Incidence of difficult bag-mask ventilation in children: a prospective observational study

Paediatr Anaesth. 2013 Oct;23(10):920-6. doi: 10.1111/pan.12144. Epub 2013 Mar 21.


Background: Difficult airway (DA), including difficult bag-mask ventilation (DBMV), and difficult intubation (DI) is an important challenge for the pediatric anesthesiologist. While expected DBMV can be successfully managed with appropriate equipment and personnel, unexpected DBMV relies on the resources available and the experience of the anesthesiologist at the time of the emergency. The incidence and risk factors of unexpected DA in otherwise healthy children, including DBMV among pediatric patients are not known. The aim of this study was to expand the scientific knowledge of unexpected DBMV among pediatric patients.

Methods: Patients between the ages of 0 and 8 years, undergoing elective surgery requiring bag-mask ventilation BMV and intubation at the Montreal Children's Hospital were recruited in this prospective observational study. Data on the incidence of DBMV and risk factors were collected over a 3-year period.

Results: In a sample of 484 children, the incidence of unexpected difficult BMV was 6.6% (95% CI [4.6, 9.2]). The incidence of expected DA among the screened patients (N = 4865) was 0.5% (95% CI [0.3, 0.7]). In a logistic regression analysis, age (OR 0.98; 95%CI [0.97, 0.99]), undergoing otolaryngology (ENT) surgery (OR 2.92; 95% CI [1.08, 7.95]) and use of neuromuscular blocking agents (OR 3.49; 95%CI [1.50-8.11]) were independently associated with DBMV. The incidence of DI was 1.2%. No association between DBMV and DI was found (Fisher's exact test, P = 1.0).

Conclusions: This is the first published report of the incidence of unexpected DBMV among healthy pediatric patients.

Keywords: airway obstruction; complications; difficult airway; intubation; pediatrics; ventilation.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Airway Management / methods
  • Airway Management / statistics & numerical data*
  • Asthma / complications
  • Asthma / epidemiology
  • Body Mass Index
  • Child
  • Child, Preschool
  • Clinical Competence
  • Data Interpretation, Statistical
  • Elective Surgical Procedures
  • Female
  • Humans
  • Incidence
  • Infant
  • Intraoperative Complications / epidemiology
  • Logistic Models
  • Male
  • Neuromuscular Blocking Agents / adverse effects
  • Prospective Studies
  • Respiration, Artificial / methods
  • Respiration, Artificial / statistics & numerical data*
  • Risk Factors
  • Sleep Apnea, Obstructive / complications
  • Sleep Apnea, Obstructive / epidemiology
  • Treatment Outcome


  • Neuromuscular Blocking Agents