Sir,
Difficult bag and mask ventilation (BMV) may lead to serious complications which can be prevented and managed with prior anticipation.[1] Here, we report the case of an 81-year-old geriatric patient with difficult mask ventilation scheduled for microdiscectomy for L4–L5 disc prolapse. Following application of standard ASA monitoring, the patient was pre-oxygenated for 3 min and injection fentanyl 100 μg was given for intraoperative analgesia. General anesthesia was commenced by administering injection propofol 80 mg intravenously. As the patient was edentulous with no pad of fat in cheeks, gauze pieces were placed around the cheeks. BMV was started with E-C technique but there was a significant leak. Appropriate size oropharyngeal airway was inserted along with head tilt and chin lift maneuver, but we were unable to ventilate again. Then, two-hand E-C technique was used, but still there was a leak which was noticed from the sides of the nose. Hence, we modified the two-hand E-C technique by applying both thumbs to the sides of the nose instead of over the nose, and the position of the other fingers remained the same [Figure 1]. With this modification, we were able to bag and mask ventilate the patient. Subsequently, injection rocuronium 40 mg was given intravenously and the patient was intubated with 8.5 mm ID endotracheal tube.
Figure 1.
The modified E-C technique by applying both thumbs on the side of nose while all other finger position same as in E-C technique
The factors associated with difficult facemask ventilation include presence of beard or moustache, lack of teeth (edentulism), obesity (body mass index >25), history of obstructive sleep apnea, history, and age over 55 years.[2] In the absence of teeth, there is no bone of alveolar ridge that leads to decrease distance between the nose and the mandible. Loss of buccinators muscle tone also leads to hollow cheeks causing a gap between the mask and skin.[3] Mask ventilation is very difficult in this group of patients as proper seal is not achieved. Moreover, there are chances of upper airway obstruction due to fall off the tongue.[4] Methods to overcome these problems include head tilt and chin lift or jaw thrust maneuvers, insertion of oropharyngeal and/or nasopharyngeal airway to prevent tongue fall, and selection of appropriate size mask to achieve the required seal. The placement of mask at lower lip (lower lip placement) has also been described for difficult BMV in this subset of patients. Retention of denture in place during BMV also helps in providing the seal. Placement of gauze pieces under the cheeks prevents air leak around the hollow cheeks. In addition, two-hand E-C technique is also helpful in this age group.[1] In our patient, modification of standard two-hand E-C technique helped us in eliminating the problem. We could also apply additional gauges to the sides of the nose to prevent leak, but it would be very cumbersome; moreover, it was easy to apply pressure with the thumb then to put more gauges. To conclude, the modified two-hand E-C technique of pressure on the side of nose with thumbs for BMV is advised in elderly edentulous patients.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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References
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