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Clinical Investigations

Prediction of Difficult Mask Ventilation

Langeron, Olivier M.D.*; Masso, Eva M.D.†; Huraux, Catherine M.D.‡; Guggiari, Michel M.D.‡; Bianchi, André M.D.‡; Coriat, Pierre M.D.§; Riou, Bruno M.D., Ph.D.∥

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Background: Maintenance of airway patency and oxygenation are the main objectives of face-mask ventilation. Because the incidence of difficult mask ventilation (DMV) and the factors associated with it are not well known, we undertook this prospective study.
Methods: Difficult mask ventilation was defined as the inability of an unassisted anesthesiologist to maintain the measured oxygen saturation as measured by pulse oximetry > 92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia. A univariate analysis was performed to identify potential factors predicting DMV, followed by a multivariate analysis, and odds ratio and 95% confidence interval were calculated.
Results: A total of 1,502 patients were prospectively included. DMV was reported in 75 patients (5%; 95% confidence interval, 3.9–6.1%), with one case of impossible ventilation. DMV was anticipated by the anesthesiologist in only 13 patients (17% of the DMV cases). Body mass index, age, macroglossia, beard, lack of teeth, history of snoring, increased Mallampati grade, and lower thyromental distance were identified in the univariate analysis as potential DMV risk factors. Using a multivariate analysis, five criteria were recognized as independent factors for a DMV (age older than 55 yr, body mass index > 26 kg/m2, beard, lack of teeth, history of snoring), the presence of two indicating high likelihood of DMV (sensitivity, 0.72; specificity, 0.73).
Conclusion: In a general adult population, DMV was reported in 5% of the patients. A simple DMV risk score was established. Being able to more accurately predict DMV may improve the safety of airway management.
DIFFICULTIES or failure in managing the airway are the major factors underlying morbidity and mortality related to anesthesia. 1 To facilitate the management of the difficult airway and to reduce the incidence of severe adverse outcomes during airway management, practice guidelines have been established, 2–4 and several algorithms have been developed. One component of many such algorithms is the preoperative assessment and recognition of the difficult airway. 2–4 Prediction is mainly based on factors associated with difficult tracheal intubation, such as mouth opening, Mallampati classification, head and neck movement (atlantooccipital joint assessment), receding mandible, protruding maxillary incisors (buck teeth), thyromental distance, sternomental distance, obesity, and a history of difficult intubation. 2–5 However, the most dangerous situation is the case in which intubation is impossible and in which mask ventilation is or becomes inadequate. The prediction of difficult mask ventilation (DMV) is therefore of vital importance. Unfortunately, the factors predicting for DMV remain unknown and have not been defined in practice guidelines for management of the difficult airway. 3,4
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Patients and Methods

