Moves that make a difference for face-mask ventilation

There is an awful lot out there about all things intubation. Blades, videos, failures and all manner of variations on the ‘putting that breathing tube in’ manoeuvre that inspire passionate opinions. So many opinions that maybe that means there isn’t one way to do things, even as people are telling you there is one way to do things.

In the real world all of that excitement generally comes after face-mask ventilation. People describe it as one of the basic airway manoeuvres but there is a tremendous amount of nuance and technique that can make a world of difference. Saying it’s ‘basic’ is, well, pretty basic.

Good mask technique is critical to all sorts of really important phases. Induction, interventions, and guarantees of oxygenation can be all about this ‘basic’ skillset. And done well it also means that airway pressures can be minimised while achieving excellent oxygenation and ventilation.

Do slightly less well and you can find yourself using more pressure, which inevitably finds a way into the stomach which only shifts the diaphragm, drops functional residual capacity and steals oxygen reserves you worked so hard to get in the lungs.

As a bonus it probably increases the rate of passive reflux of contents back up from the stomach and all that gaseous distension might translate into a bit of nausea later.

So it’s worth doing well.

But it’s also not as easy for research as something like intubation. For intubation you can time the technique. You can turn first pass success to turn into a percentage. Face-mask ventilation is not quite so concrete and people don’t seem to find it as exciting.

So it is not the literature that helps us, it’s words of wisdom straight from people who do it all the time. Particularly those who have picked up the nuances specific to paediatric care.

So we’ve asked them. This is a list of top tips about mask technique collected from Drs Sarah Johnston, Jarek Latanik, Justin Skowno, Matt Hart, Andrew Weatherall, Ian Miles and Jeeves Perera gathered across a bunch of years and a heap of locations.

And possibly with a few bits of magic they figured out themselves.

1. Sizing Matters

“Before anything else, check that the size of the mask and its shape is the right size to actually create a tight seal around the nose and mouth of the patient in front of you. It is surprising how often this basic thing can be not quite right.” (JP)

“Choosing the correct size mask for the child makes it so much easier to get a seal. But if the mask is a tiny bit too big you can just include their chin in the mask, at least until they are deep and you can quickly reassess and swap it out.” (SJ)

2. Placing the Mask

“Taking care as you place the mask on the face is crucial both for the seal and to avoid the sort of squeezing in the wrong place that causes obstruction. I was once shown the tip to place the part of the mask on the bridge of the nose first so you don’t obstruct the nostrils. Then roll it down onto the chin before undertaking the next basic manoeuvres to open the airway. This is still my approach every day.” (JL)

“Obstructing the nostrils with the top of the mask is one of the commonest problems I see. It is easy to do when you are focusing on trying to get a good seal, but thwarts attempts at ventilating little obligate nose-breathers. It’s worth looking for if you’re struggling as it is easy to spot and a quick fix.” (MH)

“I prefer to open the mouth a little, and use the lower edge of the mask against the chin to keep it open. Then I roll up to create the seal. I find this avoids pushing the tongue backwards and lets you see that it is not stuck to the roof of the mouth. When I get to the step of holding the airway, this focus on having the mouth open stops me digging in below the mandible.” (IM)

[Ed: At this point you are probably thinking ‘that tip is the opposite of the other tip. Correct. The take away message is that it is really important to get to a technique in your hands that ensures you’re not obstructing important things, and able to create an effective seal to set up success. So we figured it was important to share both tips to highlight that different solutions might be what works.]

3. The Super Seal

“Bring the face to the mask not the mask to the face. And this might sound silly but sometimes lifting the cheeks is the tip to complete a great seal and a great seal takes away the temptation to bag harder.” (SJ)

“When gripping the mask either have your thumb and index finger near the stem of the mask, or have that stem resting in the webbing of your thumb. This makes sure the small amount of force you are applying at the top of the mask is evenly distributed. (If you have your thumb and index finger low on the mask, near the edge, you are applying your force in only a couple of spots and you leak elsewhere.) Then lift the face into the mask.” (JP)

“If you realise you don’t have a great seal, small movements down or up in the mask position can quickly fix a big leak. Try that first.” (JS)

“If the seal is not great make subtle adjustments instead of just removing the mask and starting again. It’s worth a try and usually does the job.” (JP)

*Because this super seal is also worth appreciating.*

4. Stay out of those soft tissues

“I tend to use fingers behind the angle of jaw while lifting directly up to the ceiling in the supine child. It’s the easiest way to lift the tongue off the back of the pharynx and open the airway.” (SJ)

