Airway Management During Electroconvulsive Therapy
The most commonly used airway management technique during ECT is bag-mask ventilation with 100% oxygen, administered after induction of anesthesia and muscle relaxation. 1, 2
Standard ECT Airway Management Protocol
Pre-oxygenation and Ventilation
- Patients are ventilated with 100% oxygen before administration of the electrical stimulus as the standard approach 1, 2
- Bag-mask ventilation is performed after administration of methohexital (anesthetic) and succinylcholine (muscle relaxant) to maintain oxygenation during the brief period of chemical paralysis 1, 3
- The patient should have fasted for approximately 12 hours before the procedure to reduce aspiration risk 1, 2
Why Bag-Mask Ventilation is Standard
The rationale for bag-mask ventilation as the primary technique stems from several factors:
- ECT procedures are brief (typically lasting only minutes), making advanced airway devices unnecessary in most cases 1
- Succinylcholine causes transient chemical paralysis requiring airway support even with adequate preoxygenation 3
- The procedure involves a generalized seizure that makes face mask ventilation challenging but still feasible 4
Alternative and Emerging Airway Techniques
Supraglottic Airways (Less Common)
While bag-mask ventilation remains standard, supraglottic airways have been used in specific circumstances:
- Laryngeal mask airways (LMAs) can be used for airway maintenance and protection during ECT, particularly in patients with difficult mask ventilation 5, 6
- The ProSeal LMA has been successfully used in pregnant patients with known difficult airways undergoing ECT 6
- One study using LMAs with cisatracurium (instead of succinylcholine) reported mean seizure duration of 58.8 seconds with no awareness, delirium, or respiratory complications 5
Modified Protocols to Reduce Bag-Mask Ventilation
Recent evidence suggests strategies to minimize aerosol-generating bag-mask ventilation:
- A modified protocol using preoxygenation by facemask and withholding BMV unless desaturation occurs reduced BMV use by more than 50% during the COVID-19 pandemic 7
- In this approach, BMV is reserved only for patients who desaturate during the apneic period 7
- Patient BMI was the only significant factor associated with requiring BMV under this protocol 7
Novel Oxygenation Methods
- Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has been studied as a feasibility option, showing no desaturations and similar patient comfort compared to face mask ventilation 4
- THRIVE did not appear to shorten seizure duration compared to traditional face mask ventilation 4
Critical Procedural Requirements
Team and Setting
- ECT should be administered by a team including a psychiatrist, anesthesiologist, and nursing staff experienced in ECT 1
- Standard procedure always includes consultation with an anesthesiologist, preferably one experienced in treating the patient population 1, 2
- The patient should recover in a specially designated area with nursing care provided 1
Monitoring During Airway Management
- Adolescents may have lower seizure threshold and more prolonged seizures than adults, requiring careful monitoring 1
- When using advanced techniques like LMAs, continuous monitoring of train-of-four, end-tidal CO₂, and bispectral index (BIS) can optimize anesthetic depth 5
Common Pitfalls and How to Avoid Them
Inadequate Preoxygenation
- Failure to adequately preoxygenate before muscle relaxation can lead to rapid desaturation, particularly in obese patients who have reduced safe apnea time 3, 7
- Always ensure thorough preoxygenation with 100% oxygen before administering succinylcholine 1, 2
Excessive Muscle Relaxant Dosing
- Using standard succinylcholine doses in morbidly obese patients can prolong chemical paralysis and increase hypoxic episodes 3
- Consider reducing succinylcholine dose to approximately half in morbidly obese patients to allow quicker return of spontaneous respiration 3