After approval by the Local Human Subjects Committee, all adult patients scheduled for orthopedic, urologic, abdominal, gynecologic and neurosurgery with general anesthesia in our hospital were prospectively included in the study over a 6-month period (October 1998–March 1999). Because no randomization was performed and only routine care was performed, waived informed consent was accepted by the Local Human Subjects Committee. Patients undergoing regional anesthesia and those with contraindication of mask ventilation (i.e., emergency cases requiring a rapid sequence induction, planned awake intubation) were excluded.
Information was collected by the anesthesiologists on a standard form during the preoperative visit and during induction of anesthesia (appendix). During the preoperative visit, the following information was collected: (1) factors related to malproportion of overall body size (weight, height, body mass index [BMI; calculated as weight in kilograms divided by the square of the height in meters]); (2) factors that might interfere directly with external mask fit and may make mask ventilation more difficult 2,5 (receding mandible estimated on a subjective assessment, lack of teeth, and presence of beard); (3) factors related to malproportion between the oropharyngeal free space and the internal structures of the oropharynx (macroglossia estimated on a subjective assessment and Mallampati classification as modified by Samsoon and Young, 6 performed with the patient in the sitting position with the head in full extension, tongue out, and with phonation 7; the thyromental distance [in millimeters] is measured with the patient in sitting position and head in extension, 7 and the mouth opening is measured as the interincisor distance [in millimeters]). Patients were asked if they were habitual (almost every night or every night) snorers or not. Lastly, a subjective assessment of anticipated DMV by the anesthesiologist was also requested. During the induction of anesthesia, information concerning ventilation (with 10 l/min oxygen flow) and intubation were recorded by the anesthesiologist. The anesthesiologist was asked to rate mask ventilation as difficult only when he or she considered that the difficulty was clinically relevant and could have lead to potential problems if mask ventilation had to be maintained for a longer time. The anesthesiologist was then asked to indicate the main reason(s) why mask ventilation was considered difficult: (1) inability for the unassisted anesthesiologist to maintain oxygen saturation as measured by pulse oximetry (SpO2) > 92% using 100% oxygen and positive-pressure mask ventilation; (2) important gas flow leak by the face mask; (3) necessity to increase the gas flow to greater than 15 l/min and to use the oxygen flush valve more than twice; (4) no perceptible chest movement; (5) necessity to perform a two-handed mask ventilation technique; (6) change of operator required. The anesthesiologist was asked to rate mask ventilation as impossible when it completely failed, and an alternative to face mask ventilation was required in emergency conditions. Difficult intubation was defined as a proper insertion of the endotracheal tube with conventional laryngoscopy requiring more than two attempts or more than 10 min. 4 Data collected concerning tracheal intubation were use of paralyzing agents, characterization of tracheal intubation (easy, difficult, or impossible), and grading of the best laryngoscopic view according to the Cormack and Lehane classification. 8 To minimize uncertainty and inaccuracy of numerical grading system, 9 schematic diagrams were provided for classification of the view of the oropharynx and of the glottis, according to Mallampati as modified by Samsoon and Young 6 and to Cormack and Lehane 8 classifications in the data chart (Appendix).
In our institution, the routine procedure for tracheal intubation was standardized. The patient’s head and neck were placed in an optimal position (the sniff position) 10 to improve laryngoscopy and intubation outcome. Preoxygenation of each patient during 4 min by bag and mask with 100% O2 was required. Each patient was routinely monitored during the whole procedure by electrocardiography, SpO2 and end-tidal carbon dioxide tension. After intubation, the correct positioning of the endotracheal tube was confirmed by the anesthesiologist using bilateral auscultation of lungs and detection and curve analysis of carbon dioxide in the exhaled gas. In this study, all mask ventilations and endotracheal intubations were performed by a staff anesthesiologist.
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Statistical Analysis
Data are mean ± SD. Main percentages were provided with their 95% confidence intervals (CIs). Univariate comparison between patients with or without DMV was performed using the unpaired Student t test or Fisher exact method when appropriate. In addition, receiver-operator-characteristic (ROC) curves were used to judge the discrimination ability of various clues to predict DMV. The area under the ROC curve represents the probability that a randomly chosen patient with DMV is correctly ranked for a given risk factor with greater suspicion than a randomly chosen patient without DMV (i.e., the area value of 0.5 means no apparent accuracy to predict DMV, and the area value of 1 indicates a perfect accuracy to predict DMV). 11 Moreover, for significantly different continuous variables in the univariate analysis, the ROC curve was analyzed to determine the best threshold that maximized the sum of sensitivity and specificity to obtain the best diagnostic accuracy. Then, all dichotomous variables were analyzed using a stepwise forward logistic regression. The odds ratios and their 95% CIs were calculated. Lastly, the DMV prediction score was established with the ROC curve analysis to determine the number of criteria that had to be retained to obtain the best score accuracy. All comparisons were two-sided, and a P value < 0.05 was considered significant. Statistical analysis was performed on a computer using NCSS 6.0 software (Statistical Solutions Ltd., Cork, Ireland).
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Table 1
Table 1
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Table 2
Table 2
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A total of 1,502 patients were included in this study. Six hundred thirteen patients (41%) were scheduled for abdominal surgery, 474 patients (31%) for orthopedic surgery, 214 (14%) for gynecologic surgery, 130 (9%) for neurosurgery, and 71 (5%) for urologic surgery. DMV was reported in 75 patients (5%; 95% CI, 3.9–6.1%), with only one case of impossible ventilation. DMV was characterized by six possible difficulties, and its occurrence is presented in table 1. Characteristics of patients with or without reported DMV are listed in table 2.
Anticipation of DMV by the anesthesiologist during the preoperative visit was not accurate because it was predicted in only 17% (95% CI, 9–26%) of the patients with DMV, and 56 patients (4%) were predicted to have DMV but did not (table 2). This entire subjective prediction had a sensitivity of 0.17 and a specificity of 0.96, with positive and negative predictive values of 0.19 and 0.96, respectively.
