Using gel for difficult mask ventilation on the bearded patients: a simulation-based study

Use of Transparent Film Dressing to Facilitate Mask Ventilation in Bearded Patients

BACKGROUND

Mask ventilation is a critical airway procedure made more difficult in the bearded patient.

OBJECTIVE

We sought to objectively investigate whether application of transparent cling film (TegadermTM; 3M Healthcare, Maplewood, MN) over a beard in the operating room improves the quality of mask ventilation.

METHODS

This was a randomized crossover trial of bearded adult patients undergoing surgery. Exclusions included emergency procedures, American Society of Anesthesiologists physical status classification > 3, a documented history of difficult mask ventilation, and body mass index (BMI) > 50. Transparent cling film was applied snuggly over the lower face with a 2- to 3-cm slit cut over the mouth after anesthesia induction. Mask ventilation performed by an anesthesiology resident, anesthesiology assistant, or anesthesiology assistant student and standardized to a thenar-eminence grip without use of airway adjuncts in a sniffing position. Standardized pressure-controlled ventilations were delivered via an anesthesia machine. A calibrated external pneumotachograph was used to measure delivered and returned tidal volumes from which raw and percent air leak were calculated. A clinically significant difference was determined a priori to be 15%, necessitating the enrollment of 25 patients.

RESULTS

Of 25 subjects, 96% were men with a mean ± SD BMI of 29.3 ± 6. Seventeen (68%) had a full beard and 8 (32%) had a partial beard. The mean ± SD leakage was 48% ± 26% for transparent cling film vs. 46% ± 20% without its application, which was not significantly different (p = 0.67).

CONCLUSIONS

The use of transparent cling film to cover the lower half of the bearded face did not have an impact on the ability or efficacy to perform mask ventilation in the operating room setting.

CLINICALTRIALS

gov, Number NCT04274686.

Pre-intubation ventilation device for bearded patients: prospective, randomized, crossover trial in anesthetized patients

Having a beard is an independent predictor of difficult ventilation by face mask. This study evaluates the efficacy of a novel intra-oral Bag-Valve-Guedel Adaptor (BVGA) in anaesthetized bearded patients. Patients with ASA score 1-2, scheduled for elective surgery, were recruited for this prospective, crossover trial. Beard length was categorized as < 0.5 cm, 0.5-1 cm, 1-5 cm, or > 5 cm. Patients were ventilated by attending anesthesiologists using the BVGA and a facemask (both with a Guedel oral airway). End-tidal CO₂ (EtCO₂) and expiratory tidal volume (TV) were recorded as was the number of hands required for the procedure. The primary outcome was the difference between BVGA and Facemask. Sixty-one patients were enrolled. Of these, 38 had beards, and 23 were without beards or with beards < 0.5 cm length. In bearded patients, ventilation with the BVGA was superior to the face mask by EtCO₂ and non-inferior by TV (BVGA-vs-Mask, mean [95% CI]: EtCO₂ [mmHg], 33.0 [31.6, 34.3]-vs-27.2 [25.5, 28.8], p < 0.001; TV [ml∙kg^-1 IBW], 8.1 [7.4, 8.9]-vs-6.9 [6.0, 7.7], p = 0.11). The BVGA was found to be superior to the face mask by EtCO₂ across all beard lengths (p ≤ 0.001), but by TV only for the longest beard group (p = 0.009). After securing the BVGA, ventilation was possible without hands in 74% of the cases - clearly impossible with the facemask (p ≤ 0.001). The BVGA is more effective and more convenient than the facemask in anaesthetized bearded patients. A follow-up study is underway to test whether replacing the face mask with the BVGA will improve effectiveness and ease of pre-intubation field ventilation by less-experienced, first responders.

Prehospital Manual Ventilation: An NAEMSP Position Statement and Resource Document

Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. Several strategies and adjunct technologies can increase the effectiveness of manual ventilation. NAEMSP recommends:All EMS clinicians must be proficient in bag-valve-mask ventilation.BVM ventilation should be performed using a two-person technique whenever feasible.EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.