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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Comparison of Three Methods in Improving Bag Mask Ventilation</title><author><name sortKey="Golzari, Samad Ej" sort="Golzari, Samad Ej" uniqKey="Golzari S" first="Samad Ej" last="Golzari">Samad Ej Golzari</name><affiliation><nlm:aff id="aff1">Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Soleimanpour, Hassan" sort="Soleimanpour, Hassan" uniqKey="Soleimanpour H" first="Hassan" last="Soleimanpour">Hassan Soleimanpour</name><affiliation><nlm:aff id="aff2">Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Mehryar, Hamidreza" sort="Mehryar, Hamidreza" uniqKey="Mehryar H" first="Hamidreza" last="Mehryar">Hamidreza Mehryar</name><affiliation><nlm:aff id="aff3">Department of Emergency Medicine, Urmia University of Medical Sciences, Urmia, Iran</nlm:aff></affiliation></author><author><name sortKey="Salarilak, Shaker" sort="Salarilak, Shaker" uniqKey="Salarilak S" first="Shaker" last="Salarilak">Shaker Salarilak</name><affiliation><nlm:aff id="aff4">Department of Public Health, Faculty of Medicine, Tabriz Branch, Islamic Azad University, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Mahmoodpoor, Ata" sort="Mahmoodpoor, Ata" uniqKey="Mahmoodpoor A" first="Ata" last="Mahmoodpoor">Ata Mahmoodpoor</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Panahi, Jafar Rahimi" sort="Panahi, Jafar Rahimi" uniqKey="Panahi J" first="Jafar Rahimi" last="Panahi">Jafar Rahimi Panahi</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Afhami, Mohammadreza" sort="Afhami, Mohammadreza" uniqKey="Afhami M" first="Mohammadreza" last="Afhami">Mohammadreza Afhami</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Sabahi, Majid" sort="Sabahi, Majid" uniqKey="Sabahi M" first="Majid" last="Sabahi">Majid Sabahi</name><affiliation><nlm:aff id="aff6">Heart and Stroke Foundation of Canada, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Sunny Brook Hospital, University of Toronto, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Hassani, Zahra" sort="Hassani, Zahra" uniqKey="Hassani Z" first="Zahra" last="Hassani">Zahra Hassani</name><affiliation><nlm:aff id="aff8">Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24829737</idno><idno type="pmc">4018598</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018598</idno><idno type="RBID">PMC:4018598</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">002E54</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002E54</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Comparison of Three Methods in Improving Bag Mask Ventilation</title><author><name sortKey="Golzari, Samad Ej" sort="Golzari, Samad Ej" uniqKey="Golzari S" first="Samad Ej" last="Golzari">Samad Ej Golzari</name><affiliation><nlm:aff id="aff1">Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Soleimanpour, Hassan" sort="Soleimanpour, Hassan" uniqKey="Soleimanpour H" first="Hassan" last="Soleimanpour">Hassan Soleimanpour</name><affiliation><nlm:aff id="aff2">Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Mehryar, Hamidreza" sort="Mehryar, Hamidreza" uniqKey="Mehryar H" first="Hamidreza" last="Mehryar">Hamidreza Mehryar</name><affiliation><nlm:aff id="aff3">Department of Emergency Medicine, Urmia University of Medical Sciences, Urmia, Iran</nlm:aff></affiliation></author><author><name sortKey="Salarilak, Shaker" sort="Salarilak, Shaker" uniqKey="Salarilak S" first="Shaker" last="Salarilak">Shaker Salarilak</name><affiliation><nlm:aff id="aff4">Department of Public Health, Faculty of Medicine, Tabriz Branch, Islamic Azad University, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Mahmoodpoor, Ata" sort="Mahmoodpoor, Ata" uniqKey="Mahmoodpoor A" first="Ata" last="Mahmoodpoor">Ata Mahmoodpoor</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Panahi, Jafar Rahimi" sort="Panahi, Jafar Rahimi" uniqKey="Panahi J" first="Jafar Rahimi" last="Panahi">Jafar Rahimi Panahi</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Afhami, Mohammadreza" sort="Afhami, Mohammadreza" uniqKey="Afhami M" first="Mohammadreza" last="Afhami">Mohammadreza Afhami</name><affiliation><nlm:aff id="aff5">Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</nlm:aff></affiliation></author><author><name sortKey="Sabahi, Majid" sort="Sabahi, Majid" uniqKey="Sabahi M" first="Majid" last="Sabahi">Majid Sabahi</name><affiliation><nlm:aff id="aff6">Heart and Stroke Foundation of Canada, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Sunny Brook Hospital, University of