PERIOPERATIVE MEDICINE Anesthesiology 2010; 112:1190 –3 Copyright © 2010, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins Face Mask Ventilation in Edentulous Patients A Comparison of Mandibular Groove and Lower Lip Placement Ste ´ phane X. Racine, M.D., Ph.D.,* Audrey Solis, M.S.,† Nora Ait Hamou, M.S.,† Philippe Letoumelin, M.D.,‡ David L. Hepner, M.D.,§ Sadek Beloucif, M.D., Ph.D., Christophe Baillard, M.D., Ph.D. ABSTRACT Background: In edentulous patients, it may be difficult to perform face mask ventilation because of inadequate seal with air leaks. Our aim was to ascertain whether the “lower lip” face mask placement, as a new face mask ventilation method, is more effective at reducing air leaks than the standard face mask placement. Methods: Forty-nine edentulous patients with inadequate seal and air leak during two-hand positive-pressure ventilation using the ven- tilator circle system were prospectively evaluated. In the presence of air leaks, defined as a difference of at least 33% between inspired and expired tidal volumes, the mask was placed in a lower lip posi- tion by repositioning the caudal end of the mask above the lower lip while maintaining the head in extension. The results are expressed as mean  SD or median (25th–75th percentiles). Results: Patient characteristics included age (71  11 yr) and body mass index (24  4 kg/m 2 ). By using the standard method, the median inspired and expired tidal volumes were 450 ml (400 –500 ml) and 0 ml (0 –50 ml), respectively, and the median air leak was 400 ml (365– 485 ml). After placing the mask in the lower lip position, the median expired tidal volume increased to 400 ml (380 – 490), and the median air leak decreased to 10 ml (0 –20 ml) (P  0.001 vs. stan- dard method). The lower lip face mask placement with two hands reduced the air leak by 95% (80 –100%). Conclusions: In edentulous patients with inadequate face mask ventilation, the lower lip face mask placement with two hands mark- edly reduced the air leak and improved ventilation. M ASK ventilation is an essential component of airway management during anesthesia. 1,2 Difficult mask ventilation (DMV) may lead to complex situations with po- tential serious adverse outcomes. 3 The underlying pathogen- esis of DMV is not fully understood. Upper airway obstruc- tion and air leaks may promote inadequate mask seal and contribute to this problem. 1,4 The mechanisms and the suit- able approaches to overcome airway obstruction or air leak have been previously investigated. The jaw thrust and inser- tion of an oropharyngeal airway device prevent the backward fall of the tongue, a well-known cause of airway obstruc- tion. 1,4,5 Liang et al. 6 recently showed the effectiveness of nasal ventilation in reducing airway obstruction compared with oral-nasal ventilation. An air leak is usually observed when an adequate seal cannot be achieved, a situation en- countered mainly in edentulous patients with a beard. Both lack of teeth and a beard are known risk factors for DMV. 7–9 In edentulous patients, the air leak is the result of a reduced contact between the cheeks and the mask. Elderly patients are more likely to be edentulous and require general anesthe- sia. Some have proposed not to remove dentures before in- duction of anesthesia. 8 A supraglottic airway is another op- tion, which is successful in most cases when dealing with DMV. 10 In addition, Crooke 11 showed that placing the cau- dal end of the mask between the inferior lip and the alveolar ridge reduces air leak because a good seal forms around a significant part of the mask. We have observed in clinical practice that a similar approach may be effective, but to our knowledge, it has never been investigated. We named this method the “lower lip” face mask placement, a noninvasive * Staff Anesthesiologist, † Medical Student,  Professor, Depart- ment of Anesthesiology and Critical Care Medicine, ‡ Statistician, Public Health Unit, School of Medicine, Avicenne Hospital, Paris 13 University–Assistance Publique-Hôpitaux de Paris, Bobigny, France. § Assistant Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Med- ical School, Boston, Massachusetts. Received from the Department of Anesthesiology and Critical Care Medicine, Avicenne Hospital, Paris 13 University–Assistance Publique-Hôpitaux de Paris, Bobigny, France. Submitted for publi- cation April 8, 2009. Accepted for publication December 28, 2009. Support was provided solely from institutional and/or departmental sources. Address correspondence to Prof. Baillard: Department of An- esthesiology and Critical Care Medicine, Avicenne University Hospital, 125, Route de Stalingrad, Bobigny 93009, France. christophe.baillard@avc.aphp.fr. Information on purchasing re- prints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. ANESTHESIOLOGY’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue. What We Already Know about This Topic ❖ Mask ventilation can be difficult in edentulous patients be- cause of failure to obtain a good mask seal on the face What This Article Tells Us That Is New ❖ In 49 edentulous patients with difficult mask ventilation after induction of anesthesia, repositioning of the caudal end of the mask above the lower lip while maintaining neck extension significantly improved ventilation as measured by reduced air leak and increased expiratory volume Anesthesiology, V 112 • No 5 1190 May 2010 Downloaded from anesthesiology.pubs.asahq.org by guest on 06/04/2020