Journal of Anesthesia

, Volume 27, Issue 1, pp 152–156 | Cite as

How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction?

  • Yumi Sato
  • Aya Ikeda
  • Teruhiko Ishikawa
  • Shiroh IsonoEmail author
JA Symposium


S. Isono

Recent evidence suggests the possible development of difficult mask ventilation in patients with obstructive sleep apnea. Based on our current understanding of the pathophysiology of pharyngeal airway obstruction in obstructive sleep apnea patients, we conclude that anesthesiologists can decrease respiratory complications during anesthesia induction by conducting careful pre-induction preparations, including body and head positioning and sufficient preoxygenation, and by using the two-hand mask ventilation technique with effective airway maneuvers and appropriate ventilator settings while continuously assessing ventilation status with capnography.


Obstructive Sleep Apnea Continuous Positive Airway Pressure Obstructive Sleep Apnea Patient Difficult Airway Anesthesia Induction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This work was carried out in the Department of Anesthesiology, Graduate School of Medicine, Chiba University and was supported by grant-in-aid No. 24390363 from the Ministry of Education, Culture, Sports, Science and Technology, Tokyo, Japan.


  1. 1.
    Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000;92:1229–36.PubMedCrossRefGoogle Scholar
  2. 2.
    Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.PubMedCrossRefGoogle Scholar
  3. 3.
    Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110(4):891–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology. 2009;110(4):908–21.PubMedCrossRefGoogle Scholar
  5. 5.
    Isono S, Remmers JE, Tanaka A, Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol. 1997;82:1319–26.PubMedGoogle Scholar
  6. 6.
    Isono S. Optimal combination of head, mandible and body positions for pharyngeal airway maintenance during perioperative period: lesson from pharyngeal closing pressures. Semin Anesth. 2007;26:83–93.Google Scholar
  7. 7.
    Campbell IT, Beatty PC. Monitoring preoxygenation. Br J Anaesth. 1994;72(1):3–4.PubMedCrossRefGoogle Scholar
  8. 8.
    Cressey DM, Berthoud MC, Reilly CS. Effectiveness of continuous positive airway pressure to enhance pre-oxygenation in morbidly obese women. Anaesthesia. 2001;56(7):680–4.PubMedCrossRefGoogle Scholar
  9. 9.
    Tagaito Y, Isono S, Tanaka A, Ishikawa T, Nishino T. Sitting posture decreases collapsibility of the passive pharynx in anesthetized paralyzed patients with obstructive sleep apnea. Anesthesiology. 2010;113(4):812–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Isono S, Tanaka A, Ishikawa T, Tagaito Y, Nishino T. Sniffing position improves pharyngeal airway patency in anesthetized patients with obstructive sleep apnea. Anesthesiology. 2005;103(3):489–94.PubMedCrossRefGoogle Scholar
  11. 11.
    Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology. 1991;75:1087–110.PubMedCrossRefGoogle Scholar
  12. 12.
    Gozal D, Burnside MM. Increased upper airway collapsibility in children with obstructive sleep apnea during wakefulness. Am J Respir Crit Care Med. 2004;169:163–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Tagaito Y, Isono S, Remmers JE, Tanaka A, Nishino T. Lung volume and collapsibility of the passive pharynx in patients with sleep-disordered breathing. J Appl Physiol. 2007;103:1379–85.PubMedCrossRefGoogle Scholar
  14. 14.
    Joffe AM, Hetzel S, Liew EC. A two-handed jaw-thrust technique is superior to the one-handed “EC-clamp” technique for mask ventilation in the apneic unconscious person. Anesthesiology. 2010;113(4):873–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Amathieu R, Combes X, Abdi W, Housseini LE, Rezzoug A, Dinca A, Slavov V, Bloc S, Dhonneur G. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach™): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology. 2011;114(1):25–33.PubMedCrossRefGoogle Scholar
  16. 16.
    Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011;66(3):163–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Goodwin MW, Pandit JJ, Hames K, Popat M, Yentis SM. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs. Anaesthesia. 2003;58(1):60–3.PubMedCrossRefGoogle Scholar
  18. 18.
    Ikeda A, Isono S, Sato Y, Yogo H, Sato J, Ishikawa T, Nishino T. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway anatomy. Anesthesiology. 2012;117(3):487–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration; airway obstruction during manual and mouth-to-mouth artificial respiration. J Am Med Assoc. 1958;167(3):335–41.PubMedCrossRefGoogle Scholar
  20. 20.
    Isono S, Tanaka A, Tagaito Y, Ishikawa T, Nishino T. Influences of head positions and bite opening on collapsibility of the passive pharynx. J Appl Physiol. 2004;97(1):339–46. Epub 2004 Mar 12.PubMedCrossRefGoogle Scholar
  21. 21.
    Isono S, Tanaka A, Sho Y, Konno A, Nishino T. Advancement of the mandible improves velopharyngeal airway patency. J Appl Physiol. 1995;79(6):2132–8.PubMedGoogle Scholar
  22. 22.
    Isono S, Tanaka A, Tagaito Y, Sho Y, Nishino T. Pharyngeal patency in response to advancement of the mandible in obese anesthetized persons. Anesthesiology. 1997;87(5):1055–62.PubMedCrossRefGoogle Scholar
  23. 23.
    Buffington CW, Wells CMQ, Soose RJ. Expiratory upper airway obstruction caused by the soft palate during bag-mask ventilation. Open J Anesthesiol. 2012;2:38–43.CrossRefGoogle Scholar
  24. 24.
    Isono S. One hand, two hands, or no hands for maximizing airway maneuvers? Anesthesiology. 2008;109(4):576–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Jiang Y, Bao FP, Liang Y, Kimball WR, Liu Y, Zapol WM, Kacmarek RM. Effectiveness of breathing through nasal and oral routes in unconscious apneic adult human subjects: a prospective randomized crossover trial. Anesthesiology. 2011;115(1):129–35.PubMedCrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2012

Authors and Affiliations

  • Yumi Sato
    • 1
  • Aya Ikeda
    • 1
  • Teruhiko Ishikawa
    • 1
  • Shiroh Isono
    • 1
    Email author
  1. 1.Department of Anesthesiology, Graduate School of MedicineChiba UniversityChuo-ku, ChibaJapan

Personalised recommendations