Toronto, Tabriz, Iran</nlm:aff></affiliation></author><author><name sortKey="Hassani, Zahra" sort="Hassani, Zahra" uniqKey="Hassani Z" first="Zahra" last="Hassani">Zahra Hassani</name><affiliation><nlm:aff id="aff8">Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Preventive Medicine</title><idno type="ISSN">2008-7802</idno><idno type="eISSN">2008-8213</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Introduction:</title><p>Increasedlife expectancy in populations has brought along specific new scenarios in the fields of medicine for the elderly; prevalence of physical complications such as edentulism and patients with dentures is growing. Management of anesthesia and ventilation in this group of patients has turned into a great challenge. Some researchers suggest dentures to be left in place during bag-mask ventilation; yet, no unanimous agreement exists in this regard.</p></sec><sec id="st2"><title>Methods:</title><p>In a single blind randomized clinical trial, we studied 300 patients with ASA class I, II (American Society of Anesthesiologists), Mallampati class (I, II) and aged over 55 years in three groups. After induction of anesthesia, in group G dentures were removed and in each buccal space an eight-layer 10 × 10 cm gauze and an oral airway were placed. In group D, the dentures and an oral airway were left in place. In group C (control), after removing dentures just an appropriate oral airway was placed. Then, each three group underwent bag-mask ventilation. Success of bag-mask ventilation (BMV) was considered as increase in end-tidal carbon dioxide to more than 20 mmHg and back to baseline with fresh gas flow of 3 L/min and adjustable pressure limiting valve pressure of 20 cm H<sub>2</sub>O. Success rates were evaluated between groups.</p></sec><sec id="st3"><title>Results:</title><p>Effective BMV was possible in 91 (91%), 64 (64%) and 41 (41%) patients in groups G, D and C respectively. The differences were statistically significant. Successful BMV rate was significantly higher in female patients in group G compared to group C; 43/44 versus 25/46 individuals, <italic>P</italic> = 0.0001, odds ratio = 0.03, 95% confidence interval (0.00, 0.22).</p></sec><sec id="st4"><title>Conclusions:</title><p>Leaving dentures in place in edentulous patients after inducing anesthesia improves bag-mask ventilation. However, placing folded compressed gauze in buccal space leads to more significant improvement in BMV compared to leaving dentures in place.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Gholipouri, C" uniqKey="Gholipouri C">C Gholipouri</name></author><author><name sortKey="Panahi, Jr" uniqKey="Panahi J">JR Panahi</name></author><author><name sortKey="Afhami, Mr" uniqKey="Afhami M">MR Afhami</name></author><author><name sortKey="Ghafouri, Rr" uniqKey="Ghafouri R">RR Ghafouri</name></author><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Panahi, Jr" uniqKey="Panahi J">JR Panahi</name></author><author><name sortKey="Mahmoodpoor, A" uniqKey="Mahmoodpoor A">A Mahmoodpoor</name></author><author><name sortKey="Ghafouri, Rr" uniqKey="Ghafouri R">RR Ghafouri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Sarahrudi, K" uniqKey="Sarahrudi K">K Sarahrudi</name></author><author><name sortKey="Hadju, S" uniqKey="Hadju S">S Hadju</name></author><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mahmoodpoor, A" uniqKey="Mahmoodpoor A">A Mahmoodpoor</name></author><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Nia, Ks" uniqKey="Nia K">KS Nia</name></author><author><name sortKey="Panahi, Jr" uniqKey="Panahi J">JR Panahi</name></author><author><name sortKey="Afhami, M" uniqKey="Afhami M">M Afhami</name></author><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Khoshnudi, F" uniqKey="Khoshnudi F">F Khoshnudi</name></author><author><name sortKey="Movaghar, Mh" uniqKey="Movaghar M">MH Movaghar</name></author><author><name sortKey="Ziapour, B" uniqKey="Ziapour B">B Ziapour</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Shams, Vahdati S" uniqKey="Shams V">Vahdati S Shams</name></author><author><name sortKey="Mahmoodpoor, A" uniqKey="Mahmoodpoor A">A Mahmoodpoor</name></author><author><name sortKey="Panahi, Jr" uniqKey="Panahi J">JR Panahi</name></author><author><name sortKey="Afhami, Mr" uniqKey="Afhami M">MR Afhami</name></author><author><name sortKey="Pouraghaei, M" uniqKey="Pouraghaei M">M Pouraghaei</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author><author><name sortKey="Khan, Zh" uniqKey="Khan Z">ZH Khan</name></author><author><name