What are the management strategies for a patient who is difficult to mask ventilate during a planned intubation?

Management of Difficult Mask Ventilation During Planned Intubation

When mask ventilation proves difficult during a planned intubation, immediately optimize your technique with two-handed mask ventilation and jaw thrust, deepen anesthesia to maintain adequate depth for effective ventilation, and prepare to proceed through a structured algorithm prioritizing oxygenation above all else—using supraglottic airways (LMA/ILMA) as your primary rescue device if mask ventilation remains inadequate. 1

Immediate Technical Optimization

The first response to difficult mask ventilation is optimizing your technique, not abandoning the airway:

• Ensure adequate depth of anesthesia to prevent laryngospasm and optimize airway muscle relaxation, as inadequate depth is a common correctable cause of difficult mask ventilation 1
• Apply two-handed mask ventilation with jaw thrust performed by the primary operator while an assistant provides bag ventilation 2, 3
• Optimize head and neck positioning to the "sniffing" position (head extension with neck flexion) 1
• Release or reduce cricoid pressure if applied, as it frequently worsens airway obstruction and mask seal 4, 5
• Use oral and/or nasal airways to maintain upper airway patency 2

Algorithmic Approach to Persistent Difficult Mask Ventilation

If basic optimization fails to achieve adequate ventilation, follow this structured progression:

Step 1: Call for Help Early

• Summon assistance (technical support and/or senior anesthesiologist) before the situation becomes critical, as recommended by guidelines to prevent progression to cannot-intubate-cannot-ventilate scenarios 1
• Have your difficult airway cart immediately available with supraglottic devices and cricothyroidotomy equipment 4, 5

Step 2: Maintain Deep Anesthesia with Rapidly Reversible Agents

• Maintain adequate depth of anesthesia using rapidly reversible agents (propofol infusion or volatile anesthetic) to optimize conditions for both mask ventilation and potential intubation attempts 1
• Inadequate anesthetic depth impedes effective mask ventilation and increases risk of laryngospasm 1

Step 3: Consider Supraglottic Airway as Primary Rescue

If mask ventilation remains inadequate despite optimization, place a supraglottic airway device (LMA or intubating LMA) as your primary rescue technique:

• Supraglottic airways are the recommended first-line rescue for failed mask ventilation in the planned intubation setting 1
• The intubating LMA (ILMA) allows both rescue oxygenation and serves as a conduit for fiberoptic-guided intubation 1
• This approach maintains oxygenation while providing time to formulate your next plan 1

Step 4: Proceed with Intubation Strategy

Once oxygenation is secured (either via optimized mask ventilation or supraglottic airway):

• Limit intubation attempts to maximum 2-3 attempts to avoid progressive airway trauma and edema 1, 5
• Use videolaryngoscopy as your second-line intubation technique if direct laryngoscopy fails and mask ventilation is possible 1
• Have a gum elastic bougie immediately available for all intubation attempts 1
• Consider fiberoptic intubation through the ILMA if placed 1

Step 5: Plan C - Wake the Patient

If intubation fails but oxygenation is maintained:

• Revert to face mask or supraglottic airway ventilation, maintain oxygenation, and wake the patient 1
• Postpone surgery and reassess with awake fiberoptic intubation or surgical airway under local anesthesia 1

Step 6: Plan D - Cannot Intubate, Cannot Ventilate (CICV)

If you cannot ventilate by any means (mask, supraglottic airway) and cannot intubate:

• Proceed immediately to emergency cricothyroidotomy without further delay 1, 4, 5
• This is a life-threatening emergency requiring immediate surgical airway access 4, 5

Critical Pitfalls to Avoid

Common errors that worsen outcomes in difficult mask ventilation:

• Do not perform multiple intubation attempts while oxygenation is failing—this causes progressive airway trauma, edema, and bleeding that eliminates your ability to ventilate 5
• Do not allow inadequate depth of anesthesia—light anesthesia causes laryngospasm and poor airway muscle relaxation, making mask ventilation impossible 1, 4
• Do not persist with failed techniques—accept failure early (after 2 attempts at intubation) and move to your rescue plan 1
• Do not forget that cricoid pressure worsens mask ventilation—reduce or release it if ventilation is difficult 4, 5

Special Consideration: Laryngospasm with Failed Mask Ventilation

If laryngospasm develops during difficult mask ventilation:

• Administer succinylcholine immediately rather than waiting for propofol to wear off or giving additional propofol, as laryngospasm represents complete airway obstruction that will cause death before spontaneous recovery occurs 4
• Deepening anesthesia with more propofol prolongs apnea without guaranteeing laryngospasm resolution and wastes critical oxygenation time 4
• Have cricothyroidotomy equipment immediately available as laryngospasm may not resolve even with succinylcholine 4

Risk Factors to Recognize Preoperatively

Independent predictors of difficult mask ventilation that should trigger heightened preparation:

• Body mass index ≥26-30 kg/m² 6, 3
• Age >55-57 years 6, 3
• Presence of a beard (the only easily modifiable risk factor—consider shaving preoperatively) 6, 3
• Lack of teeth 6, 3
• History of snoring or sleep apnea 6, 3
• Mallampati Class III or IV 6, 3
• Limited or severely limited mandibular protrusion 3
• Thyromental distance <6 cm 3

The presence of two or more of these factors indicates high likelihood of difficult mask ventilation and should prompt preparation of rescue devices before induction 6.