“Another frequent issue when people just can’t get the airway right is applying too much pressure to the submandibular tissues with their jaw thrust or chin lift. Even small amounts can cause significant airway obstruction compared with an adult, and the reflex response of "more jaw thrust" to try to fix thing can make it worse. Try limiting your grip to bony prominences e.g. the angle of the mandible.” (MH)

“It is just so easy to slip into the soft tissue under the mandible and with very little pressure obstruct the airway. When your fingers fall into that soft tissue you’re just pushing the tongue to block everything off. I found the advice to stay along the jaw line with my fingers just not that good. Eventually I’d slip. So my preferred technique in the smaller kids is to take just my middle finger and place it gently on the skin a little below the point of the chin (it is pretty much parallel to the surface of the bed, lying across that skin just a few centimetres under the chin – just a little above where the skin tissue at the front of the neck hits that angle that sweeps towards the chin). I then just gently stretch the skin up so my finger is pretty much at the level of the chin. Then I find I can just keep my finger gently there. It means I don’t fall into the soft tissues, the bit of tension at the neck splints the tongue down a little and it usually makes the seal better. Add the mask and it’s kind of a one-finger airway hold.” (AW)

“The tissues of the face and underside of the jaw area are all fairly mobile in most cases, and the way you “gather” them into the mask makes a huge difference to leak/no leak. I try and get people to move from digging their fingers under the jawline ferociously to using them to gently tension the submandibular skin/sub cut tissue. This reduces iatrogenic airway obstruction too.” (JS)

“If that really doesn’t work I might try jaw thrust. But jaw thrust is entirely behind the angle of the mandible. No fingers on the jawline. But also the one-finger hold almost always does the trick in smaller kids.” (AW)

5. Lend a hand

“When struggling with ventilation, a two-handed technique can often help. But from a practical point of view it’s also good to have ways to do it that don’t rely on using your only assistant….” (MH, with more to come.)

“A two-handed technique if you are struggling is never wasted. But once you have got to a stable point it’s always good to try transitioning back to a one-hand hold as it increases your options (or for learners is giving them more chances to get better and better).” (JS)

6. Perfect Positioning

“One other thing that can cause problems and that isn’t often remarked upon is head positioning, Under, or more frequently, over-extension of the head can distort airway anatomy drastically in small kids and make things hard. But a big head tilt is often ingrained practice from the land of adults. If struggling and other things have been tried or problems eliminated, try gentle adjustments to get back to a pretty neutral position. Often things will get easier.” (MH)

“It’s a different position thing, but the position of your hand and wrist matters. You want to use just enough force and effort. Not more. And part of that is helped by maintaining a straight wrist. It helps avoid muscle tension so you can do everything else better and with less effort.” (IM)

7. Positive Pressure

“CPAP or PEEP is your friend. You may find that as much as 20 cmH2O is required in the induction phase as you overcome some of the initial changes to airway tone and reactivity. CPAP just makes a big difference. It does not matter if it’s with a T-piece or you close the APL valve. Done right you can get 99% of kids spontaneously ventilating.” (SJ)

“Maintain some CPAP. Not only will it help with airway patency but it will make it obvious if you've lost your seal.” (IM)

“There are bits of the literature where they use ‘application of CPAP’ as a sign that face-mask ventilation was difficult. Using CPAP is just what makes sense on pretty much every crack at face-mask ventilation. Whether it’s with a T-piece or circle, adding positive pressure as a way of supporting the airway while ongoing spontaneous ventilation happens is the best way to ensure you’re looking after oxygenation, keeping the airway open or overcoming any reactivity and, at induction, working towards a good plane of anaesthesia.” (AW)

8. Add extras. Carefully.

“Oropharyngeal airways can be helpful. I size them from the maxillary gum, where the incisors will be one day, to the angle of the mandible. Slightly too big is anecdotally better than slightly too small. Be prepared that in small people placing one can often increase the surface area a mask needs to cover, so much so that you'll frequently need to swap for a mask one size larger.” (MH)

“The better you get, the less you need to use an oropharyngeal airway. But they work so there is no need to be shy about using it.” (JS)

“An oropharyngeal airway can certainly make things a lot easier. But it’s something to add only after using CPAP to maintain the airway while the patient is still a little reactive. Reaching for the oropharyngeal airway during the ‘excited’ phase might mean that placing it induces laryngospasm and other nasty reflexes. Add the airway once you’re confident you’re past that phase, or you’re confident the patient won’t react when it goes in.” (AW)