sortKey="Ghabili, K" uniqKey="Ghabili K">K Ghabili</name></author><author><name sortKey="Hosseinzadeh, H" uniqKey="Hosseinzadeh H">H Hosseinzadeh</name></author><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Azarfarin, R" uniqKey="Azarfarin R">R Azarfarin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Gholipouri, C" uniqKey="Gholipouri C">C Gholipouri</name></author><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author><author><name sortKey="Rahmani, F" uniqKey="Rahmani F">F Rahmani</name></author><author><name sortKey="Sabahi, M" uniqKey="Sabahi M">M Sabahi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kheterpal, S" uniqKey="Kheterpal S">S Kheterpal</name></author><author><name sortKey="Han, R" uniqKey="Han R">R Han</name></author><author><name sortKey="Tremper, Kk" uniqKey="Tremper K">KK Tremper</name></author><author><name sortKey="Shanks, A" uniqKey="Shanks A">A Shanks</name></author><author><name sortKey="Tait, Ar" uniqKey="Tait A">AR Tait</name></author><author><name sortKey="O Eilly, M" uniqKey="O Eilly M">M O’Reilly</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sokouti, M" uniqKey="Sokouti M">M Sokouti</name></author><author><name sortKey="Montazeri, V" uniqKey="Montazeri V">V Montazeri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mahmoodpoor, A" uniqKey="Mahmoodpoor A">A Mahmoodpoor</name></author><author><name sortKey="Golzari, Se" uniqKey="Golzari S">SE Golzari</name></author><author><name sortKey="Hamidi, M" uniqKey="Hamidi M">M Hamidi</name></author><author><name sortKey="Hamidi, M" uniqKey="Hamidi M">M Hamidi</name></author><author><name sortKey="Parish, M" uniqKey="Parish M">M Parish</name></author><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Conlon, Np" uniqKey="Conlon N">NP Conlon</name></author><author><name sortKey="Sullivan, Rp" uniqKey="Sullivan R">RP Sullivan</name></author><author><name sortKey="Herbison, Pg" uniqKey="Herbison P">PG Herbison</name></author><author><name sortKey="Zacharias, M" uniqKey="Zacharias M">M Zacharias</name></author><author><name sortKey="Buggy, Dj" uniqKey="Buggy D">DJ Buggy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Susheela, T" uniqKey="Susheela T">T Susheela</name></author><author><name sortKey="Anju, G" uniqKey="Anju G">G 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article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Prev Med</journal-id><journal-id journal-id-type="iso-abbrev">Int J Prev Med</journal-id><journal-id journal-id-type="publisher-id">IJPVM</journal-id><journal-title-group><journal-title>International Journal of Preventive Medicine</journal-title></journal-title-group><issn pub-type="ppub">2008-7802</issn><issn pub-type="epub">2008-8213</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24829737</article-id><article-id pub-id-type="pmc">4018598</article-id><article-id pub-id-type="publisher-id">IJPVM-5-489</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Comparison of Three Methods in Improving Bag Mask Ventilation</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Golzari</surname><given-names>Samad EJ</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Soleimanpour</surname><given-names>Hassan</given-names></name><xref ref-type="aff" rid="aff2">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Mehryar</surname><given-names>Hamidreza</given-names></name><xref ref-type="aff" rid="aff3">2</xref></contrib><contrib contrib-type="author"><name><surname>Salarilak</surname><given-names>Shaker</given-names></name><xref ref-type="aff" rid="aff4">3</xref></contrib><contrib contrib-type="author"><name><surname>Mahmoodpoor</surname><given-names>Ata</given-names></name><xref ref-type="aff" rid="aff5">4</xref></contrib><contrib contrib-type="author"><name><surname>Panahi</surname><given-names>Jafar Rahimi</given-names></name><xref ref-type="aff" rid="aff5">4</xref></contrib><contrib contrib-type="author"><name><surname>Afhami</surname><given-names>Mohammadreza</given-names></name><xref ref-type="aff" rid="aff5">4</xref></contrib><contrib contrib-type="author"><name><surname>Sabahi</surname><given-names>Majid</given-names></name><xref ref-type="aff" rid="aff6">5</xref><xref ref-type="aff" rid="aff7">6</xref></contrib><contrib contrib-type="author"><name><surname>Hassani</surname><given-names>Zahra</given-names></name><xref ref-type="aff" rid="aff8">7</xref></contrib></contrib-group><aff id="aff1">Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="aff2"><label>1</label>Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="aff3"><label>2</label>Department