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Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table's height was adjusted at four points: the operator's umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table's height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures. [ABSTRACT FROM AUTHOR]

Introduction: End-tidal CO2 (ETCO2) detector is currently recommended for confirmation of endotracheal tube placement during neonatal resuscitation. Whether it is feasible to use ETCO2 detectors during mask ventilation to reduce risk of bradycardia and desaturations, which are associated with increased risk of death in preterm babies, is unknown. Methods: This is a pilot randomized controlled trial (NCT04287907) involving newborns 24 + 0/7 to 32 + 0/7 weeks gestation who required mask ventilation at birth. Infants were randomized into groups with or without colorimetric ETCO2 detectors. Combined duration of any bradycardia (<100 bpm) and time below prespecified target oxygen saturation (SpO2) as measured by pulse oximetry were compared. Results: Fifty participants were randomized, 47 with outcomes analysed (2 incomplete data, 1 postnatal diagnosis of trachea-oesophageal fistula). Mean gestational age and birthweight were 28.5 ± 1.9 versus 29.4 ± 1.6 weeks (p = 0.1) and 1,252.7 ± 409.7 g versus 1,334.6 ± 369.1 g (p = 0.5) in the intervention and control arm, respectively. Mean combined duration of bradycardia and desaturation was 276.7 ± 197.7 s (intervention) and 322.7 ± 277.7 s (control) (p = 0.6). Proportion of participants with any bradycardia or desaturation at 5 min were 38.1% (intervention) and 56.5% (control) (p = 0.2). No chest compressions, epinephrine administration, or death occurred in the delivery room. Conclusion: This pilot study demonstrates the feasibility of a trial to evaluate colorimetric ETCO2 detectors during mask ventilation of very preterm infants to reduce bradycardia and low SpO2. Further assessment with a larger population will be required to determine if ETCO2 detector usage at resuscitation reduces risk of adverse outcomes, including death and disability, in very preterm infants. [ABSTRACT FROM AUTHOR]

Mask ventilation is a critical airway procedure made more difficult in the bearded patient. We sought to objectively investigate whether application of transparent cling film (TegadermTM; 3M Healthcare, Maplewood, MN) over a beard in the operating room improves the quality of mask ventilation. This was a randomized crossover trial of bearded adult patients undergoing surgery. Exclusions included emergency procedures, American Society of Anesthesiologists physical status classification > 3, a documented history of difficult mask ventilation, and body mass index (BMI) > 50. Transparent cling film was applied snuggly over the lower face with a 2- to 3-cm slit cut over the mouth after anesthesia induction. Mask ventilation performed by an anesthesiology resident, anesthesiology assistant, or anesthesiology assistant student and standardized to a thenar-eminence grip without use of airway adjuncts in a sniffing position. Standardized pressure-controlled ventilations were delivered via an anesthesia machine. A calibrated external pneumotachograph was used to measure delivered and returned tidal volumes from which raw and percent air leak were calculated. A clinically significant difference was determined a priori to be 15%, necessitating the enrollment of 25 patients. Of 25 subjects, 96% were men with a mean ± SD BMI of 29.3 ± 6. Seventeen (68%) had a full beard and 8 (32%) had a partial beard. The mean ± SD leakage was 48% ± 26% for transparent cling film vs. 46% ± 20% without its application, which was not significantly different (p = 0.67). The use of transparent cling film to cover the lower half of the bearded face did not have an impact on the ability or efficacy to perform mask ventilation in the operating room setting. ClinicalTrials.gov, Number NCT04274686. [ABSTRACT FROM AUTHOR]

Paratracheal pressure has been recently suggested to compress and occlude the upper esophagus at the lower left paratracheal region to prevent gastric regurgitation alternative to cricoid pressure. It also prevents gastric insufflation. The aim of this randomized cross-over study was to investigate the effectiveness of paratracheal pressure on mask ventilation in obese anesthetized paralyzed patients. After the induction of anesthesia, two-handed mask ventilation was initiated in a volume-controlled mode with a tidal volume of 8 mL kg‒1 based on ideal body weight (IBW), a respiratory rate of 12 breaths min− 1, and positive end-expiratory pressure of 10 cmH2O. Expiratory tidal volume and peak inspiratory pressure were recorded alternately with or without the application of 30 Newtons (approximately 3.06 kg) paratracheal pressure during a total of 16 successive breaths over 80 s. Association of patient characteristics with the effectiveness of paratracheal pressure on mask ventilation, defined as the difference in expiratory tidal volume between the presence or absence of paratracheal pressure were evaluated. In 48 obese anesthetized paralyzed patients, expiratory tidal volume was significantly higher with the application of paratracheal pressure than without paratracheal pressure [496.8 (74.1) mL kg− 1 of IBW vs. 403.8 (58.4) mL kg− 1 of IBW, respectively; P < 0.001]. Peak inspiratory pressure was also significantly higher with the application of paratracheal pressure compared to that with no paratracheal pressure [21.4 (1.2) cmH2O vs. 18.9 (1.6) cmH2O, respectively; P < 0.001]. No significant association was observed between patient characteristics and the effectiveness of paratracheal pressure on mask ventilation. Hypoxemia did not occur in any of the patients during mask ventilation with or without paratracheal pressure. The application of paratracheal pressure significantly increased both the expiratory tidal volume and peak inspiratory pressure during face-mask ventilation with a volume-controlled mode in obese anesthetized paralyzed patients. Gastric insufflation was not evaluated in this study during mask ventilation with or without paratracheal pressure. [ABSTRACT FROM AUTHOR]

