Mask Ventilation

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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Joshua H. Atkins, MD, PhD Joshua H. Atkins, MD, PhD

Associate Professor
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
| Acknowledgements Acknowledgements

Jeremy D. Kukafka, MD
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Infraclavicular Nerve Block: Ultrasound-Guided Technique
Intercostal Nerve Block: Ultrasound-Guided Technique
Intraoperative Transesophageal Echocardiography
Psoas Compartment Block: Ultrasound-Guided Technique
Supraclavicular Nerve Block: Ultrasound-Guided Technique

Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA


To deliver supplemental oxygen and assisted ventilation in patients with compromised airway function. Examples include:

  • Induction of general anesthesia
  • Patients with partial mechanical or functional airway obstruction
  • Patients with respiratory failure requiring mechanical assistance
  • Patients with pharmacologically-induced respiratory failure (e.g., narcotic overdose)
  • As a bridge to more definitive airway control, such as placement of a laryngeal mask airway, endotracheal tube, or tracheostomy

All contraindications to mask ventilation are relative. In clinical circumstances where mask ventilation is indicated, the need to deliver oxygen and to support ventilation usually outweighs the risks.

  • Full stomach, bowel obstruction, or other clinical condition increasing risk of aspiration
  • Major facial trauma
  • Anticipated difficult ventilation due to anatomic features
  • Bronchial or other major airway disruption
  • Tracheoesophageal fistula
  • Face mask
  • Disposable oral/nasal airways
  • Disposable tongue blade
  • Anesthesia machine with circuit, Mapleson bag-valve circuit, or resuscitation (Ambu) bag
  • Oxygen supply
  • Suction apparatus

Mask ventilation involves the entire anatomy of the upper airway including nasal passages. A working familiarity with the anatomy of the nasopharynx, oropharynx, velopharynx (soft palate) and hypopharynx will facilitate skill development with this technique. Upper airway obstruction is most likely to occur in the region of the velopharynx. Airway obstruction in this area is exacerbated by the supine position, neck flexion, and decreased pharyngeal muscle tone due to loss of consciousness, neurological injury or the presence of muscle relaxants. In the supine position, the tongue falls backwards across the airway accompanied by soft palate collapse, enhancing obstruction. The sniffing position (lower cervical flexion, upper cervical extension with full extension of head on neck) combined with a jaw thrust and chin lift is likely to be the optimum initial position for mask ventilation. Oral and nasal airway devices lift the tongue off the posterior pharyngeal wall and hold posterior airway structures open, and may provide a conduit for effective mask ventilation in the unconscious patient. Anatomic features associated with difficult mask ventilation include edentulousness, obesity, limited jaw mobility, the presence of a beard or other perioral facial hair, some congenital syndromes, and some pathological states.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
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  • Clinical pearls providing practical clinical tips from medical experts
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  • Links to medical evidence and related procedures


In most cases mask ventilation is either followed by another airway management procedure, such as endotracheal intubation or LMA placement, or is carried out until resumption of spontaneous respiration.

  • Common:
    • Skin irritation from mask seal
  • Uncommon:
    • Pressure-related trauma to the face from excessive mask pressure, including mylohyoid neurapraxia and numb chin
    • Hypotension from excessive tidal volume/pressure during ventilation
    • Bleeding from oral/nasal airway placement
  • Rare:
    • Pulmonary barotrauma if excessive peak pressures are used
    • Insufflation of gastric contents with air, resulting in regurgitation and aspiration
    • Jaw dislocation from excessive force on the angle of the mandible during subluxation
  • Predictors of difficult mask ventilation have been shown to include presence of a beard, body-mass index >26 kg/m2, history of regular snoring, edentulousness, and age >55.
  • Leaving dentures in during mask ventilation has been shown to improve efficacy by over 50%.
  • Ventilator-assisted mask ventilation has been shown to be associated with a significant reduction in peak inspiratory pressures. Research regarding risks and efficacy of ventilatory assisted mask ventilation continues.
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