of Emergency Medicine, Urmia University of Medical Sciences, Urmia, Iran</aff><aff id="aff4"><label>3</label>Department of Public Health, Faculty of Medicine, Tabriz Branch, Islamic Azad University, Tabriz, Iran</aff><aff id="aff5"><label>4</label>Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, I.R, Iran</aff><aff id="aff6"><label>5</label>Heart and Stroke Foundation of Canada, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="aff7"><label>6</label>Sunny Brook Hospital, University of Toronto, Tabriz, Iran</aff><aff id="aff8"><label>7</label>Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</aff><author-notes><corresp id="cor1"><bold>Correspondence to:</bold> Dr. Hassan Soleimanpour, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. E-mail: <email xlink:href="soleimanpourh@tbzmed.ac.ir">soleimanpourh@tbzmed.ac.ir</email></corresp></author-notes><pub-date pub-type="ppub"><month>4</month><year>2014</year></pub-date><volume>5</volume><issue>4</issue><fpage>489</fpage><lpage>493</lpage><history><date date-type="received"><day>08</day><month>5</month><year>2013</year></date><date date-type="accepted"><day>04</day><month>11</month><year>2013</year></date></history><permissions><copyright-statement>Copyright: © International Journal of Preventive Medicine</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec id="st1"><title>Introduction:</title><p>Increasedlife expectancy in populations has brought along specific new scenarios in the fields of medicine for the elderly; prevalence of physical complications such as edentulism and patients with dentures is growing. Management of anesthesia and ventilation in this group of patients has turned into a great challenge. Some researchers suggest dentures to be left in place during bag-mask ventilation; yet, no unanimous agreement exists in this regard.</p></sec><sec id="st2"><title>Methods:</title><p>In a single blind randomized clinical trial, we studied 300 patients with ASA class I, II (American Society of Anesthesiologists), Mallampati class (I, II) and aged over 55 years in three groups. After induction of anesthesia, in group G dentures were removed and in each buccal space an eight-layer 10 × 10 cm gauze and an oral airway were placed. In group D, the dentures and an oral airway were left in place. In group C (control), after removing dentures just an appropriate oral airway was placed. Then, each three group underwent bag-mask ventilation. Success of bag-mask ventilation (BMV) was considered as increase in end-tidal carbon dioxide to more than 20 mmHg and back to baseline with fresh gas flow of 3 L/min and adjustable pressure limiting valve pressure of 20 cm H<sub>2</sub>O. Success rates were evaluated between groups.</p></sec><sec id="st3"><title>Results:</title><p>Effective BMV was possible in 91 (91%), 64 (64%) and 41 (41%) patients in groups G, D and C respectively. The differences were statistically significant. Successful BMV rate was significantly higher in female patients in group G compared to group C; 43/44 versus 25/46 individuals, <italic>P</italic> = 0.0001, odds ratio = 0.03, 95% confidence interval (0.00, 0.22).</p></sec><sec id="st4"><title>Conclusions:</title><p>Leaving dentures in place in edentulous patients after inducing anesthesia improves bag-mask ventilation. However, placing folded compressed gauze in buccal space leads to more significant improvement in BMV compared to leaving dentures in place.</p></sec></abstract><kwd-group><kwd>Bag-mask ventilation</kwd><kwd>dentures</kwd><kwd>edentulous patients</kwd><kwd>end-tidal carbon dioxide</kwd><kwd>folded gauze</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>Establishing a secure airway has always been of ultimate priority in providing care and treatment for patients for millennia.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref>] Bag-mask ventilation, as an undeniable part of airway management, plays a major role in establishing airway not only in patients undergoing general anesthesia but also in those with emergency airway requirements.[<xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref7" ref-type="bibr">7</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref><xref rid="ref11" ref-type="bibr">11</xref>] Edentulous patients with dentures and required to be intubated are considered a challenge for most anesthesiologists.