Background: Telesimulation may be an alternative to face-to-face simulation-based training. Therefore, we investigated the effect of a single telesimulation training in inexperienced providers. Methods: First-year medical students were recruited for this prospective observational study. Participants received a low-fidelity mannequin and medical equipment for training purposes. The one-hour telesimulation session was delivered by an experienced trainer and broadcast via a video conference tool, covering all elements of the neonatal resuscitation algorithm. After the telesimulation training, each student underwent a standardized simulated scenario at our Clinical Skills Center. Performance was video-recorded and evaluated by a single neonatologist, using a composite score (maximum: 10 points). Pre- and post-training knowledge was assessed using a 20-question questionnaire. Results: Seven telesimulation sessions were held, with a total of 25 students participating. The median performance score was 6 (5–8). The median time until the first effective ventilation breath was 30.0 s (24.5–41.0) and the median number of effective ventilation breaths out of the first five ventilation attempts was 5 (4–5). Neonatal resuscitation knowledge scores increased significantly. Conclusions: Following a one-hour telesimulation session, students were able to perform most of the initial steps of the neonatal resuscitation algorithm effectively while demonstrating notable mask ventilation skills. [ABSTRACT FROM AUTHOR]

Background: The use of noninvasive ventilation (NIV) during and after extubation is common. We designed this study to determine the optimal strategy to compensate for mask leaks and achieve effective ventilation during NIV by comparing commonly used operating room ventilator systems and a regular facemask. Methods: We tested four operating room ventilator systems (Dägger Zeus, Dägger Apollo, Dägger Fabius Tiro, and General Electric Healthcare Carestation 650) on a lung model with normal compliance and airway resistance and evaluated pressure control ventilation (PCV), volume control ventilation (VCV), and AutoFlow mode (VAF). We set the O2 flow at 10 L/min and the maximal flow at 13, 16, or 26 L/min. We simulated five leak levels, from no leak to over 40 L/min (I to V levels), using customized T-pieces placed between the lung model and the breathing circuit. We recorded the expired tidal volume (Vte) from the lung model and peak inspiratory pressure via two flow/pressure sensors that were placed distally and proximally to the T-pieces. Results: 1. Comparison of four ventilators: with any given ventilation mode, an increase in leak level caused a decrease in Vte. With PCV, only Zeus produced Vte larger than 150 ml at leak level V. 2. Effect of ventilation mode on Vte: across all four ventilators, PCV resulted in a higher Vte than VCV and VAF (P

According to tacit knowledge theory, checklists and textbooks cannot convey important aspects of nonroutine mask ventilation (MV) learned experientially. Our objective was to elicit tacit knowledge underlying experienced MV performance to support novice anesthesia providers' MV execution by identifying targets for clinical coaching. We utilized the Critical Decision Method to elicit experienced anesthesia providers' tacit knowledge during nonroutine MV. Using semistructured interviews guided by a general anesthesia (GA) induction checklist and conducted using equipment utilized in GA induction, we probed participants' experiences. A cognitive map was produced depicting critical MV decisions and associated environmental cues. We validated the map via member check and comparison against GA checklists, textbooks, and novice MV knowledge. Experience is necessary to skillfully interpret environmental cues signaling changing conditions in nonroutine MV. Our cognitive map featured 34 critical decisions and 23 environmental (visual, tactile, auditory, and olfactory) cues. Validation identified 45 (16 preoperative, 29 intraoperative) items not found in the GA induction checklist, 15 not presented in textbooks, and 16 not identified by novices. Identifying tacit knowledge may provide a novel way to guide novice anesthesia learners' experiential learning. Highlighting the environmental cues could guide hands on learning, accelerating time to competency. [ABSTRACT FROM AUTHOR]

Aim: Estimation of end‐tidal carbon dioxide (EtCO2) with capnography can guide mask ventilation in infants born at less than 30 weeks of gestation. Chemical‐sensitive colorimetric devices to detect CO2 are widely used at resuscitation. We aimed to quantify EtCO2 in the first breaths following initiation of mask ventilation at birth and correlated need for endotracheal intubation. Methods: Infants <30 weeks gestation receiving mask ventilation were randomised into two groups of mask‐hold technique (one‐person vs. two‐person). Data on EtCO2 in the first 30 breaths, time to achieve 5 mmHg, 10 mmHg and 15 mmHg CO2 using a respiratory function monitor was determined. Results: Twenty‐five infants with a mean gestation of 27.3 (±3 weeks) and mean birth weight 920.4 (±188.3 g) were analysed. The median EtCO2 was 5.6 mmHg in the first 10 breaths, whereas it was 12.6 mmHg for 11–20 breaths and 18 mmHg for 21–30 breaths. There was no significant difference in maximum median EtCO2 for the first 20 breaths, although EtCO2 was significantly lower in infants who were intubated (32.0 vs. 15.0, p = 0.018). Conclusion: EtCO2 monitoring in infants <30 weeks gestation at birth is feasible and reflective of alveolar ventilation. EtCO2 may help guide ventilation of preterm infants at birth. [ABSTRACT FROM AUTHOR]

Abstract Background Mask ventilation progressively improves after loss of consciousness during anesthesia induction possibly due to progression of muscle paralysis. This double-blinded randomized placebo-controlled study aimed to test a hypothesis that muscle paralysis improves mask ventilation during anesthesia induction. Methods Forty-four adults patients including moderate to severe obstructive sleep apnea undergoing scheduled surgeries under elective general anesthesia participated in this study. Randomly-determined test drug either rocuronium or saline was blinded to the patient and anesthesia provider. One-handed mask ventilation with an anesthesia ventilator providing a constant driving pressure and respiratory rate (15 breaths per minute) was performed during anesthesia induction, and changes of capnogram waveform and tidal volume were assessed for one minute. The needed breaths for achieving plateaued-capnogram (primary variable) within 15 consecutive breaths were compared between the test drugs. Results Measurements were successful in 38 participants. Twenty-one and seventeen patients were allocated into saline and rocuronium respectively. The number of breaths achieving plateaued capnogram did not differ between the saline (95% C.I.: 6.2 to 12.8 breaths) and rocuronium groups (95% C.I.: 5.6 to 12.7 breaths) (p = 0.779). Mean tidal volume changes from breath 1 was significantly greater in rocuronium group than saline group (95% C.I.: 0.56 to 0.99 versus 3.51 to 4.53 ml kg-IBW−1, p = 0.006). Significantly more patients in rocuronium group (94%) achieved tidal volume greater than 5 mg kg-ideal body weight−1 within one minute than those in saline group (62%) (p = 0.026). Presence of obstructive sleep apnea did not affect effectiveness of rocuronium for improvement of tidal volume during one-handed mask ventilation. Conclusions Use of rocuronium facilitates tidal volume improvement during one-handed mask ventilation even in patients with moderate to severe obstructive sleep apnea. Trial registration The clinical trial was registered at (05/12/2013, UMIN000012495): https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000014515