In the univariate analysis, several risk factors for DMV were identified. BMI, age, Mallampati class, thyromental distance, macroglossia, lack of teeth, beard, and snoring history were significantly different between the two groups, with or without DMV (table 2). In contrast, mouth opening, occurrence of receding mandible, and use of paralyzing agents were not significantly different between the two groups (table 2). The areas under the ROC curve were 0.71 ± 0.11 (P < 0.05) and 0.68 ± 0.10 (P < 0.05) for BMI and age, respectively. The thresholds that maximized the sum of sensitivity and specificity were 26 (kg/m2) for BMI and 55 (yr) for age.
Table 3
Table 3
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In the multivariate analysis, the following criteria were found to be significantly associated with DMV: age older than 55 yr, BMI > 26 kg/m2, lack of teeth, history of snoring, and presence of a beard (table 3). Moreover, no type of difficulties encountered during mask ventilation and listed in table 1 was significantly associated with a specific and independent risk factor identified in the multivariate analysis, despite a tendency without reaching statistical significance (P = 0.06) between SpO2 < 92% and history of snoring.
Table 4
Table 4
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Among patients who were intubated (n = 1,374), difficult intubation and Cormack and Lehane grades III and IV occurred significantly more frequently in patients with DMV (table 4). Difficult intubation and impossible intubation were, respectively, fourfold and 12-fold more frequent in patients with DMV (table 4). Moreover, the incidence of a difficult ventilation–difficult intubation and difficult ventilation–impossible intubation scenarios were 1.5% (95% CI, 0.9–2.1%) and 0.3% (95% CI, 0–0.6%), respectively (table 4).
Table 5
Table 5
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Fig. 1
Fig. 1
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The risk factors identified in the multivariate analysis and listed in table 3 were pooled together to determine the DMV prediction score (table 5). The number of retained criteria in the DMV prediction score associated with the best sensitivity and specificity was two (table 5 and fig. 1). We also tried to use a weighted score (using the odds ratio), but the accuracy was not significantly improved as compared with the nonweighted score (data not shown).
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In the current study, we made the following observations: (1) the reported incidence of DMV was 5%; (2) DMV was reported more frequently when intubation was difficult; (3) anesthesiologists did not accurately predict DMV during the preoperative visit; and (4) five criteria (age older than 55 yr, BMI > 26 kg/m2, lack of teeth, presence of a beard, history of snoring) were independent risk factors for DMV, and the presence of two of these risk factors indicated a high likelihood of DMV (sensitivity, 0.72; specificity, 0.73).
Incidence of DMV has been rarely assessed in studies related to the airway management, 12–15 and no previous specific studies regarding difficulty with mask ventilation alone have been performed. 2,4 This may partly explain the discrepancies between our study and previous studies. 12–15 Lower rates of DMV have been reported in prospective studies by Asai et al. (1.4%), 12 Rose and Cohen (0.9%), 13 and El-Ganzouri et al. (0.07%). 14 In contrast, in a retrospective study of 2,000 incident reports during anesthesia, DMV incidence reached 15% when a difficult intubation occurred. 15 No precise definition of DMV was effectively provided in most of these studies, 12,13,15 and SpO2 was not recorded in the study by El-Ganzouri et al.14 We may assume that these discrepancies were related to the lack of a standardized definition for DMV.
Difficult mask ventilation occurs significantly more frequently in cases of difficult intubation. 13–15 In our study, we also observed a significantly higher incidence of difficult intubation in patients with DMV (30%) compared with those without DMV (8%). Our finding agrees with the 30% DMV incidence reported in a prospective audit of failure to intubate the trachea in a maternity unit. 16 Incidence of difficult ventilation or intubation depends on the definition used, 17 but we may assume that when the difficult ventilation–intubation scenario is specifically investigated, either retrospectively 15 or prospectively, 16,18 the incidence could be much greater than that previously reported. 2 In addition, previous estimates of difficult ventilation–intubation situation came from serious incident reports with brain damage or death, probably underestimating this incidence. In our study, we determined that a difficult ventilation–intubation situation occurred in 1.5% of cases, an incidence much greater than that previously reported (0.1%) in a prospective study. 18 However, as the authors mentioned, 18 their incidence of difficult ventilation–intubation scenario could have been underestimated because their study was based on self-reporting of adverse events by anesthesiologists, and the definition used for DMV was restricted to a peripheral oxygen saturation ≤ 90% without associated clinical signs of DMV, as was suggested by the American Society of Anesthesiologists practice guidelines for management of the difficult airway to define DMV. 3
In our study, DMV was anticipated by the anesthesiologist during the preoperative visit in only 17% of the DMV cases. Asai et al.12 reported that, in patients in whom ventilation through a face mask was difficult, no airway problems had been anticipated before induction of anesthesia in 57% of cases. In our study, the use of muscle relaxants was equally reported when ventilation was easy or difficult (table 2), as previously reported by Rose and Cohen. 13 These results support the need to identify predicting factors for DMV, to decrease the incidence of unexpected difficult ventilation after induction of general anesthesia, and to make more discerning use of muscle relaxants.
A BMI > 26 kg/m2 and a history of snoring were risk factors for DMV (table 3). A reduced posterior airway space behind the base of the tongue is associated with an increased BMI, impairs the airway patency during sleep, and is therefore an important risk factor for obstructive sleep apnea syndrome. 19 Moreover, upper airway obstruction can occur after induction of general anesthesia with posterior displacements of the soft palate, base of tongue, and epiglottis, and attempts at inspiration during anesthesia caused major secondary collapse of the pharynx with multiple site of obstruction, similar to that found in obstructive sleep apnea. 20 Consequently, in patients with a moderately increased BMI and unsuspected anatomic upper airway abnormalities related to obstructive sleep apnea, DMV may occur during general anesthesia, whereas an increased risk of difficult tracheal intubation may also exist. 21 In contrast, in morbidly obese patients (BMI > 40 kg/m2), because oxygen desaturation after induction of anesthesia 22,23 and difficult intubation 24,25 risks are increased and feared, the likelihood of a difficult airway management is usually suspected before anesthesia, and the patient is intubated while awake. 2–4 Consequently, in patients with a slight increased BMI, the difficult airway may not be anticipated, as in morbidly obese patients, leading to a more difficult airway management than it should be with the degree of awareness. Age has been found to be closely correlated with an increased pharyngeal resistance to airflow (from choanae to epiglottis) in men but not in women, 26 supporting the predominance of obstructive sleep apnea in men. In our study, age older than 55 yr was a significant risk factor for DMV, independently of gender. Lack of teeth and the presence of a beard were also associated with DMV, decreasing the airtight seal of the face mask and increasing air leakage around the mask with a more difficult positive-pressure ventilation. 5 Consequently, these five criteria should be included in the preoperative airway assessment to better predict DMV and to detect a difficult ventilation–intubation scenario.