[<xref rid="ref3" ref-type="bibr">3</xref>] Routinely in most centers, their dentures are removed prior to being transferred to the operating room. This mostly has been due to the belief that the dentures inside patients’ mouth could cause airway obstruction and compromise the sterility of the surgical field. Although, bag-mask ventilation (BMV) in edentulous patients or those having their dentures removed is difficult, prevalence of edentulism is high among individuals over 65 years (60%) and due to the problem of proper covering of mask in patients with hollow cheeks (caused by edentulism) BMV has turned into a great challenge in these patients.[<xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref12" ref-type="bibr">12</xref><xref rid="ref13" ref-type="bibr">13</xref>] To overcome this problem various techniques have been introduced including smaller-size oral masks, intraoral Rendell-Baker-Saucek Mask, special anatomical masks, oral airway or nasal mask or even approaches for not removing the dentures.[<xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref12" ref-type="bibr">12</xref><xref rid="ref13" ref-type="bibr">13</xref>]</p><p>Another rarely-reported yet simple way of improving ventilation in edentulous patients is using oral gauze.[<xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref13" ref-type="bibr">13</xref>] In the present study, we aimed to compare the efficacy of three methods (leaving dentures in place, insertion of folded gauze in buccal space and placing just an appropriate oral airway after removing dentures) in establishing proper airway.</p></sec><sec sec-type="methods" id="sec1-2"><title>METHODS</title><p>In a single blind prospective randomized clinical trial, edentulous patients (<italic>n</italic> = 300, all over 55 years old) with ASA class I and II referring to the operating room of a referral hospital who were scheduled to undergo cataract surgery under general anesthesia were recruited. The project was approved by the University Ethics Committee and informed written consents were obtained prior to the study. Sample size was calculated based on the following formula and a total of 300 individuals (100 for each group) were calculated:</p><p><italic>N</italic> = 2 (1.96 + 0.84) 2 * 0.2625 (1 − 0.2625)/(0.35 − 0.175) 2</p><p><italic>N</italic> = 99.11 ≠ 100(for each group)</p><p>Patients not having the criteria for difficult bag mask ventilation, i.e., body mass index ≥31 kg/m<sup>2</sup>, history of snoring or sleep apnea, thick neck circumference, limited thyromental distance, Mallmapati class III and IV and long beard or mustache were arrived into the study. All patients were edentulous and aged over 55 years old. In addition, patients with nasogastric tube or facial anomalies were not included. Later, patients were randomly divided into three groups of 100 patients by picking a ballot:</p><p>Group gauze (G): Patients with removed dentures; in each buccal space, an eight-layer gauze 10 * 10 cm which was quadrupled and an appropriate size oral airway was selected measuring the distance from the corner of the mouth to the tip of the ear and placed between gauzes [<xref ref-type="fig" rid="F1">Figure 1</xref>].</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Placing a folded gauze in the buccal cavities (on the both sides of the airway) in edentulous patients is performed to improve bag.mask.ventilation</p></caption><graphic xlink:href="IJPVM-5-489-g001"></graphic></fig><p>Group denture (D): Patients with their dentures in place without oral gauzes; an appropriate size oral airway was placed in the oral cavity.</p><p>Group control (C): Patients with their dentures removed; an appropriate size oral airway was placed in order to maintain the airway without placing gauzes in the oral cavity.</p><p>BMV of patients was performed by a skilled anesthesiologist who was not a project member. All patients were preoxygenated by oxygen (3 L/min for 5 min). Premedication was performed with fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) 5 min prior to anesthesia induction. All patients were hydrated before anesthesia induction by Ringer's solution 5 ml/kg. Anesthesia induction was performed by propofol (2 mg/kg) and atracurium (0.5 mg/kg). Ventilator was set to the following values: Fresh gas flow = 3 L/min and valve pressure adjustable pressure limiting (APL valve) =20 cm H<sub>2</sub>O.