Anaesthetists can make safer airway plans if they know which airway techniques worked previously and which ones did not. Anaesthetic charts do not always capture this information, however, and guidelines from the Australian and New Zealand College of Anaesthetists do not specify what details on airway management they should include. To assess how anaesthetic charts support airway documentation, we audited the airway management section of blank charts from 132 hospitals accredited for training by the Australian and New Zealand College of Anaesthetists. We evaluated charts for the presence of 17 clinically important data fields describing tracheal intubation, supraglottic airway use and bag-mask ventilation. Our audit revealed that data fields on anaesthetic charts focus more on tracheal intubation than bag-mask ventilation or supraglottic airway use. Nearly all charts (99%) had prompts for intubation and most had prompts for both operator technique and patient outcome. For supraglottic airway use, 95% of charts had at least one data field, but few had prompts for difficulty or outcome. For bag-mask ventilation, 58% of charts had a data field for difficulty but most of these were subjective; few (1.5%) included any outcome measures. Data fields describing bag-mask ventilation and supraglottic airway use were also inconsistent. In summary, data fields on Australian and New Zealand anaesthetic charts focus on tracheal intubation with consistent prompts for both operator method and outcome. The inclusion of fields for outcome and difficulty of bag-mask ventilation and supraglottic airway use could help clinicians make better records of airway management. [ABSTRACT FROM AUTHOR]

Abstract&#xD;Objective: Abnormal regional lung ventilation can lead to undesirable outcomes during the induction of anesthesia. Head rotated ventilation has proven to change the airflow of upper airway tract and be effective in increasing the tidal volume. This study aimed to investigate the influence of head rotated mask ventilation on regional ventilation distribution during the induction phase of anesthesia.&#xD;Approach: Ninety patients undergoing anesthesia induction were randomly assigned to receive either neutral head (neutral-head group) or rotated right side head (rotated-head group) mask ventilation. Pressure-controlled mode was used in all mechanical ventilation. The regional lung ventilation was monitored by electrical impedance tomography (EIT). The primary outcome was the ratio of left/right lung ventilation distribution. The secondary outcomes were GI, centre of ventilation (CoV,100%=entirely dorsal), regional ventilation delays standard deviation (RVDSD), and the regional lung distribution differences between spontaneous and mask ventilation.&#xD;Main results: Forty-two patients with neutral-head and 38 with rotated-head mask ventilation were analyzed finally. Compared with spontaneous ventilation, mask positive-pressure ventilation caused significant changes in the ratio of left/right lung ventilation distribution[0.85(0.27) versus 0.94(0.30);P=0.022]. However, there were no differences in the ratio of left/right lung ventilation distribution between neutral and rotated head groups (P=0.128). When compared with spontaneous ventilation, mask ventilation caused regional distributions of ventilation shifts towards ventral lung areas (CoV: 45.8%±5.1% versus 39.9%± 5.1%; P<0.001), significant lung ventilation inhomogeneity (GI: 0.41±0.08 versus 0.50±0.15; P<0.001), and decreased RVDSD (7.6±2.6 versus 5.2±3.0; P<0.001). Compared with neutral-head mask ventilation, rotated-head mask ventilation was associated with higher TVe (575.1 ml ± 148.6 ml versus 654.2 ml ± 204.0 ml; P = 0.049).&#xD;Significance: Mask positive ventilation caused regional lung ventilation changes. When compared with neutral-head mask ventilation, rotated-head mask ventilation did not improve the regional ventilation towards to left lung. However, rotated-head mask ventilation was associated with higher TVe.&#xD., (Creative Commons Attribution license.)

Background: Telesimulation may be an alternative to face-to-face simulation-based training. Therefore, we investigated the effect of a single telesimulation training in inexperienced providers. Methods: First-year medical students were recruited for this prospective observational study. Participants received a low-fidelity mannequin and medical equipment for training purposes. The one-hour telesimulation session was delivered by an experienced trainer and broadcast via a video conference tool, covering all elements of the neonatal resuscitation algorithm. After the telesimulation training, each student underwent a standardized simulated scenario at our Clinical Skills Center. Performance was video-recorded and evaluated by a single neonatologist, using a composite score (maximum: 10 points). Pre- and post-training knowledge was assessed using a 20-question questionnaire. Results: Seven telesimulation sessions were held, with a total of 25 students participating. The median performance score was 6 (5–8). The median time until the first effective ventilation breath was 30.0 s (24.5–41.0) and the median number of effective ventilation breaths out of the first five ventilation attempts was 5 (4–5). Neonatal resuscitation knowledge scores increased significantly. Conclusions: Following a one-hour telesimulation session, students were able to perform most of the initial steps of the neonatal resuscitation algorithm effectively while demonstrating notable mask ventilation skills.