9. Brilliant bagging

“If using a T-piece on a neonate or small baby choose the smaller bag and gather half the bag into your palm. This means a small part of the overall bag is the bit actually filling up with oxygen (so it is not the size of the whole bag). This makes sure when you squeeze the bag with your thumb and index finger, you will be giving an appropriately-sized breath, not a breath bigger than the child could ever manage themselves.” (JP)

“When using a circle, again use a small bag, close that APL valve to 20-30 and just squeeze the bag enough to make the chest rise and fall a bit. You are only aiming for the right amount of ventilation without distending the stomach. So from that initial point dial the APL valve to be more and more open – you want the smallest degree of closure that still gets the job done.” (JP again)

“This bit particularly helps when you are using the two-handed mask hold and you just have the one assistant (see above), though it obviously works if you’re holding the mask one-handed as well. When I'm on my own e.g. out of hours, I feel slightly uncomfortable handing a bag to my anaesthetic assistant, as they are frequently the second (or even the first if they’re a veteran) most experienced anaesthetic team member. Handing them a bag stops them doing much more helpful things more commensurate with their skill level. I like instead to try using my ventilator in a mixed mandatory/assisted ventilation mode e.g. CPAP + PSV. I can program settings that will consistently deliver inspiratory pressures below the opening pressure of the lower oesophageal sphincter, at an age appropriate rate, with PEEP to counter atelectasis. The ventilator will happily switch between assisted and mandatory breaths depending on depth of anaesthesia, and most importantly my anaesthetic assistant is freed up to perform tasks which require more skill.” (MH)

10. Above all else, use your eyes

“If you are delivering breaths to a child and have a good view of their thorax and abdomen, you can quickly get a good idea if you are providing volumes that are too large or too small (you want to see the chest just start to rise), and can often see if you're delivering gas into the stomach rather than the lungs. In a spontaneously breathing child you can easily spot see-saw movements and tracheal tug developing as obstruction worsens and get immediate feedback that your interventions are working when those signs disappear. So always keep looking at the patient, and if your efforts are not quite working, adjust.” (MH)

“With everything you’re doing, look at the patient and assess. Is the chest rising and falling easily? Is the spontaneously ventilating patient working hard or finding it easy? If you’re bagging is the chest rising just enough, or are you making the stomach bigger? And if it’s not quite right, don’t just persist. Change something. Check what you’re doing and make an adjustment to do better. And then reassess that whatever you changed has made things better. Good airway management requires constant clinical assessment to stay in front of the game.” (AW)

“Remember that the goal is a good airway that gets the job done, not a ‘good looking’ airway. You might have a great airway in a slightly weird position. But if your assessment says ‘this is working’ then you don’t necessarily need to fix how it looks. It is working.” (IM)

“One last bit of assessing is trying to have monitors that help quickly enough. If possible set the SpO2 averaging time to 5-10 sec when doing small babies. This helps pick up any changes quicker than the standard averaging times most places use as the default setting. (JP)

11. And reset as necessary

“And if you lose the airway entirely? By all means try little adjustments and assess that they work. But if you need to, start from your step 1 to get things working. You had it right once, you’ll get back there quickly.” (IM)

12. Oh, one last position thing

“This applies mostly in the postoperative phase when you’ve chosen the lateral position. The average child is better at maintaining their own airway than the average anaesthetist when it comes to this bit. If you're trying to get a seal and prove to yourself you have an airway in the lateral position, often the best approach is to let everything go, gently open their mouth and feel for breath/look for misting. During this phase patients mostly do fine without us (provided they are actually breathing…..). Iatrogenic airway obstruction is more common in this position than supine. Let the patient have a go.” (JS)

How is that for a starting set of tips? Face-mask ventilation is the foundational skill that sets us all up for success. And might just be a lot more interesting than which blade to wield as your weapon.

If you have tips we’d love to hear them. Help us be better.

And maybe you’ll give us a new thing to add to the simple mantra of ‘do the thing, look at the patient, check it is working and change if it’s not (or celebrate a little when it is)’.

The Wrap

We totally get that there are a few of the descriptions above which would be great with an image. Those images can be a bit hard to appropriately grab, so for now the written version is what we have. We figured we’d start here and update when we can.

We have also turned these tips into a pdf format over inside the Practical Pearls part of the website. You can go straight to that pdf here.

This is not the sort of thing that comes with lots of references because it’s just people sharing what they actually do. The tips and tricks were compiled by JL and AW.

Mask Magic