</p><p>The exact time for the evaluation of BMV was determined by a zero TOF using a nerve stimulator following anesthesia induction, i.e., administration of propofol and muscle relaxant; patients being connected to a mainstream capnogram device (Respironics model number: 7100, Respironics California Inc., California) were bag-mask ventilated for 10 times by a skilled anesthesiologist. At the end of each time of ventilation, patients’ end-tidal carbon dioxide (ETCO<sub>2</sub>) was recorded. Successful BMV was determined as a return to the baseline ETCO<sub>2</sub> following increased ETCO<sub>2</sub> to more than 20 mmHg at FGF = 3 L/min and APL valve pressure of 20 Cm H<sub>2</sub>O.</p><sec id="sec2-1"><title>Statistical analysis</title><p>Chi-square test was used for analyzing categorical variables. Odds ratio (OR) and 95% confidence interval (CI) was calculated for point estimations of OR. One-way analysis of variance was used for analyzing age and weight variables for groups of study [<xref ref-type="table" rid="T1">Table 1</xref>]. <italic>P</italic> < 0.05 was considered to be significant.</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Demographic characteristics of the patients</p></caption><graphic xlink:href="IJPVM-5-489-g002"></graphic></table-wrap></sec></sec><sec sec-type="results" id="sec1-3"><title>RESULTS</title><p>No significant difference was observed between the three studied groups regarding gender, age and weight distribution [<xref ref-type="table" rid="T1">Table 1</xref>]. Successful BMV rate was significantly higher in female patients compared with male patients in group C, <italic>P</italic> = 0.01, OR = 2.827, 95% CI (1.241, 6.441) [<xref ref-type="fig" rid="F2">Graph 1</xref>]. In spite of great success in BMV in female patients of the control group (25 out of 46 patients), the ratio was lower compared with the females in group G (43/44 patients); the difference between two groups was statistically significant [<xref ref-type="fig" rid="F3">Graph 2</xref>]; <italic>P</italic> = 0.0001, OR = 0.03 CI 95% (0.00, 0.22). The overall success rate was significantly higher in patients of the group D compared to the group C (64% vs. 40%; <italic>P</italic> = 0.001). On the other hand, successful BMV rate in group G (91/100 patients) was higher comparing to the group D (64/100 patients); the difference between two groups was statistically significant (<italic>P</italic> = 0.01) [<xref ref-type="fig" rid="F4">Graph 3</xref>].</p><fig id="F2" position="float"><label>Graph 1</label><caption><p>Successful bag-mask ventilation in patients of the control group according to gender distribution (<italic>P</italic> = 0.01)</p></caption><graphic xlink:href="IJPVM-5-489-g003"></graphic></fig><fig id="F3" position="float"><label>Graph 2</label><caption><p>Successful bag-mask ventilation in female patients of the groups C and G (<italic>P</italic> = 0.0001)</p></caption><graphic xlink:href="IJPVM-5-489-g004"></graphic></fig><fig id="F4" position="float"><label>Graph 3</label><caption><p>Successful bag-mask ventilation in patients of all groups (G, D and C) (<italic>P</italic> = 0.01)</p></caption><graphic xlink:href="IJPVM-5-489-g005"></graphic></fig></sec><sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title><p>BMV, as a main essential technique in controlling airway, provides oxygenation and ventilation before securing a stable airway. Thanks to its life-saving properties, BMV is of special importance to the rescuers.[<xref rid="ref3" ref-type="bibr">3</xref>] Weiss and Lutes showed that endotracheal intubation in traumatic patients does not increase the survival rate compared to BMV.[<xref rid="ref14" ref-type="bibr">14</xref>] To perform proper BMV the mask should be kept firmly and appropriately in place followed by positive pressure ventilation; this is of so great importance that lack of qualification in BMV is a relative contraindication to its performance. BMV is often used along with oral or nasal airways. To perform effective BMV proper coverage of mouth and nose by mask is essential because there are three major problems in performing sufficient BMV: Insufficient volume of air, poor oxygenation, stomach distention. The two former concerns could be eliminated by full coverage of mouth and nose by mask.[<xref rid="ref15" ref-type="bibr">15</xref>]</p><p>Throughout general anesthesia, muscle tone reduces in oropharynx leading to collapse of the tongue, soft palate and epiglottis contributing to airway obstruction as a factor of difficult BMV in anesthetized patients. Edentulous patients are at increased risk of the obstruction and difficult BMV comparing to patients with teeth.[<xref rid="ref16" ref-type="bibr">16</xref><xref rid="ref17" ref-type="bibr">17</xref>] Furthermore, these patients have relatively big tongues due to jaw bones cavity and collapse of the tongue in edentulous patients’ mouth.