Measurement of the lateral parapharyngeal wall has been shown to correlate with severity of obstructive sleep apnea, which is believed to increase risk of difficulty in mask ventilation (MV). This study aimed to assess the efficacy of using ultrasound to measure the lateral parapharyngeal wall thickness (LPWT) to predict the difficulty of MV. The LPWT was measured as the distance between the inferior border of the carotid artery and the lateral wall of the pharynx. Difficulty of MV was assessed according to an MV scale. A total of 92 patients were enrolled. Measurements of the LPWT ranged from 1.52 to 4.43 cm. There was a significant correlation between LPWT and difficulty of MV (P = 0.004). Every increase in 1 cm of LPWT was associated with an odds of increase in MV score of 3.17 (P < 0.05). With a cutoff of 3.5 cm, the area under the curve for LPWT was 0.67. The negative predictive value was 0.89, and the positive predictive value was 0.57. Use of point-of-care ultrasound to measure the LPWT shows promise in its ability to aid in airway management planning. Ultrasonic measurements of the LPWT have reasonable accuracy for predicting difficulty of MV. [ABSTRACT FROM AUTHOR]

A 77-year-old man with laryngeal cancer was scheduled for total laryngectomy and lymph node dissection surgery under general anesthesia. The patient did not present with airway obstruction signs, including dyspnea or wheezing sounds during spontaneous respiration, and the laryngeal opening could be easily identified on the fiberoptic bronchoscope examination preoperatively. Due to his poor cognition and cooperation, we decided not to try awake fiberoptic intubation. During the induction of general anesthesia, total airway obstruction occurred a few minutes after muscle relaxation. The patient could not be ventilated by mask ventilation; nevertheless, tracheal intubation using a conventional laryngoscope was performed without difficulty. It turned out that even a laryngeal mass that does not cause obstructive symptoms, not large in size or totally blocking the airway, can cause difficulty in mask ventilation.

Background: The two most common techniques for mask ventilation are CE and jaw thrust (JT) technique. However, few studies have validated their efficiency in terms of tidal volume (TV). Aims: This study aimed to compare the effectiveness of the CE technique and JT technique during pressure-controlled ventilation (PCV) by the mean of returned TV on apneic anesthetized adults. Design: This was a prospective, randomized cross over study. Settings: This study was conducted in a tertiary care hospital. Methods: Ethical Committee approval from our institution was taken (ss-1/EC 049/2017) and was registered in Clinical Trials Registry of India (CTRI/2018/04/012958). Sixty-five American Society of Anesthesiologists Physical Status classes I and II adult patients were enrolled in the study. After induction and muscle relaxation, mask ventilation was performed with CE and JT technique on PCV mode (Pinsp 15 cm H2O, respiratory rate 15) for 1 min each. The mean of returned TV of last 12 breaths, gastric insufflation, audible mask leak, and operator comfort in each technique were compared. Statistical Analysis: Statistical software namely IBM SPSS 22.0 and R environment version 3.2.2 (IBM Corp. SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA) were used for data analysis. Microsoft Excel was used to generate graphs and tables. Data were expressed as mean ± standard deviation for continuous variables and number (%) for categorical variables. Student's t-test (two tailed, independent) was used to find the significance of the study parameters on a continuous scale. Chi-square/Fisher's exact test was used to find the significance of the study parameters on a categorical scale between two or more groups. Results: There was a significant increase in mean TV generated by JT technique over CE technique (591.46 ± 140.27 mL vs. 544.59 ± 159.08 mL; P < 0.001). Gastric insufflation (12.9% vs. 14.5%) and mask leak (11.3% vs. 38.7%) were more in CE technique. Operator comfort (79% vs. 19.4%) was more in JT technique. Conclusion: A two-handed JT technique is more effective than a one-handed CE technique for mask ventilation in apneic anesthetized adults. [ABSTRACT FROM AUTHOR]

Background: Mask ventilation progressively improves after loss of consciousness during anesthesia induction possibly due to progression of muscle paralysis. This double-blinded randomized placebo-controlled study aimed to test a hypothesis that muscle paralysis improves mask ventilation during anesthesia induction. Methods: Forty-four adults patients including moderate to severe obstructive sleep apnea undergoing scheduled surgeries under elective general anesthesia participated in this study. Randomly-determined test drug either rocuronium or saline was blinded to the patient and anesthesia provider. One-handed mask ventilation with an anesthesia ventilator providing a constant driving pressure and respiratory rate (15 breaths per minute) was performed during anesthesia induction, and changes of capnogram waveform and tidal volume were assessed for one minute. The needed breaths for achieving plateaued-capnogram (primary variable) within 15 consecutive breaths were compared between the test drugs. Results: Measurements were successful in 38 participants. Twenty-one and seventeen patients were allocated into saline and rocuronium respectively. The number of breaths achieving plateaued capnogram did not differ between the saline (95% C.I.: 6.2 to 12.8 breaths) and rocuronium groups (95% C.I.: 5.6 to 12.7 breaths) (p = 0.779). Mean tidal volume changes from breath 1 was significantly greater in rocuronium group than saline group (95% C.I.: 0.56 to 0.99 versus 3.51 to 4.53 ml kg-IBW−1, p = 0.006). Significantly more patients in rocuronium group (94%) achieved tidal volume greater than 5 mg kg-ideal body weight−1 within one minute than those in saline group (62%) (p = 0.026). Presence of obstructive sleep apnea did not affect effectiveness of rocuronium for improvement of tidal volume during one-handed mask ventilation. Conclusions: Use of rocuronium facilitates tidal volume improvement during one-handed mask ventilation even in patients with moderate to severe obstructive sleep apnea. Trial registration: The clinical trial was registered at (05/12/2013, UMIN000012495): https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000014515 [ABSTRACT FROM AUTHOR]

