Bag-mask ventilation in rapid sequence induction


We read with interest Koerber et al.’s [1] survey on modifications to the traditional technique of rapid sequence induction. It would be interesting to ask a question about a further modification: the use of bag-mask ventilation after administration of drugs yet prior to intubation.

Traditional and current teaching avoids any positive pressure ventilation after drug administration for fear of gastric insufflation, and the increased hazard of regurgitation and pulmonary aspiration [2]. Some texts however are more circumspect, notably Miller, who references Sellick’s original paper which states ‘during cricoid pressure the lungs may be ventilated by intermittent positive pressure without risk of gastric distention’ [3, 4].

There is evidence that significant gastric insufflation is unlikely to occur during positive pressure ventilation with correctly applied cricoid pressure [5–7]. We feel that the traditional teaching is potentially detrimental in certain patient subgroups, notably those with high oxygen consumption and/or low functional residual capacity where pre-oxygenation is less effective. Indeed many paediatric anaesthetists, intensivists and emergency physicians will regularly ventilate during a rapid sequence induction for this very reason [8].

We feel that in such subgroups gentle bag-mask ventilation early in the sequence, can not only prevent significant desaturation, but also gives additional time should a difficult intubation result. This may be of increasing relevance with the rising popularity, demonstrated by Koerber [1], of rocuronium in modified rapid sequence. The time taken between administering drugs and achieving good intubating conditions is arguably longer and the end point less defined than with suxamethonium, increasing the period of time in which hypoxia may intervene. Successful bag-mask ventilation also reassures the practitioner that, in the event of a failed intubation, ventilation and oxygenation are possible, in accordance with the Difficult Airway Society algorithms [9].

Gentle ventilation during rapid sequence induction is, as most things in anaesthetics, a balance of risks (aspiration) and benefits (preventing desaturation). Given the available evidence, routine exclusion of ventilation from a rapid sequence induction does not seem justified. Indeed it may have significant advantages in many patient sub-groups. Anecdotally, this technique is increasing in our region, something we plan to investigate more formally.