and grade IV (ventilation inadequate with no PE ′ CO 2 measurement and no perceptible chest wall movement during attempts at positive pressure ventilation) in one patient (0.5%) (grades I and II, and grades III and IV being equivalent to scores ,3 and 3 or more, respectively, used by Roberts and colleagues). Thus, of those 188 patients with predicted difficult BMV, barely 7% actually demonstrated difficult BMV. This is less than half the incidence reported by Roberts and colleagues. 1 It is conceivable that the higher incidence in the latter report was caused by the absence of muscle relaxation at the time of assessment of BMV.In patients with ,3 risk factors, the quality of BMV was assessed before administration of a neuromuscular blocking agent. After the administration of succinylcholine in 90 patients with BMV difficulty grade III, the quality of BMV improved by one grade in 56 (62%), and did not worsen in any of the remaining 34 patients. After administration of a nondepolarizing neuromuscular blocking agent in 12 003 patients with BMV difficulty grade I and II, the quality of BMV did not worsen in a single patient. These findings confirm previous ones showing that in patients with unimpaired 3 or with a mix of unimpaired and moderately difficult BMV, 4 the quality of BMV either remained unchanged or improved after the administration of a neuromuscular blocking agent, but never worsened.During the past 25 yr, in the absence of indication for awake fibreoptic tracheal intubation, I have routinely administered the planned full dose of the neuromuscular blocking agent as soon as the patient went off to sleep. With this practice, I have rarely encountered impossible BMV. In my view, lack of administration of muscle relaxation immediately after induction of anaesthesia should be considered a predictor of difficult BMV. I fully agree with the authors' statement that BMV is 'a vital, life-saving skill for anaesthetists' 1 (although with the advent of supraglottic airway devices, the importance of BMV has somewhat diminished). However, BMV may iatrogenically be made difficult by the reluctance of early muscle relaxation. 1 Roberts S, Cyna AM, Walsh JP, Davis JS. Assessment of anaesthetists' ability to predict difficulty of bag-mask ventilation. Br J Anaesth 2013; 111: 676-7 2 Amathieu R, Combes X, Abdi W, et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach TM ): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114: 25-33 3 Goodwin MWP, Pandit JJ, Hames K, Popat M, Yentis SM. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs. Anaesthesia 2003; 58: 60-3 4 Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation.
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