, practice and then more. Medical students are always really excited to intubate the pt and when they hear the attending say "you really need to know how to mask, that will save a life" they often don't understand that it's really the truth and is often much harder to accomplish correctly.

 

[jennyboo]

You will get better at masking, and learn your own tricks, over time. Masking is more difficult than intubating. Many people have different sets of tricks, some of which will work for you and some of which won't. For now, just let your attendings try to give you both helpful and useless advice. All this needs is tincture of time.

I have small hands (the XSMALL nitrile gloves are still wrinkly on me). Here are some small-hands tricks I've learned over time.


JENNYBOO'S TRICKS FOR MASKING WITH SMALL HANDS

- Use a small mask even for large patients. Yeah, I know that the medium mask is the "standard" one, but if you have small hands consider making the small mask your standard one. Only use a medium/large mask if they have a gigantic nose that doesn't fit into the small mask. The small mask has a smaller profile and is easier to get your hand around.

- When an airway is needed, a nasal airway lets you move air without increasing the jaw profile like an oral airway does, allowing small hands to hold the mask-jaw apparatus better. Check your cart every day to make sure you have a nasal airway.

- Use an LMA as your mask if, for example, you RSI a 400lb patient with huge neck folds and then can't get the tube in on the first attempt and need to mask. If you know you're going to have a hard time masking, why bother to even try struggling with nasal airway plus oral airway plus two-handed mask that barely moves any air? Just shove in the LMA.

As a small-handed person, I never heard these things from large-handed people, and some of them will really make your large-handed attendings look at you funny (like using a small mask on a beefy 300lb construction worker). So you won't hear these tips much from people who have larger hands and don't struggle as much to mask. But although they look weird to large-handed people, they often work.

 

[fakin' the funk]

I just grip the jaw and mask in the most comfortable way for me, making sure to stay off of the soft tissues. Good head position is helpful, as is an oral airway. I lift up the jaw MUCH more than I press down on the mask, for me this creates the tightest seal. I can't tell you how mnay times in residency I responded to a code or whatever on the floor only to find the RT with the mask smushed down on the pts. face w/horrible ineffective ventilation. THRUST the jaw up and hold the mask in place.

I will offer two newbie points of advice
1. Everyone always says "Pull the face to the mask, don't smash the mask on the face." I like that part, but they forget to tell you that it takes a fair amount of pressure to get a good seal a lot of the time, and you might have to smash the mask into the mandible, which is OK as long as the mandible is thrust anteriorly and not occluding the airway.
2. In some pts you might have to put your index and middle fingers on the most anteroinferior aspect of the mandible instead of the lateral, inferior part you normally use. I've heard this called "the claw."

 

[cchoukal]

some great suggestions here. I'm in the "pull the face up into the mask" camp. Unlike Jennyboo, I sometimes use a larger mask. It has a bigger "cuff" which might help your seal, and you can seal it around the underside of the chin so it ends up not having a much bigger profile than the medium mask. This under-the-chin approach can be nice for patients without teeth, as well... Other than that, practice, practice, practice... Does your hospital do ECTs? A day of ECTs (GA via mask, lots of short cases) can really advance your technique...

 

[leviathan]

Face into the mask = best tip. I can't believe someone said an RT was smashing the mask into the face...where the heck did they go to school?!

 

[IctalSmile]

I just finished my anesthesia rotation, and I gotta say, even with my gorilla hands, I found mask ventilation more difficult than intubation, etc.

Thanks for the tips!

 

[jwk]

One thing I haven't seen mentioned is that if the airway is fully obstructed, you may have a leak because of the high pressures you're generating against an obstructed airway.

Mask airways, once you learn the technique, should be pretty darn easy.

 

[dfk]

what can also work is if/when you have a big bull-ish type face with facial hair (you can even do this with just facial hair peeps) is put a large tegaderm over the mouth/lips/cheeks/chin and cut a hole in the mouth part to ventilate. makes for a much easier seal. helps tape stay if needed as well.

 

[Bougie]

Have a low threshold for putting in an oral airway.

 

[jwk]

what can also work is if/when you have a big bull-ish type face with facial hair (you can even do this with just facial hair peeps) is put a large tegaderm over the mouth/lips/cheeks/chin and cut a hole in the mouth part to ventilate. makes for a much easier seal. helps tape stay if needed as well.

OWWWWW - I would wake up and slap you if you did that to me! 😉

Have a low threshold for putting in an oral airway.