The finding of a distinct hierarchy of independent risk factors for DMV (table 3) is important to consider because some of them can be reversed, and thus DMV may be prevented by simple precaution: to shave a beard, to lose some weight, or not to remove dentures before induction of anesthesia. These points deserve further studies to be confirmed, considering that these risk factors could be reversible more efficiently and rapidly in decreasing order as follows: improvement in the external mask fit, decrease in the malproportion of overall body size, and decrease in malproportion between the oropharyngeal free space and the internal structures of the oropharynx.
Because five variables were independent predictors of DMV, we attempted to define a simple DMV prediction score. We observed that the presence of two criteria was the most accurate evidence of DMV with a sensitivity of 0.72 (table 5 and fig. 1), despite a low positive predictive value being related to the relatively low incidence of DMV and with consequently a high negative predictive value (table 5). DMV prediction score is easy to perform and is established with objective criteria that are probably not operator-dependent. Moreover, as we investigated the subjective assessment of an anticipated DMV by the anesthesiologist, we observed that this screening test had a much lower sensitivity (0.17) than the one of the DMV prediction score with two criteria (0.72). Thus, this simple DMV prediction score permits a simple warning of a high-risk situation for difficult airway and potentially a better anticipated airway management.
The following points must be considered in the assessment of the relevance of our study. First, it must be recognized that the definition of DMV was subjective in our study. However, the anesthesiologist was considered as an expert able to recognize the occurrence of a clinically relevant DMV and had to precisely indicate the main reason(s) why mask ventilation was considered difficult (Appendix). This sequence of steps—first, reporting a case of DMV by the anesthesiologist, and second, retrospectively classifying the type of difficulties encountered during mask ventilation—may have underestimated the incidence of reported DMV. The lack of an independent observer to report DMV could also have underestimated its incidence in our study; however, before initiating the study, we considered that relying on the anesthesiologist in charge of the patient care was the best pragmatic approach. Second, we performed this study in a general adult population with various types of scheduled surgery. These results cannot be extrapolated to a pediatric population or high-risk populations for difficult intubation, such as ear/nose/throat, obstetric, or emergency patients. Third, the incidence of impossible ventilation was very low, and consequently this phenomenon could not be analyzed and its risk factors could not be identified. Patients with low pulmonary compliance or high airway resistance, related to a laryngospasm or a bronchospasm, have an increased risk of DMV without any predicting factors of DMV, as we described in our study. Fourth, the DMV prediction score provides an initial assessment of mask ventilation without any previous attempts of intubation. However, if the development of progressive difficulty in ventilating via mask occurred because of persistent and prolonged failed intubation attempts as previously described, 2 then prediction of DMV may be initially underestimated. Difficulties with mask ventilation and intubation cause swelling that makes ventilation and intubation more difficult with repeated attempts and may increase the incidence of the difficult ventilation–intubation scenario. Lastly, we failed to identify significant association between a given type of difficulty during mask ventilation and risk factors. However, because of the small number of patients with DMV, the power of such analysis was low, and thus further studies are needed to answer this question.
In conclusion, in a general adult population, DMV was reported in 5% of cases, and in case of DMV the risk of difficult intubation was increased fourfold. Five criteria (age older than 55 yr, BMI > 26 kg/m2, lack of teeth, presence of beard, history of snoring) were independent risk factors for DMV, and the presence of two of these criteria should at best indicate a DMV. The DMV prediction score is an indicator of a high risk of difficult airway and may lead to a better anticipation of difficult airway management, potentially decreasing the morbidity and mortality resulting from hypoxia or anoxia associated with a failed ventilation.
The authors thank Dr. David Baker (Hôpital Necker-Enfants Malades, Paris) for reviewing the manuscript and the anesthesiologists involved in this study.
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Difficult Mask Ventilation (DMV) Data Form
The two parts (preoperative visit and induction of anesthesia) were provided on separate sheets and have been reassembled. FIGURE Cited Here...
Figure. Appendix....
Figure. Appendix....
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American Journal of Surgery
Challenges of laparoscopic colectomy in the obese patient: a review
Lascano, CA; Kaidar-Person, O; Szomstein, S; Rosenthal, R; Wexner, SD
American Journal of Surgery, 192(3): 357-365.
The London OMED position statement for credentialing and quality assurance in digestive endoscopy
Faigel, DO; Cotton, PB
Endoscopy, 41(): 1069-1074.
Comparison of algorithms for management of the difficult airway
Heidegger, T; Gerig, HJ; Keller, C
Anaesthesist, 52(5): 381-392.
Annales Francaises D Anesthesie Et De Reanimation
Consensus conference - Airway management in adult scheduled anaesthesia, difficult airway excepted - Saint-Mande, 07 June 2002
Annales Francaises D Anesthesie Et De Reanimation, 22(): 3S-17S.
Annales Francaises D Anesthesie Et De Reanimation
Which are the anamnestic, clinical and paraclinical criteria for intubation and/or difficult mask ventilation?
Diemunsch, P; Mion, G; Bauer, C; Giraud, D
Annales Francaises D Anesthesie Et De Reanimation, 22(): 18S-27S.
Annales Francaises D Anesthesie Et De Reanimation
Preoxygenation and upper airway patency control
Bourgain, JL
Annales Francaises D Anesthesie Et De Reanimation, 22(): 41S-52S.
Emergency Medicine Clinics of North America
The High-Risk Airway
Vissers, RJ; Gibbs, MA
Emergency Medicine Clinics of North America, 28(1): 203-+.
Anesthesia and Analgesia
Clinical application of acoustic reflectometry in predicting the difficult airway
Ochroch, EA; Eckmann, DM
Anesthesia and Analgesia, 95(3): 645-649.
Journal of Clinical Anesthesia
The airway approach algorithm: A decision tree for organizing preoperative airway information
Rosenblatt, WH
Journal of Clinical Anesthesia, 16(4): 312-316.
Difficult Airway Society Guidelines
Cook, TM
Anaesthesia, 59(): 1243-1245.

