Neuromuscular Blockade in Face Mask Ventilation: January 2026, editorial Highlights Improvements in Gas Exchange

These findings were published in January 2026, in Trends in Anaesthesia and Critical Care.

The Clinical Burden of Difficult Airway Management

Face mask ventilation (FMV) remains a cornerstone of anesthetic practice, yet evidence regarding its failure is less documented than tracheal intubation. Statistics indicate an incidence of failed mask ventilation at 0.15%, while the pooled incidence of difficult mask ventilation (DMV) is approximately 6.1%, rising significantly to 14.1% in patients with obesity. For nearly two decades, the debate has centered on whether to administer NMBAs simultaneously with induction agents or wait for confirmation of an open airway. Historically, many European practices favored the latter, but emerging evidence suggests this "safe practice" may actually compromise patient safety by delaying optimal conditions for gas exchange.

Evidence Analysis and Comparative Studies

The editorial synthesized data from numerous randomized controlled trials (RCTs) and observational studies conducted over the past decade. The analysis focused on how various NMBAs—including rocuronium, vecuronium, suxamethonium, and cis-atracurium—impact respiratory parameters and the four-point Han scale of ventilation ease. Inclusion criteria for the cited trials often included patients with normal airway anatomy as well as those with significant predictors of difficulty, such as obstructive sleep apnea (OSA), male sex with a beard, or a history of neck radiotherapy.

The key findings from the editorial include:

• Across multiple clinical studies, NMBAs were found to significantly increase tidal volumes (VT) during controlled ventilation, with one specific trial noting a 71% increase in volume for difficult-to-ventilate patients.

• Early administration of rocuronium reduced the time required for tracheal intubation when compared to the practice of waiting for ventilation confirmation.

• Neuromuscular blockade leads to a reduction in peak inspiratory pressures (Ppeak), which subsequently decreases the risk of gastric insufflation during manual bagging.

• Anatomical factors such as a neck circumference exceeding 40 cm were identified as independent risk factors for reduced tidal volumes during ventilation, even after paralysis.

Clinical Relevance and Individualized Management

For practicing clinicians, this editorial underscores that NMBA administration (VTE increase) aligns with improved safety profiles, provided patient selection is meticulous. The evidence suggests that 71% volume improvements can be life-saving in DMV scenarios, meaning practitioners should consider paralysis to "rescue" an airway rather than viewing it as a risk. However, an individualized approach remains essential; patients with known anterior mediastinal masses or neuromuscular disorders like myasthenia gravis (MG) require specialized consideration. Overall, the combination of proper patient positioning, two-handed techniques, and the strategic use of second-generation supraglottic airway devices (SADs) remains vital to achieving successful outcomes.

Reference

Michalek P, Gómez-Ríos MÁ, Pereira AI, Gaszynski T. Face mask ventilation – to paralyze or not to paralyze, is that the question? Trends in Anaesthesia and Critical Care. 2026 Jan 22