Not too long ago, safety in airway management hinged on two pillars of safety: the first was the ability to mask ventilate, and the second was cricoid pressure (CP).
The ability to mask ventilate was perceived to be a required first step in elective airway management before giving muscle relaxants. Multiple anesthesia studies have now shown that muscle relaxation correlates with improvement in mask ventilation, not collapse of the airway as many of us were taught. Warters et al. demonstrated that rocuronium improved mask ventilation in 67 percent of patients, resulted in unchanged ventilation in 33 percent, and made ventilation more difficult in no instance.1
In addition to making mask ventilation easier, muscle relaxation has a second safety benefit—it permits insertion of a supraglottic airway (laryngeal mask airway [LMA] type device, or King LT-D). In the past, difficulty of mask ventilation led to awakening the patient and avoiding rapid sequence intubation; now some anesthesiologists advocate that the response should be the opposite—give muscle relaxants—and improve mask ventilation, insert an LMA, or intubate. Within the anesthesia community, many are questioning whether demonstrating mask ventilation prior to intubation should be abandoned.2,3