You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.
What is the problem?
Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.
What are the choices of grip?
- One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
- Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
- Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.
Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?
Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.
What happens when A is higher than M?
When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.
What is a better way?
JAW THRUST MASK GRIP
The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.
Is there anything else that will help?
NASAL AND ORAL AIRWAYS
Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.
Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.
TAKE HOME POINTS
-Use the jaw thrust mask grip technique for ventilation
-Good mask ventilation is a crucial airway skill. Invest in it.
-If you are have ANY trouble, place nasal and oral airways
Efficacy of facemask ventilation techniques in novice providers.
Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.
J Clin Anesth. 2013;25:193-7