Objective. Mask positive-pressure ventilation could lead to lung ventilation inhomogeneity, potentially inducing lung function impairments, when compared with spontaneous breathing. Lung ventilation inhomogeneity can be monitored by chest electrical impedance tomography (EIT), which could increase our understanding of mask ventilation-derived respiratory mechanics. We hypothesized that the two-handed mask holding ventilation technique resulted in better lung ventilation, reflected by respiratory mechanics, when compared with the one-handed mask holding technique. Approach. Elective surgical patients with healthy lungs were randomly assigned to receive either one-handed mask holding (one-handed group) or two-handed mask holding (two-handed group) ventilation. Mask ventilation was performed by certified registered anesthesiologists, during which the patients were mechanically ventilated using the pressure-controlled mode. EIT was used to assess respiratory mechanics, including ventilation distribution, global and regional respiratory system compliance (C RS), expiratory tidal volume (TVe) and minute ventilation volume. Hemodynamic parameters and the PaO2-FiO2 ratio were also recorded. Main results. Eighty adult patients were included in this study. Compared with spontaneous ventilation, mask positive-pressure ventilation caused lung ventilation inhomogeneity with both one-handed(global inhomogeneity index: 0.40 ± 0.07 versus 0.50 ± 0.15; P  < 0.001) and two-handed mask holding (0.40 ± 0.08 versus 0.50 ± 0.13; P  < 0.001). There were no differences in the global inhomogeneity index (P  = 0.948) between the one-handed and two-handed mask holding. Compared with the one-handed mask holding, the two-handed mask holding was associated with higher TVe (552.6 ± 184.2 ml versus 672.9 ± 156.6 ml, P  = 0.002) and higher global C RS (46.5 ± 16.4 ml/cmH2O versus 53.5 ± 14.5 ml/cmH2O, P  = 0.049). No difference in PaO2-FiO2 ratio was found between both holding techniques (P  = 0.743). Significance. The two-handed mask holding technique could not improve the inhomogeneity of lung ventilation when monitored by EIT during mask ventilation although it obtained larger expiratory tidal volumes than the one-handed mask holding technique. [ABSTRACT FROM AUTHOR]

Abstract Background Oropharyngeal airways are used both to facilitate airway patency during mask ventilation as well as conduits for flexible scope intubation, though none excel at both. A novel device, the Articulated Oral Airway (AOA), is designed to facilitate flexible scope intubation by active displacement of the tongue. Whether this active tongue displacement also facilitates mask ventilation, thus adding dual functionality, is unknown. This study compared the AOA to the Guedel Oral Airway (GOA) in regards to efficacy of mask ventilation of patients with factors predictive of difficult mask ventilation. The hypothesis was that the AOA would be non-inferior to the GOA in terms of expiratory tidal volumes by a margin of 1 ml/kg, thus demonstrating dual functionality. Methods In this randomized controlled clinical trial, fifty-eight patients with factors predictive of difficult mask ventilation were mask ventilated with both the GOA and the AOA. Video of the anesthetic monitors were evaluated by a blinded member of the research team, noting inspiratory and expiratory tidal volumes and expiratory CO2 waveforms. Results The AOA was found to be non-inferior to the GOA at a margin of 1 ml/kg with a mean weight-standardized expiratory tidal measurement 0.45 ml/kg lower (CI: 0.34–0.57) and inspiratory tidal measurement 0.109 lower (CI: − 0.26-0.04). There was no significant difference in expiratory waveforms (p = 0.2639). Conclusions The AOA was non-inferior to the GOA for mask ventilation of patients with predictors of difficult mask ventilation and there was no significant difference in EtCO2 waveforms between the groups. These results were consistent in the subset of patients who were initially difficult to mask ventilate. Trial registration ClinicalTrials.gov, NCT03144089 , May 2017.

Background: The head's position during mask ventilation on the time of anesthesia induction in children may improve the lung ventilation. Aim: Current study was designed to verify whether lateral head rotation improves face mask ventilation efficiency during anesthesia induction in children. Methods: Fifty-six patients aged 1-4 years, candidate for elective surgery, were randomly divided into two equal groups. During induction of general anesthesia, face mask lung ventilation of patients continued with pressure-controlled mode, at a peak pressure level of 10 cmH2O for children 13-24 months and 14cmH20 for children 24-48 month. In patients in the N group, the head position during ventilation was initially in the neutral position for one minute, then the head was axially rotated 45-degree to the right position for one minute and pulmonary ventilation continued in this position, then the head was rotated again to the neutral position and ventilation continued for one minute. In group R patients, mode and time of ventilation was the same, but the order of head placement was first in the lateral rotated to the right, then neutral and then lateral rotated to the right. The primary outcome was the measurement of expiratory tidal volume in each position. Results: Generally, the mean measured expiratory tidal volume did not change in the neutral position compared to laterally rotated head position, 256.6 vs. 233.5 ml: difference -23.1 [95% confidence interval: 10.8 to 39.4 ml]. Also, the change of head position from lateral to neutral position did not show a significant change in the mean expiratory tidal volume, 232.28 vs.247.86 ml: difference -15 .82 (p= 0.4). Conclusion: The rotation of the head to the lateral position during induction of anesthesia in apnoeic children 1-4 years old could not improve the efficiency of mask ventilation relative to the neutral head position.

Background: Intubation, laryngoscopy, and extubation are considered highly aerosol‐generating procedures, and additional safety protocols are used during COVID‐19 pandemic in these procedures. However, previous studies are mainly experimental and have neither analyzed staff exposure to aerosol generation in the real‐life operating room environment nor compared the exposure to aerosol concentrations generated during normal patient care. To assess operational staff exposure to potentially infectious particle generation during general anesthesia, we measured particle concentration and size distribution with patients undergoing surgery with Optical Particle Sizer. Methods: A single‐center observative multidisciplinary clinical study in Helsinki University Hospital with 39 adult patients who underwent general anesthesia with tracheal intubation. Mean particle concentrations during different anesthesia procedures were statistically compared with cough control data collected from 37 volunteers to assess the differences in particle generation. Results: This study measured 25 preoxygenations, 30 mask ventilations, 28 intubations, and 24 extubations. The highest total aerosol concentration of 1153 particles (p)/cm³ was observed during mask ventilation. Preoxygenations, mask ventilations, and extubations as well as uncomplicated intubations generated mean aerosol concentrations statistically comparable to coughing. It is noteworthy that difficult intubation generated significantly fewer aerosols than either uncomplicated intubation (p =.007) or coughing (p = 0.006). Conclusions: Anesthesia induction generates mainly small (<1 µm) aerosol particles. Based on our results, general anesthesia procedures are not highly aerosol‐generating compared with coughing. Thus, their definition as high‐risk aerosol‐generating procedures should be re‐evaluated due to comparable exposures during normal patient care. Implication Statement: The list of aerosol‐generating procedures guides the use of protective equipments in hospitals. Intubation is listed as a high‐risk aerosol‐generating procedure, however, aerosol generation has not been measured thoroughly. We measured aerosol generation during general anesthesia. None of the general anesthesia procedures generated statistically more aerosols than coughing and thus should not be considered as higher risk compared to normal respiratory activities. [ABSTRACT FROM AUTHOR]