Anesthesia and Analgesia
Risk factors assessment of the difficult airway: An Italian survey of 1956 patients
Cattano, D; Panicucci, E; Paolicchi, A; Forfori, F; Giunta, F; Hagberg, C
Anesthesia and Analgesia, 99(6): 1774-1779.
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
The Proseal (TM) LMA is a useful rescue device during failed rapid sequence intubation: two additional cases
Cook, TM; Brooks, TS; Van der Westhuizen, J; Clarke, M
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 52(6): 630-633.

Journal of Clinical Anesthesia
Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane
Arain, SR; Barth, CD; Shankar, H; Ebert, TJ
Journal of Clinical Anesthesia, 17(6): 413-419.
European Journal of Anaesthesiology
Pressure support ventilation during inhalational induction with sevoflurane and remifentanil in adults
Banchereau, F; Herve, Y; Quinart, A; Cros, AM
European Journal of Anaesthesiology, 22(): 826-830.

Survey of airway management equipment in day surgery centres
Brownlow, H; Grice, A
Anaesthesia, 57(4): 407.

Annales Francaises D Anesthesie Et De Reanimation
Impact of Cormack and Lehane's grade on intubating laryngeal mask airway Fastrach (TM) using: a study in gynaecological surgery
Roblot, C; Ferrandiere, M; Bierlaire, D; Fusciardi, J; Mercier, C; Laffon, M
Annales Francaises D Anesthesie Et De Reanimation, 24(5): 487-491.
Journal of Clinical Anesthesia
Airway management in a 980-lb patient: use of the Aintree intubation catheter
Doyle, DJ; Zura, A; Ramachandran, M; Lin, J; Cywinski, JB; Parker, B; Marks, T; Feldman, M; Lorenz, RR
Journal of Clinical Anesthesia, 19(5): 367-369.
Emergency Medicine Clinics of North America
High-Risk Chief Complaints II: Disorders of the Head and Neck
Nentwich, L; Ulrich, AS
Emergency Medicine Clinics of North America, 27(4): 713-+.
Treatment of the Obese Patient in the Emergency Medical Services An Increasing Problem
Wiesener, S; Francis, RCE; Schmidbauer, W; Lewandowski, K; Baumann, A; Kerner, T
Notarzt, 24(5): 155-162.
Natural airway before artificial airway
Williamson, R
Anaesthesia, 58(5): 484-485.

A response to 'The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs', Goodwin MWP et al., Anaesthesia 2003; 58 : 60-2
Cumming, C; Barker, K
Anaesthesia, 58(6): 617-618.

Journal of Cardiothoracic and Vascular Anesthesia
Difficult laryngoscopy: Incidence and predictors in patients undergoing coronary artery bypass surgery versus general surgery patients
Ezri, T; Weisenberg, M; Khazin, V; Zabeeda, D; Sasson, L; Shachner, A; Medalion, B
Journal of Cardiothoracic and Vascular Anesthesia, 17(3): 321-324.
Journal of Clinical Anesthesia
Factors influencing time of intubation with a lightwand device in patients without known airway abnormality
Wong, SY; Coskunfirat, ND; Hee, HI; Li, JY; Chen, C; Tseng, CH
Journal of Clinical Anesthesia, 16(5): 326-331.
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Changing practice in airway management: are we there yet?
Hung, O; Murphy, M
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 51(): 963-968.

A reply
Dawson, JS
Anaesthesia, 64(): 1146-1147.

British Journal of Anaesthesia
Confirmation of the ability to ventilate by facemask before administration of neuromuscular blocker: a non-instrumental piece of information?
Broomhead, RH; Marks, RJ; Ayton, P
British Journal of Anaesthesia, 104(3): 313-317.
British Journal of Anaesthesia
Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea
Altermatt, FR; Munoz, HR; Delfino, AE; Cortinez, LI
British Journal of Anaesthesia, 95(5): 706-709.
Annales Francaises D Anesthesie Et De Reanimation
Anaesthetic management of adult patients with obstructive sleep apnea syndrome
Siyam, M; Benhamou, D
Annales Francaises D Anesthesie Et De Reanimation, 26(1): 39-52.
Annales Francaises D Anesthesie Et De Reanimation
Out-of-hospital management characteristics of severe obese patients
Jbeili, C; Penet, C; Jabre, P; Kachout, L; Schvahn, S; Margenet, A; Marty, J; Combes, X
Annales Francaises D Anesthesie Et De Reanimation, 26(): 921-926.
British Journal of Anaesthesia
Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation
Cadi, P; Guenoun, T; Journois, D; Chevallier, JM; Diehl, JL; Safran, D
British Journal of Anaesthesia, 100(5): 709-716.
Acta Anaesthesiologica Scandinavica
Evaluation of the airway of the SimMan (TM) full-scale patient simulator
Hesselfeldt, R; Kristensen, MS; Rasmussen, LS
Acta Anaesthesiologica Scandinavica, 49(9): 1339-1345.
Emergency Medicine Clinics of North America
Procedural sedation and analgesia in the emergency department: What are the risks?
Miller, MA; Levy, P; Patel, MM
Emergency Medicine Clinics of North America, 23(2): 551-+.
Critical Care
Clinical review: Management of difficult airways
Langeron, O; Amour, J; Vivien, B; Aubrun, F
Critical Care, 10(6): -.
AGA institute review of endoscopic sedation
Cohen, LB; Delegge, MH; Aisenberg, J; Brill, JV; Inadomi, JM; Kochman, ML; Piorkowski, JD
Gastroenterology, 133(2): 675-701.
New England Journal of Medicine
Bag and mask ventilation
Kheterpal, S; Tremper, KK; Mashour, GA
New England Journal of Medicine, 357(): 2091.

Troponin I and myocardial infarction
Lopez, AM; Valero, R; Pons, M; Anglada, T
Anaesthesia, 64(): 1146.

Annales Francaises D Anesthesie Et De Reanimation
Inspiratory support versus spontaneous breathing during preoxygenation in healthy subjects. A randomized, double blind, cross-over trial
Tanoubi, I; Drolet, P; Fortier, LP; Donati, F
Annales Francaises D Anesthesie Et De Reanimation, 29(3): 198-203.
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Poor Man's LMA: achieving adequate ventilation with a poor mask seal
Boyce, JR
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 48(5): 483-485.

