As anesthesiologists, it is encouraging that recent attention has been paid to airway management improvements in and out of the operating suites. Our goals of positive patient safety outcomes have led to many recent airway management publications. The most recent of which included the investigation of the temporal trends in difficult and failed intubations over a 14-yr period (2002 to 2015) by Schroeder et al.1  in the March 2018 issue of Anesthesiology.

Airway management outcomes have improved through enhanced education, better airway algorithms, and innovations in airway management. Mask ventilation, the precursor to intubation, has unfortunately received minimal attention over the same period. We contend that mask ventilation is as important as intubation, but it is commonly a less popular skill to teach and learn. As airway management experts, we believe it is our duty to educate the healthcare community on the importance of mask ventilation improvement strategies.

Skills required for bag-mask ventilation and endotracheal intubation are very different, although they are taught, at most times, simultaneously. As educators in airway management, we believe the primary focus should begin with mastery of mask ventilation before endotracheal tube insertion because it is not uncommon to encounter situations of both difficult ventilation and intubation that will ultimately call upon this much-needed skill.

Improvements in mask ventilation beyond the ergonomics of different masks and noninvasive strategies have been lacking, and recent studies further lend support to this need. The difficult intubation rates in the out-of-hospital setting have been reported to be between 9 and 11% both in the United States,2  where emergency medical technicians and paramedics are the frontline, and in Europe, where anesthesiologists are present in the field. Because bag-mask ventilation is a skill that is equivalent to—if not more important than—intubation, our education should focus on greater implementation and training of this specific skill. Highlighting the importance of mask ventilation is a recent study by Jabre et al.,3  in the February issue of JAMA. The study saw similar neurologic outcomes with either airway modality of bag-mask ventilation or endotracheal intubation after out-of-hospital cardiopulmonary arrest,3  which supports the value in teaching, learning, and ultimately mastering this less noteworthy skill.

The education level of the practitioner is questioned by Lewis and Gausche-Hill4  regarding the study of Jabre et al.,3  Lewis and Gausche-Hill4  illustrate the differences between emergency response teams in Europe and America. In Europe, physicians are part of the ambulance care team and thus are the first responders who perform the intubations. Comparatively, in the United States, the emergency responders are largely paramedics, who often lack training in airway management proficiency compared with anesthesiologists, emergency physicians, and intensivists.

We applaud our colleagues for improvements in airway support over the past decade, but bag-mask ventilation is seldom a topic of research. Our airway management education begs for focus on improving our mask ventilation techniques to reproduce the results of Jabre et al.3  Most recent research with bag-mask ventilation has relied on different hand placement, with greatest success attributed to the two-handed mask holding approach.

In our opinion, the anesthesiology community has maintained its integrity with regard to patient safety via airway management. However, the next step is to continue progressive strides and gain momentum on how we perform these skills. The attention should be on techniques to optimize ventilation, including mask seal and accurate mandibular advancement. In exploring alternative mask ventilation techniques, we believe innovation in education and equipment needs to be expanded and improved.

Dr. Rosen is the founder of Oteg Medical LLC. The other authors declare no competing interests.

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2