Background: Two-handed mask ventilation techniques are often used in cases of difficult mask ventilation scenarios. A comparison of two methods of two-handed techniques in terms of tidal volume was undertaken in the context of the obese population. Aims and Objectives: To determine and compare the effectiveness of mask ventilation in obese Indian adult subjects by using either the C-E technique or the V-E technique after induction of general anaesthesia. Material and Methods: This was a randomised interventional study conducted on eighty obese patients. They were randomized into Group A ventilated with C-E technique and Group B with V-E technique. Expired tidal volume (VTe), Peak inspiratory pressure (PIP), SpO2, EtCO2 and vital signs were noted. Results: The BMI and hemodynamic parameters were comparable between the two groups. The expired tidal volume of 702 ± 77 mL with the V-E technique was significantly more than the C-E technique, which was 492 ± 71 mL. The ventilatory failure rate with the C-E technique was 15% and 0% with the V-E technique. There was no significant difference between the peak airway pressures for the two techniques: 20.3 ± 1.5 mm H2O for Group A and 20.5 ± 1.2 mm H2O for Group B. Conclusions: Mask ventilation with the two-handed V-E technique is associated with better tidal volumes and reduced failure rates in the obese population. So the V-E technique should be attempted first as a rescue measure in obese adult patients if the return of spontaneous breathing and tracheal intubation is impossible. [ABSTRACT FROM AUTHOR]

Background and Aims: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. Material and Methods: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed. Results: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). Conclusion: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.

Aim:The aim of our study was to evaluate specific factors in predicting difficult mask ventilation (DMV) in obese patients undergoing elective surgery.Methods:This prospective and observational study was performed in 90 obese patients. We assessed age, height, weight, sex, body mass index (BMI), dental structure, presence of facial hair, modified Mallampati test result, mouth opening, thyromental distance (TMD), sternomental distance, mandibular protrusion, mandibular length, neck circumference (NC), neck length, upper lip bite test result, height to TMD ratio, NC to TMD ratio (NC/TMD), and history of snoring and Obstructive Sleep Apnea syndrome for estimation of DMV.Results:The mean age of the patients was 40.9±9.4 years and the mean BMI was 44.7±6.2 kg/m2. Of all patients 38.9% were determined to have DMV. Clinical variables associated with DMV were male gender, mandibular length, snoring, NC, and NC/TMD. Multiple logistic regression analysis showed that male gender (p=0.047) and snoring (p=0.02) were independent factors.Conclusion:We believe that NC/TMD and ML are predictive tests for DMV in obese patients. Tests and measurements at the bedside are not sufficient alone and we believe that they will be more reliable when considered together.

Background: The neutral or sniffing position is advised for mask ventilation in neonates to avoid airway obstruction. As definitions are manifold and often unspecific, we wanted to investigate the reliability and reproducibility of angle measurements based on facial landmarks that may be used in future clinical trials to determine a hypothetical head position with minimal airway obstruction during mask ventilation. Methods: In a prospective single‐center observational study, 2D sagittal photographs of 24 near‐term and term infants were taken, with five raters marking facial landmarks to assess interobserver agreement of those landmarks and angle δ, defined as the angle between the line parallel to the lying surface and the line crossing Subnasale (Sn) and Porion' (P'). Angle δ was assessed in sniffing (δsniff) and physiologic (δphys) head position, the former based on a published, yet poorly defined head position where the tip of the nose aligns to the ceiling with the head in a supine, relaxed mid‐position. Results: Infants had a mean (SD) gestational age of 37.3 (2.3) weeks. Angle δ could be determined in all 48 images taken in either the sniffing or the physiological head position. Interobserver correlation coefficient was 98.6 for all measurements independent of head position. Angle δsniff was 90.5° (5.7) in the sniffing position. Conclusions: This study provides a new measuring technique using an angle that is reproducible and reliable and may be used in future studies to correlate head position with airway obstruction. [ABSTRACT FROM AUTHOR]

Background: Oropharyngeal airways are used both to facilitate airway patency during mask ventilation as well as conduits for flexible scope intubation, though none excel at both. A novel device, the Articulated Oral Airway (AOA), is designed to facilitate flexible scope intubation by active displacement of the tongue. Whether this active tongue displacement also facilitates mask ventilation, thus adding dual functionality, is unknown. This study compared the AOA to the Guedel Oral Airway (GOA) in regards to efficacy of mask ventilation of patients with factors predictive of difficult mask ventilation. The hypothesis was that the AOA would be non-inferior to the GOA in terms of expiratory tidal volumes by a margin of 1 ml/kg, thus demonstrating dual functionality. Methods: In this randomized controlled clinical trial, fifty-eight patients with factors predictive of difficult mask ventilation were mask ventilated with both the GOA and the AOA. Video of the anesthetic monitors were evaluated by a blinded member of the research team, noting inspiratory and expiratory tidal volumes and expiratory CO2 waveforms. Results: The AOA was found to be non-inferior to the GOA at a margin of 1 ml/kg with a mean weight-standardized expiratory tidal measurement 0.45 ml/kg lower (CI: 0.34–0.57) and inspiratory tidal measurement 0.109 lower (CI: − 0.26-0.04). There was no significant difference in expiratory waveforms (p = 0.2639). Conclusions: The AOA was non-inferior to the GOA for mask ventilation of patients with predictors of difficult mask ventilation and there was no significant difference in EtCO2 waveforms between the groups. These results were consistent in the subset of patients who were initially difficult to mask ventilate. Trial registration: ClinicalTrials.gov, NCT03144089, May 2017. [ABSTRACT FROM AUTHOR]