Annals of Emergency Medicine
Out-of-hospital rescue oxygenation and tracheal intubation with the intubating laryngeal mask airway in a morbidly obese patient
Combes, X; Leroux, B; Jabre, P; Margenet, A
Annals of Emergency Medicine, 43(1): 140-141.
Anesthesia and sleep apnea syndrome
Hartmann, B; Junger, A; Klasen, J
Anaesthesist, 54(7): 684-+.
American Journal of Respiratory and Critical Care Medicine
Noninvasive ventilation and intubation of hypoxic patients: ICU versus operating room
Sorbello, M; Antonelli, M; Guarino, A; Merli, G; Petrini, F; Frova, G
American Journal of Respiratory and Critical Care Medicine, 177(3): 357-358.

Annales Francaises D Anesthesie Et De Reanimation
Comparison of eight deep breaths and tidal volume breathing preoxygenation techniques in morbid obese patients
Rapaport, S; Joannes-Boyau, O; Bazin, R; Janvier, G
Annales Francaises D Anesthesie Et De Reanimation, 23(): 1155-1159.
Use of the fibreoptic intubating LMA-CTrach (TM) in two patients with difficult airways
Goldman, AJ; Rosenblatt, WH
Anaesthesia, 61(6): 601-603.
Anaesthesia, Pain, Intensive Care and Emergency Medicine
The importance of guidelines in airway management
Petrini, F; Sorbello, M; Scoponi, M
Anaesthesia, Pain, Intensive Care and Emergency Medicine, (): 113-122.

Journal of Clinical Anesthesia
Self-reported changes in attitude and behavior after attending a simulation-aided airway management course
Russo, SG; Eich, C; Barwing, J; Nickel, EA; Braun, U; Graf, BM; Timmermann, A
Journal of Clinical Anesthesia, 19(7): 517-522.
Annales Francaises D Anesthesie Et De Reanimation
Prediction and definition of difficult mask ventilation and difficult intubation - Question 1
Diemunsch, P; Langeron, O; Richard, M; Lenfant, F
Annales Francaises D Anesthesie Et De Reanimation, 27(1): 3-14.
Journal of Clinical Anesthesia
Gender difference in mask ventilation training of anesthesia residents
Koga, T; Kawamoto, M
Journal of Clinical Anesthesia, 21(3): 178-182.
Journal of Clinical Anesthesia
The adult ergonomic face mask concept: historical and theoretical perspectives
Matioc, AA
Journal of Clinical Anesthesia, 21(4): 300-304.
Minerva Anestesiologica
The unanticipated difficult intubation. Rigid or flexible endoscope?
Rudolph, C; Henn-Beilharz, A; Gottschall, R; Wallenborn, J; Schaffranietz, L
Minerva Anestesiologica, 73(): 567-574.

Anesthesia and Analgesia
Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope (R) videolaryngoscope
Tremblay, MH; Williams, S; Robitaille, A; Drolet, P
Anesthesia and Analgesia, 106(5): 1495-1500.
Minerva Anestesiologica
Airway management in trauma
Langeron, O; Birenbaum, A; Amour, J
Minerva Anestesiologica, 75(5): 307-311.

Journal of Clinical Anesthesia
A retrospective analysis of airway management in obese patients at a teaching institution
Hagberg, CA; Vogt-Harenkamp, C; Kamal, J
Journal of Clinical Anesthesia, 21(5): 348-351.
Journal of Clinical Anesthesia
The application of fiberoptic intubation in difficult airway patients Reply
Hagberg, CA
Journal of Clinical Anesthesia, 22(4): 301-302.
Emergency Medicine Clinics of North America
Management of the difficult airway: alternative airway techniques and adjuncts
Butler, KH; Clyne, B
Emergency Medicine Clinics of North America, 21(2): 259-+.
Medical Engineering & Physics
A new mask designed for patients implanted with a nasogastric tube
So, EC; Chen, YH; Wong, KL; Poon, PWF; Huang, BM
Medical Engineering & Physics, 30(8): 1020-1023.
Clinics in Chest Medicine
Airway Management in the Obese Patient
El Solh, AA
Clinics in Chest Medicine, 30(3): 555-+.
Anesthesia and Analgesia
Context-Sensitive Airway Management
Hung, O; Murphy, M
Anesthesia and Analgesia, 110(4): 982-983.
The secured respiratory system - a safe way for the anesthetist
Ragaller, M
Anaesthesist, 52(5): 375-376.
Acta Anaesthesiologica Scandinavica
Tube tip in pharynx (TTIP) ventilation: Simple establishment of ventilation in case of failed mask ventilation
Kristensen, MS
Acta Anaesthesiologica Scandinavica, 49(2): 252-256.
Anaesthesia, Pain, Intensive Care and Emergency Medicine - Apice 19
Respiratory management in obese patients
Pelosi, P; Luecke, T; Caironi, P
Anaesthesia, Pain, Intensive Care and Emergency Medicine - Apice 19, (): 379-394.

Anesthesia and Analgesia
Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography
Oschatz, E; Wunderbaldinger, P; Sterz, F; Holzer, M; Kofler, J; Slatin, H; Janata, K; Eisenburger, P; Bankier, AA; Laggner, AN
Anesthesia and Analgesia, 93(1): 128-133.

Annales Francaises D Anesthesie Et De Reanimation
Orbitary exenteration: an unusual cannot ventilate situation
Devys, JM; Bourdaud, N; Baracco, P; Plaud, B
Annales Francaises D Anesthesie Et De Reanimation, 21(3): 224-227.
UNSP S0750765802005749/SCO
Predicting difficult intubation 2 - Reply
Yentis, SM
Anaesthesia, 57(6): 613-614.

Simulation and airway management
Timmermann, A; Eich, C; Nickel, E; Russo, S; Barwing, J; Heuer, JF; Braun, U
Anaesthesist, 54(6): 582-587.
Anesthesia and Analgesia
The LMA is a critical rescue device in airway emergencies
Atkins, RF
Anesthesia and Analgesia, 101(6): 1888-1889.

