Management of Difficult Mask Ventilation

Immediate Technical Optimization

The American Society of Anesthesiologists recommends ensuring adequate depth of anesthesia to prevent laryngospasm and optimize airway muscle relaxation, as inadequate depth is a common correctable cause of difficult mask ventilation 3, 4
Optimizing head and neck positioning to the "sniffing" position (head extension with neck flexion) can improve mask ventilation 5, 6
Releasing or reducing cricoid pressure if applied can help improve mask seal and reduce airway obstruction 7, 8

The Difficult Airway Society recommends summoning assistance (technical support and/or senior anesthesiologist) before the situation becomes critical, to prevent progression to cannot-intubate-cannot-ventilate scenarios 2, 9, 10
Maintaining adequate depth of anesthesia using rapidly reversible agents (propofol infusion or volatile anesthetic) can optimize conditions for both mask ventilation and potential intubation attempts 3
Supraglottic airways are the recommended first-line rescue for failed mask ventilation in the planned intubation setting, according to the American Society of Anesthesiologists 1, 2, 4, 9, 10

The American Society of Anesthesiologists advises against performing multiple intubation attempts while oxygenation is failing, as this causes progressive airway trauma, edema, and bleeding that eliminates the ability to ventilate 8
Allowing inadequate depth of anesthesia can cause laryngospasm and poor airway muscle relaxation, making mask ventilation impossible, as noted by the American Society of Anesthesiologists 3, 4, 7

The American Heart Association recommends administering succinylcholine immediately if laryngospasm develops during difficult mask ventilation, rather than waiting for propofol to wear off or giving additional propofol 7

The American Society of Anesthesiologists suggests limiting intubation attempts to a maximum of 2-3 attempts to avoid progressive airway trauma and edema 2, 9, 10, 8
Using videolaryngoscopy as a second-line intubation technique if direct laryngoscopy fails and mask ventilation is possible is recommended by the American Society of Anesthesiologists 3
Having a gum elastic bougie immediately available for all intubation attempts is advised by the American Society of Anesthesiologists 1, 2, 4, 9, 10