Background and Aims: Supraglottic airway devices (SGAs) are used to rescue difficult and failed mask ventilation (DMV). We aimed to use the SGA as first-line device, prior to obtaining a definitive airway and to find any predictors of difficulty for the same, in the morbidly obese patients. Material and Methods: Obese surgical patients [body mass index (BMI) >35 kg/m2] were investigated. Difficulties with bag mask ventilation (MV) was graded using the following scale: MV-1, one anesthesiologist unassisted could achieve MV and maintain SpO2 >90%; MV-2, one additional anesthesiologist was needed to facilitate MV to achieve SpO2> 90%; MV-3, two additional anesthesiologists were needed for this purpose; and MV-3P, when a supraglottic device was required to ventilate and maintain SpO2more than 90%. Parameters studied were age, gender, neck circumference (NC), BMI, STOPBANG score, and safe apnea time (SAT). Results: Logistic regression was performed for predictors of MV-3P; receiver operating characteristic curve was used to locate the best cut-off. Analysis of 834 morbidly obese patients revealed an incidence of MV 1/2/3/3-P as 16%/38%/27%/19%, respectively. DMV was associated with BMI ≥50 kg/m2, NC ≥49.5 cm, and STOPBANG ≥6; P < 0.001. The mean SAT for a population with mean BMI 48 ± 8 kg/m2 was 256 ± 66 s. The SAT showed inverse relation to BMI and NC. As per our results, the NC was the single most important predictor of MV-3P, with sensitivity 0.62 and specificity 0.85 at best cut-off 49.5 cm; P < 0.001. Conclusion: NC ≥49.5 cm is strongly associated with low SAT and need for SGA to achieve MV. SGA may provide safety for initial management following induction of anesthesia in this patient population.

Abstract Background and objectives Nerve injury following mask ventilation is a rare but serious anesthetic complication. The majority of reported cases are associated with excessive pressure applied to the face mask, long duration of mask ventilation, excessive digital pressure behind the mandible to relieve airway obstruction and pressure exerted by the plastic oropharyngeal airway. Case report We present a case of bilateral mandibular nerve injury following mask ventilation with short duration, most likely due to a semi-silicone facemask with an over-inflated cushion. Conclusion An over-inflated sealing cushion of a facemask may trigger difficult mask ventilation leading to mandibular nerve injury following mask ventilation. Alternative airway management techniques such as laryngeal mask airway should be considered when airway maintenance can only be achieved with strong pressure applied to the facemask and/or mandible.

A 42-year-old female patient suffered an infranuclear hypoglossal nerve paresis with right-sided swelling and weakness of the tongue following a short duration mask anesthesia for a follicle puncture. This resulted in dysarthria and dysphagia persisting for more than 3 months. A return to work was initially impossible. Etiopathogenetically, a mechanical compression of the peripheral hypoglossal nerve by positioning or reclination during mask ventilation is discussed. Conclusion for clinical practice: In order to protect against lesions of the hypoglossal nerve, the pre-anaesthesiological examination should ask specifically about cervical problems as an indication of individual sensitivity to reclination. In such cases, special attention should be paid to careful patient positioning. Even shorter periods of reclination or compression of the soft tissues of the neck can result in lesions, therefore tolls such as a Wendl or Guedel tube should be used accordingly. [ABSTRACT FROM AUTHOR]

Objectives: Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.Design: A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.Setting: Forty-six international PICUs.Patients: Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.Interventions: None.Measurements and Main Results: The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).Conclusions: Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies. [ABSTRACT FROM AUTHOR]

After induction, but before intubation, many general anesthesia patients are manually bag-mask ventilated. The objective of this study was to determine the efficacy of bag-mask ventilation (MkV) of an anesthetized patient versus mask ventilation using a noninvasive ventilator (NIV). We hypothesized that feedback-controlled, mask ventilation via NIV is more efficacious and safer. This critical short period of time in the operating room was chosen to compare MkV versus NIV. 30 ASA I-III patients, aged 18-74, presenting for elective surgery under general anesthesia were enrolled in the study. Patients were ventilated first with MkV and then with NIV. One minute of ventilation data was collected for each method. Respiratory inductance plethysmography (RIP) bands around the chest and abdomen were used to measure tidal volumes and breath rates for each method of ventilation. The NIV was set to deliver 10 breaths per minute with 12 cmH2O of pressure support. A non-inferiority test was used to compare MkV and NIV. MkV breaths had an average of 13 breaths and tidal volume of 364 mL (SD 145 mL). NIV resulted in an average of 10 breaths and tidal volume of 552 mL, i.e., 188 mL more than MkV (lower bound of the 95% confidence interval equal to 120 mL). The hypothesis of non-inferiority at the - 100 mL level and the superiority hypothesis at the + 100 mL level was accepted. NIV also resulted in much more consistent ventilation rates (zero variation since it is controlled by the ventilator) when compared to manual ventilation while maintaining safe airway pressures (8 cmH2O EPAP and 20 cmH2O IPAP). Feedback controlled mask ventilation via a NIV is a viable alternative to MkV. It can deliver more optimal tidal volumes with the operator utilizing only one hand. The airway pressures are fixed at safe limits during a period where the goal is to reach a maximal level of oxygenation prior to intubation. Over-ventilation or over-pressurization of the airway is not a concern with NIV since the pressures are maintained well within safe thresholds to avoid injury. [ABSTRACT FROM AUTHOR]