Anesthesia and Analgesia
Relying on just a few predictors of easy airway management may bite back!
Law, JA
Anesthesia and Analgesia, 106(2): 668.
Anesthesia and Analgesia
The Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study
Delay, JM; Sebbane, M; Jung, B; Noccal, D; Verzilli, D; Pouzeratte, Y; El Kamel, M; Fabre, JM; Eledjam, JJ; Jaber, S
Anesthesia and Analgesia, 107(5): 1707-1713.
Minerva Anestesiologica
Algorithms for difficult airway management: a review
Frova, G; Sorbello, M
Minerva Anestesiologica, 75(4): 201-209.

Notfall & Rettungsmedizin
Morbid obesity in an emergency scenario
Giesel, M; Wissuwa, H; Puchstein, C
Notfall & Rettungsmedizin, 12(3): 211-214.
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Management of the anticipated difficult airway-a systematic approach: Continuing Professional Development
Drolet, P
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 56(9): 683-701.
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Increased body mass index per se is not a predictor of difficult laryngoscopy
Ezri, T; Medalion, B; Weisenberg, M; Szmuk, P; Warters, RD; Charuzi, I
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 50(2): 179-183.

Anesthesia and Analgesia
Combined McCoy and balloon laryngoscopy for the emergency airway management of a patient with acute postoperative airway obstruction due to extreme engorgement of the tongue
Mentzelopoulos, SD; Rellos, KV; Magoufis, GL; Gini, CS; Tobris, S; Michalopoulos, AS
Anesthesia and Analgesia, 96(5): 1531.
Canadian Journal of Anesthesia-Journal Canadien D Anesthesie
Airway management and oxygenation in obese patients
Murphy, C; Wong, DT
Canadian Journal of Anesthesia-Journal Canadien D Anesthesie, 60(9): 929-945.
Oral and Maxillofacial Surgery Clinics of North America
Adult Airway Evaluation in Oral Surgery
Phero, JC; Rosenberg, MB; Giovannitti, JA
Oral and Maxillofacial Surgery Clinics of North America, 25(3): 385-+.
Annales Francaises D Anesthesie Et De Reanimation
Difficult airway management: Assessment of knowledge and experience in anaesthesiology residents
Duwat, A; Hubert, V; Deransy, R; Dupont, H
Annales Francaises D Anesthesie Et De Reanimation, 32(4): 231-234.
Anaesthesia and Intensive Care
Use of a modified bite-block to facilitate mask ventilation in edentulous elderly patients
Zhang, XQ; Liu, S; Liu, JH; Qin, XJ
Anaesthesia and Intensive Care, 41(1): 132-133.

British Journal of Anaesthesia
Complications and failure of airway management
Cook, TM; MacDougall-Davis, SR
British Journal of Anaesthesia, 109(): I68-I85.
Prehospital Emergency Care
The Performances of Standard and Resmed Masks During Bag-Valve-Mask Ventilation
Lee, HY; Jeung, KW; Lee, BK; Lee, SJ; Jung, YH; Lee, GS; Min, YI; Heo, T
Prehospital Emergency Care, 17(2): 235-240.
Performance of the i-gel (TM) during pre-hospital cardiopulmonary resuscitation
Haske, D; Schempf, B; Gaier, G; Niederberger, C
Resuscitation, 84(9): 1229-1232.
Journal of Anesthesia
How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction?
Sato, Y; Ikeda, A; Ishikawa, T; Isono, S
Journal of Anesthesia, 27(1): 152-156.
Clinics in Plastic Surgery
Airway Management in the Outpatient Setting
Luba, K; Apfelbaum, JL; Cutter, TW
Clinics in Plastic Surgery, 40(3): 405-+.
Emergency Medicine Clinics of North America
Critical Airway Skills and Procedures
Hawkins, E; Moy, HP; Brice, JH
Emergency Medicine Clinics of North America, 31(1): 1-+.
Acta Clinica Croatica
New Techniques and Devices for Difficult Airway Management
Shirgoska, B; Netkovski, J
Acta Clinica Croatica, 51(3): 457-461.

Acta Clinica Croatica
Management of the Difficult Airway
Novak-Jankovic, V
Acta Clinica Croatica, 51(3): 505-510.

Journal of Clinical Monitoring and Computing
Respiratory parameters as a surrogate marker for duration of intubation: potential application of automated vital sign collection
Hester, D; McGrane, S; Higgins, MS
Journal of Clinical Monitoring and Computing, 27(5): 561-565.
Sugammadex to rescue a "can't ventilate' scenario in an anticipated difficult intubation: is it the answer?
Mendonca, C
Anaesthesia, 68(8): 795-799.
Successful use of sugammadex in a 'can't ventilate' scenario
Paton, L; Gupta, S; Blacoe, D
Anaesthesia, 68(8): 861-864.
British Journal of Anaesthesia
Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool
Cattano, D; Killoran, PV; Iannucci, D; Maddukuri, V; Altamirano, AV; Sridhar, S; Seitan, C; Chen, Z; Hagberg, CA
British Journal of Anaesthesia, 111(2): 276-285.
Lightwand Tracheal Intubation with and without Muscle Relaxation
Massó, E; Sabaté, S; Hinojosa, M; Vila, P; Canet, J; Langeron, O
Anesthesiology, 104(2): 249-254.

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Predicting Difficult Intubation
Rincón, DA
Anesthesiology, 104(3): 618.