[<xref rid="ref18" ref-type="bibr">18</xref>] In fact, during anesthesia induction tongue tends to be placed laterally in patients without dentures causing more airway obstruction.[<xref rid="ref19" ref-type="bibr">19</xref>] The importance of the above-mentioned factors were highlighted in our study; firstly placing compressed folded gauze in buccal space would prohibit the soft-tissue from obstructing the airway and secondly improved mask coverage of patient mouth would contribute to more proper ventilation.</p><p>The positioning throughout ventilation is also of importance. Weiss and Lutes in a study showed that BMV whereas the patient is in the supine position and external auditory meatus is aligned with the sternal notch is better compared with sniffing position.[<xref rid="ref14" ref-type="bibr">14</xref>] Using denture adhesive in patients with nasogastric tube increases expiratory volume comparing to patients without using adhesive.[<xref rid="ref20" ref-type="bibr">20</xref>] Lack of teeth can be considered a major factor in difficult BMV while very few studies have been conducted to address this concern. In a study carried out by Kheterpal <italic>et al</italic>., risk factors for difficult BMV were evaluated amongst which lack of teeth also was stated as a significant risk factor.[<xref rid="ref9" ref-type="bibr">9</xref>] Using dentures and long tubed gauzes packing vestibular cavities in edentulous patients has been reported to improve BMV.[<xref rid="ref12" ref-type="bibr">12</xref><xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref21" ref-type="bibr">21</xref><xref rid="ref22" ref-type="bibr">22</xref>] Unlike the study of Conlon <italic>et al</italic>., results of our study demonstrated that placing folded gauze in buccal space was more successful (91% vs. 73%)[<xref rid="ref12" ref-type="bibr">12</xref>] which could be due to the more accurate exclusion criteria and utilization of skilled anesthesiologists rather than various individuals with various experience and skills in our study as well.</p><p>In our study, females without dentures and without folded gauze in their buccal spaces were ventilated better than edentulous males in similar conditions; this major finding has not been mentioned in similar studies. In addition, complete dentures (upper and lower jaws) were used in our study; however, in Colon's study partial dentures (only upper jaw or only lower jaw) were used probably contributing to the differences in the success rates between groups (73% in Colon's vs. 64% in our study). Although using partial dentures, the rest of the teeth are natural and consequently in such cases anatomical changes of tongue and jaw will be less. Therefore, despite associated increased risk of swallowing the dentures, it is expected that the success chance in patients with partial dentures would be higher.[<xref rid="ref12" ref-type="bibr">12</xref>]</p><p>Similar to the study of Kheterpal <italic>et al</italic>., being male was a prognostic factor in difficult BMV and females without dentures and without folded gauze in their buccal space were ventilated better than males with similar conditions.[<xref rid="ref9" ref-type="bibr">9</xref>]</p><p>Limited alveolar tissue in upper and lower jaws would consequently decrease the volume of the oral cavity and place pressure on the tongue leading to tongue swelling in edentulous patients. This could be prevented by insertion of dentures in patient mouth.[<xref rid="ref22" ref-type="bibr">22</xref>] However, dentures place pressure on the submandibular soft-tissue and push tongue toward palate causing airway obstruction; especially, in edentulous individuals in which this space is expected to be smaller than those with teeth.[<xref rid="ref23" ref-type="bibr">23</xref>] Therefore, removal of the dentures and placement of oral gauze throughput BMV seems quite rational as it would be with more appropriate ventilation and less undesirable complications.</p><sec id="sec2-2"><title>Limitations</title><p>Our study was a single-center study performed on patients undergoing ophthalmic surgeries. Therefore, further multi-center studies on patients undergoing different surgeries are recommended.</p></sec></sec><sec sec-type="conclusion" id="sec1-5"><title>CONCLUSIONS</title><p>Findings of our study revealed that leaving dentures in place improves BMV; furthermore, placing folded gauze in buccal space in edentulous patients considerably facilitates BMV. 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