Objective: With inappropriately large facemasks, it is more difficult to create a seal on the face, potentially leading to ineffective ventilation during neonatal stabilisation. We investigated whether commonly available round facemasks are of appropriate size by measuring facial dimensions in near-term and term infants using two-dimensional (2D) and three-dimensional (3D) images.Design: Prospective single-centre observational study.Setting: Infants born in our centre at 34-41 weeks' gestation were eligible.Intervention: Patients were photographed with 2D and 3D technique.Main Outcome Measures: Distances between nasion and gnathion were measured and compared with the outer diameter of various round facemasks.Methods: 2D and 3D images were performed using standard equipment. Correlations between gestational age and the above-mentioned distances were assessed using Pearson's r.Results: Images were taken from 102 infants with a mean (SD) gestational age of 37.9 (2.3) weeks. Mean distance between nasion and gnathion was 46.9 mm (5.1) in 2D and 49.9 mm (4.1) in 3D images, that is, on average 3 mm smaller in 2D than with 3D (p<0.01). Based on these measurements, round facemasks with an external diameter of 50 mm seemed fitting for most (61%) term infants and 42 mm masks for most (72%) near-term infants (GA 34-36 weeks).Conclusions: Round facemasks with an external diameter of 60 mm are too large for almost all newborn infants, while 42/50 mm round facemasks are well fitting. Important anatomical structures were only visible using 3D images.Clinical Trial Registration Number: NCT03369028. [ABSTRACT FROM AUTHOR]

This study aimed to assess the technique of using transesophageal echocardiography (TEE) to detect gastric inflation and to determine the optimal level of inspiratory pressure during face mask ventilation (FMV). In this prospective and randomized trial, seventy-five adults scheduled for cardiac surgery were enrolled to one of the three groups (P12, P15, P20) defined by the applied inspiratory pressure during FMV. After induction, mask ventilation was performed with the corresponding level of pressure-control ventilation for 2 min in each patient. Respiratory and hemodynamic parameters were recorded every 15 s. Arterial blood gases were tested before induction and at the time of intubation. Gastric cross-section area was detected using transesophageal echocardiography after intubation. The gastric cross-section areas were 3.1 ± 0.81, 3.8 ± 1.37 and 4.8 ± 2.29 cm2 respectively. It statistically increased in group P20 compared with group P12 and P15. PaCO2 before intubation statistically increased compared with the baseline in groups P12 and P15, while decreased in group P20. The mean values of PaCO2 equaled to 44.4 mmHg (40-51.5), 42.9 mmHg (34-50.5) and 36.9 mmHg (30.9-46) respectively in three groups. Peak airway pressure of 12-20 cmH2O could provide acceptable sufficient ventilation during mask ventilation, but 20 cmH2O result in higher incidence of gastric inflation. TEE is useful to detect the gastric inflation related to the entry of air into the stomach during pressure-controlled face mask ventilation.Trial Registration Number ChiCTR-IOR-14005325. [ABSTRACT FROM AUTHOR]

A 77-year-old man with laryngeal cancer was scheduled for total laryngectomy and lymph node dissection surgery under general anesthesia. The patient did not present with airway obstruction signs, including dyspnea or wheezing sounds during spontaneous respiration, and the laryngeal opening could be easily identified on the fiberoptic bronchoscope examination preoperatively. Due to his poor cognition and cooperation, we decided not to try awake fiberoptic intubation. During the induction of general anesthesia, total airway obstruction occurred a few minutes after muscle relaxation. The patient could not be ventilated by mask ventilation; nevertheless, tracheal intubation using a conventional laryngoscope was performed without difficulty. It turned out that even a laryngeal mass that does not cause obstructive symptoms, not large in size or totally blocking the airway, can cause difficulty in mask ventilation. [ABSTRACT FROM AUTHOR]

Frontonasal encephalocele is a rare anatomical variant of the meningoencephalocele. Peri-operative anesthesia concerns involve anticipated difficult mask ventilation as well as surgical complications such as compression and rupture of meningoencephalocele. The compression of encephalocele is associated with raised intracranial pressure (ICP) and even rupture of overlying skin leading to cerebrospinal fluid leak, hemorrhage, exposure of underlying frontal lobe, meningitis, seizures, and even death. We report a case of 6-year-old female presenting with rare variant of frontonasal encephalocele for bifrontal craniotomy, excision of encephalocele, and repair. Difficult mask ventilation was anticipated, and patient airway was managed with use of size 4 anatomical mask. [ABSTRACT FROM AUTHOR]

Background Bag-mask ventilation is an essential life-saving skill. The E-C technique of mask holding is the most popular. In patients with suspected cervical injury, the jaw thrust maneuver is recommended instead of the E-C technique with head tilt-chin lift. Should jaw thrust fail to produce adequate chest rise, the operator is advised to switch to the E-C technique with the head tilt-chin lift maneuver with head extension as it is vital to move oxygen into the lungs. We hypothesized that the E-C clamp with the head in the neutral position without head tilt might permit adequate ventilation without producing excessive movement of the cervical spine, which in turn might translate as less strain to the cervical spine. Methods In this prospective, randomized, double-blind, crossover study, we evaluated the relative efficacy of three airway maneuvers in opening the airway in anesthetized and paralyzed adults: jaw thrust, two-handed E-C technique with head in the neutral position, and two-handed E-C technique with head fully extended. The tidal volume generated during mechanical ventilation using these three techniques was considered as the primary outcome. Seventy-two subjects were recruited for this trial and all three techniques of mask holding were performed in each of these subjects in a sequence as dictated by a randomization table. Results The jaw thrust technique provided a mean tidal volume significantly higher than the two-handed E-C technique, with the head in the neutral position (p<0.001). Similarly, the two-handed E-C technique with the head fully extended provided a mean tidal volume significantly higher than the two-handed E-C technique with the head in neutral position (p<0.011). The mean tidal volume obtained with jaw thrust and two-handed E-C technique with head fully extended were comparable (p=0.78). Conclusion The two-handed E-C technique with the head fully extended, and the jaw thrust technique both produce good and comparable tidal volumes. The two-handed E-C technique with the head in a neutral position provides adequate though lower tidal volumes as compared to the other two techniques., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Ramakkannu et al.)