Are Difficult Mask Ventilation and Difficult Intubation the Same?🤔

♦️ Introduction

In the operating room, terms like “difficult airway cart” and “history of difficult intubation” are often mentioned. The WHO Surgical Safety Checklist also requires anesthesiologists to evaluate the risk of a difficult airway before induction.

♦️ What Is a Difficult Airway?

A “difficult airway” refers to a situation where trained providers encounter difficulty in establishing and maintaining airway patency, whether by mask ventilation, intubation, or other techniques.

Normally, when awake or even during natural sleep, the airway remains patent. Under anesthesia, however, sedatives and muscle relaxants can cause the tongue base to fall back, obstructing airflow.
Simple maneuvers such as chin lift, jaw thrust, or tracheal intubation usually restore patency—but in certain patients, these steps remain difficult even for experienced anesthesiologists.

👉 The concept of a difficult airway is broadly divided into Difficult Mask Ventilation (DMV) and Difficult Intubation (DI).

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🔷 DMV vs DI: Not the Same Thing

A patient may have DMV but easy intubation, or easy mask ventilation but very difficult intubation. They are related but not identical concepts.

For many trainees, the surprising lesson is how challenging proper mask ventilation can be. Bag-valve-mask devices can give a false sense of ventilation because air can be pushed regardless of airway obstruction. In contrast, anesthesia ventilators or breathing circuits give clearer feedback (stiff bag, collapse, or resistance).

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🔷  If You Can Ventilate, You Can Wait

If mask ventilation is possible, there is no need to panic. One can stop induction, call for senior help, or prepare alternative intubation devices.

👉 The truly dangerous scenario is CVCI (cannot ventilate, cannot intubate). This is why repeated, blind intubation attempts are strongly discouraged.

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♦️ Preoperative Airway Evaluation (Updated per ASA 2022)

Before general anesthesia or airway management, whenever feasible, perform a thorough airway risk assessment. The ASA 2022 Guidelines introduced a structured decision-tree to help determine whether to proceed with awake vs asleep intubation.

🔷 Awake intubation should be considered if any of the following are anticipated:

🔷 Additional considerations emphasized by ASA 2022:

🔷 Other Common Risk Factors (from ASA & DAS guidelines)

👉 Multiple factors combined significantly increase the likelihood of airway difficulty.

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📝 Summary

📚 References & Links

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