Verification of Ventilation before Neuromuscular Blocker Administration during Anesthetic Induction and Endotracheal Tube Insertion in the Non-Rapid Sequence Induction Setting

  • Skyler Murdock Texas Christian University


Anatomically, the upper airway consists of the cartilaginous and bony structures of the nose and mouth, followed by the soft tissue of the oropharynx and laryngopharynx, and ending in the rigid trachea.1 The soft tissue of the pharynx is prone to collapse in the unconscious, or anesthetized, patient and may be further compromised by obesity, a large tongue, airway edema, large neck circumference, external compression, and many other factors.1,4 In response to this collapse, anesthesia professionals who plan to place an endotracheal tube have historically been instructed to refrain from administering muscle relaxation until adequate mask ventilation in the anesthetized patient was confirmed in order to both avoid a critical hypoxemic event, and to ensure an attempt at an escape wake up.  However, there is little published evidence to support this practice, and the administration of muscle relaxation before ensuring adequate BVM ventilation remains controversial.1-8


1. Saddawi-Konefka DS, Hung SL, Kacmarek RM, Jiang, Y. Optimizing mask ventilation: literature review and development of a conceptual framework. Respiratory care. 2015;60(12):1834-1840.
2. Joffe AM, Ramaiah R, Donahue E, Galgon RE, Thilen SR, Spiekerman CF, Bhananker SM. Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial. BMC anesthesiol. 2015;15:134. PMID 26444853.
3. Broomhead RH, Marks RJ, Ayton MP. Confirmations of the ability to ventilate by facemask before administration of neuromuscular blocker: a non-instrumental piece of information? British Journal of Anaesthesia. 2010;104(3):313-317
4. Patel A. Facemask ventilation before or after neuromuscular blocking drugs: where are we now? Anaesthesia. 2014;69:801-815.
5. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011;66:163-167.
6. Priebe H. Ventilation before paralysis. Anesthesiology. 2013;4(118):992-993.
7. Patel A, Pearce A. Progress in management of the obstructed airway. Anaesthesia 2011;66:93-100.
8. Calder I, Yentis SM. Could ‘safe practice’ be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker? Anaesthesia. 2008; 63:113-5
9. Frerk C, Pearce A. Induction and maintenance of anaesthesia. In: Cook T, Woodall N, Frerk C, eds. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major Complications of Airway Management in the United
Kingdom. London: RCoA, 2011: 55–61.
10. 10. Thomas BF, Parks LJ. Propofol. Statpearls. 2018.
11. Jense HG, Dubin SA, Silverstein PI, O’Leary-Escolas U. Effect of obesity on safe duration of apnoea in anesthetized humans. Anesth Analg 1991; 72: 89–93
12. Wittekamp BH, VanMook WN, Tjan DH, Zwaveling JH, Bergmans DC. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult paitents. Crit Care. 2009;13(6):233.
13. Apfelbaum, JL, Hagberg CA, Caplan RA, Blitt CD, et al. Practice guidelines for management of the difficult airway: an updated report by the American society of anesthesiologists task force on management of difficult airway. Anesthesiology. 2013;118:251-
14. Kpman AF, Zhaku B, Lai KS. The “intubating dose” of succinylcholine: the effect of decreasing doses on recovery time. Anesthesiology. 2003;99(5):1050-1054.
15. Pseudocholinesterase deficiency. U.S. National Library of Medicine. Genetic home reference.
16. Naguib M, Brewer L, LaPierre C, Kopman AF, Johnson KB. The myth of rescue reversal in “can’t intubate, can’t ventilate” scenarios. Anesth Analg. 2016;123(1):82-92.
17. Mevorach DL. The management and treatment of recurrent postoperative laryngospasm. Anaesth Analg 1996;83:1110-1111.
How to Cite
MURDOCK, Skyler. Verification of Ventilation before Neuromuscular Blocker Administration during Anesthetic Induction and Endotracheal Tube Insertion in the Non-Rapid Sequence Induction Setting. Anesthesia eJournal, [S.l.], v. 7, p. 15-16, sep. 2019. ISSN 2333-2611. Available at: <>. Date accessed: 27 mar. 2023.