You'll find you need oral/nasal airways far less frequently once you've mastered the mask. Our population has a relatively high incidence of expensive dental work. so we'd prefer not to have biting on hard plastic if at all possible.

 

[Trisomy13]

what can also work is if/when you have a big bull-ish type face with facial hair (you can even do this with just facial hair peeps) is put a large tegaderm over the mouth/lips/cheeks/chin and cut a hole in the mouth part to ventilate. makes for a much easier seal. helps tape stay if needed as well.

we have a lot of patients with big hillbilly beards and this technique works nicely. it looks unpleasant coming off later, but that's the price the patient pays for being a ZZ Top wannabe and drunk-driving his ATV into a tree.

 

[jwk]

we have a lot of patients with big hillbilly beards and this technique works nicely. it looks unpleasant coming off later, but that's the price the patient pays for being a ZZ Top wannabe and drunk-driving his ATV into a tree.

At my first gig in the 80's, one of our docs made them shave the beard pre-op - no shave, no general anesthetic.

 

[Gimlet]

At my first gig in the 80's, one of our docs made them shave the beard pre-op - no shave, no general anesthetic.

Nice!

We have an attending here that was making all the CA-1s he worked with last month do their Ortho I&D cases by masking. I think it was good experience, kinda like doing a day of ECTs as mentioned above.

I had another attending last month who showed me a cool old-school way to hold the mask on a patient I was having trouble masking. It's hard to explain, but she basically had me use the whole ulnar aspect of my palm to smoosh the patient's left cheek into the mask (with pinky still under the angle of the jaw). It worked really well. I think it was the way they used to hold the masks before the the nice supple rubbery plastic ones came into vogue.

 

[dfk]

we have a lot of patients with big hillbilly beards and this technique works nicely. it looks unpleasant coming off later, but that's the price the patient pays for being a ZZ Top wannabe and drunk-driving his ATV into a tree.

oh so true 😎😎😎

 

[epidural man]

what can also work is if/when you have a big bull-ish type face with facial hair (you can even do this with just facial hair peeps) is put a large tegaderm over the mouth/lips/cheeks/chin and cut a hole in the mouth part to ventilate. makes for a much easier seal. helps tape stay if needed as well.

A guy down at UCSD taught me this once. It worked great! I can't remember his name though - really a pretty cool guy. I wonder what he was doing in an academic setting? He was the hardest working guy at that place i thought.

Anyway, it just occured to me that a plastic bag over the guys head and face with a hole punched out over the mouth would work just as well and you wouldn't have to worry about the tape coming off (as someone mentioned this as a downside) - plus, it will help keep the patient warm. I have seen several people place a plastic bag over someone's head under general anesthesia to help keep them warm. It seems to work well.

 

[epidural man]

A guy down at UCSD taught me this once. It worked great! I can't remember his name though - really a pretty cool guy. I wonder what he was doing in an academic setting? He was the hardest working guy at that place i thought.

Anyway, it just occured to me that a plastic bag over the guys head and face with a hole punched out over the mouth would work just as well and you wouldn't have to worry about the tape coming off (as someone mentioned this as a downside) - plus, it will help keep the patient warm. I have seen several people place a plastic bag over someone's head under general anesthesia to help keep them warm. It seems to work well.

I just remembered his name - I think it was Rick Bellars.

 

[pgg]

I have seen several people place a plastic bag over someone's head under general anesthesia to help keep them warm. It seems to work well.

I'm a big fan of the "mob hit" look.

 

[dhb]

there was a good article in last month's anesthesiology on how nasal mask ventilation is superior to nasal + oral ventilation

 

[jennyboo]

there was a good article in last month's anesthesiology on how nasal mask ventilation is superior to nasal + oral ventilation

heheh -- that was published by the guy who told me that a nasal airway is good for small hands because it doesn't increase the jaw profile as much as an oral airway, and to always look for it every morning. 🙄

Quote:

Originally Posted by epidural man View Post
I have seen several people place a plastic bag over someone's head under general anesthesia to help keep them warm. It seems to work well.

I'm a big fan of the "mob hit" look.

It does look scary, but you wouldn't believe how happy I was to "discover" this trick in a big-burn (> 40% TBSA) excision and grafting case when they turned up the room temp to 110F to try to keep the patient's temp from diving. There's a place for putting plastic bags on people's heads.