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Mallampati Classification, an Estimate of Upper Airway Anatomical Balance, Can Change Rapidly during Labor
Isono, S
Anesthesiology, 108(3): 347-349.
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Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese
Tait, AR; Voepel-Lewis, T; Burke, C; Kostrzewa, A; Lewis, I
Anesthesiology, 108(3): 375-380.
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Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics
Kheterpal, S; Martin, L; Shanks, AM; Tremper, KK
Anesthesiology, 110(4): 891-897.
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Obstructive Sleep Apnea of Obese Adults: Pathophysiology and Perioperative Airway Management
Isono, S
Anesthesiology, 110(4): 908-921.
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Is Difficult Mask Ventilation Only Correlated to the Physical Status of the Patient?
Takenaka, I; Aoyama, K; Kadoya, T
Anesthesiology, 94(5): 935.

Large Hypopharyngeal Tongue: A Shared Anatomic Abnormality for Difficult Mask Ventilation, Difficult Intubation, and Obstructive Sleep Apnea?
Chou, H; Wu, T
Anesthesiology, 94(5): 936-937.

Large Hypopharyngeal Tongue: A Shared Anatomic Abnormality for Difficult Mask Ventilation, Difficult Intubation, and Obstructive Sleep Apnea?
Langeron, O
Anesthesiology, 94(5): 937.

Unanticipated Difficult Airway in Anesthetized Patients: Prospective Validation of a Management Algorithm
Combes, X; Le Roux, B; Suen, P; Dumerat, M; Motamed, C; Sauvat, S; Duvaldestin, P; Dhonneur, G
Anesthesiology, 100(5): 1146-1150.

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Submandible Angle in Nonobese Patients with Difficult Tracheal Intubation
Nishino, T; Suzuki, N; Isono, S; Ishikawa, T; Kitamura, Y; Takai, Y
Anesthesiology, 106(5): 916-923.
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Face Mask Ventilation in Edentulous Patients: A Comparison of Mandibular Groove and Lower Lip Placement
Racine, S; Solis, A; Hamou, N; Letoumelin, P; Hepner, D; Beloucif, S; Baillard, C
Anesthesiology, 112(5): 1190-1193.
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Comparison of the Intubating Laryngeal Mask Airway with the Fiberoptic Intubation in Anticipated Difficult Airway Management
Langeron, O; Semjen, F; Bourgain, J; Marsac, A; Cros, A
Anesthesiology, 94(6): 968-972.

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Intubating Laryngeal Mask Airway in Morbidly Obese and Lean Patients: A Comparative Study
Motamed, C; Brain, A; D’Honneur, G; Combes, X; Sauvat, S; Leroux, B; Dumerat, M; Sherrer, E
Anesthesiology, 102(6): 1106-1109.

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Nasal Ventilation Is More Effective than Combined Oral–Nasal Ventilation during Induction of General Anesthesia in Adult Subjects
Liang, Y; Kimball, WR; Kacmarek, RM; Zapol, WM; Jiang, Y
Anesthesiology, 108(6): 998-1003.
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Anatomical Balance of the Upper Airway and Obstructive Sleep Apnea
Tsuiki, S; Isono, S; Ishikawa, T; Yamashiro, Y; Tatsumi, K; Nishino, T
Anesthesiology, 108(6): 1009-1015.
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Learning Curves for Bag-and-mask Ventilation and Orotracheal Intubation: An Application of the Cumulative Sum Method
Komatsu, R; Kasuya, Y; Yogo, H; Sessler, D; Mascha, E; Yang, D; Ozaki, M
Anesthesiology, 112(6): 1525-1531.
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The Unexpected Difficult Airway and Lingual Tonsil Hyperplasia: A Case Series and a Review of the Literature
Ovassapian, A; Glassenberg, R; Randel, GI; Klock, A; Mesnick, PS; Klafta, JM
Anesthesiology, 97(1): 124-132.

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Grading Scale for Mask Ventilation
Han, R; Tremper, KK; Kheterpal, S; O’Reilly, M
Anesthesiology, 101(1): 267.

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Impossible Mask Ventilation
Kheterpal, S; Tremper, KK
Anesthesiology, 107(1): 171-172.
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Sniffing Position Improves Pharyngeal Airway Patency in Anesthetized Patients with Obstructive Sleep Apnea
Isono, S; Tanaka, A; Ishikawa, T; Tagaito, Y; Nishino, T
Anesthesiology, 103(3): 489-494.

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One Hand, Two Hands, or No Hands for Maximizing Airway Maneuvers?
Isono, S
Anesthesiology, 109(4): 576-577.
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Predicting Trouble in Airway Management
Yentis, SM
Anesthesiology, 105(5): 871-872.

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Incidence and Predictors of Difficult and Impossible Mask Ventilation
Kheterpal, S; Han, R; Tremper, KK; Shanks, A; Tait, AR; O’Reilly, M; Ludwig, TA
Anesthesiology, 105(5): 885-891.

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Critical Care Medicine
Preoperative planning of airway management in critical care patients
Rosenblatt, WH
Critical Care Medicine, 32(4): S186-S192.
PDF (357) | CrossRef
Critical Care Medicine
The difficult airway in adult critical care
Lavery, GG; McCloskey, BV
Critical Care Medicine, 36(7): 2163-2173.
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European Journal of Anaesthesiology (EJA)
Prediction of difficult mask ventilation
Gautam, P; Gaul, TK; Luthra, N
European Journal of Anaesthesiology (EJA), 22(8): 638-640.
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European Journal of Anaesthesiology (EJA)
Difficult to intubate, mandatory to oxygenate
Sorbello, M; Guarino, A; Merli, G; Petrini, F; Frova, G
European Journal of Anaesthesiology (EJA), 24(10): 894-895.
PDF (44) | CrossRef
Back to Top | Article Outline
Airway management; anesthesia complication; anesthesia risk; difficult intubation.

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